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19181195-DS-3 | 29,768,725 | Dear Mr. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You were admitted to the ICU with difficulty breathing and a
lung infection after CPR.
What was done while I was here?
- You needed a breathing tube which was removed when your
breathing improved.
- You were given medications to treat pneumonia.
- You were seen by the addiction psychiatry team to discuss
substance abuse resources and counseling.
What should I do when I get home?
- Please take all of your medications as prescribed. You will
need to continue taking the antibiotic (called cefpodoxime)
until ___.
- You are being provided a prescription for narcan which you
should make sure to have at home. Make sure those around you
know to use it in case of another overdose.
- It has been a pleasure to care for you. Your team sincerely
wishes you luck with your recovery. Please continue to work with
your outpatient providers in this regard.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ with a history of opioid use disorder who was
found down at home requiring CPR and intubation in the field. He
was admitted to the ICU for ARDS and acute hypoxemic respiratory
failure and was treated for aspiration pneumonia.
#Acute hypoxemic respiratory failure:
#Aspiration pneumonia:
#ARDS:
Patient developed ARDS after heroin overdose, likely in the
setting of aspiration vs. inhalation injury given bilateral
consolidation on CXR. Initially with worsening oxygenation after
intubation. He was initially on Veletri and was transferred for
ECMO consideration. He was also paralyzed and sedated with
midazolam and hydromorphone (fentanyl did not sedate him
adequately). Veletri and paralysis were successfully weaned and
he did not require ECMO. He was given IV diuresis to minimize
pulmonary edema and treated for aspiration pneumonia. He was
extubated on ___. Given vancomcyin, cefepime, and
azithromycin, narrowed to cefazolin when sputum culture grew
MSSA. He was transitioned to cefpodoxime to complete a 14 day
course which will finish on ___.
#Opioid use disorder
Discussed substance abuse resources with addiction psychiatry
team and social work. He was initially started on methadone for
pain management, however was weaned off when he expressed that
he would not want this as a maintenance therapy. His last dose
was 5 mg methadone on ___. He was found to be HIV negative.
Quantiferon gold pending at time of discharge.
#Chest pain
Felt to be most likely related to bruising following CPR without
evidence of rib fractures on radiology. His pain was initially
managed with methadone then transitioned to
acetaminophen/naproxen, which he was no longer requiring on
discharge.
#Acute transaminitis
Unclear etiology, may be ___ downtime/mild ischemic liver injury
in the setting of overdose and being found down. Hepatitis
serologies negative (non-immune to Hep B), HIV negative, iron
level low. RUQUS showed moderately distended gallbladder with
sludge and tiny gallstones. His LFTs downtrended throughout the
admission. Recommend outpatient HAV/HBV vaccinations.
#Acute normocytic anemia
Consistent with mixed iron deficiency/anemia of inflammation. No
evidence of hemolysis.
#CODE STATUS: Full Code
#EMERGENCY CONTACT: Mother (___) ___
___ Issues
====================
[] Cefpodoxime 400 mg BID should be continued until ___ to
treat aspiration pneumonia.
[] Continued discussion regarding substance abuse treatment.
[] Recommend establishing with PCP as an outpatient
[] Narcan prescribed on discharge. | 165 | 362 |
15794797-DS-24 | 22,490,900 | It was a pleasure taking care of you at ___.
You were admitted with shortness of breath and fatigue
consistent with your known congestive heart failure. You were
treated with an infusion of lasix (furosemide) to remove extra
fluid. Your breathing improved with this treatment. It is
possible that you may need another mitral valve replacement as
this may be causing the heart failure or fluid buidlup. You had
an echocardiogram through your esophagus to better evaluate the
valve and you will see Dr ___ in ___ to discuss the valve.
Please weigh yourself daiy and call Dr ___ your weight
increases more than 3 pound sin 1 day or 5 pounds in 3 days.
Your weight at discharge is 192 pounds. | ___ F hx of rheumatic heart disease and MS ___ MVR with residual
stenosis of MR, TR ___ annuloplasty, chronic R sided heart
failure, fatigue and malaise presenting with fatigue and
hypotension.
ACTIVE DIAGNOSES
# HFPEF: No evidence of end organ hypoperfusion. Hypotention
likely ___ to exacerbation of known right sided heart failure
from MV stenosis. Initially we held pts lisinopril and BB, as pt
was hypotensive, and pt was given IVF in the ED. Pts SBP
improved. Pt was then diuresed with lasix drip, with decrease in
peripheral edema and subsequent improvement in symptoms. Pt was
restarted on BB at the time of discharge, but lisinopril was
held due to increasing Cr. Pt was restarted on decreased dose of
torsemide at time of dicharge as well.
# Mitral valve stenosis: Most likely cause of her chronic and
severe fatigue and dyspnea. Prior imaging demonstrates
significant residual stenosis of the bioprosthetic mitral valve,
which was again noted on repeat TTE while pt was in the
hospital. Dr. ___ t/b with the pt as an outpt to discuss
MVR.
# ___: Baseline creatinine low 1.0's however in last 2 mo
creatinine >1.5 on three readings. Concern for preprenal
azotemia because of decrease in forward flow from right sided
heart failure. Urine lytes were not checked in the ED and there
was low utility of checkig once pt arrived to CCU, since she had
received IVF. Plan to avoid nephrotoxic agents and stop
lisinopril with outpt monitoring of Cr.
CHRONIC DIAGNOSES
# Lupus: Stable.
# Gout: Stable, but allopurinol redosed for current renal
clearance: 150 mg PO QD.
# OSA: Stable.
# HTN: Stable.
# Depression: Stable. | 122 | 273 |
11369345-DS-17 | 25,913,281 | Dear Mr. ___,
You came into the hospital with shortness of breath, cough, and
chest pain. You were found to have pneumonia and fluid in the
lining surrounding your heart. You were treated with
antibiotics. For the fluid surrounding your heart, you were
given colchicine throughout your hospital stay, but it was
discontinued once you were started on HIV medications due to
potentially severe drug interactions. You may take Tylenol or
ibuprofen as needed for pain.
You had pain and swelling in your left knee after falling. Knee
x-ray showed no fracture, which was confirmed by a CT scan. The
fluid in your knee was not obviously infected, but you were
treated with antibiotics until the Infectious Disease
specialists thought that your knee pain and swelling was most
likely not due to infection. You may continue taking ibuprofen
or Tylenol as needed for pain.
During your hospitalization, you were found to have HIV. You
were started on antiviral therapy for your HIV with medications
called Truvada, darunavir, and ritonavir. You must take these
medications every day as prescribed. If you don't, your HIV
virus may develop resistance to the medication, and the
medication would no longer be effective in fighting the virus.
You should keep in contact with ___, the case worker at
AIDS Action Committee ___ number ___ main number
___. Please notify AIDS Action Committee about any
location changes or any change in your living situation.
You were found to have swollen lymph nodes in your chest. One of
them was removed, which showed that the swelling was not due to
cancer or an infection called tuberculosis but was most likely a
reaction to your recent pneumonia and HIV infection.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team | ___ year old man with a history of homelessness and GSW several
decades ago who presented with hypoxemia, cough, and infiltrate
c/f pneumonia. Patient was found to have multifocal pneumonia,
pericarditis, left knee effusion, and newly diagnosed HIV along
with lymphadenopathy concerning for TB vs lymphoma, with TB
ruled out and preliminary pathology and cytology encouraging for
no lymphoma.
# HIV:
HIV status checked due to pt being intermittently homeless with
recurrent multifocal PNA and pericarditis and was found to be
positive. No h/o IVDU. Sexually active with women only. Per pt,
ex-girlfriend died recently of unknown causes. CD4 289. Viral
load 1,160,000 copies/mL. Cryptococcus antigen negative. RPR
negative. Urine GC/chlamydia negative. HBV serologies negative
for infection and immunity. Given first dose of HBV vaccine
in-house. HCV negative. HAV Ab positive, IgM negative,
indicating either prior infection or vaccination. Toxoplasma
antibody negative. Baseline Hgb A1c 5.8%. Lipid panel: TC 83,
HDL 22, LDL 42, Trig 93. G6PD WNL (11.4). Per ID consult,
started HAART in-house with Truvada 1 tab daily, darunavir 800mg
daily, and ritonavir 100mg daily. SW followed while in-house and
gave pt information about AIDS Action Committee for ___
___. Pt instructed to keep in contact with ___,
the case worker at AIDS ___ ___ number
___ main number ___. Pt asked to notify AIDS
Action Committee about any location changes or any change in
living situation.
# R/O TB:
Given HIV+, homelessness, multifocal PNA, and hilar LA on CTA
___, pt placed on TB isolation precautions on ___. AFB
smears negative x4. Quant gold indeterminate. NAAT negative x2.
Airborne precautions d/c'ed ___. AFB cultures from ___ and
___ pending on discharge. LN biopsy AFB culture pending on
discharge.
# MEDIASTINAL AND HILAR LYMPHADENOPATHY:
CTA ___ and non-con CT chest ___ showed extensive
mediastinal and hilar lymphadenopathy. Most likely not TB, given
negative AFB smears x4 and negative NAAT x2. Given LA on CTA
___, histoplasmosis antibody and antigen ordered on ___ and
were negative. Per radiology, chest CT is concerning for
lymphoma, Castleman's disease less likely given radiographic
appearance. LDH WNL (147). Beta2-microglobulin elevated at 5.4.
Cytology from L axillary LN biopsy without monoclonal cell line
that would be concerning for lymphoma, and had polytypic cells
c/w reactive process. Cytogenetics karyotypically normal.
Pathology found no granulomas or necrosis that would be c/f TB
and no e/o high grade lymphoma. Lymphoproliferative studies
pending on discharge. LN biopsy AFB culture pending on
discharge.
# KNEE PAIN:
Pt reports recent fight/fall ___ days PTA. On admission, AROM
only to about 15 degrees, full PROM, but unable to weight bear
on left leg on admission. Small area of suprapatellar effusion
vs. edema, c/f septic arthritis i/s/o possible bacteremia from
PNA. Knee x-ray showed moderate knee joint effusion with no
fracture. CT scan confirmed suprapatellar joint effusion but no
fracture. MRI contraindicated due to retained bullet fragments
in chest. Performed L knee arthrocentesis on ___. Joint fluid
showed ___ WBCs, 875 RBCs, 91% PMNs, no crystals, no organisms
on Gram stain. Fluid culture NG (final). Most likely trauma vs.
reactive arthritis and not septic arthritis, given that would
expect WBC count to be higher and organisms to be seen on Gram
stain and/or culture (although was treated with 3 days of
antibiotics prior to arthrocentesis, so septic arthritis could
have been partially treated and no longer show organisms). Abx:
vanc/cefepime (___), PO levofloxacin (___), IV
ceftriaxone (___). Per ID, no need to continue treating
for septic arthritis. ___ consult saw him and found that he was
partial weight bearing with crutches and has no further acute ___
needs. Pt now with full AROM and able to walk short distances
without crutches. Pt should continue taking acetaminophen PRN
for pain.
# Anemia
H&H low (9.2/26.2) on admission and slowly downtrending during
admission. H&H 7.9/24.2 on discharge. Pt denies melena or BRBPR.
Ibuprofen d/c'ed on ___ in case it was contributing. Iron
studies c/w ACD. Stool guaiac negative x3. Therefore, PPI was
not initiated.
# PERICARDITIS: Pleuritic CP, cardiomegaly on CXR, STEs on ECG,
and CTA chest showing pericardial effusion. Possible viral
infection superimposed on bacterial PNA. TSH WNL (0.64). HIV
positive. Pulsus ~6 (WNL), so no exam e/o tamponade. TTE ___
showed pericarditis and small to moderate pericardial effusion
without e/o tamponade. In-house treated with ibuprofen 400mg q8h
and colchicine 0.6mg BID. Received 2.5 weeks of colchicine,
which was d/c'ed prior to discharge due to potentially severe
drug-drug interaction with HIV medications.
# SEPSIS: ___ SIRS criteria on admission (tachycardic to 110s,
WBC 17, RR >20) with normal lactate (1.8 -> 1.4). Improved s/p
fluid resuscitation with 4L NS and antibiotics. Most likely
source is PNA. Blood cx negative. Sputum culture heavily
contaminated with upper respiratory secretions. Urine legionella
and Strep pneumo negative. Initially treated with
___ for HCAP (treated for pneumonia at ___
___ several months ago) and flagyl for possible aspiration
pneumonia given heavy alcohol use. Antibiotics were narrowed to
levofloxacin 750mg PO daily on ___, which was d/c'ed on ___
given c/f TB i/s/o newly diagnosed HIV. Pt was started on IV
ceftriaxone and PO azithro on ___. Antibiotic course was
completed on ___. Pt developed diarrhea while in-house, Cdiff
negative.
# PNEUMONIA: Patient with leukocytosis, hypoxemia, sputum
production, and CXR with RLL opacity. ABG on admission c/w
respiratory ___. Reported having been
treated at OSH several months ago for PNA, no records available,
so empirically treated for HCAP +/- aspiration with
vanc/cefepime/flagyl (___), which was narrowed to PO
levofloxacin on ___. Lefloxacin was d/c'ed on ___ given c/f TB
i/s/o newly diagnosed HIV, and pt was started on IV ceftriaxone
and PO azithro on ___. Antibiotic course was completed on ___.
Urine legionella and Strep pneumo negative. Sputum culture was
heavily contaminated with upper respiratory secretions. Pt also
with bilateral wheezing, significant smoking history, and
emphysema on CTA chest. Gave PRN albuterol and ipratropium nebs
for reactive airway disease/COPD and PRN guaifenesin for cough.
Was no longer requiring breathing treatments or cough
suppressants on discharge.
# TACHYCARDIA: Resolved on HD2. Possible etiologies include
sepsis from PNA, alcohol withdrawal, and pericarditis. PE ruled
out by CTA ___, which did show e/o pericarditis and
pericardial effusion. Fluid resuscitated with 2L IVF in ED and
2L NS on floor and given broad-spectrum antibiotics. Was on ___
protocol x4 days with PRN diazepam, which he never required.
Treated with ibuprofen 400mg q8h and colchicine 0.6mg BID for
pericarditis while in-house.
# ECG CHANGES: Most likely due to pericarditis given pleuritic
CP, cardiomegaly on CXR, sepsis, STEs on ECG, CTA chest showing
pericardial effusion, and TTE showing pericarditis and small to
moderate pericardial effusion without e/o tamponade. No prior
ECGs in our system. ACS ruled out with trop x2 negative. TTE
revealed normal EF (61%), no regional wall motion abnormalities,
mild symmetric LVH, and no pathologic valvular flow.
# ALCOHOL ABUSE: Pt reports drinking >1 pint hard liquor/day,
last drink ___ days PTA. Pt tachycardic on admission but CIWA
never >8, and pt never required diazepam. CIWA protocol was
d/c'ed on ___.
# RENAL FAILURE: Cr downtrended 1.5 -> 1.0 after 2L NS, so most
likely ___ from prerenal etiology. | 295 | 1,169 |
19935888-DS-15 | 21,178,042 | ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ 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.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.
Physical Therapy:
activity as tolerated; lumbar corset brace when OOB.
Treatments Frequency:
ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ 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.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___ Spine
Specialists, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery. | ___ year-old man with history of trauma to his back years ago,
s/p extensive thoracic, lumbar and S1 surgery including
laminectomy and fusion and revision, presented to ED as a
transfer from ___ with worsening of back pain and 2
episodes of fecal incontinence c/f spinal root impingement. CT
lumbar spine without contrast revealed disc bulge, disc
protrusion, bilateral facet arthropathy, igamentum flavum
thickening at the L2-L3 level (level above previous fusion),
causing severe spinal canal narrowing.
The patient was then admitted to the ___ Spine Surgery Service
and taken to the Operating Room on for a posterior spinal fusion
L2-L4. Refer to the dictated operative note for further details.
The surgery was performed without complication, the patient
tolerated the procedure well, and was transferred to the PACU in
a stable condition. TEDs/pneumoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initially,
postop pain was controlled with a dilaudid PCA and epidural.
The epidural was removed POD1. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2 and the patient
was voiding well. Post-operative labs were grossly stable. A
hemovac drain that was placed at the time of surgery was also
removed on POD#2. Physical therapy was consulted for
mobilization OOB to ambulate. A lumbar corset brace was fitted
for the patient. 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. | 557 | 268 |
12521000-DS-20 | 20,771,461 | Mr. ___,
You were admitted after you had a fall at home.
Your scalp laceration was repaired during your stay.
Additionally, you were diagnosed with multiple spinal fractures.
Orthopedic surgery assessed these fractures and thought that
they did not require surgery.
You are to wear your ___ J collar constantly for a total of 6
weeks, except you may remove it for eating and bathing. You do
not require a brace for the fractures in your lower back at this
time, and you can move as tolerated with assistance. If you have
lower back pain that is interfering with your ability to move,
then you may wear a TLSO brace as needed.
Please call your doctor 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 mobilize with appropriate
assistance, 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.
Warm regards,
Your ___ Surgery and Medicine Teams | ___ h/o metastatic prostate CA and multiple falls admitted for
fall and 21hr downtime, found on imaging to have multiple spinal
acute vs pathologic fx including C7,L1,L2,T7 and evidence of
bony infiltrates, as well as scalp laceration and
rhabdomyolysis. | 331 | 40 |
17107885-DS-17 | 23,980,163 | Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. You were admitted following a fall at
home. You have had chronic problems with dizziness and balance,
and this is likely an interplay of both your liver disease and
the sedating medications that you are taking. While in the
hospital, we saw that you did not have an intracranial bleed. We
also gave you lactulose to help reduce the contribution of the
liver disease. Please follow up with your PCP, the ___,
and your neurologist after discharge. | PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ male with PMH of cirrhosis from
HCV/hemachromatosis, chronic dizziness/lightheadedness, HIV
(reported undetectable viral load and CD4~400) who presents from
home with fall and head strike without LOC. CT head was negative
for bleed and he was steady on his feet during hospital stay. He
was discharged to PCP followup with plan to wean sedating
medications. | 91 | 63 |
16662186-DS-7 | 28,077,207 | Mr. ___,
You are now being discharged from ___ after being admitted due
to nausea/vomiting, dehydration, hypotension and acute kidney
injury following exchange of your biliary drainage catheter. The
plan is for you to have a biliary stent placed next week by
Interventional Radiology, and they will call you to notify you
of when this will be. In the interim, please call your doctor
or nurse practitioner if you experience 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 is 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.
.
PTBD Drain Care:
*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).
*Wash the area gently with warm, soapy water and place a drain
sponge. Change daily and as needed.
*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. | Mr. ___ is a ___ year old man who presented to the ED with
symptoms of dizziness, lightheadedness, and emesis on ___
just prior to his scheduled exploratory laparoscopy and
portacath placement for his recently diagnosed pancreatic mass.
On the day prior he had undergone a cholangiogram and upsizing
of his PTBD from an ___ to a ___ catheter, and while he did
complain of one episode of dizziness and emesis the evening
prior to his ___ procedure and an episode of dizziness in the car
on his way to the procedure, he was doing well after his drain
upsizing and both he and his family felt comfortable going home,
so he was sent home with instructions to call Dr. ___
return to the ED if he had a return of his symptoms. In the ED
he was afebrile but hypotensive to 89/61 with dizziness, and his
labs were remarkable for a leukocytosis (WBC 15.6) with acute
renal failure (creatinine 2.1 and K 6.2) and hyperbilirubinemia
(total bilirubin 8.2). The decision was
made to cancel his surgery and admit him for IV antibiotics and
IV fluid rescusitation. He was immediately given one amp of D50
and 8 units of IV insulin, and an EKG was performed that did not
show any T wave changes. He was placed on Unasyn. On HD 2 he
remained afebrile, his blood pressure was normalized and he had
not experiened any additional dizziness or emesis, and his labs
were improved with a WBC 8.7, creatinine 1.3, K 4.4, and total
bilirubin 6.6. He underwent an EUS with biopsy and placement of
fiducials, with the EUS showing a 3.48 cm X 2.51 cm hypoechoic,
heterogenous ill-defined mass in the head of the pancreas with
findings suspicious for invasion of the portal vein. Following
this procedure, he was given a regular diet and his IV fluids
were discontinued. He tolerated his diet well, and on HD 3 his
labs continued to show improvement with WBC 7.4, creatinine 1.1,
K 4.5, and total bilirubin 5.7. He was feeling well without any
symptoms of lightheadedness or dizziness and had no nausea or
emesis. His biliary drainage catheter was working well with
bilious fluid in the gravity bag, and he was making adequate
urine. At this point, Mr. ___ was deemed stable for discharge
home with services and a 7 day course of PO augmentin. He was
still in need of a biliary stent for his common bile duct
stenosis, and Interventional Radiology was contacted and made
plans to call the patient the following week with an appointment
time to come in for his biliary stenting procedure. Mr ___ was
given instructions to await a call from Interventional Radiology
regarding his stenting procedure, but that if he did not hear
from them by ___ to call Dr. ___. He
was instructed to also call Dr. ___ office to make an
appointment for ___ weeks from the day of discharge, and to call
his medical oncologist this coming week to schedule an
appointment as well. He was also instructed to call Dr. ___
___ return to the ED if he experienced recurrence of his
presenting symptoms or any fevers, chills, or other concerning
symptoms. | 287 | 535 |
16718650-DS-20 | 27,561,687 | Dear Mr. ___,
You were admitted to ___ on ___ after a fall. You had a
large bleed in your pelvis for which you went to interventional
radiology and had gel foam placed to stop the bleeding. You had
multiple blood transfusions and now your blood levels are
stable. You had a small bleed in your head. The neurosurgery
team was consulted and the bleed is stable and does not require
surgery. You have left rib fractures which will continue to heal
over time. You have a pelvic, sacral, and lumbar (spine)
fracture. You were taken to the operating room by the orthopedic
surgery team and had a screw placed in your hip. The orthopedic
team recommend non-weight bearing on the left leg and weight
bearing as tolerated on the right leg. For your lumbar
fractures, the orthopedic spine team recommended that you wear a
back and neck brace when you are out of bed for support.
During this hospitalization your breathing was assisted by a
ventilator. In order to help you breath on your own and better
clear your secretions, a tracheostomy tube was placed. You had
chest tubes placed to help drain extra fluid from your lungs
which are now removed. You are now able to cough and breath
effectively on your own.
You have a fast, irregular heart rate called atrial fibrillation
that is difficult to control. You were evaluated the the
cardiology team and a pace maker was placed to help regulate
your heart rate.
You had a foley catheter placed to measure your urine output.
After removal of this catheter you were initially unable to
urinate on your own. You are not urinating on your own without
difficulty. We recommend you follow up with a urologist if this
problem persists.
You are now breathing more comfortably, your pain is better
controlled, and you are ready to be discharge to a
rehabilitation center to continue your recovery.
Please note the following discharge 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. | Patient is an ___ who was admitted s/p fall approximately 20
stairs with likely LOC with polytrauma and hemodynamic
instability. Trauma evaluation and imaging revealed left
parietal subdural hematoma, C2 transverse fracture, T5 vert body
fx with hematoma, right sacral fracture, left ___ rib
fractures, bilateral sup pubic rami fracture, right inferior
rami fracture, left anterior acetabula fracture, left iliac wing
fracture with hematoma, sternal fracture and substernal
hematoma. FAST was negative. During the primary trauma
evaluation, the patient's mental status deteriorated and he
became hypotensive, and required packed red blood cell and
platelet transfusions. He was taken to Interventional Radiology
where several branches of left posterior iliac vein and L5
lumbar artery were embolized. He was transfused a total of 5
units packed red blood cells and 3 units fresh frozen plasma.
Please see radiology report for details. Given the complexity of
his injuries and his hemodynamic instability he was admitted to
the trauma/surgical intensive care unit. | 620 | 158 |
18026603-DS-9 | 20,170,078 | Dear ___,
You were admitted to the hospital because of bleeding from your
GI tract while going to the bathroom. While in the hospital, you
underwent a colonoscopy which showed dilated veins in your
rectum and hemorrhoids, but no active bleeding. You had no
further bleeding while in the hospital, and your blood counts
were stable.
You were seen by physical therapy in the hospital. They
recommended physical therapy visit your home after discharge.
After discharge, because of your live disease, please weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Sincerely,
Your ___ Team | ___ F w/ h/o NASH cirrhosis (c/b rectal varices, portal
gastropathy, no h/o HE, SBP, esophageal varices) and
thrombocytopenia presenting with BRBPR. Last EGD (___):
portal hypertensive gastropathy. Last colonoscopy (___):
rectal varices.
# Acute blood loss anemia: Patient p/w BRBPR x3 with subsequent
BMs showing minimal blood. Colonoscopy was preformed during
hospitalization with no clear source identified. Upper GI
studies not preformed given low likelihood as an etiology for
BRBPR.
Upon presentation, stool guaiac neg in ED. Rectal exam in ED
showed non-bleeding external hemorrhoids. Hgb initially stable
at 10.0 but later dropped to 8.5, pt hemodynamically stable. Pt
was given Ciprofloxacin for SBP prophylaxis (Penicillin allergy)
i/s/o NASH cirrhosis with c/f GIB. Infectious work up was
negative. Pt was also given put on octreotide for known rectal
varices on last colonoscopy (___). Colonoscopy (___)
showed a polyp in the colon (not bx'ed given c/f bleed), grade 1
internal hemorrhoid, rectal varices, but no sign of active or
recent bleeding. She had no further BRBPR and her Hbg remained
stable throughout the rest of her hospitalization.
# Prolonged anesthetic effect: Pt was obtunded, unresponsive to
noxious stimuli ___ ___ upon arrival to floor after her
colonoscopy. Colonoscopy was uncomplicated but she had been
given midazolam 4mg, ketamine 40mg, propofol for GA maintenance
during colonoscopy. NCHCT was neg for intracranial bleed. During
NGT placement to try to give lactulose pt became aroused. NGT
placement discontinued ___ pt rapidly becoming A&Ox3. Given
lactulose Q2H PR until BMx1, given PO for bowel reg per
patient's request. Patient remained at baseline mental status
for the remainder of her hospitalization.
# NASH cirrhosis: She has a history of ascites and is on
diuretics. H/o rectal varices, portal gastropathy No history of
HE, SBP, or esophageal varices. Pt's home Lasix and
spironolactone were stopped on admission given c/f GIB. She was
restarted on Lasix and spironolactone prior to discharge.
# Thrombocytopenia: Chronic, likely due to splenic
sequestration. Platelet count was at baseline throughout
hospitalization and on day of discharge.
# Diabetes: On U-500 sliding scale with breakfast and dinner at
home. In hospital, patient was placed on HISS. On home U-500
sliding scale when eating on day of discharge (___).
# Hypertension: Home lisinopril held in the setting of GI
bleed, and restarted ___ given no e/o active bleed on
colonoscopy and stability.
# Asthma: Continued home albuterol prn. In hospital, placed on
Symbicort vs. home Advair as not on formulary.
# Hyperlipidemia: Pt was continued on home simvastatin.
# Depression/anxiety: Pt was continued on home fluoxetine and
prn lorazepam. | 96 | 424 |
15672432-DS-50 | 24,271,872 | Dear ___,
You were admitted to ___ for a fast heart rate. Your fast
heart rate was caused by dehydration. You were dehydrated
because of diabetes, which is a new diagnosis for you.
We rehydrated you and got your blood sugars under good control.
Your fatigue, body aches and joint pains, as well as changes in
your voice, are likely from a viral cold-type syndrome.
Your liver enzymes were found to be elevated while in the
hospital. We belive this is secondary to _________.
Please follow up with your doctors ___ appointments below).
It was a pleasure taking care of you! We wish you the very best.
-- Your inpatient team at ___ | ___ is a ___ year old man with HIV (on salvage regimen, as
below; VL UD/CD4+ 400s in ___, CAD (with DES to OM1) and
sCHF (EF 40%) who presented with tachycardia, polydipsia,
polyuria and weight gain, found to have diabetes mellitus and
non-specific complaints consistent with viral-type illness.
ACTIVE ISSUES
# VIRAL ILLNESS, NOS: ___ reports malaise, diffuse &
non-specific myalgias and arthralgias, with nasal congestion and
changes in his voice caliber and quality. He has remained
afebrile, without leukocytosis. The patient did present with
transaminitis, which could be consistent with CMV infection (or
EBV infection, though likely already IgG positive). CXR not
concerning. Conservative management for his viral-type symptoms.
CMV serology showed undetecetable viral load. EBV serology
showed positive IgG.
# TRANSAMINITIS: Found to be elevated on admission. The patient
is without any stigmata of cirrhosis. As above, may be related
to viral syndrome. HAV and HBV immune. LFTs trended up during
admission. HAV and HBV documented immune. HCV Ab negative this
admission. CMV and EBV serology as above. The patient has a
history of hepatosteatosis, and does not report recent EtOH or
APAP use/abuse. RUQ ultrasound demonstrated coarse, hyperechoic
hepatic parenchyma compatible with known diagnosis of steatosis.
Coarsened and heterogeneous appearance may be suggestive of
cirrhosis though not diagnostic and splenomegaly. No clear cause
of transaminitis was identified, however at the time of
discharge, had been trending down (see above in # PERTINENT
RESULTS).
# HIV: ___ stopped his ARV regimen ___ weeks ago secondary to
issues with prescription refills. His last VL was UD and CD4+
was 430 in ___. He has no history of OIs. While in house, HIV
VL checked and found to be 75 copies/mL. Virtual phenotype and
integrase inhibitor resistance panel sent while in house:
results pending on discharge. ARV regimen restarted.
# DIABETES MELLITUS: FSG under good control with SSI - FSG in
range of 130s-180s. ___ consulted yesterday: good control
with current SSI. SW saw patient for coping while in house. On
discharge, the patient was sent on a regimen of 2.5 mg glipizide
XR with planned follow up with ___
diabetic education.
CHRONIC, INACTIVE ISSUES.
# PSYCHIATRIC COMORBIDITIES: Currently euthymic, though having a
difficult time with his new diagnosis of diabetes, given his
poor support network. SW consult requested by the patient while
in house. Continued quetiapine, lorazepam.
# HTN: only on metoprolol as outpatient, normotensive on
admission. This AM, BP 152/92, but had not received metoprolol
yet. Continued home metoprolol.
# CAD + compensated sCHF: ___ has a history of CAD s/p stenting
w/ sCHF secondary to mild global hypokinesis (LVEF ~40%) on last
TTE from ___. He was hypovolemic on admission likely secondary
to volume loss from uncontrolled hyperglycemia. Tachycardia
resolved with fluids and restarting of beta-blockade. Patient
does report occasional orthopnea, however appears dry on exam.
Not decompensated. Continued home metoprolol.
# BPH: On tamsulosin at home, however, fosamprenavir decreases
clearance of tamsulosin and can lead to hypotension. The patient
has been taking these medications together without adverse
effect. Educated the patient on the risks of these medications
combined. As patient hasn't had symptoms of hypotension with
these medications combined, continue currently & monitor for
signs of interaction.
*** TRANSITIONAL ISSUES ****
- Optimization of CHF medication regimen
- Follow up LFTs | 109 | 542 |
17496275-DS-7 | 29,932,211 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were found to
have very low oxygen levels at your facility.
WHAT WAS DONE WHILE I WAS HERE?
- You were given antibiotics to treat a pneumonia.
- You were seen by our speech and swallow team to evaluate how
well you swallow foods and liquids; at first we didn't allow you
to eat, but then you tried eating pureed foods and thick liquids
and did well with those.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Go to all your appointments and take all your medicines.
- All your food should be pureed and all your drinks should be
thickened to "nectar thick" consistency.
Best wishes,
Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[ ] He was hypernatremic intermittently during the
hospitalization, likely due to poor PO fluid intake. Fluids
should be encouraged when he is discharged (always nectar
thick).
[ ] He should have a diet of pureed solids and nectar thick
liquids. He is at high risk for aspiration, so should be
monitored with all feeding.
[ ] He has follow up with his primary care doctor on ___ as listed above.
#CODE:DNR/DNI
#CONTACT:
Sister in law (___)
Next of Kin: ___,___ SERVICES
Relationship: OTHER
Phone: ___
Next of Kin: ___
Phone: ___ | 135 | 92 |
13915085-DS-15 | 21,621,660 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted with concern
for a heart attack but were actually found to have a severe
infection. We are still not entirely sure what caused your
infection, but you improved on antibiotics.
During your hospitalization, you had elevated liver enzymes
which may be related to a medication reaction. You also had a
decrease in your kidney function, which is probably related to
being dehydrated from your infection. Your kidney function
returned to the normal range and your liver enzymes were
significantly improved at the time of discharge.
We made the following changes to your medications:
- STOP atenolol
- STOP cardizem (diltiazem)
- START metoprolol succinate (for atrial fibrillation and blood
pressure)
- START amlodipine (for blood pressure) | Ms. ___ is a ___ ___ speaking woman
with a history of DM II, CVA, cognitive impairment, atrial
fibrillation, and recent NSTEMI who initially presented to an
OSH (___) s/p fall and was found to have elevated troponin,
non-elevated CK-MB, and fever/leukocytosis. She was transferred
to ___ for management of NSTEMI. Her initial exam was
concerning for meningitis, but LP was negative.
ACTIVE ISSUES
1. Fever/Leukocytosis: Patient's WBC was markedly elevated to 24
upon transfer, from a baseline of 7 on ___. Given nuchal
rigidity, photophobia, and AMS on initial exam, patient's
symptoms were initially concerning for meningitis and she was
covered empirically with vancomycin, cepefime, Bactrim (for
Listeria, given PCN allergy), and acyclovir. Her heparin gtt was
held for 6 hours and she underwent ___ LP, showing just 1
WBC. Bactrim was therefore discontinued. Acyclovir was
discontinued after 48 hours. Patient was continued on vancomycin
and cefepime with improvement in her leukocytosis and in her
fever curve. Blood cultures from ___ grew coag
negative staph in 1 bottle, which was thought to be a
contaminent. The etiology of her infection remained unclear;
differential included pneumonia (though lung exam remained
unremarkable), C. dif (though no diarrhea developed), and pyelo
(given LL pole lesion on renal u/s, though UA's were
unconvincing). Patient underwent abdominal ultrasound, which
showed mild dilation of pancreatic duct but no clear infectious
source. She was followed by the ID service. Sputum cultures were
unrevealing. Antibiotics were stopped on ___ and patient
remained afebrile and without leukocytosis.
2. LFT Abnormalities: Patient had elevated LDH and
transaminases. Transaminases initially improved, then trended up
again to 100's. This may have been due to a drug reaction, given
exposure to multiple antibiotics including Bactrim early in
hospitalization. CK was initially high but trended down.
Lymphoproliferative disorder was also considered, especially
given axillary LAD seen on CT scan, but patient had no clear
evidence of malignancy.
2. AMS: Patient was altered upon presentation, A+O x 1 from a
baseline of A+O x 2. Although there was initially concern for
meningitis as above, her LP was negative. Her AMS was likely due
to delerium in the setting of infection, as mental status
rapidly improved to baseline with antibiotics. Seizure was
considered given patient's history of seizure, but it was felt
to be less likely given patient has been adherent to Keppra.
3. Troponin Elevation: Patient presented with troponin elevation
and EKG changes initially concerning for NSTEMI. However, normal
MB and rise in LDH suggested possibility of non-cardiac source,
and these changes were most likely due to demand in the setting
of severe infection. She was started on Plavix and a heparin
gtt, which were both stopped as ACS became less likely. Giving
climbing CK, atorvastatin 80 mg daily (started at outside
hospital) was discontinued. CK downtrended. In order to simplify
nodal blockade and because of renal failure, patient was
transitioned from atenolol and diltiazem to metoprolol. She was
continued on ___ 325 mg daily (high dose for a. fib).
4. Acute Kidney Injury: Patient's admission Cr was 2.2 from a
baseline of 0.9. This was likely due to prerenal physiology in
the setting of infection, which was supported by FeNa of 0.5%.
Repeat uring 'lytes on ___ show no EOS, and FeNa had increased
to 1.43%, suggesting an intrinsic renal process such as ATN.
Patient received IV fluids and creatinine improved.
5. Atrial Fibrillation: Patient has a CHADS2 score of 6. She is
on ___ 325mg daily but not systemically anticoagulated (per
___ notes, this is due to history of ICA aneurysm and high
fall risk). Her predominant rhythm was a. fib, though she was
intermittently in sinus. Her nodal blocade was changed from
atenolol to metoprolol in the setting of renal failure and
diltiazem was discontinued. As an outpatient, may consider
risk/benefit of systemic anticoagulation.
6. Chronic Diastolic CHF: EF 57%. Patient was hypovolemic in the
setting of infection. She received IVF. Home lasix was held due
to ___.
7. Failed Speech & Swallow: Patient had a speech and swallow
evaluation and was advised to be a strict NPO. This was
discussed extensively with patient and family, who reported her
swallowing deficits are from a prior stroke and unchanged from
recent baseline. The risk of aspiratory pneumonia was discussed
extensively with patient and family, who preferred for patient
to continue to eat for comfort.
8. HTN: In final days of hospitalization, patient was
increasingly hypertensive. Amlodipine was added to her regimen
with good effect.
CHRONIC ISSUES
1. DM II: Last A1C was 6.5% in ___. Patient's metformin was
held and she received ISS.
2. HLD: Last LDL 140 in ___. Patient was initially started on
high-dose atorvastatin for NSTEMI, which was then stopped given
no evidence of cardiac event, elevated CK and transaminases.
3. Epilepsy: Patient has a history of seizure and takes
levetiracetam. Her dose was reduced from 1000 mg BID to ___ mg
BID because of ___. She resumed her home dose on day of
discharge.
TRANSITIONAL ISSUES
- Trend Cr for stability and LFT's for resolution of elevation
- Needs dental follow-up as outpt to complete infectious work-up
- Recheck cholesterol panel as outpatient and consider need for
statin if CK and transaminase return to normal levels
- Consider risk/benefit of systemic anticoagulation with
Coumadin
- MRI vs targed ultrasound to evaluate hypodense lesion seen on
CT and ultrasound
- Repeat CT scan of chest in 6 months to monitor non-specific
axillary lymphadenopathy
- consider repeat RUQ US vs ERCP to re-assess and further
work-up mildly dilated pancreatic duct seen on RUQ US
- Pending studies at discharge
### CSF viral culture (___): pending
### Sputum fungal culture (___): pending | 132 | 937 |
12683111-DS-10 | 20,125,297 | Dear Mr. ___,
You were seen at the ___
for abdominal pain. You were found to have inflammation of your
small bowel on cat scan and also had a scope to look into you
small intestine, which also found inflammation and swelling,
which is likely the cause of your abdominal pain. On admission
your sugars were in the 600's and were quickly brought back down
to more normal levels. During your stay, you were unable to
urinate without the foley catheter, so we had to replace the
foley catheter and reschedule a follow up urology appointment
for further workup of your urinary retention. Finally, you were
anemic, and required one unit of blood to raise your reb blood
cells. Otherwise you were managed with pain medications and
continued on your ___ hemodialysis
schedule.
Please make sure to continue taking your medications as
prescribed and follow up with your outpatient providers. You
need to see your primary care provider, urologist, and the
diabetes specialists. All of the scheduled appointments are
listed below. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs.
Thank you for letting us take care of you. | Assessment and Plan: ___ year old male hx type 1 DM , ESRD on
HD, HTN, HPL, admitted with hyperglycemia and jejunitis
# Abdominal Pain: he had one week of progressive abdominal pain
and vomitting and new onset diarreha in ED, with evidence of
jejunitis on CT of admission. Differential included viral vs
bacterial eneteritis. Gastroenterologists consulted and ___
cultures were sent. His abdominal pain improved during his stay,
but intermittently painful requiring opiates. He remained
afebrile with a normal WBC count. Given continued pain,
enteroscopy was done which showed inflammation, and biopsies
were sent, still pending. Given his duodenal ulcer history in
___, he was kept on a PPI and sucralfate. H pylori antibodies
were negative. Stool cultures before discharge were positive
for c. difficile and he was started on metronidazole. We
ultimately felt that his abdominal pain was likely due to
jejunitis. There was also concern that it may be from his PD
catheter, but it improved over the course of his hospital stay.
# Acidosis: admitted with mild acidosis concerning for diabetic
ketoacidosis, but he didn't have an anion gap or urine ketone.
His end-stage renal disease likely contributed to acidosis as
well as his diarrhea and emesis. Sugar levels were quickly
normalized with insulin drip.
# Type 1 DM ( A1c 8% in ___: he reported several
critically high levels of blood sugars on the day of admission,
with non-anion gap acidosis as above. It was likely precipitated
by his enertitis(see below). Hemodialysis and Peritoneal
dialysis lines looked good. Lab values did not suggest
hepatobiliary source, and chest x-ray was clear. Compliance had
been an issue in the past, but he reported increased compliance
with medications with his visiting nurse. Original hyperglycemia
fixed with insulin drip and then the diabetes specialists
followed him for appropriate control. He remained
intermittently hyperglycemic, and required multiple adjustments
to his insulin sliding scale.
# HTN- The patient has a history of malignant hypertension,
followed by Dr. ___, but remained at his
baseline of 140-150's systolic. He was continued on his home
medications, except briefly lisinopril during the time that he
was hyperkalemic, but restarted after its resolution.
# Urinary Retention: His foley catheter was removed for 2 days,
but despite being on tamsulosin, he required straight caths and
a foley had to be replaced for outpatient urological follow up.
# Hyperkalemia- The patient was hyperkalemic on admission to 6.6
and agian to 7.2 on HD. EKG showed peaked T waves. He was
treated with 30mg Kayexlate an lisnopril was held as above
# ESRD- HD on ___ was continued.
# HPL- LDL 75 ___. Was not on medication.
# Anemia of chronic disease- there was no evidence of acute
bleeding. received EPO and Fe with HD, but hematocrit dropped to
___ range, where he has been before, and he required one unit
of blood. | 202 | 482 |
15493947-DS-9 | 28,945,409 | Please restart your rivaroxaban on ___. Otherwise, make sure
to follow up in the ___ clinic on ___. | 1. Bile Duct Obstruction due to Probable Malignant Neoplasm -
Pancreas. Seen on outside imaging. CA ___ elevated. On ___,
patient had a CTA pancreas which redemonstrated the pancreatic
mass with involvement of nearby vessels and enlarged lymph
nodes. On ___ the patient had an ERCP with stent placement, as
well as brushing of the bile duct. The patient's diet was
advanced on ___, and by time of discharge he was eating a
regular diet. His bilirubin had downtrended from 18 to 16 on day
of discharge. His rivaroxaban was held after the procedure, and
will be restarted on ___. He has follow up scheduled on
___, when he will be seen in ___ clinic. He
will finish a five day course of ciprofloxacin on ___
- ___ cytology results
- patient will be seen in pancreatic ___ clinic of
___
- ciprofloxacin 500 mg BID, last day ___
2. CAD. Patient was continued on his home medications, with the
exception of fenofibrate which was discontinued
- Aspirin, Simvastatin, Lisinopril
- Patient is status post pacemaker
- STOP Fenofibrate
3. Chronic Systolic CHF. Euvolemic throughout hospitalization.
- Lasix, Toprol XL continued (125 QAM, 50 QPM)
- Keep euvolemic
- LVEF of 35-40% with moderate global hypokinesis
4. Atrial Fibrillation. In the setting of his ERCP, rivaroxaban
was held. It will be restarted on ___. Amiodarone was
initially held but then resetarted on day of discharge.
- Holding rivaroxaban until ___.
5 Type 2 Diabetes with nephropathy, CKD Stage 3. Patient was on
his home insulin and ISS throughout the day. | 18 | 246 |
17261845-DS-8 | 27,467,707 | Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
us after a fall. You were found to have a fracture in your
spine. Fortunately, there is no surgery that will be needed for
this.
You were also noted to have joint pains and fevers. For this,
you were seen by the Rheumatologists. You will need a biopsy of
your wrist to help the Rheumatologists determine how to best
treat you. Our hand surgeons will be communicating with your
rehab, and the Rheumatologists, to help schedule this.
Your rash was found to be due to Psoriasis, and will improve
slowly, over time, with treatment. You are scheduled to see the
skin doctors in ___.
We wish you all the best,
___ Medicine Team | Mr. ___ is a ___ y/o M with a h/o EtOH abuse, who presented s/p
a fall and intoxicated, found to have T5 fracture, as well as
fever, inflammatory arthritis, anemia, and hyperkeratotic rash.
# T5 Fracture - Traumatic from falls while intoxicated. He was
seen by Neurosurgery, who recommended no intervention. There is
no need for any brace. He has no activity restrictions.
# Palmoplantar Keratoderma (PPK) due to Psoriasis
Presented with many hyperkeratotic lesions, and per Derm
consultants this was consistent with "PPK". Skin biopsy was done
and was consistent with Psoriasis. He was started on Clobetasol
and Urea creams. He will follow-up with Derm in ___. This
diagnosis its with his history of inflammatory arthritis, except
for that you would not expect his hand x-rays to show
___ osteopenia with psoriatic arthritis.
Extensive workup was done to ensure no other etiology of his
PPK, and was negative: HIV/syphilis (negative), crusted scabies
(not seen on biopsy), Reiter's syndrome (Gonorrhea/Chlamydia
negative), arsenic poisoning (pending but unlikely), and HPV
(not seen on biopsy). It can be drug induced but he has no
offending meds on his list (digoxin, venlafaxine, verapamil,
hydroxyurea, quinacrine, practolol, and chemotherapeutics).
Paraneoplastic PPK also a possibility, but no evidence of cancer
on CT scans, and PSA not elevated.
# Arthritis: Presented with multiple painful, swollen joints. L
wrist, bilateral elbows are the main joints involved. Rheum was
consulted. L Hand XR showed pronounced periarticular
osteopenia, no chondrocalcinosis. R Wrist XR for comparison did
not show any periarticular osteopenia. Rheumatoid factor, ESR,
and CRP were all markedly elevated. Anti-CCP and ___ were
negative, SPEP and Cryo's negative, uric acid low. The lack of
a symmetrical small-joint arthritis pointed against RA, despite
the +RF. Joint fluid aspiration was attempted, little could be
obtained, but what was obtained showed no organisms or cells on
gram stain. Given the skin biopsy results showing psoriasis,
this was felt to be most consistent with Psoriatic Arthritis.
However, he will need outpatient synovial biopsy of left wrist
to confirm the diagnosis. From there, we will follow up with
Rheum to discuss treatment options.
# EtOH abuse: Prior to admission had been drinking
significantly. He was in withdrawal on arrival to floor. He was
treated with PRN Diazepam via the CIWA protocol. This was
discontinued several days into the hospital stay once he was no
longer scoring. Significant drinking history and took very
little PO nutrition prior to admission. Thus he was starting on
vitamin supplementation, and Nutrition was consulted.
# Anemia
Retic B12 and Folate WNL. Ferritin WNL but may be falsely high
in setting of acute inflammation. LDH/Bili suggest against
hemolysis. Likely related to nutritional reasons in addition to
anemia of chronic disease. Started on PO Iron. Hgb/Hct were
completely stable during stay, and he never needed a blood
transfusion.
# Thrombocytosis: PLT count rose every day this admission, from
100's on admit to 501 on discharge. Consider unmasking of EtOH
marrow suppression, vs secondary to underlying autoimmune
inflammatory state.
# Pulm nodules: He told the team of a history of multiple (9)
pulmonary nodules, up to 5mm, which were monitored by a
pulmonologist with serial CT scans, and most recent scans showed
increase in size. He was then lost to follow up. CT chest here
confirmed these nodules.
- Will need outpatient follow up of these
# Fall: Most likely this happened in setting of
EtOH/intoxication and general failure to thrive. Also, he has
significant skin lesions on his feet which would make walking
very difficult. Thus, he has multiple reasons for a mechanical
fall, and a cardiac cause of fall seems unlikely. Telemetry was
unremarkable other than sinus tachycardia and was discontinued
after several days. ___ preliminary report showed no depression
of EF or valve disease.
# Fever: He had a fever three times during this hospital stay.
No clear source of infection. His impressive skin lesions did
not appear to be infected or cellulitic, and biopsy confirmed
this. Inflammatory markers ESR and CRP both elevated but likely
due to autoimmune. UA/Urine culture negative, CXR without PNA,
blood cultures no growth, HIV/RPR/GC/Chlamydia negative, CT
C/A/P without infectious source, TTE without vegetation. Most
likely a noninfectious fever, due to autoimmune disease,
possibly worsened initially by withdrawal from EtOH.
# Tobacco abuse - nicotine patch
# Hep B non-immune: Based on labs done as part of arthritis
workup. Hep B non-immune, got dose ___ of vaccine ___.
- dose ___ or later
- dose ___ or later
# Pain control: Diffuse pain, likely multifactorial in setting
of withdrawal, joint swelling, skin lesions.
- Tylenol Q8 PRN
- Ibuprofen Q8 PRN
- Oxycodone PRN for breakthrough
===================
TRANSITIONAL ISSUES
===================
- The Hand Surgery team at ___ will contact his Rehab facility
to discuss timing and scheduling of an outpatient wrist biopsy.
From there, he will follow-up with ___ Rheumatology once the
results of biopsy are known.
- Found to be non-immune for Hepatitis B. Received vaccine ___
on ___. Needs dose ___ on ___ or later. Needs dose ___ on
___ or later.
- Started nicotine patch for tobacco use
- Needs continued encouragement and support for abstinence from
alcohol
- Started multivitamin, folate, and thiamine for nutritional
support given history of alcohol use
- Started daily Clobetasol (x2 weeks on, x2 weeks off), and
daily Urea for Psoriasis. Has Derm follow-up in early ___ at
___
- Urine Arsenic level pending on discharge. It was sent as part
of workup for his rash, but given biopsy showing psoriasis, now
thought unlikely to be the etiology
- On discharge, his Hgb was 7.9 and Hct 25.3. These were
completely stable throughout stay and he required no blood
transfusions. Could recheck as outpatient if clinically
indicated.
- Needs nonurgent screening colonoscopy
- Needs nonurgent Outpatient CT chest to follow-up his pulm
nodules. 6 month follow-up in ___ recommended
- Sutures for his skin biopsies should be removed on ___ | 128 | 987 |
10637368-DS-14 | 27,738,841 | 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 ___ at the suggestion of her PCP due to abdominal pain with
associated fevers and hematuria. Upon arrival, intravenous
fluids/ pain medication were administered and radiographic
imaging was obtained. An abdominal CT scan suggested
'extensive inflammatory changes about gastric banding catheter
tubing spanning approximately 10 to 11 cm with small amount of
free fluid in the right hemipelvis' without fluid collection.
Given the findings, intravenous metronidazole and ciprofloxacin
were administered and the patient was taken to the operating
room where she underwent laparoscopic exploration with lysis of
adhesions, infected band removal, washout, and upper endoscopy.
There were no adverse events in the operating room; please see
operative note for details. The patient was extubated and taken
to the PACU for recovery. Once deemed stable, she was admitted
to the general surgical ward for further observation.
Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially managed with intravenous
hydromorphone and tylenol and then transitioned to oral
oxycodone and tylenol once tolerating clears.
CV: The patient was persistently tachycardic to 110-120s on
POD1, which responded to fluid boluses and aggressive IV fluid
resuscitation. She remained stable from a cardiovascular
stanpoint throughout the remainder of her hospitalization; vital
signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: She was initially kept NPO until an upper GI study
was performed on post-operative day 1, which was negative for a
leak. Therefore, her diet was advanced to a clears, however on
POD2, the patient developed nausea with associated dry heaves
and mild abdominal distention. Her nausea resolved by POD3 and
she began passing flatus with + BM on POD4; she was subsequently
able to tolerate diet advancement. She continued to report
bloating and fullness which was relieved with Reglan. Of note,
the patient had one left-sided JP drain placed intraoperatively.
On POD4, drain output changed in character from
serous/serosanguionous to dark brown, returning to serous over
the next day. A JP amylase was 3263 and total bilirubin was
1.3. Patient was clinically improving but this prompted a CT
abdomen on POD 5 which failed to demonstrate a a leak or abcess.
However, it did continue to show pelvic fluid with a small
foreign body in the dependent fluid with a tubular structure,
thought to be a small piece of the trocar sheath, and the
decision was made not to intervene. JP drain was discontinued
POD 7 before discharge. Also, immediately post-operatively,
urine output remained marginal requiring mulitple fluid boluses.
A foley catheter, placed on POD2 for urine output monitoring,
was discontinued on POD 4 due to adequate urine output after
aggressive fluid resuscitation. Subsequently, the patient was
able to void adequate amounts of urine throughout the remainder
of her hospitalization.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. She was treated empirically
with intravenous ciprofloxacin and metronidazole. This was
changed to vancomycin once gram stain from intra-operative
cultures showed gram + cocci in pairs/clusters. Cultures were
consistent with strep anginosus; ID recommended starting
ceftriaxone and resuming metronidazle for a total of 2 weeks.
Patient received a PICC line on POD 5 in order to continue home
abx therapy. WBC peaked at 15.6 on POD4, consistently
normalizing throughout her hospitalization. Her abdominal drain
was discontinued on POD 7 before discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible. She also receieved a PPI
thoughout her stay for GI prophylaxis.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
to assist her with her PICC line and IV antibiotics for a 2 week
duration. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 294 | 724 |
11925648-DS-9 | 21,497,563 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were experiencing nausea, lightheadedness and palpitations
and you were found to have worsened anemia.
What did you receive in the hospital?
- You received 2 transfusions of red blood cells with
improvement of your anemia.
- You had a CT scan of you abdomen.
- You felt better and you were ready to leave the hospital.
What should you do once you leave the hospital?
- Please make sure you follow up with your gastroenterologist as
scheduled on ___.
- Please take your medications as prescribed and go to your
future appointments.
- You should call your doctor and return to the emergency room
if you experience any of the warning signs listed below.
We wish you all the best!
- Your ___ Care Team | ___ with hx dysautonomia and chronic fatigue syndrome,
depression/anxiety, possible Sjogren's syndrome vs
undifferentiated autoimmune condition, chronic nausea,
osteoarthritis s/p recent R TKA presenting with nausea and
lightheadedness, admitted for acute on chronic anemia.
# Normocytic anemia:
# Iron deficiency:
Hgb 11.2 in early ___, downtrended to 8.4 on ___ and
nadired at 6.1 this presentation. Etiology unclear, but
potentially concerning for slow UGIB given one guaiac positive
stool this admission (in absence of gross melena/hematochezia)
and mild iron deficiency (ferritin 48, Tsat 9%). Colonoscopy in
___ (and per patient a more recent colonoscopy) normal; EGD
___
showed non-erosive gastropathy. R knee without evidence of
hematoma, and onset of anemia reportedly preceded her recent
surgery. No e/o RP bleeding, hematuria, hemoptysis, or
post-menopausal bleeding. No e/o hemolysis with nl bili, LDH,
haptoglobin, and retic count. CRP WNL and ferritin 48, making
anemia of inflammation unlikely as well. B12/folate WNL.
Responded robustly to 2u pRBCs this admission, with Hgb 6.1 ->
9.4 on discharge. She likely warrants a repeat EGD +/-
colonoscopy, which can be performed as an outpatient given
absence of HD-significant bleeding and resolution of her
symptoms. Previously arranged GI ___ at ___ is scheduled for
___. Would consider initiation of iron supplementation at PCP
or GI ___.
# Lightheadedness:
# Palpitations:
# Fatigue:
# Dysautonomia:
# Chronic fatigue syndrome:
Presents with acute on chronic lightheadedness, palpitations,
and
fatigue in setting of suspected underlying dysautonomia and
chronic fatigue syndrome. Suspect that these underlying
conditions were exacerbated by concurrent anemia, as above, but
low suspicion that anemia is directly/causally related. CTA
chest
and CTA head/neck in ED without e/o PE, CVA, or carotid
stenosis.
AM cortisol was negative. EKG NSR without e/o ischemia and
cardiac enzymes negative. Telemetry without arrhythmias. TTE
deferred in absence of murmur. Initial orthostasis resolved with
fluids and transfusion, so no clear indication for pharmacologic
intervention for dysautonomia at present (was previously on
florinef and mestinon; midodrine had previously been considered
but not initiated). Her home propranol was held in hospital and
on discharge, to be resumed by PCP as deemed appropriate. She
may
benefit from ___ with Dr. ___ at ___ for further evaluation
and management of chronic fatigue syndrome and dysautonomia.
# Nausea:
Unclear etiology despite extensive evaluation over years. In
setting of possible slow UGIB, likely warrants repeat EGD, which
can be pursued as an outpatient (GI ___ previously arranged for
___ at ___). At request of patient's PCP, CT ___ w/cont
obtained, which preliminarily showed no suspicious
masses/lesions
and no e/o obstruction. Preliminary read comments on mild
dilation of CBD, but normal LFTs argue against biliary
obstruction. Could consider MRCP vs ERCP for further w/u as
outpatient. Patient was tolerating a regular diet at discharge.
# Osteoarthritis:
# S/p R TKA:
R TKA appeared to be healing well without e/o hematoma. Home
oxycodone PRN continued. She will ___ with her orthopedic
surgeon
as previously scheduled.
# Prior concern for Sjogen's:
# Positive ___:
Previously evaluated by rheumatology in setting of positive ___
with titer 1:320 (___), initially thought to have Sjogren's,
which was then deemed less likely on subsequent evaluations. Had
been on Cellcept, Plaquenil, and IVIG, not recently. No
arthralgias, myalgias, or sicca symptoms to suggest active
autoimmune condition, including Sjogren's. Absence of morning
stiffness largely exonerates PMR, and no HA/claudication to
suggest GCA (and CRP/ESR WNL). RF and CCP negative this
admission. ___ positive with titer pending at discharge, but SLE
thought less likely. Can consider further rheumatology
evaluation
as outpatient.
# Depression:
# Anxiety:
Continued home clonazepam, brexpiprazole, paroxetine.
# Possible EBV viremia:
Reports that she was diagnosed with this by physician in
___ and started on valacyclovir. No clear marrow
suppression reported from valacyclovir, which was resumed on
discharge.
# Emergency contact: ___
Relationship: Husband Phone: ___
** ___ **
[ ] repeat CBC in ___ days to ensure stability; consider
initiation of iron supplementation
[ ] GI ___ for EGD +/- colonoscopy
[ ] ___ final CT ___ read, pending at discharge; could consider
ERCP vs MRCP for mild CBD dilation
[ ] ___ titer, pending at discharge; could consider further
rheumatology evaluation as outpatient
[ ] home propranolol held on discharge; can be resumed by
outpatient providers as deemed appropriate
[ ] consider ___ with Dr. ___ at ___ for further management
of dysautonomia/chronic fatigue syndrome | 142 | 626 |
19017482-DS-5 | 28,706,587 | Dear ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted for evaluation
of unsteady gait, lightheadedness, and worsening tremor. You had
imaging of your head which did not show any signs of stroke. You
were seen by neurologist specialists who did not think you had
seizures and recommended outpatient follow up for further
evaluation. It is possible that some of your symptoms may be
from taking a long acting dilitiazem. Therefore you were
switched to short acting diltiazem. You were seen by physiacl
theapy who recommended home physical therapy at home but your
refused physical therapy. Please follow up with your primary
care physician, gastroenterologist and cardiologist for further
evaluation and discussion regading possibly starting you back on
metoprolol. | ___ year old woman with history of hypertension, paroxysmal
atrial fibrillation, history of esophageal spasms, who presented
with unsteady gait, transient feelings of lightheadedness,
transient shortness of breath and worsening tremors for past
three days.
.
# Unsteady gait/lightheadedness: Patient reported feeling clumsy
and lightheaded since being started on diltiazem few weeks ago
albeit worse in the past ___ days prior to admission. She
reportedly presented to ___ few days prior to this admission and
was ruled out for MI and found to have normal stress test.
During this admission she was not orthostatic; EKG was not
concerning for any ischemic changes or any arrythmias. She was
once again ruled out for MI with three sets of negative cardiac
enzymes. She had CT head which did not show any signs
concerning for stroke. Patient was also seen by neurology who
felt her symptoms were unlikely to be caused by seizures,
strokes or any other serious neurological problem. It is likely
that her symptoms were caused from taking long acting diltiazem.
Her 120mg long acting diltiazem was decreased to 30mg TID short
acting diltiazem with some improvement in her symptoms. She was
evaluated by physical therapy on the day of discharge, who
recommended patient home physical therapy however patient
refused to have any physical therapy services at home. She was
encouraged to follow up with primary care physician, neurologist
and cardiologist for further care.
.
# Worsening Tremors/shakiness: Benign essential tremor is the
most likely etiology. Her symptoms were controlled with
metoprolol in the past however three weeks ago she was switched
from metoprolol to diltiazem which may have precipitated her
tremors in patient who has history of anxiety and PTSD. She did
not have other findings to suggest ___. As above patient
was evaluated by neurology who did not have any concern for
seizures and recommended outpatient follow up in the movement
disorder clinic. She will follow up with PCP and neurologist
who should consider restarting patient back on metoprolol for
better control of tremors.
.
# Transient shortness of breath: Patient reported one episode of
transient shortness of breath prior to presentation. As above
she was ruled out for MI. She did not have any arrythmia on
EKG. There was no sign of volume overload and CXR did not show
any pulmonary process. Her transient shortness of breath was
likely secondary to her anxiety. She did not have any further
episodes of shortness of breath during this admission.
.
#Night sweats: Only happened once. She was monitored and did not
have any localizing signs or symptoms of infection. Certainly
anxiety may have contributed.
.
#Torticollis/Cervical dystonia: This is a long standing
diagnosis for her; the etiology is unclear. She had previously
considered botox injections but decided against that option. She
will follow up in outpatient movement disorder clinic for
further care.
.
# Paroxysmal afib: Patient was switched to lower dose of short
acting diltiazem, as patient's lightheadedness may have been
caused by long acting diltiazem. She was continued on aspirin.
She remained in sinus rhythm during this admission.
.
#Esophageal spasm: She was recently started on diltiazem by her
gastroenterologist with some control of her symptoms. During
this hospital stay she was switched to short acting diltiazem as
above. She was encouraged to follow up with her
gastroenterologist for further care.
.
# CODE: Full code, confirmed
# CONTACT: husband ___ ___,
___.
. | 130 | 583 |
12455543-DS-9 | 27,307,854 | * You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. | Briefly, Ms. ___ presented to the emergency department at
___ on the evening of ___ with a second pneumothorax (see
admission note). In the ED, she was hemodynamically stable with
O2 sats >92% on 3L nasal cannula. She had a CXR which showed a
contained pneumothorax without tension. Given that she was
comfortable, stable, and likely needed to go to the OR, she did
not have a pigtail catheter placed at that time. However,
overnight she became short of breath and was switched to a
nonrebreather mask with pigtail catheter insertion as the
pneumothorax was more prominent on CT. She remained stable
throughout ___ and went to the OR the morning of ___ for a
possible VATS blebectomy and mechanical pleurodesis. She
received her morning dose of subcutaneous heparin, epidural
placement, foley placement, and underwent sedation/intubation
uneventfully. In the OR, findings were notable for numerous
blebs, none of which were found to be the cause of her current
pneumothorax. Therefore, a thorough mechanical pleurodesis was
performed. She extubated uneventfully and was transferred to the
PACU for continued recovery. Her chest tube remained to suction
for 48 hours, was removed, and follow up chest xray showed no
pneumothorax. Her post-operative course was notable for itching
from her epidural, well controlled, but otherwise was
uneventful. She was discharged in excellent condition with a
mobile tank of O2 for travel, pain well controlled with PO pain
medications, tolerating a full diet, and voiding well. She has a
follow up appointment with Dr. ___ prior to her
departure to ___. She was also given copies of her
radiology images to take with her for follow up in ___. | 247 | 275 |
16484690-DS-9 | 25,195,435 | Dear Ms. ___,
You were admitted due to confusion. Studies showed you had no
infection but you did have electrolyte abnormalities which we
corrected. We increased your lactulose to help you get rid of
extra toxins that were making you confused. If you notice any
confusion in the future, increase your lactulose so you have ___
bowel movements per day.
It is very important that you follow up with your liver doctor
as scheduled. You will also need to have your labs drawn ___
___.
New medications: omeprazole 40 mg daily, Carafate 1 mg four
times daily for 7 days (___).
Please drink only clear liquids today, ___, and a soft diet
tomorrow (___). On the ___, you can have a regular
diet.
It was a pleasure to care for you!
-Your ___ Team | ___ yo female with DM and overlap AIH/PBC cirrhosis complicated
by esophageal varices s/p banding several weeks ago and HE on
lactulose/rifaximin without prior history of SBP recently
presenting with fever, confusion, and leukocytosis.
#ALTERED MENTAL STATUS:
She had no further fevers at ___ and repeat WC was wnl.
Infectious w/u including blood cultures, urine cultures
negative. US w/ minimal ascites. She was hypokalemic which may
have contributed to hepatic encepalopathy. Electrolytes
corrected and lactulose increased and she improved such that she
was more alert and was usually A&Ox3. However, she did at times
wax and wane c/w hospital induced delirium. She may have some
baseline cognitive deficits which will need further w/u with
cognitive neurology.
#GIB/VARICES: Last EGD (___) showed Grade 1 varices
Repeat EGD done on ___: "3 cords of varices seen (1 cord of
grade I and two cords of grade II/III) were seen in the lower
third of the esophagus. The varices were not bleeding. 2 bands
were successfully placed." Patient started on PPI and Carafate x
7 days.
#PBC/AIH cirrhosis c/b varices, HE, ascites (minimal) and EGD
___ and then again on this admission (___) with varices
s/p banding.
-Continued lactulose/rifaximin and continued ursodiol.
#T2DM: Continued home lantus. ISS.
#CKD Stage III: Creatinine at baseline during hospitalization.
Transitional Issues
- Patient's delirium thought to be combination of HE, hospital
induced delirium, and possibly an underlying cognitive
dysfunction. She will need to follow up with cognitive neurology
for evaluation (appt scheduled).
- patient complained of bilateral foot pain c/w diabetic
neuropathy. Consider increasing gabapentin as an outpatient
- hepatology f/u as above
- lactulose should be titrated to ___ BMs; discharged on QID
dosing
- labs should be drawn on ___ CBC INR LFTs Chem10 and
faxed to ___ Hepatology ___
- new medications : omeprazole 40 mg qD, Carafate 1 mg QID x 7
days
- Patient with varices banded on this admission. Will need
repeat banding in ___ weeks. | 136 | 326 |
18719447-DS-18 | 20,035,944 | You were admitted with a neutropenic fever. No source of
infection was found and your blood counts improved. You did not
have a fever while admitted. | ___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM
who was admitted with neutropenic fever. | 26 | 18 |
12684917-DS-22 | 22,765,782 | You came to the hospital with swelling and redness of your right
leg. You had an ultrasound, which was negative for blood clots.
You were treated for cellulitis with an intravenous antibiotic
called vancomycin, which was subsequently changed to two oral
antibiotics (Keflex and Bactrim). You should continue the oral
antibiotics for another 6 days.
You were seen by the dermatology service, who recommended
applying mupiricin ointment to the area of skin breakdown on
your right ankle. They also recommended using mupiricin ointment
and betamethasone lotion for your scalp psoriasis, and econazole
cream for your athlete's foot.
The dermatology service recommended that you be seen by Dr.
___ or by the resident who saw you here in the hospital (Dr.
___ within the next ___ weeks. Please call the
dermatology office on ___ to schedule an earlier appointment.
Please also call Dr. ___ office on ___ to schedule an
appointment to be seen within the next week.
Please do not take Humira until at least 1 week after your
infection resolve. Discuss restarting Humira with your
gastroenterologist once the infection resolves.
There are some changes to your medications:
START Keflex (cephalexin) and Bactrim
(trimethoprim-sulfamethoxazole) for another 7 days.
START mupiricin ointment for area of skin breakdown on right
ankle.
START betamethasone lotion and mupiricin ointment for psoriasis
on scalp.
START econazole cream for athlete's foot.
STOP Humira for now and discuss with your gastroenterologist
when it is okay to restart this.
Do not take the medications that you were prescribed in ___,
as one of them (metamizole) can cause severe bone marrow
problems and was banned in the ___ in ___. | ___ M with Crohn's disease, recently returning from vacation in
___, presenting with right lower extremity swelling,
erythema, pain.
# Cellulitis: Due to the somewhat atypical appearance of the
patient's cellulitis and his recent travel to ___,
dermatology was consulted. Dermatology felt that the patient's
exam was consistent with cellulitis, with possible superimposed
contact dermatitis. The patient was treated with IV vancomycin,
then transitioned to Bactrim and Keflex, which he tolerated
well. The edema and redness were improving at the time of
discharge. He will complete a total 10-day course of antibiotics
on ___. Additionally, he was given a prescription for
mupiricin ointment, to apply to the open area over his medial
malleolus. He was advised to avoid adhesive bandages given the
concern for contact dermatitis. The patient was advised to
follow up with primary care and dermatology in ___ weeks.
# RLE edema: Likely related to cellulitis. Lower extremity
ultrasound negative for DVT.
# Crohn's disease: Held Humira in setting of infection. The
patient was instructed not to restart Humira until one week
after the cellulitis had resolved. He was asked to discuss this
with his gastroenterologist.
# Tinea pedis: The patient was prescribed econazole cream
# Psoriasis on scalp: The patient was instructed to use mupirin
ointment and betamethasone lotion daily on the affected area,
and to follow up with dermatology in ___ weeks.
# Code status: FULL CODE, confirmed | 261 | 230 |
16125308-DS-20 | 23,276,037 | Dear Mr. ___,
You were admitted to the hospital because you were having very
high blood pressures. You were closely monitored in the
intensive care unit because of these blood pressures. Please see
below for a more detailed account of your hospital course.
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You had very high blood pressures
-You were feeling nauseated, sweaty, and short of breath
WHAT WAS DONE FOR YOU IN THE HOSPITAL:
-You were given medications to lower your blood pressure quickly
-You had multiple scans of your head and your kidney to try and
figure out why your blood pressures were so high
-You had many blood tests run to try and figure out why your
blood pressures were so high
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
-PLEASE follow up with your outpatient doctor
-___ pick up a 24-hour urine collection container at ___ on
the ___ floor of the ___ Building
-Please take your medications as prescribed
-Come back to the ED right away if you have another episode
Best Wishes,
Your ___ Care Team | ___ yo M with hx of HTN on lisinopril, GERD, presents with
nausea, vomiting, dyspnea, diaphoresis found to be HTN to
220s/120s requiring labetalol gtt.
#Hypertensive urgency-considered pheochromocytoma vs paroxysmal
hypertension (pseudopheochromocytoma) vs intoxication (cocaine,
amphetamine). Has had negative 24 hr urine catecholamine study
for pheochromocytoma workup but was asymptomatic at the time.
Less likely panic disorder given anxiety appears to occur after
nausea, vomiting.
At discharge, he had several studies pending including
aldosterone, renin, plasa metanephrines, renin, catecholamines,
renal Doppler. He was continued on his lisinopril 5mg given that
his blood pressure had normalized and he is thought to be very
responsive to antihypertensives. ** It was advised that patient
stay in-hospital for further diagnosis and treatment but patient
opted to leave to attend a wake. He was able to state risks of
leaving.
#Leukocytosis-WBC elevated up to 17.2, though no symptoms on ROS
(denies cough, dyspnea, diarrhea, dysuria). Blood and urine
cultures were drawn and he was not initiated on antibiotic
therapy.
___. Creatinine 1.2 on discharge. Left AMA as above.
TRANSITIONAL ISSUES:
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Incidental Findings: None
# CODE: Full
# CONTACT: ___, MOTHER (___)
[] Follow up rise in Creatinine with Chem 7 within 1 week of
discharge
[] Follow up aldosterone, renin, plasma metanephrines,
catecholamines, renal Doppler, UDS | 166 | 217 |
13892101-DS-12 | 25,089,764 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted at
___,
Why was I admitted to the hospital?
-You were having dark black stools which were concerning for
bleeding. Your liver disease puts you at high risk for bleeding.
What was done while I was admitted?
-We performed several laboratory tests to confirm that you were
not bleeding.
-We monitored your blood pressure and heart rate very carefully
-We ensured that you would not have withdrawal symptoms from
alcohol.
What should I do when I go home?
-It is very important for you to stop drinking alcohol.
-Attend AA sessions to assist you in stop drinking alcohol
-See your primary care physician
-___ doctor. We have scheduled an appointment for you
(time and location are noted below)
-Continue taking all of your medications as prescribed in the
discharge paperwork. | Summary Statement for Admssion
___ with h/o EtOH cirrhosis c/b recurrent variceal bleeding s/p
TIPS (___), history of HCV, HTN, T2DM on insulin, COPD,
seizure disorder, presents to the emergency department for
alcohol use and c/f melena with guaiac negative stool.
Acute Medical Problems Addressed:
==========================
# Alcohol-related cirrhosis:
#Report of melena:
MELD-Na 15 on admission. Historically complicated by EV &
bleeding, s/p TIPs, and encephalopathy. Initial report of
melena, though H/H stable and stools are guaiac negative, so low
suspicion for clinically significant GI bleed. No reported
episodes of melena since arrival. TIPS patent on US. No ascites
or edema, no evidence of infection, and no encephalopathy
currently, thus cirrhosis appears to be compensated. Abdominal
exam benign with low c/f SBP. While inpatient we trended daily
MELD labs, restarted his home medications of lactulose and
rifaximin for encephalopathy prevention (though patient
intermittently refused to take these). Restarted spironolactone,
furosemide, and nadolol on ___ as Cr is very close to baseline.
We restarted PO pantoprazole.
# Alcohol Use Disorder, Alcohol withdrawal
Last drink AM of ___. Unclear history of withdrawal seizures.
We continued him on CIWA scale with several doses of lozarepam
given per CIWA protocol. Patient would like to abstain going
forward. Initially patient stated he was interested in an
inpatient detox program however, he later decided that he would
follow up with AA and go home. He was given supplemental
MVI/thiamine/folate
___: Cr 1.2 on admission from 1.0 baseline
Likely in the setting of poor PO intake with EtOH use. He is s/p
12.5 albumin in ED, and additional 12.5 g on ___ on floor. We
restarted diuretics on ___
Chronic Issues:
===========
#Thrombocytopenia: Chronic, related to liver disease and
ongoing alcohol use.
-Continue to monitor
#Rash: Pruritic rash appears consistent with urticaria.
Suspect recent allergic exposure. Improving since admission
-Continue to monitor
-Benadryl 25 mg q6, sxs resolving
-Sarna lotion PRN
#HTN: Previously on losartan
- Will continue to hold in setting of slightly elevated Cr from
baseline and stable BPs.
- Continue amlodipine 10 mg PO daily
#T2DM: Not taking any insulin at home; A1C 8.9%. Hyperglycemic
on
admission to 476, sugars now improving (133 last night, although
up to 317 and 296 this morning)
- Restart insulin at prior documented dose: 20 U NPH BID, with
ISS
- Monitor, may need up-titration of insulin regimen if sugars
remain in high 200-300 range
#Seizure disorder
- Restarted prior dose of Keppra, 500 BID
- Restarted gabapentin at lower dose (discharged in ___ on 800
mg
PO TID), will restart at 200mg TID, can up-titrate as needed
- Will need OP neurology f/u
# Depression
- Restarted fluoxetine at prior dose (20mg daily)
#Medication reconciliation: Previously was also on acamprosate,
sucralfate, and trazodone in addition to above.
- Will not restart these medications to decrease pill burden,
but continue to monitor symptoms
Transitional Issues:
[ ]EtOH use: Please continue to reinforce importance of sobriety
[ ]Cirrhosis: Please encourage patient to follow up with
hepatology
[ ]Need for op neurology follow up. | 142 | 482 |
17259909-DS-3 | 25,983,236 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I ADMITTED?
- You came to us because you fainted and hit your head
WHAT WAS DONE FOR ME WHILE I WAS IN THE HOSPITAL?
- We performed a CT of your head to see if you had any bleeding
around your brain
- We performed an EKG and monitored your heart to see how your
heart was functioning
- We performed an echocardiogram to see if there was any
abnormality in the structure or function of your heart
- We performed a number of blood tests to monitor the
electrolytes in your blood
- We gave you IV fluid with potassium to hydrate you and
increase the level of potassium in your blood
- We stopped giving you your diuretic because it may have been
contributing to your low potassium levels
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed.
- Please stop taking your hydrochlorothiazide as this may have
reduced your potassium
- Please follow up with your primary care physician as described
in this summary
- If you have chest pain, shortness of breath, lightheartedness
or other danger signs listed below please call your PCP or come
to the emergency department
Best Wishes,
Your ___ Care Team | Ms ___ is a ___ woman with a history of stage IB Grade 2
endometriod endometrial adenocarcinoma s/p TAH-BSO ___,
HTN, history of DVT/PE in ___ who was transferred from ___
with syncope, and was found to have SAH on head CT.
ACUTE MEDICAL/SURGICAL ISSUES ADDRESSED
#Syncope
#Orthostatic Hypotension
Patient presented after fainting. Likely etiology is orthostatic
hypotension in the setting of hypovolemia from GI illness.
Physical exam positive for orthostatic hypotension. Her EKG was
normal sinus rhythm on presentation. Patient was monitored with
telemetry with no evidence of arrhythmia. Echo demonstrated
normal function and structure with the exception of a mildly
dilated ascending aorta. Pulmonary embolism was considered given
patients history, but she denied any shortness of breath or
chest pain. Head CT ___ with evidence suggestive of
subarachnoid hemorrhage. Likely the SAH occurred traumatically
after she struck her head when fainting and was not the cause of
the syncope. She was hydrated with IVF and discharged home with
services.
# Subarachnoid hemorrhage:
Patient presented with a fall & head strike. CT ___ notable for
hyperdensities concerning for subarachnoid hemorrhage or
cerebellar calcifications. Neurosurgery consulted and did not
believe she required a surgical intervention. She had q4h neuro
checks and a goal SBP <160. Her neuro exam was stable over the
course of this admission.
# Hypokalemia: Patient presented to OSH with K of 2. This likely
resulted from potassium losses in her diarrhea in combination
with HCTZ use. Her electrolytes were monitored and repleated as
needed.
# Nausea / Vomiting / Diarrhea: Patient presented after four
days of nausea, vomiting and diarrhea. Likely due to a viral
gastroenteritis. This issue resolved on day of admission.
CHRONIC ISSUES PERTINENT TO ADMISSION
# Stage IB Grade 2 endometriod endometrial adenocarcinoma - s/p
TAH-BSO ___ refusing adjuctive vaginal brachytherapy. No
further treatment at this time.
# Hypertension: Discontinued home HCTZ. Continued Aspirin 81 mg
PO DAILY
# Asthma: Continued Fluticasone-Salmeterol Diskus (250/50) 1 INH
IH BID and Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
# Anxiety: Continued LORazepam 0.5 mg PO BID:PRN anxiety
# Glaucoma: Held home Betimol (timolol) 0.5 % ophthalmic (eye)
DAILY as not on formulary. Continued Latanoprost 0.005% Ophth.
Soln. 1 DROP BOTH EYES QHS
# Hypothyroidism: Continued home Levothyroxine Sodium 75 mcg PO
6X/WEEK (___) and 150mg on ___
Transitional Issues
[ ] Patient should no longer take her HCTZ
[ ] check her orthostatics on the next office visit.
[ ] check a chem 10 on the follow up visit day.
[ ] f/u neurological exam for any neurological deficit.
[ ] On her echocardiography, there was evidence for mild
ascending aorta dilation.
New Medications: None
Discontinued Medications: HCTZ
>30 minutes spent on discharge planning | 206 | 436 |
11932181-DS-25 | 23,011,056 | Dear ___,
You were admitted to the hospital because you were having some
unsteady gait and confusion. You were found to have new masses
in your brain from spread of your lung cancer.
While you were here, you were started on radiation therapy for
the masses in your brain. You were also seen by physical
therapy, who recommended you go to rehabilitation to help make
you stronger. You were discharged in good condition.
When you leave the hospital, it is important you continue to go
to your radiation appointments. It is also important you take
you medications as prescribed.
If you have any increasing confusion, nausea, vomiting,
headaches, or increasing sedation, it is important you go to the
ER immediately.
It was a pleasure to care for your, and we wish you the best of
luck!
Your ___ Care Team | Mrs. ___ is a ___ female with history
of NSCLC (adenocarcinoma, EGFR exon 19 deletion) s/p adjuvant
chemotherapy followed by ___ ___ Afatinib who developed
recurrence with transformation to small cell lung cancer s/p
multiple courses of chemotherapy currently on docetaxel who
presented with episodic confusion at home and gait unsteadiness
for two months as well as nausea/vomiting in the setting of
recent chemotherapy found to have brain MRI with multiple brain
metastases. Neurosurgery did not recommend surgical resection.
Pt was started on keppra and dexamethasone. Radiation oncology
was consulted and started WBRT with plans for 10 fractions. ___
evaluated patient and recommended short term rehab. Pt was
discharged from the hospital in stable condition
Active Issues
===========
# Gait Unsteadiness:
# Confusion:
# Metastatic Brain Lesions:
Pt had been having increasing symptoms of confusion and
unsteadiness at home, so an MRI was done by her outpatient
providers on ___, which showed multiple brain lesions both
supratentorial and infratentorial, which were the most likely
cause of her symptoms. She was transferred to the ER for further
work-up and evaluation. Pt was seen by neurology, who started
the patient on Dexamethasone 4mg q6h and Keppra 500mg q12. Pt
continued to experience somnolence throughout the day and was
difficult to arouse, so an EEG was done to evaluate for seizures
in the setting of suspected post-ictal confusion. EEG did not
demonstrate seizures, so urgent WBRT was started and she was
give an extra dose of steroids and ritalin. The patient's mental
status improved greatly and she was more alert. Radiation
oncology then performed more formal mapping and pt received her
second dose of WBRT on ___ with the plan for a total of 10
fractions. She continued to improve and only notable symptom
that persisted on physical exam was horizontal nystagmus and a
fine tremor. The patient did continue to have a flat affect, but
remained AAOx3.
# Small Cell Lung Cancer: Patient progressed on multiple prior
rounds of chemotherapy, and was receiving docetaxel prior to
admission, but had imaging consistent with multiple brain mets
as above. The pt's outpatient oncologist Dr. ___ Dr. ___
___ contacted, who recommended a CT head/neck and torso to
assess for further disease progress to be used in treatment
planning. Her disease had been found to progress. Dr. ___
___ these finding and explained her poor prognosis and
lack of effective treatment available at this point. She will
continue her palliative radiation treatments, but not pursue any
additional chemotherapy treatments. She was discharged with
___ Care.
# Tachycardia: Unclear cause. Per patient, she has intermittent
episodes of tachycardia which she was evaluated for as an
outpatient without known cause. She is not symptomatic and
denies chest pain and shortness of breath. ECG showed sinus
tachycardia. The suspicion for PE remained low throughout the
hospitalization, as the patient remained free from symptoms and
did not require oxygen. It did improve to the high ___ to 100s
after IVF hydration.
# History of Knee Infection
Patient was continued on home dose of doxycycline for
suppression of infection.
MEDICATION CHANGES:
======================================
STOPPED Medications/Orders Physician ___
___ 10 mg PO DAILY
NEW Medications/Orders Physician ___
___ 650 mg PO Q6H:PRN Pain - Mild
LevETIRAcetam 500 mg PO Q12H
MethylPHENIDATE (Ritalin) 5 mg PO BID
Sulfameth/Trimethoprim SS 1 TAB PO DAILY
CHANGED Medications/Orders Physician ___
___ 4 mg PO Q8H
TraZODone 25 mg PO QHS:PRN insomnia
TRANSITIONAL ISSUES:
======================================
- Pt is getting whole brain radiation and has gotten 5 out of 10
fractions while in house. Will complete 5 more fractions
___ as scheduled above
- Patient was discharged with home ___ & ___ services and ___
___
- MOLST was completed on admission. Patient is DNR/DNI, do not
hospitalize unless for comfort
CODE: DNR/DNI, do not hospitalize unless for comfort
EMERGENCY CONTACT HCP: ___ (husband/HCP)
___ | 134 | 621 |
13437561-DS-16 | 21,653,515 | ___,
You were admitted to the hospital for a skin infection of your
left leg. This improved with antibiotics. You will be discharged
with antibiotic pills to complete two weeks of treatment.
Please keep your left leg elevated at all times while sitting
during healing process.
You will need to follow-up with your primary care provider after
hospital discharge.
It was a pleasure taking care of you!
Sincerely, your ___ Team | Ms. ___ is a ___ female with past medical history
notable for asthma who presents with left leg swelling with
concern for cellulitis.
# Left lower extremity erythema/swelling/likely cellulitis:
# Leukocytosis:
# Nasolabial folds erysipelas?:
Patient's symptoms consistent with bacterial cellulitis of left
leg. However worsened in the ED despite initial treatment with
ceftriaxone (x24h) and as such broadened to vancomycin and
ceftriaxone (for another 24h), with minimal improvement. LLE
ultrasound ruled out DVT. No
evidence of joint involvement to suspect septic arthritis. Of
note nasolabial region also with new erythema concerning for
erysipelas. This really seems to be clinically consistent with
cellulitis based on appearance rather than inflammatory
condition. ID consulted, recommended continuing treatment to
cover both staph and strep. IV access lost on ___ therefore
antibiotics switched to PO clindamycin, with plan to complete
total 14 day course of antibiotics ending on ___. | 67 | 140 |
17569886-DS-18 | 21,910,115 | Mr. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted due to nausea and vomiting with low
blood pressure due to a viral gastroenteritis. You were given
IV fluids and managed with supportive care, and your blood
pressure came up to normal. Your symptoms resolved and you were
discharged the following day.
Some of your blood pressure medications were held while you were
in the hospital because your blood pressure had been low. We
restarted your metoprolol but not your lisinopril or
hydrochlorothiazide. You will talk to your primary doctor about
restarting these when you see him next ___. | ___ year-old man w/CAD, ischemic cardiomyopathy with LV EF 30%
s/p AICD for primary prevention, CVA (___), HTN, HLD, CKD (bl
Cr 1.3-1/6), admitted with vomiting and diarrhea, found to have
gastroenteritis.
ACTIVE ISSUES
# Gastroenteritis: Most likely viral process given the
symptoms, and now resolved. His volume losses likely led to
hypovolemia, leading to hypotension. Hypotension resolved after
2L IVF with NS. Stool culture and C. diff were sent which were
negative. Symptoms resolved quickly by the following morning.
# Hypotension: Likely related to volume loss in setting of
N/V/D. Resolved with 2L IVF. Orthstatics negative on AM of
discharge; patient ambulated without symptoms. Initially
anti-hypertensives had been held. Home metoprolol was
restarted, but lisinopril and HCTZ were held pending BP check as
outpatient with PCP.
CHRONIC ISSUES
# CAD: Extensive history, with known RCA and LCA occlusions that
were not amenable to intervention. No chest pain or EKG changes
at this admission. Continued aspirin, plavix, statin.
Restarted metoprolol after holding for a day, and held
lisinopril as above d/t the hypotension, to be restarted by PCP
when outpatient blood pressure check performed.
# sCHF: Ischemic cardiomyopathy with LV EF 30% s/p AICD for
primary prevention. No acute exacerbation at this admission.
Continued ASA, statin, metoprolol. Held lisinopril d/t
hypotension above, to be restarted as outpatient as long as
blood pressure tolerates.
# HLD: Continued statin.
# BPH: Finasteride, tamsulosin continued.
TRANSITIONAL ISSUES
-ACEi and HCTZ will need to be restarted once blood pressure is
confirmed to be stable at outpatient visit with PCP | 115 | 270 |
13210385-DS-15 | 25,937,437 | 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:
-Nonweightbearing right lower externally
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 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.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
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
Physical Therapy:
ASSESSMENT/CLINICAL IMPRESSION: Pt is a ___ y/o F hospitalized
for
ankle fx, now POD ___ s/p ORIF. pt presents with progress
including: increased strength, endurance and functional
mobility,
however is limited by decreased endurance due to NWB status, and
inappropriate HDR to mobility. Due to patients strong home
supports, ability to live on 1 level, and progress demonstrated
so far with mobility, I recommend the patient DC to home with
home ___, a WC and commode. Family reports they can move a bed to
the ___ living level, and have 2 people assist with WC transfer
up/down her front stairs. patient will require ___ more ___
sessions for family education on WC management and stair
negotiation. patient may require rehab placement if family
unable
to comply.
Recommended Discharge: (X)see clinical impression
PLAN:
Progress functional mobility including bed mobility, transfers,
gait and stairs as tolerated.
Balance training
Pt/caregiver education RE: fall risk
D/C planning
Recommendations for Nursing: OOB for all meals and at least 3
hours a day no more than 1 hour at a time to prevent skin
breakdown.
Treatments Frequency:
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.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower. | Ms. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Right Ankle 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. 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 with home
___ was appropriate. Of note, she had a hypotensive episode on
POD2 while working with ___ which responded to fluid
resuscitation.
At the time of discharge the patient's pain was well controlled
with oral medications, her splint was clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right 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. | 763 | 265 |
14207656-DS-22 | 22,209,819 | You came to the hospital with abdominal pain and white blood
count of 15 on ___. You were found to have a cecal volvulus.
You underwent an emergent exploratory laparotomy with right
colectomy and primary anastamosis. Your abdomen was left open so
you were again brought to the operating room and underwent a
washout and closure on ___. After extubation on ___ you
had difficulty with phonation so otolaryngology was consulted to
assist with laryngeal exam. You started to feel better and were
advanced to a regular diet which you are now tolerating. You are
ready to be discharged to a rehabilitation facility. Please
adhere to the following instructions for discharge.
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. | Ms. ___ is a very pleasant ___ year old female who
presented with a cecal volvulus on ___.
The patient was admitted to the Acute Care Surgical Service for
evaluation and treatment. On ___ the patient underwent an
Exploratory laparotomy, right colectomy with primary
anastomosis, and temporary abdominal closure, which went well
without complication (reader referred to the Operative Note for
details). Intraoperatively she was discovered to have a region
of bowel which peristalsed more slowly than the others, and so
was left open for a second look. The patient arrived in the PACU
intubated, and sedated floor NPO, on IV fluids and antibiotics.
The patient was hypotensive. Ms ___ was tachycardic
perioperatively, she takes calcium channel blockers at baseline
and was trialled on a diltiazem drip, but became hypotensive
with diltiazem drip. This was stopped. She got PRN albumin and
IV fluids. In the afternoon of POD 1 she was taken again to the
OR for a second look. All bowel was found to be satisfactorily
perfused and the patient was closed. Please refer to the
operative note regarding this surgery as well.
The patient did well post operatively exceptfor a new weak voice
and clinical aspiration. She had an ENT consult on ___. On
that day she demonstrated hypomobility of her left cord with
discoordinated adduction and glottic gap. It was recommended
that she remain on a strict NPO diet and to be consulted by
speech and swallow. Increase of her PPI to 40mg BID and
discontinuation of nasal cannula and start humidification via
shovel mask given the excoriation along her nasal septum and dry
mucosa.
On ___ she was seen by speech and swallow. Per their
recommendation, she was advanced to a PO regular solids,
nectar-thick liquids diet, PO meds: whole in puree (cut if
large). Oral care three times a day was initiated. She was
placed on standard aspiration precautions and she was followed
by speech and swallow for the rest of her hospitalization for
her dysphagia.
On ___ she tolerated the regular solids, nectar-thick
liquids diet and was ready to be discharged to a rehabilitation
facility. She is to follow up with ACS and ENT in ___ weeks. | 404 | 364 |
18819076-DS-6 | 29,221,812 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after vomiting blood and we also noticed you had a fever and
cough. We looked into your stomach with a camera and found that
you have irritation of the throat, called esophagitis. We gave
you some medications for the irritation. Your cough also
gradually improved with medications and we think it is from an
upper respiratory infection. We discharged you back to your
group home. When you return home, you do not have to return to
work right away; we have written you a letter for work.
Our GI doctors ___ be calling your home to set up a follow-up
appointment for an ultrasound. If you experience additional
episodes of vomiting blood, please call clinic right away or go
to the Emergency Department. | Mr. ___ is a ___ gentleman with a history of
developmental delay and chronic Hep B who presented with coffee
ground emesis concerning for UGIB.
# Severe esophagitis c/b UGIB: patient underwent an EGD on ___
after presenting with coffee-ground emesis and was found to have
severe esophagitis, which is likely the source of his bleeding.
He was placed on carafate slurry for protection as well as
pantoprazole 40 mg BID. His H&H was trended daily and remained
stable.
#Duodenal stricture: based on results of EGD, concerning for
possible malignant process. On CT abd/pelvis, possible excess
pancreatic tissue compressing the duodenum. The patient was able
to eat well with no signs of obstruction. GI will arrange for a
follow-up appointment for consideration of an endoscopic
ultrasound (EUS).
# Fever/Cough/Leukocytosis: Negative UA makes urinary sources
less likely. Suspect viral URI is responsible for cough. Also
possible fever/leukocytosis secondary to bleeding. CXR
unremarkable for acute infectious process. Patient placed on
respiratory precautions and a nasopharyngeal swab ordered. The
swab was unable to be interpreted, however. He was given
guaifenasin and tylenol for pain and cough. Ucx negative, blood
cx pending at discharge. Symptomatically, he felt improved at
discharge.
# Chronic Hepatitis B: Has Tenofovir listed as allergy (for
renal failure side effect) but continues to take it under Dr.
___. Was continued on tenofovir and has
hepatology f/u already scheduled.
# CKD: Baseline appears to be 1.3-1.4. Cr 1.5 on admission.
Trended daily, no increase with IV contrast.
# History of HCV: Cleared; negative VL in ___
# HTN: restarted atenolol
# Gout: restarted allopurinol
# Pernicious anemia
- Continued B12
# Peridontal disease
- Continued Rx toothpaste
# OA
- Tylenol PRN
# Emergency Contact: Group Home, ___, ___
# Disposition: Medicine for now | 136 | 307 |
15307658-DS-20 | 27,971,988 | Dear ___ was a pleasure taking care of you. Thank you for choosing
___ for your care. You were admitted to the hospital with
weakness and trouble breathing. We found that you had too much
fluid in your body, and likely had a viral upper respiratory
infection.
Your heart rate was also fast, likely due to your atrial
fibrillation and your infection. We increased your heart rate
medication (metoprolol) to help better control your heart rate
as well. Your doctors ___ continue to increase your medication
as needed.
If you have trouble breathing, or other symptoms that worry you,
please let your doctor know or return to the hospital for
further care.
Thank you,
___, M.D. | ___ with hx of afib on warfarin, mild/moderate dementia with
impaired short term memory, brought to ED by family for
generalized weakness, most likely decompensated diastolic heart
failure in the setting of viral URI.
# Decompensated heart failure with a preserved EF:
Patient was noted to have new oxygen requirement on admission.
She also had lower extremity edema, bibasilar crackles, and
pulmonary edema on chest x-ray. This was likely due
decompensated diastolic heart failure in the setting of a viral
URI, as well as due to IV fluid. Likely also exacerbated by
atrial fibrillation with RVR. A TTE was performed that showed an
EF of ~50%, but was limited by afib with RVR. She received IV
furosemide for several days, with excellent urine output,
decrease in weight from 61kg to 54.5kg, and resolution of
hypoxia. After resolution of other issues that may have been
contributing to tachycardia, her metoprolol was increased to
improve heart rate control, and her furosemide was initiated
back at her home dose.
# Viral upper respiratory infection:
Patient's initial weakness and hypoxia was likely partially due
to viral upper respiratory infection. Patient had mild sore
throat and laryngitis, suggestive of viral infection. This was
improving, but not entirely resolved, at the time of discharge.
# Generalized weakness:
Most likely due to mild viral syndrome given diffuse weakness,
myalgias, laryngitis. Pt denies localizing symptoms to suggest
infectious etiology. CXR is without infiltrate, UA argues
against UTI. Abdominal exam is benign. She denies headache. With
respect to toxic metabolic etiologies, labs were unrevealing,
with TSH
1.1, without leukocytosis or significant uremia. Na is WNL. She
was not anemic. No focal neurologic deficits to suggest acute
cerebrovascular event. No ischemic changes on EKG.
# Atrial fibrillation:
CHADS2 is 4 (hypertension, age, prior CVA). ___ hospital
course significant for poorly controlled heart rate requiring
metoprolol titration. She remained asymptomatic throughout.
Metoprolol titrated up to total dose of 150mg daily. Continue to
titrate as necessary to achieve adequate heart rate control.
Consider adding additional agents if not adequately controlled.
Continued warfarin, but had to lower dose due to
supratherapeutic INR. Would monitor daily initially given labile
INR.
# ___: Baseline creatinine in ___ system appears to be
1.0-1.1, although she has had occasional values of 1.2-1.5.
Improved to 1.0 by the time of discharge.
# Dementia: Prior notes reference Aricept and Namenda, but
patient is no longer taking these medications due to side
effects.
# Parkinsonism: Pt has known gait disturbance and Parkinsonism
per prior ___ neurology notes. Per notes, prior adverse
reaction to Sinemet and this may not have helped her symptoms.
Per PCP, etiology is vascular Parkinsonism.
# Hypothyroidism: TSH 1.1.
- Continued levothyroxine 88mcg qd | 113 | 438 |
13244694-DS-11 | 28,982,138 | Dear Mr. ___,
You were admitted to the vascular surgery department at ___
and you were found to have osteomyelitis of the right toe. You
underwent a right third toe amputation and are now ready to be
discharged.
ACTIVITY
Keep your foot elevated to prevent swelling.
It is very important that you put no weight or pressure on your
toe to allow the wound to heal properly.
You may use the opposite foot for transfers and pivots, if
applicable.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the wound. If there is no drainage, you
may leave the incision open to air.
If used, any staples/sutures will remain in place until
follow-up with ___ clinic
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth at your amputation site.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
It has been a pleasure looking after you and we wish you a
speedy recovery.
Best,
Vascular Surgery Team at ___ | The patient presented to the Emergency Department on ___.
Patient was found to have osteomyelitis of the right third toe.
He was given broad spectrum antibiotics (vanc/cefepime/flagyl).
He was taken to the operating room with podiatry and had a right
third toe amputation. | 386 | 44 |
11004072-DS-7 | 24,701,017 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with an drainable collection in your abdomen due to perforated
appendicitis. You were given IV antibiotics and taken to
Interventional Radiology for drainage of the infection. You are
now doing better, tolerating a regular diet, and pain is better
controlled.
You are now ready to be discharged to home with your 2 drains to
continue your recovery.
Please note the following discharge 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.
Drain Care:
*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).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*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. | Mr. ___ is a ___ yo M with history of perforated
appendicitis managed nonoperatively with antibiotics who
presented on ___ to the emergency department with new onset
dyspnea on exertion and chest pain. CT imaging revealed multiple
right lower quadrant abscesses, WBC was elevated at 14.5. The
patient was admitted for bowel rest, IV antibiotics, and ___
consult. The patient was hemodynamically stable.
On ___ the patient was taken to Interventional Radiology for
drainage of the pelvic abscesses. Two drains were left in place.
the patient tolerated the procedure well.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. Antibiotics
were transitioned to oral. The patient voided without problem,
and had a bowel movement. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
for drain care. The patient received discharge teaching
including drain teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 406 | 221 |
12696360-DS-16 | 25,985,655 | You were admitted for further evaluation of abdominal pain due
to stones in your bile ducts and an inflammation of your colon
(diverticulitis). For this, you were monitored by the surgery
and GI teams. You were given antibiotic therapy with good
effect. In addtion, you underwent an ERCP where attempts were
made to remove the stones in your bile ducts. However, you were
found to have some large stones and these were unable to be
removed at this time. Therefore, you have a stent in place to
keep the area opened. You will need to return in 2 week's time
for repeat ERCP and stent removal. You will also need to follow
up with general surgery for consideration of having your
gallbladder out. Your symptoms improved and your diet was
successfully advanced.
.
Medication changes:
1.cipro/flagyl - take for another 5 days
2.stop asa and cilostazol - can be restarted in 5 days. You
should stop cilastazol 3 days before your next ERCP.
3. You were start on a PPI called omeprazole for GERD.
.
Please take all of your medications as prescribed and follow up
with the appointments below. | ___ is an ___ y.o male with h.o HTN, HL, who presented to OSH with
abdominal pain, imaging concerning for obstructive
choledocholithiasis, and diverticulitis.
.
#choledocholithiasis/obstructive jaundice/bile duct
obstruction/transaminitis-?cholecystitis. Imaging was
suggestive of biliary dilatation with stone present in the CBD.
Gallbladder wall thickening was seen as well. ERCP was performed
on ___ showing multiple large CBD stones. Unfortunately, stones
were large and not all stones were able to be removed. A stent
was placed and pt will need repeat ERCP in ___'s time to attempt
stone removal/stent change. Pt was placed on cipro/flagyl. The
ERCP and ACS teams followed the patient during admission. He
will follow up with surgery for cholecystectomy.
.
#diverticulitis- uncomplicated sigmoid diverticulitis seen on
OSH imaging. CT scan here confirmed it. Pt was initially NPO,
and was given cipro and flagyl. Symptoms improved. He will
complete a 10 day course.
.
#chest pain/GERD-Pt reported "chest burning" at OSH. EKG was
non-ischemic appearing, cardiac enzymes x2 negative. Pt reports
CP is due to "heartburn". There were no events on tele, EKG and
cardiac enzymes negative. Pt was previously on zantac but
reported much improvement on a PPI and was discharged on
omeprazole.
.
#Acute on chronic renal failure- He presented with Cr 2.3 and CT
findings suggestive of chronic renal disease. At the OSH a Cr of
2.6 was recorded. Cr per outpt records 1.6-1.9. He was given IVF
with improvement. Urinalysis did not suggest infection. Cr was
1.4 at discharge.
.
#HTN, benign-continue betablocker, converted atenolol to
metoprolol given GFR, held lisinopril for now. Held ASA
.
#HL-Simvastatin was held given transaminitis but can be resumed
as an outpatient.
.
#h.o c.diff infection-The pt reports he was on abx therapy for 6
months in the last year. He reported a few episodes of loose
stools while in the hospital. C.diff toxin was negative.
.
#peripheral arterial ___ reports a hx of claudication
without any interventions. His aspirin and cilostazol was held
in the setting of getting a sphincterotomy. He may resume
aspirin and cilostazol after 5 days. ERCP recommended stopping
cilostazol 3 days before ERCP.
. | 184 | 362 |
13747041-DS-21 | 27,233,830 | Dear Mr. ___,
You were admitted to the hospital for left-sided facial tingling
and mild word-finding difficulties concerning for a new stroke.
You had a CT scan and MRI, both of which were reassuring and
showed no new stroke. We checked some more labs to see whether
you have a coagulation disorder predisposing you to strokes,
which showed....
Please attend your previously-scheduled follow up appointment
with neurology with Dr. ___ cardiac surgeon with Dr.
___ below.
We made the following changes to your medications:
1. INCREASED aspirin from 81mg daily to 325mg daily | Mr. ___ was admitted to the Stroke service for further imaging
and work-up of his new neuro symptoms. CTA head/neck were
performed, showing expected encephalomalacia secondary to his
prior right hemispheric strokes but no acute ICH or
cervical/intracranial vessel aneurysm/flow limiting
stenosis/significant atherosclerotic disease. MRI showed no
acute stroke on DWI/ADC; only expected evolution of prior
stroke. The following morning, patient's subtle neuro deficits
had resolved on exam, with the exception of mildly INCREASED
sensation to pinprick on his left face. Given his symptom
improvement and unchanged imaging, it was suspected that he had
likely had a TIA. In the setting of his risk factors for
recurrent stroke -- specifically the PFO and his
hyperhomocysteinemia -- his ASA was increased from 81mg to 325mg
daily. His folic acid/B6/B12 were continued. The patient was
also strongly advised to never use anabolic steroids again (has
h/o abuse in the past) as this too increases his coagulopathic
state. Finally, the possibility of future percutaneous PFO
closure was raised and discussed extensively with patient. Given
that he is in a population not studied in the CLOSURE trial
(hypercoagulable patients), and has increased risk of paradoxic
embolism with Valsalva given his hobby of weightlifting, he
could potentially be a good candidate for PFO closure. He will
follow up as an outpatient with Dr. ___ cardiac surgery
and his neurologist Dr. ___ to continue exploring this
option.
=====================
TRANSITION OF CARE:
-Studies pending on discharge = cryoglobulins (looking for cold
agglutinin disease)
-Patient needs homocysteine levels rechecked as outpatient | 91 | 252 |
13065620-DS-3 | 28,191,091 | 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 take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* You may eat a regular diet.
You were admitted to the gynecology service after your
miscarriage. You had a procedure done in the operating room to
remove pregnancy tissue. You were found to have an infection.
Your infection was treated antibiotics.
Please complete your entire antibiotic course as instructed,
even when you start feeling better.
You were also diagnosed with hyperthyroidism during this
admission and had a high heart rate. You were started on a
medication called atenolol to help bring your heart rate down to
a normal range. Please continue taking it as instructed.
You were also diagnosed with chlamydia during this admission and
you were treated for it. | Ms. ___ is a ___ G1P0 admitted to the postpartum
service from the emergency department after being diagnosed with
an intrauterine fetal demised with presumed septic abortion.
She presented at 9w2d by LMP with two weeks of nausea and
vomiting. Her LMP, however, was unclear due to irregular menses.
In the emergency department, she was afebrile with tachycardia
ranging from 112-161 with otherwise normal vital signs including
a normal blood pressure. Her abdomen was non-tender and
non-distended with no rebound or guarding. Speculum exam showed
no evidence of blood in the vault and a closed cervix. There was
no adnexal tenderness or fundal tenderness.
Labs were done in the emergency room which were significant for
a leukocytosis of 16.0 and a lactate of 2.9. Urine toxicology
screen was negative. A TSH was drawn and was pending upon
admission. Electrolytes were significant for a potassium of 2.4,
sodium 127, a chloride of 77, bicarbonate of 27, creatinine of
1.0, and an anion gap of 25. A pelvic ultrasound was done which
demonstrated no cardiac activity. Fetal biometry was not done
but visually the fetus appeared to be in the ___ trimester.
Bedside transabdominal ultrasound done once patient was admitted
showed a fetus roughly 13 weeks in gestational age.
In the emergency room, she was aggressively fluid resuscitated
and received 1g ceftriaxone for presumed early sepsis. Her
potassium was repleted and she was started on fluids with
potassium supplementation.
OB/GYN was consulted who recommended starting ampicillin and
gentamicin for a presumed septic abortion in the setting of an
undiagnosed IUFD of unclear length of time. An immediate
dilation and evacuation was recommended. The patient was made
NPO, started on antibiotics, and continued on fluids and
admitted to the postpartum service for further management. MFM
was consulted and the patient underwent an uncomplicated
dilation and evacuation. Patient's blood type was B positive so
Rhogam was not indicated. Her pain was controlled with oral pain
medications of Tylenol and ibuprofen.
She was treated with ampicillin, gentamicin, and clindamycin for
48 hours post-procedure. She was transitioned to oral
levofloxacin and flagyl for an additional 10 days. She was
continued on 20mEq potassium D5LR until her resolution of her
hypokalemia. Electrolytes were trended and repleted prn.
Labs were trended which were notable for a resolved hypokalemia
with a serum potassium of 3.6, a resolved leukocytosis with a
white count of 7.5, and a resolving lactate of 2.9 down from
5.2. Chlamydia culture returned as positive for which she was
treated with a 1g does of PO Azithromycin.
Thoughout her hospitalization she remained persistently
tachycardia ranging from the 100-120s with episodes up to the
150s with ambulation despite aggressive fluid hydration and
antibiotic treatment of her infection. Thyroid function tests
were done which were significant for a TSH of 0.01 and an
elevated free T4 of 3.6.
A full panel of thyroid function tests were performed which were
consistent with hyperthyroidism likely secondary to hyperemesis
gravidarum secondary to severe nausea for the past month. On
exam, she was euthyroid with no signs of Grave's disease
including ophthalmopathy. FT4 and TT3 improved after the D&E;
TPO, anti-thyroglobulin antibodies, TSI and TBII all returned as
negative further suggesting against Grave's disease and favoring
hyperemesis as the likely etiology. She was started on 25mg of
Atenolol for heart rate control and discharged home with
recommendation to follow-up with Endocrinology within one week
of discharge.
By postoperative day 3, she was tolerating a regular diet,
ambulating independently, and pain was controlled with oral
medications. She was afebrile with stable vital signs. She was
then discharged home in stable condition with outpatient
follow-up scheduled. | 179 | 607 |
13226870-DS-24 | 29,664,952 | Mr ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you had an infection in your finger. A
collection of fluid was drained by the plastic surgeons. You
were given antibiotics which you will need to continue for 12
more days. You will also need to soak your finger in betadine
three times a day.
We made the following changes to your medications
1. START Augmentin 500 mg daily for 12 more days
2. DECREASE simvastatin to 20 mg daily
3. START Tylenol ___ mg three times a day as needed for pain
You should continue to take all your other medications as
instructed. Please feel free to call with any questions or
concerns. | ___ yo male with a history of DM, ESRD on HD, PVD who presents
with a L thumb infection.
.
# Paronychia- Patient presented with a paronychia of the left
thumb. He was seen by plastic surgery in the ED who removed his
nail. He was initially started on IV unasyn and admitted to
medicine for monitoring. There were signs of systemic infection
on exam. Additionally patient was afebrile with a normal white
blood cell count throughout admission. Blood and wound cultures
were pending at the time of discharge. He was transitioned to
oral augmentin for a planned 14 day course. Pain was managed
with oral tylenol. The patient was instructed to complete
betadine soaks three times a day. He will follow-up with Plastic
surgery and his PCP.
.
STABLE ISSUES
.
# Diabetes- Last A1C 6.8 in ___. Patient was continued on his
home regimen of lantus and humalog sliding scale.
.
# Hypertension- Patient was continued on his home regimen of
amlodipine and labetalol
.
# ESRD- Patient is on hemodialysis MWFS via a R sided fistula.
The patient had missed dialysis the day of admission however
there were no current signs of volume overload on exam. He was
dialyzed the day of admission. He was continued on his home
nephrocaps and phos binder.
.
# Mild chronic diastolic congestive heart failure- Patient did
not have signs of volume overload. He was continued on his home
beta blocker.
.
# Hyperlipidemia- Patient was continue on his home statin
however the dose was decreased to 20 mg is also on amlodipine.
.
# PVD- Patient with history of significant PVD, s/p bilateral
BKAs. He was continued on his home aspirin and plavix
.
# Hypothyroidism- Patient was continued on his home
levothyroxine
.
TRANSITIONAL ISSUES
- Patient was DNI ok to resuscitate
- Blood and wound cultures were pending at the time of discharge
- Patient will follow up with Plastic surgery on ___
and his Primary Care Physician | 125 | 327 |
17562616-DS-7 | 22,630,834 | Mrs. ___,
___ was a pleasure taking care of you at ___. You were
transferred for further management of neisseria meningitis. You
were continued on the correct dose of antibiotics and completed
the appropriate IV antibiotic course. You also took 2 days of
oral meds to clear any colonization in your upper airway. All of
your close contacts should take the prescribed prophylactic
antibiotics to prevent infection.
During your stay you were found to have episodes of low oxygen
when walking around. You have been told in the past that you
might benefit from oxygen at home and it was reordered while you
were here.
Of note, our radiologists commented on small nodularities on
your right upper lung, which is likely from an old infection.
This should be followed by a 3 month chest ___.
You should follow up with your primary doctor when you return to
___.
Wishing you well,
Your ___ Medicine Team | ___ yo F with PMH of asthma, CAD s/p stents, HTN, multiple UTI's,
and OSA (not treated) who initially presented to ___
___ on ___ with T 104.5, left sided neck pain,
and hypotension. Started on ceftriaxone/azithromycin for PNA,
found to have neisseria bacteremia in 1 blood culture on ___.
Increased ceftriaxone dose to 2g Q12H on ___. Transferred to
___ ___ for further management of possible meningitis and
respiratory management.
# Meningococcal Meningitis: Since transfer pt afebrile,
hemodynamically stable, mentating well. Finished course of
ceftrixone last dose 2g IV on ___ in the AM for total 7 day
course from first dose. Also finished 2 day course of rifampin
PO 600 mg BID for nasal decolonization. Close contacts on
prophylaxis.
# PNA vs atelectasis on outside CXR: Pt initially started on
ctx/azithro, ctx increased for meninigitis and azithro held on
transfer out of less concern for pna. Repeat CXR shows
atelectasis only, lungs CTAB throughout stay.
# Asthma: Pt with cough variant asthma. No wheezing on exam but
pt desats on ambulation to 88 on room air. Pt states she has
been told she needs oxygen in the past but has not used it
except while flying, which she is very concerned about. Plan for
home oxygen and for flight home.
# CAD s/p stents: Without symptoms. Continued aspirin, plavix,
statin, beta blocker
# HTN: Normotensive. Continued spironolactone without need for
potassium supplementation.
# Paroxysmal atrial fibrillation- Found to be in a fib at OSH,
converted to sinus with mag administration. CHADS2 score 2
(although borderline diabetes hx). Has been in sinus during stay
here. Deferred to outpt ___.
# Hyperglycemia at OSH: no hx of DM but has elevated a1c of 6.3
and pt states she has been offered metformin in the past but did
not take it as her cardiologist told her not to. Was on sliding
scale while in house. Transitional issue for PCP to ___ | 150 | 316 |
18266518-DS-23 | 21,869,547 | You were admitted because you were feeling unwell. You appeared
very dehydrated and we gave you lots of fluid and held your
lasix. The CAT scan of your abdomen did not reveal the cause for
your pain. You also complained of vision loss however the eye
doctors did not find a reason for this. At discharge you were
able to tolerate food. You will need to follow up with your
doctor to work this pain up further. | ___ yo F with h/o SLE and chronic steroids and PVD presents with
abdominal pain x 2 days and elevated lactate. | 77 | 21 |
19383212-DS-21 | 27,946,108 | Ms. ___, you were admitted because of a fever. We thought
this was from a herpes outbreak because of your oral and vaginal
lesions. The lesions in your mouth are probably related to
chemotherapy because that can cause breakdown of mucous
membranes. We treated you with acyclovir for the outbreak and we
are sending you home with a prescription for this medication
which you should continue throughout the duration of your
chemotherapy unelss you hear otherwise from your oncologist.
We also had some concern that your port site could have an
infection but we monitored you carefully and it seemed to be
fine. Please call your doctor immediately if that site develops
any drainage or redness or tenderness. | ___ year old female with stage IIIC breast cancer on chemotherapy
(last ___, s/p Neulasta on ___ who presents with two
hours of fever, mouth sores and throat pain.
# Neutropenic fever: no source at this time. CXR unremarkable,
UA unremarkable. No skin findings, port site looks OK. Given
hard palate, labial, lateral lingual lesions HSV likely. She was
treated with IV acyclovir and cefepime, with discontinuation of
cefepime when no longer neutropenic. Her fevers were attributed
to HSV (mucocutaneous) and she was discharged with valacyclovir
1g BID x5 more days. She may benefit from prophylactic
valacyclovir with further chemotherapy. She was also discharged
with viscous lidocaine.
# Heel pain: patient with right-sided heel pain and hypothenar
erythema/blistering. This is most suggestive of palmoplantar
erythrodysesthesia, commonly seen with doxorubicin.
# Anemia: Hgb ~8. Likely related to bone marrow suppression from
chemotherapy. There were no signs of active bleeding.
# Breast cancer: Stage IIIc. EGFR+. S/p 4 cycles
doxorubicin/cyclophosphamide + Neulasta as neoadjuvant tx.
Planned for further neoadjuvant and then surgical removal of
primary mass.
# Hyperlipidemia: appears not currently on therapy.
# Hypertension: Normotensive here. Restarted home meds on
discharge.
# Anxiety: continued home lorazepam | 117 | 197 |
15945590-DS-10 | 25,930,173 | Dear Mr. ___,
It has been a pleasure taking care of you in the hospital. You
were admitted for chest pain and trouble breathing. You were
treated with intravenous antibiotics for pneumonia and diuretics
for your heart failure. During your hospital course, you were
found to have an infection in your knee. You had surgery and are
now on antibiotics which will require treatment for several
weeks. | ___ with dCHF, HTN, HLD, CAD, CKD, AF on warfarin who presents
with dyspnea and chest pain, found to have HCAP with septic
shock requiring intubation, septic arthritis of the left knee
s/p washout, and supratherapeutic INR.
ACUTE ISSUES
#Healthcare associated pneumonia complicated by septic shock and
hypoxic respiratory failure:
Patient presenting with dyspnea and found to have LLL pneumonia,
treated empirically for HCAP with vancomycin, cefepime, and
levofloxacin. Upon presentation in the ED, the patient was
intubated for hypoxic, hypercarbic respiratory failure. Patient
developed hypotension refractory to volume resuscitation and was
started on pressors with the presumed etiology being pneumonia
vs. septic arthritis. Patient was successfully extubated with
stabilization of his hemodynamic status. The patient completed a
full course for HCAP during his hospitalization.
#Septic arthritis:
Patient reportedly had knee pain prior to admission, was found
to have WBC 15,000 on arthrocentesis, though no culture growth.
Patient taken to the OR by Orthopedics on ___ for washout.
Patient previously had knee replacement in the same joint.
Culture of the intraarticular material from the washout grew
enterococcus. The patient had a PICC line placed and was started
on vancomycin. Infectious Disease was consulted and recommended
a beta-lactam antibiotic citing evidence that beta-lactams had
superior outcomes, but transition to a beta-lactam was limited
to the patient's reported penicillin allergy. Allergy evaluation
and testing was arranged for after hospitalization with the plan
of undergoing penicillin allergy testing, and if possible,
transition to a beta-lactam. IV antibiotics required for an
extended duration, likely six weeks. The patient has also been
arranged for Orthopedics follow-up.
#Metabolic Encephalopathy:
Patient had episodes of confusion after extubation while in the
ICU which persisted during his stay on the general medicine
floor. This was attributed to his hospital stay as well as his
infection. The patient did require occasional antipsychotics for
agitation. His delirium improved during the course of his stay,
though at discharge, was still off from baseline. The patient
was started on standing qhs olanzapine with improvement in his
agitation.
#Rash:
Patient found to have a maculopapular rash with excoriations on
his back. Given the distribution, it was thought that this
represented a dermatitis from being in bed. Other etiologies
considered included drug rash, though the distribution favored a
contact-type etiology. The patient was trialed on topical
corticosteroid during his stay.
#Chest pain:
Patient reported chest pain upon admission in setting of known
CAD. His troponin was found to be mildly elevated to 0.02, but
remained stable with normal MB component. Given the stability in
the enzymes and lack of EKG changes, there was low suspicion for
ACS.
CHRONIC ISSUES
#CKD Stage 3:
Patient with known chronic kidney disease, with baseline
creatinine of 1.5. During hospital course, creatinine rose to
2.9, likely secondary to ATN in setting of hypotension. His
creatinine improved over the course of his hospital stay.
#Afib on warfarin:
Rate well controlled during his stay. The patient was continued
on his rate-control and anticoagulant agents.
#Chronic Diastolic CHF:
Patient with known diastolic dysfunction. The patient was
continued on an adjusted course of torsemide, though metolazone
and spironolactone was held with no evidence of volume overload.
These agents might need to be added in the future should he
develop symptoms of fluid overload.
#Gout:
Patient with history of gout, continued on home allopurinol.
TRANSITIONAL ISSUES
-Patient will continue on IV antibiotics for extended period,
please maintain PICC until course complete.
-Patient will follow-up in ___ clinic. Please send weekly CBC
with differential, chem-7, vancomycin trough (prior to dose) and
ESR/CRP faxed to ___.
-Patient has an Allergy appointment scheduled in early ___,
please notify ID at ___ once the testing is complete.
-Patient CANNOT have antihistamines one week prior to allergy
testing (montelukast is OK) as this will affect the test.
-Please discontinue the olanzapine once the patient's delirium
resolves. | 66 | 618 |
14542372-DS-14 | 21,030,568 | Dear Ms. ___,
You were admitted to ___ after
a car crash and you sustained a head laceration which was
repaired with staples, as well as a minor liver laceration.
Your blood levels were trended and have remained stable. Your
diet was advanced to a regular diet, which you are tolerating,
and your pain is better controlled with pain medication. You
are now ready to be discharged home to continue your recovery.
Please note the following discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA. | Ms. ___ is a ___ y/o F who was involved in ___ as the restrained
driver, extricated by EMS. At OSH in ___ the patient had a
CT head, Cspine, Chest which were negative, and a CT
abdomen/pelvis suggestive of a liver laceration. She did have a
head laceration which was repaired with staples at the OSH. The
patient was transferred to ___ for further hemodynamic
monitoring.
Serial abdominal exams were performed and HCT was trended. HCT
remained stable. The patient did report some vaginal bleeding,
however, this was not felt to be traumatic in cause and was
believed to be due to menstruation. Upon arrival to the
surgical floor from the ED, the patient was agitated and stated
she wanted to leave AMA. The surgical team met with her to
discuss her plan of care and, given the patient's history of
mood disorder, ___ ___ from ___ visited with the
patient and her parents. A home medication regimen was obtained
and the patient was prescribed her home psychiatric medications.
Social work also met with the patient and her parents. Diet was
advanced to regular which she tolerated. IVF were discontinued.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 162 | 255 |
14137151-DS-6 | 28,634,726 | You were admitted to ___ after a fall. You were experiencing
numbness, pain and tingling in your extremities, MRI obtained
was concerning for cord injury at C3/C4. You were seen by
Neurosurgery and they recommended hard cervical collar to be
worn at all times and outpatient follow-up. You also had facial
fractures, a scalp laceration, and a scrotal laceration. Plastic
Surgery evaluated you and recommended bacitracin to the scalp
laceration and non-operative management of the facial fractures.
Because you fractured the bones around your left eye,
Ophthalmology did an eye exam which was normal. If you do
experience any vision changes, you should have your eye
re-examined. Urology was consulted and determined the scrotal
injury did not involve the genitourinary system. You were taken
to the operating room for a washout and repair of this injury.
There is a surgical drain that will remain in place until your
follow-up in clinic.
You are regaining your sensation and are medically cleared for
discharge home. Please note the following:
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 | Mr. ___ presented to the Emergency Department on ___ as a
trauma activation as described in the HPI above. He was
evaluated immediately upon arrival. Between ___ and our
institution he received CT head, CT C-spine, CT chest, CT
maxillofacial/sinus, and MR of the C/T/L spines. His injuries
were found to be a right perineal/scrotal laceration, nasal bone
fractures, left orbital floor fracture without entrapment, left
lamina papyracea fracture, C3-C4 narrowing felt to be possibly
degenerative changes however with clinical symptoms most
consistent with central cord syndrome, C6 superior endplate
fracture, and scalp abrasion with underlying hematoma.
Neuro/MSK: The patient was alert and awake throughout his
hospitalization with appropriate mental status. He was seen by
neurosurgery and ___ for his central cord syndrome and C6
superior endplate fracture. He was initially admitted to the ICU
for pressor support to achieve MAP goal of >85 while awaiting
final determination of whether he had any spinal cord injury.
Ultimately the spine service determined that he should be
managed with at least 1 month of cervical collar, outpatient
f/u, and required no logroll precautions or elevated MAP goal;
he will follow up as an outpatient and may be a candidate for
elective surgery for his C3-C4 area of narrowing. He was
therefore transferred from the ICU to the floor on hospital day
2. His symptoms gradually improved over the course of his
hospitalization and at discharge he was ambulating independently
with improved motor control of his upper extremities. He
continued to have paresthesias and some weakness of his arms and
hands. Occupational Therapy worked with him multiple times and
recommended additional rehabilitation.
His pain was managed with IV medications and subsequently
transitioned to PO medications. At his request, narcotics were
minimized given his prior history of substance use disorders. He
was also noted to have facial fractures as above for which
plastic surgery was consulted; they recommended elevating HOB
and conservative management.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: He was seen by urology in the ED for his complex
scrotal and perineal laceration; his testicle was determined not
to be violated and they recommended washout and repair per ACS
vs. plastic surgery. He was therefore taken to the operating
room early in the morning on ___ for washout, drain placement,
and closure of his scrotal and perineal laceration. There were
no adverse events in the operating room; please see the
operative note for details. Pt was extubated, taken to the PACU
until stable, then transferred to the ICU for observation.
After leaving the operating room, diet was advanced sequentially
to a regular diet, which was well tolerated. Patient's intake
and output were closely monitored. His Foley catheter was
removed and bladder scans were monitored in case of any
neurogenic bladder issues; he was able to void successfully and
spontaneously.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. He received 5 days of Ancef
for his contaminated scrotal laceration. On discharge he was
transitioned to Keflex to complete the 5 day course.
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
venodyne 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. | 362 | 626 |
18435540-DS-11 | 27,595,580 | Discharge Instructions
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.
Onc:
- Will consider restarting chemotherapy after wound evaluation
at first follow-up.
- Check at least 1 CBC w/ diff at rehab per oncology team
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, Xarelto) until cleared by the
neurosurgeon.
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 | On ___, Mr. ___ presented to the ED at an OSH after a
fall. ___ showed a right subdural hematoma; he was given
KCentra and transferred to ___.
#Subdural Hematoma
The patient was admitted to the ___ for close neurologic
monitoring of his subdural hematoma. Anticoagulation was held
in the setting of acute hemorrhage. Repeat CT showed stable
hematoma. The patient was taken to the OR on ___ and underwent
a right craniotomy for subdural hematoma evacuation. He
tolerated the procedure well and was extubated in the operating
room. He was later transferred to the ___ for close monitoring.
On ___ the patient was transfused with one unit of FFP,
and his subdural drain was removed.
#Atrial Fibrillation
The patient has a history of atrial fibrillation on xarelto,
which was held on admission. The patient was noted to be in
atrial fibrillation with a right bundle branch block on EKG with
frequent PVC's. Cardiology was consulted who recommended
changing his long acting metoprolol to Q6H dosing. He was
cleared from a cardiovascular standpoint for surgery on ___.
He should remain of Xeralto until cleared by Neurosurgery, this
will be determined at his follow up appointment in 4 weeks.
#Thrombocytopenia
Hematology was consulted for recommendation regarding
anticoagulation reversal and recommended a full dose of KCentra
due to history of CLL and chemotherapy. Hematology recommended a
platelet transfusion in the OR for surgery on ___. | 551 | 237 |
18079244-DS-23 | 29,246,716 | It was a pleasure participating in your care at ___. You were
admitted to the hospital and found to have a blood clot in your
leg and possibly lungs. You have been treated with blood
thinning medicine for this. You were also found to have extra
fluid in your chest outside of the right lung called a pleural
effusion. You have decided to follow up with Interventional
Pulmonology as an outpatient for possible drainage of this
liquid.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
colace, senna, warfarin (blood thinner), tylenol
Medications STOPPED this admission:
lisinopril (given kidney function) - this should be addressed
with your primary care doctor regarding resuming this medicine.
Medication DOSES CHANGED that you should follow:
metoprolol succinate was decreased from 75mg daily to 25mg
daily.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
** It is very important that you call your PCP or come into ED
for any changes in your breathing or for fevers given your
pleural effusion (fluid around the lung)** | Ms. ___ is a ___ with history of PCKD, congenital hepatic
fibrosis, recently admitted for Klebsiella sepsis with course
c/b inferior STEMI while in the MICU, left arterial line
thrombosis, and RUE line associated superficial clot who
presented from rehab with chest pain x 2 days, found to have RLE
DVT, now heparinized and with course complicated by acute on
chronic renal insufficiency, hypovolemic hyponatremia and a
decreased hematocrit.
# RLE DVT and likely PE: The patient was found to have RLE DVT
and given her presentation, likely that she has a PE; CTA was
deferred given her renal function. The patient was started on a
heparin drip; heme was consulted and said that a heparin drip
was ok in the setting of her thrombocytopenia. The patient as
monitored on tele. Her chest pain improved while she was
continued on her heparin drip. She was also using supplemental
O2 as needed for comfort. Her initial trops were 0.06-0.07 ___K-MB and there was no new ischemic changes on EKG or RV
strain. The patient was ultimately bridged with heparing to
warfarin with goal of being therapeutic with INR ___ for 2 days
on both heparin and warfarin. She was discharged on warfarin.
# Right sided pleural effusion: ddx includes secondary to
pulmonary embolism or fluid overload from MICU stay. Patient
deferred thoracentesis and preferred instead to followup with
interventional pulmonology as outpatient. She had no fevers or
leukocytosis suggestive of empyema. She will have follow-up
with interventional pulmonology to monitor this issue.
# hyponatremia: The patient developed hyponatremia during this
hospitalization, with nadir of 125 without any neurologic
symptoms. Unclear etiology. Renal was consulted and was
thought that this could be due to consumption of large amount of
free water, although exact etiology of her hyponatremia remains
unknown. The patient did ultimately improve with addition of
salt tablet, blood products, and free water restriction.
# Anemia: The patient was found to have decreased hematocrit a
few days into her treatment with heparin drip. No obvious
source of bleeding was identified. She was transferred 2U PRBC
after which hematocrits remained stable.
# recurrent clots: The patient has history of multiple clots in
the past, including DVT in the setting of OCPs and smoking s/p
coumadin, arterial thrombus and PICC associated clot, both
occurring on her previous admission, and now with likely PE.
The patient was found to have positive lupus anticoagulant on
last admission. Heme was consulted and the lupus anticoagulant,
anti cardiolipin antibody, and anti phospholipid panel were
sent. The patient will follow up as an outpatient with
hematology to determine the duration of her anticoagulation, and
ultimately discuss whether lifetime anticoagulation is
indicated.
# hypotension: The patient was triggered for hypotension
initially on the floor, was thought to be related to IV pain
medications, as well as possible vasovagal episode. Pressures
were otherwise stable during the admission, and she was started
back on low dose metoprolol. Her lisinopril was held in the
setting ___ (see below). She was also monitored on tele.
# CAD s/p STEMI: During recent hospitalization found to have
STEMI, subsequent ECHO with EF of 40% with systolic dysfunction.
EKG on this admission with no new ischemic changes, CK-MBs
flat, trops 0.06-0.07 in the setting of her CKD. The patient
was continued on her ASA. Her metoprolol and lisinopril were
both initially held. The patient's metoprolol was restarted a
lower dose, but her lisinopril was held in the setting of ___.
She was continued on her atorvastatin 80 mg daily.
# thrombocytopenia: Likely in the setting of her congential
hepatic fibrosis and resulting portal HTN and splenomegaly. As
per heme recommendations, it was ok to start heparin drip in the
setting of thrombocytopenia.
___ in setting of PCKD: The patient has baseline creat
1.7-1.9, but notable for fluctuance in the past. Creat bumped
to 3.2, renal U/S and doppler flow reassuring. Creat was
trended and medications were renally dosed, and nephrotoxic
agents were avoided. Upon discharge, the patient's creat had
returned to its baseline.
# congenital hepatic fibrosis: The patient has history of
congenital hepatic fibrosis complicated by portal HTN, 2 cords
of grade 1 esophageal varices, and splenomegaly. While she was
anticoagulations, she was monitored for s/s of bleeding.
# Depression/anxiety: The patient was continued on her home
buproprion and sertraline. | 174 | 747 |
10123421-DS-19 | 29,885,856 | You were admitted to ___ for
chest pain. We treated you with medications for your chest pain
and then you underwent a cardiac cath. You cardiac cath
revealed 2 blockages that will be treated with medications. You
will need to start new medications (see below for details).
Please follow up with your primary care doctor and your
cardiologist.
Medication Changes:
START taking dabigatran (pradaxa) 150mg by mouth every 12 hours
START taking clopidogrel (plavix) 75mg by mouth daily
START taking lisinopril 20mg by mouth daily
START taking isosorbide mononitrate (imudr) 30mg by mouth daily
START taking aspirin 81mg by mouth daily
START taking atorvastatin 80mg by mouth daily
INCREASE metoprolol succinate to 400mg by mouth daily
STOP taking Warfarin
STOP taking simvastatin
Continue taking sotalol 120mg by mouth daily
Continue taking Furosemid 40mg by mouth as needed for ankle
edema | The patient is a ___ year old female with a history of AFib on
Warfarin, hypertension, and hyperlipidemia who presents with new
unstable angina and an abnormal stress test performed at ___
___.
.
#Unstable Angina/CAD- The patient reported new exertional chest
pain and SOB over the last two weeks prior to hospitalization.
A stress testing at ___ was reportedly positive, and
she was sent to ___ for further workup. She continued to have
chest pain with minimal exertional with no EKG changes. Her
troponin trending upward from 0.01->0.02->0.03->0.03. She was
taken for cardiac cath that revealed two vessel coronary artery
disease with severe apical LAD lesion and diffusely disease
mid-distal LAD not favorable for PCI due to length of disease or
CABG given absense of graftable target in the mid-distal LAD.
She was started on aspirin 325mg daily, clopidogrel 75mg daily,
atorvastatin 80mg dialy, and isosorbide mononitrate 30mg dialy.
She will need further medical optimization as an outpatient.
.
#. atrial fibrillation- The patient has a history of atrial
fibrillation treated with Warfarin, Metoprolol succ 200mg daily,
and Sotalol. She had inadequate rate control and was uptitrated
to metoprolol tartrate 200mg BID, which acheived good rate
control (80-90's on tele). Her INR was subtherapeutic at 1.6 on
initial labs, but was held pending cardiac cath. The patient
was started on Pradaxa 150mg BID the night after her cath. She
was discharged on sotalol 120mg BID and metoprolol succinate
400mg daily.
.
#. hypertension- The patient demonstrated elevated systolic
blood pressure to the 170-180's. She was started on lisinopril
and uptitrated to 20mg dialy prior to discharge. She was
discharged on metoprolol XL 400mg, Imdur 30mg daily, and
lisinopril 20mg daily for BP control. She should follow up with
her PCP for further optimization for her hypertension.
.
#. Hyperlipidemia:She has been on Simvastatin 80 mg, but will be
switched to Atorvastatin to optimize cardioprotection.
.
#. thalassemia- prior diagnosis. Her CBC demonstrated
microcytic anemia with HCT in mid to upper 30's. She should f/u
with her PCP for further evaluation and treatment. | 134 | 349 |
12225562-DS-3 | 21,890,511 | Dear Mr. ___,
It was a pleasure taking part in your care during your
hospitalization at ___. You underwent diagnostic work up
because you lost conciousness, fell, and struck your head while
at ___. Your fall was most likely
due to orthostatic hypotension, low blood pressure when you are
standing. We recommend that you drink plenty of fluids, and
that you rise slowly when changing from sitting to standing.
Because you struck your head, we did a CT-scan to look at your
brain. A small amount of blood was seen in your brain. Blood
can irritate the brain and cause seizures. We have put you on a
medication to prevent seizures for 1 week. You have already had
2 days of this medication and only need to take it for 5 more
days.
You have schizophrenia and were being seen at ___
for psychosis. It is important for you to continue in patient
treatment for pyschosis. Managing mental illness is
challenging, continue to take your antipsychotic medications and
keep intouch with your providers.
You had some abnormalities on EKG, a study of electrical
conduction in your heart, howevever, these do not seem to be
new. You had no evidence of a heart attack. You did not have any
symptoms while in the hospital, and an ECHO of your heart showed
normal heart function. You should discuss with your primary
care provider if you have questions about these findings.
It was a pleasure participating in your care.
We wish you the best of luck! | Mr. ___ is a ___ with history of HTN, schizophrenia
transfered from ___ Unit after a witnessed
syncopal episode.
# Syncopal episode: Mr. ___ was folding laundry at ___
___ when he fell and struck his head. He had LOC for 10
minutes and altered mental status. He had no witnessed seizure
activity. He was transfered to ___ with stable vital signs.
Labs taken the ED were unremarkable, and he was evaluated for
trauma with CT-Head and Spine, CXR, Pelvic XR. CT Head showed a
small subarachnoid hemorrhage, which was likely a result of his
head strike and which would not have contributed to altered
mental status. Neurosurgery evaluated the patient and made
recommendation for Keppra seizure prophylaxis 500mg BID x7days,
24hr observation, but no other follow up needed. Cardiogenic
cause of syncope was ruled out with EKG and ECHO. The patient
was kept on tele and had no events. Patient tox screen was
negative. The patient had orthostatic hypotension, and it's
possible this was an orthostatic episode complicated by head
strike. We repleted him with IV fluids.
#C4 on C5 anterolithesis: CT C-spine showed multi-level
degenerative changes mild anterolisthesis of C4 on C5 -probably
degenerative, but acute process cannot be excluded without prior
images. Patient had no spine tenderness, full range of motion,
no neurlogic deficits, no distracting injuries, and C-collar was
removed when his mental status stabilized.
#Subarachnoid hemorrhage: Small traumatic subarachnoid
hemorrhage was seen on CT Head. Neurosurgery evaluated patient
and felt no acute intervention was appropriate given size of
hemorrhage, and that such a small hemorrhage would not explain
mental status change. Patient had q4h neuro checks x24 hours,
and was placed on seizure prophylaxis, Keppra 500 BID x 7days,
and seizure precautions. Ibuprofen held.
# Schizophrenia: Patient has history of schizophrenia and was
being treated at ___ for psychosis since
___. We continued his haldol 5mg PO BID, but he refused
many doses. No other psychopharm was given to the patient due
to his refusal.
# Delirium: Patient had waxing and waning mental status
consistent with delirium. He was seen by psychiatry who agreed
with keeping his on haldol 5mg BID. Nursing measures were taken
to reduce delirium risks.
# Abnormal EKG: EKG showed RBBB and diffuse ST elevations with
question of PR prolongations concerning for nodal conduction
disease. TTE showed no wall motion defects, no valvular defects,
nl HF. BNP and trops were neg x2. QTc 362. Patient had no
episodes of arrhythmias on tele. No interventions were done.
# Rhabdomyolysis: Patient had elevated CKP 1514, most likely do
to use of physical restraints prior to ___ admission. He was
given IVF, and Cr was stable 0.9-->0.7. CK trended down.
# Right shoulder sublaxation: Noted on imaging. Had altrecation
with ___ with resultant injury. Previously controlled with
Ibuprofen, but held in setting of bleeding. Tramadol was given
in house. Patient should have outpatient orthopaedics visit for
further management.
# Hypertension: cont'd home amlodipine, lisinopril
# CODE STATUS: Presumed Full
# CONTACT: ___ ___ ask for nursing supervisor,
___ | 258 | 516 |
11345609-DS-14 | 21,193,001 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
and right sided weakness resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is bleeding in the brain. 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:
- High blood pressure
We are changing your medications as follows:
- continue lisinopril 40mg daily
- continue labetalol 100mg three times daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ man with history of uncontrolled
HTN who initially presented with right face and arm weakness and
was subsequently found to have a left frontoparietal
intraparenchymal hemorrhage.
#Left frontoparietal IPH:
The hemorrhage was thought to be secondary to hypertension as
patient's systolic blood pressures were initially greater than
200. He also has longstanding history of hypertension but has
not been on medication because he has not regularly seen a
doctor.
Patient underwent MRI to evaluate for other causes of hemorrhage
but there was no evidence of underlying mass or vascular
malformation. A repeat MRI is recommended in 3 months.
Patient was evaluated by speech therapy, occupational therapy,
and physical therapy who recommended rehab.
#Hypertension:
Patient initially required nicardipine infusion to maintain SBP
less than 150. He was then transitioned to oral
antihypertensives. Blood pressures were well controlled on
lisinopril and labetalol at time of discharge.
Echo was done because of longstanding hypertension. Echo showed
normal EF. IT also showed a mildly dilated ascending aorta. A
follow-up echocardiogram is suggested in ___ year.
#Oropharyngeal dysphagia: patient initially failed swallow eval
so NG tube was placed. On subsequent evaluations, his swallowing
improved and he was advanced to modified diet. He was tolerating
modified diet so NG tube was removed.
# Alcohol use disorder: Patient endorsed drinking several beers
per night so he was initially placed on CIWA protocol. He never
exhibited signs of withdrawal.
=========================================================
Transitional Issues:
[ ] monitor blood pressure. titrate medications as needed
[ ] repeat MRI in 3 months
[ ] PCP follow up
[ ] Neurology Follow Up
[ ] repeat echo in ___ year
=========================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () 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? (x) Yes - () No | 280 | 361 |
18583455-DS-19 | 22,191,377 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to manage an infection in
your legs. You were given antibiotics and your infection
appeared to resolve rapidly. We discharged you with a short
course of antibiotics to complete your therapy.
Please be sure to complete your antibiotic course and attend all
follow-up appointments.
Thank you for allowing us to be part of your care. | ___ woman with history of HTN, chronic pain, presenting with
10d chest pain s/p fall and found to have possible bilateral
lower extremity cellulitis, managed with IV antibiotics, course
c/b febrile episode with rigors, tachycardia and relative
hypotension.
Acute Issues
========
#Cellulitis c/b SIRS (sepsis): Though patient presented with
chest pain, bilateral lower extremity edema was noted in the
emergency room, prompting her admission to the hospital. She
received 6 doses of IV vancomycin during her stay with rapid
resolution of her erythema to her baseline venous stasis
pattern. Patient was febrile to 102.9 overnight into HD2, with
tachycardia and relative hypotension as low as SBP 105. She had
received one dose of IV vancomycin prior to the episode. She
rapidly defervesced and her hemodynamics stabilized. Blood
cultures drawn during this episode were negative at time of
discharge. She was seen by neurosurgery for evaluation of
possible abscess or osteomyelitis related to her spinal
stimulator, wound dehiscence, or recent battery pack relocation.
Though ESR and CRP were elevated, CT of thoracic and lumbar
spine were benign and showed her stimulator to be in place.
Though patient had a recent tooth extraction, the surgical site
appeared clean and non-erythematous. No other potential cause
of her SIRS could be identified. She had been afebrile for 48
hours on day of discharge. She is being discharged on a course
of PO antibiotics for cellulitis.
#MUSCULOSKELETAL CHEST PAIN: Cardiac workup was negative, and
her symptoms and history were consistent with her recent fall as
the inciting event. She was continued on her home pain regimen
and her discomfort was well-controlled throughout admission.
#DYSKINESIA: Patient was given ropinirole initially on admission
as this was on her medication list provided to our team. On the
morning of HD2 she was noted to have intermittent myoclonus in
the hands and feet. On further questioning, she reported having
stopped her ropinirole some time ago. The medication was
discontinued and her myoclonus rapidly resolved.
Chronic Issues
=========
#HTN: Patient was continued on her pre-admission amlodipine and
lasix.
#DEPRESSION/ANXIETY: Patient was continued on her pre-admission
cymbalta, nortriptyline, and ambien.
#CHRONIC PAIN: Patient was continued on her pre-admission pain
regimen as above.
Transitional Issues
============
- Patient would benefit from adjustment of her pain regimen, as
she is reporting some unsteadiness, which may have contributed
to her fall.
- Please follow-up final results of blood cultures
- complete course of antibiotics for cellulitis and f/u with PCP
for resolution
- f/u with ___ with Dr. ___ in approximately 2
weeks
- referral to ___ Pain ___ (per pt request) | 73 | 428 |
15634195-DS-17 | 29,448,117 | You were admitted to the hospital and found to have orthostatic
hypotension. Your blood pressure drops when you go from a lying
to standing position. We have adjusted your medications, and
you are now only on diltiazem 30mg three times per day for your
blood pressure.
When you go from a lying or sitting to standing we recommend
that you sit for ___ minutes before standing. Once you stand,
give yourself a minute before you begin walking. We have set up
a visiting nurse to come to the house and check your blood
pressures. If you continue to feel dizzy despite following
these recommendations please call our office, or your PCP, ___.
___. | Mr. ___ was admitted for orthostatic hypotension. His
blood pressure medications were adjusted. He was taken off
flomax 0.8mg daily on this admission, and his diltiazem was
decreased again from 120mg extended release daily, to 30mg short
acting three times per day. His PCP, ___ was involved
in the medication titration. He had a carotid duplex wich
showed patent right internal carotid artery stent, and mild
heterogenous plaque in the left common carotid with less than
40% stenosis. He continued to have some orthostasis with BP's
on discharge of 131/180 hr 71 lying; 125/73 hr 75 sitting and
100/63 hr80 standing. He had very minor sypmtoms of a slight
dizzy feeling when standing but this resolved when he rested
for a few minutes. We educated him on the need to have his
blood pressure checked often at home by a ___, as well as the
need to rest for several minutes when transitioning from sitting
to standing. Also once standing he needs to rest a minute
before walking. He is able to comply with these instructions
and is feeling well and stable for discharge home. He has close
follow up with his PCP. He will follow up with vascular surgery
in a month. | 118 | 215 |
15802145-DS-21 | 28,871,195 | 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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
Physical Therapy:
NWB LLE
Treatments Frequency:
Splint: please leave splint on until follow-up appointmen with
Dr. ___ in ___ days. | The patient was directly transferred from an outside hospital
and was evaluated by the orthopedic surgery team. The patient
was found to have displaced left calcaneus fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for closed reduction
and percutaneous pinning (CRPP) of the left calcaneus, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight-bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 153 | 246 |
13173458-DS-17 | 29,000,055 | Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because of abdominal pain. You were found
to have a small bowel obstruction related to your ___
Disease. You were seen by the gastroenterology team and your
symptoms were treated conservatively. On hospital day ___ you
were passing gas and having stool. You tolerated a liquid diet
and we advanced you to a soft diet. You will need to follow-up
with gastroenterology about further treatment of your ___
Disease.
You wanted a prescription for flagyl to take home. Please take
500mg every 8 hours for 7 days. Do not drink alcohol while
taking this medication.
You should see your primary care doctor about receiving the
hepatitis B vaccine series. Your prednisone was being tapered
by your outpatient GI team. Your last dose was 5mg on ___.
You should not take more prednisone unless directed by your
outpatient gastroenterologists. | This is a ___ gentleman with a history of ___
disease, recurrent SBO admitted with abdominal pain. KUB shows
dilated small bowel, but air remains in colon.
# ABDOMINAL PAIN: Likely SBO in the setting of ___.
Patient has had side effects from multiple ___ medications
and as such, is just on prednisone. He will need to see his
outpatient gastroenterologist about more definitive treatment
for his disease. On this admission, patient was kept NPO and
his diet was slowly advanced. Never had an NG tube placed. He
was able to tolerate soft food on day of discharge. Of note,
KUB on day of discharge did not demonstrate resolution of SBO
and in fact, showed even less air in the colon. However, Mr.
___ felt well, had no pain or nausea, and was passing gas
and having bowel movements. He insisted on going home although
he was encouraged to stay one more night. Also told to just
take in full liquids for now. He knows to call his outpatient
GI team if his symptoms worsen. Mr. ___ requested a
prescription for flagyl (he has used this for flares in the
past) and was given this to take at home.
Patient was taking prednisone 5mg QD at home. Dr. ___ was
trying to taper this off. Patient received one dose of
methylpred 20mg on admission, but no further steroids. He will
be discharged without prednisone.
GI had wanted patient to receive first dose of HBV vaccine
during admission. Unfortunately, this was not coordinated
before he was discharged.
# PRURITIS: Treated with antihistamines and sarna lotion. | 165 | 280 |
14940609-DS-8 | 29,285,690 | Dear ___,
___ was a pleasure taking care of you in the hospital. You were
admitted for evaluation of calf pain and found to have a DVT -
deep vein thrombosis - a clot in your leg. You were started on
Lovenox and warfarin to thin your blood. You will need close
monitoring of your blood levels for the first part of treatment
until the levels stabilize. Please go to your primary care
physician's office on ___ morning to have your blood drawn
(see below). The office will help you adjust your dose. Use
the Lovenox injections until they tell you to stop. This will
be when your INR (warfarin level) is > 2.
You began to have bleeding again after your Provera was stopped.
We discussed your case with Dr. ___, and they
will see you on ___ during your scheduled appointment.
**Please call their office immediately if you have bleeding that
requires more than one pad per hour for more than one hour at
___
Please see the attached medication list for your updated
medication list.
Please STOP Provera. | ___ with hx of asthma and menorrhagia on Provera here with R
calf pain found to have a fluid collection and DVT on ___.
.
# DVT: Likely provoked by recent Provera use and relative
immobilization from fatigue. Pt has no signs or symptoms of PE
and no history of blood clots. She was started on lovenox bridge
to warfarin. Her goal INR is ___. PCP office was contacted and
appropriate follow up for anticoagulation was arranged. Pain was
managed with standing tylenol and prn tramadol.
.
# ___ fluid collection: Unlikely to be infectious, more likely
all related to DVT and decreasing in size. Discontinued Keflex.
.
# Menorrhagia: GYN team made aware of discontinuation of
Provera. Iron supplements continued. Patient began to have
withdrawal bleed on day of discharge which was mild. She was
advised per the GYN team to call Dr. ___ she
require more than one pad per hour for over one hour.
.
# Anemia: Follow up with GYN, continue iron supplements. Stable
during this admission and has appointment with GYN on ___.
.
# Asthma: Continued home albuterol and monteleukast.
.
.
Transitional Issues:
- Communication: Patient, ___ (dtr) ___
- follow up with PCP, anticoagulation management
- INR checks and warfarin dose adjustment | 182 | 210 |
14199097-DS-6 | 29,310,767 | Dear Mr. ___,
You were hospitalized due to symptoms of weakness resulting from
an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High cholesterol
- High blood pressure
We are changing your medications as follows:
- Start aspirin 81mg daily
- Start atorvastatin 20mg daily
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
You are being advised not to drive at this time. Please follow
up with a driving assessment as outpatient. You can get this
referral through your primary care doctor's office.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team | Mr ___ is a ___ ___ WWII Veteran with PMHx of high risk
prostate cancer, HTN, central retinal vein occlusion and fall
with head strike without loss of consciousness one week prior
who presented to the ___ ED one day after a 20 minute episode
of sudden onset left sided weakness and garbled speech. Head CT
was obtained that showed no acute intracranial hemorrhage, mass
effect or any evidence of an acute large territorial infarction.
However, because of the sudden onset and the left sided
symptoms, he was admitted to the stroke neurology service for
workup.
MRI/MRA head was performed to assess for stroke with revealed a
small focus of diffusion abnormality at the left frontal
convexity region consistent with a subacute infarction. MRA of
the head did not reveal any major abnormalities. | 311 | 132 |
18233845-DS-17 | 23,284,485 | Dear Ms. ___,
You were admitted to the hospital because you had chest pain and
felt short of breath. This is because your heart was not pumping
as well as it should, and so fluid built up in your lungs. You
were given a diuretic medication to help get the fluid out of
your lungs. Also, your heart was beating abnormally fast with an
abnormal rhythm called A Fib, and so we gave you medications to
slow down your heart rate. Finally, we found that you had a clot
in your heart and also in your leg. We started you on a blood
thinner to help the clots dissolve.
You were started on a number of new medications in the hospital.
Please continue to take these medications as prescribed when you
go home. Please weigh yourself every morning when you go home,
and call your doctor if your weight goes up by 3lb.
It was a pleasure taking care of you!
- Your ___ team | Ms. ___ is a ___ yo woman with a history of hypertension
who presented with cough and chest pain, found to be in atrial
fibrillation with a rapid ventricular rate and acute HFrEF (LVEF
20%). Chest CT on ___ and then TEE on ___ showed a right atrial
appendage thrombus and so cardioversion was deferred. Lower
extremity ultrasound ___ showed right DVT, but CT torso with
contrast with no signs of malignancy. Her atrial fibrillation
and acute systolic heart failure were medically managed; patient
discharged with PCP and cardiology follow up.
# Atrial fibrillation with RVR: She has no known history of
atrial fibrillation and presented with palpitations for the
prior ~3 days. Unclear precipitant though could be secondary to
recent URI and viral cardiomyopathy; history of negative
coronary angiography in ___, so less likely to be ischemic. Of
note, she complained of palpitations to her PCP in ___,
though unclear whether these were undiagnosed atrial
fibrillation vs. NSVT. She was initially given diltiazem in the
ED, with plan for cardioversion. However, ___ demonstrated RA
thrombus and so cardioversion was deferred given risk of
pulmonary embolus. Additionally, amiodarone was deferred given
20% risk of chemical cardioversion. Therefore atrial
fibrillation was managed medically with rate control and
anticoagulation without attempt at rhythm control. She was
initially difficult to rate control despite therapeutic digoxin
and increasing doses of metoprolol tartrate, ultimately at 50 mg
q6h. Due to persistent tachycardia in the 130s-160s, diltiazem
was initiated on ___ and ultimately uptitrated to 30 mg q6h
with good effect, keeping in mind her depressed LVEF, a relative
contraindication to diltiazem or verapamil. At discharge, she
continued to be in atrial fibrillation but was rate controlled
well, with ventricular rates in the ___ at rest. For rate
control she was discharged on digoxin 0.125 mg every other day
and diltiazem ER 120mg daily. Her home metoprolol succinate dose
was increased from 100mg to 200mg daily. She was anticoagulated
with dabigatran 150 mg bid. She will follow up as outpatient
with Dr. ___ potential outpatient TEE/cardioversion once
anticoagulated x 4 weeks.
# DVT and right atrial appendage thrombus: CT ___ and TEE ___
with 3x1.9cm RA thrombus, ___ ___ with right posterior
tibial DVT. Given that the RA thrombus was nestled against the
cardiac wall and not free-floating, and no signs of extension
from the IVC, it was felt to be likely secondary to atrial
fibrillation rather than an embolus from DVT, IVC, or elsewhere.
The patient was initially started on rivaroxaban 20 mg daily but
was subsequently switched to dabigatran 150 mg BID given
potential for enhanced anticoagulation with BID dosing and
higher potency. She tolerated this well with no issues.
Diagnostically, these concurrent blood clots, with history of
prior thrombophlebitis in ___, are concerning for a
hypercoagulable state. The differential includes
inherited/sporadic thrombophilia and malignancy.
Antiphospholipid testing (cardiolipin Abs, beta-2-glycoprotein
Abs, lupus anticoagulant) was negative. We deferred rest of
thrombophilia workup to outpatient setting once clots resolve.
In regards to malignancy, she had no evidence on CT
chest-abdomen-pelvis, but could still ___ a cancer somewhere,
such as the colon. She stated she is up to date on mammograms
but not colon cancer screening or pap testing. Of note, she has
had 10-pound weight loss since ___ and complains of
decreased appetite. There is a family H/O gastric cancer in her
mother. She was discharged on dabigtran 150 mg BID, a new
medication.
# Acute HFrEF. Previously normal LVEF (___), now with LVEF
20% on TTE ___, with elevated pro-BNP but normal troponin-T.
The etiology was not entirely clear. Distribution of
hypo-/akinesis somewhat consistent with Takotsubo; could be
tachycardia-induced cardiomyopathy from atrial fibrillation with
RVR. Alternatively, viral cardiomyopathy (given recent URI)
might have triggered new atrial fibrillation. Cardimyopathy
likely non-ischemic given reportedly normal coronary angiography
___. She had mild volume overload on exam with shortness of
breath and received intermittent diuresis with furosemide
boluses with good effect for her diastolic heart failure. She
was also started on captopril, later switched to lisinopril 5mg,
for afterload reduction given reduced EF, though this was
discontinued on day of discharge due to hyperkalemia to 5.6. She
was discharged home on furosemide 60mg PO daily, a new
medication, as well as diltiazem, digoxin, and metoprolol
succinate as above.
# Hyperkalemia: Patient had potassium of 5.6 on ___, repeat
whole blood sample was normal at 4.2. Chemistry ___ again
showed hyperkalemia to 5.5, repeat whole blood sample was 4.9.
This is most likely secondary to ACE-inhibition and so
lisinopril was discontinued. BUN/Cr within normal limits
therefore not due to renal insufficiency, also no signs/symptoms
of digoxin toxicity and on a very low dose so dig toxicity
highly unlikely. Potassium should be monitored as an outpatient,
please check this value at PCP follow up on ___.
# Chest pain: On admission, patient presented with atypical,
nonexertional pain, with chest wall tender to palpation, and was
diagnosed with musculoskeletal pain. Troponin-T and CK-MB were
negative in the ED and again on ___ and ___, and EKG showed no
acute ST changes. History of coronary angiography in ___
with reportedly no CAD. Therefore pain felt to be most likely
musculoskeletal, secondary to coughing given persistent URI. She
was given acetaminophen and lidocaine patches as needed with
good effect. If chest pain persists as outpatient, cardiology
can consider outpatient stress testing.
# E. coli uncomplicated UTI: She spiked a fever to 102.2 on ___
and had UA with WBCs and +nitrites and urine culture growing E
coli. She was asymptomatic, with no dysuria or flank pain.
However, given her persistent atrial fibrillation with RVR, with
cardioversion not an option, it was felt to be reasonable to
treat a potential infectious source to limit any ongoing
triggers for her AF and decrease her cardiovascular demand. She
was initially started on IV ceftriaxone and then switched to
Bactrim given pan-sensitive E. coli for a total 3-day course and
remained afebrile and asymptomatic.
# Hypertension: Patient has history of hypertension, on
amlodipine and metoprolol at home. Amlodipine was stopped
because of diltiazem use for synergy in rate control. Captopril
was added for LVSD. She was discharged home on metoprolol
succinate 200 mg daily as above (up from 100 mg on admission),
diltiazem and captopril.
TRANSITIONAL ISSUES
[ ] Hyperkalemia on day of discharge (5.5) and day prior (5.6),
so lisinopril discontinued. Please recheck K at PCP follow up on
___ to ensure normal value.
[ ] Consider completing hypercoagulability workup: Protein C/S
deficiency, factor V leiden, antithrombin deficiency,
prothrombin gene mutation testing. For malignancy workup:
colonoscopy, pap testing, mammogram.
[ ] Dr. ___ office to arrange cardiology follow up
[ ] New medications: Furosemide 60 mg daily, digoxin 0.125 mg
q2d, dabigatran 150 mg bid, diltiazem ER mg 120 daily
[ ] Changed meds: Metoprolol succinate 200 mg daily (from 100 mg
daily)
[ ] Discontinued meds: amlodipine
[ ] Discharge weight: 59.2 kg
[ ] Discharge Cr: 0.7
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (daughter) ___ | 165 | 1,149 |
14340944-DS-12 | 27,344,509 | Please follow up with the appropriate studies. You will see the
interventional pulmonologists on ___. On ___ you should
see your primary care doctor and call Dr. ___ office
to discuss getting pulmonary function tests (spirometry and
DlCO), a PET scan and a VQ scan. | The patient was admitted to the thoracic surgery service with a
new diagnosis of a lung mass. There was concern on the OSH CT
chest of a pulmonary embolism but upon review with our
radiologists this was not the case. While here he started a
pre-op workup for lung mass resection. He underwent a CT head
with contrast (final read pending). He also met with the
interventional pulmonologists who scheduled an appointment for
bronchoscopy on ___. He will go home and get the remainder
of the requested studies there. (LFTs, VQ scan, PET scan)
While in the hospital he remained afebrile with stable vital
signs. He had serial tropnins which were negative. He tolerated
a regular diet and had normal bowel and bladder function. | 45 | 124 |
18062069-DS-20 | 26,179,955 | Dear ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ with shortness of breath and
vomiting. Fortunately, you did not have a blood clot as the
cause of your symptoms. You were instead found to have fluid in
your lungs that was treated with a diuretic, lasix (furosemide).
You urinated well after this and your breathing improved. You
should take oral lasix for 4 days, with some potassium tablets
as well to keep your potassium levels normal.
You were also very constipated. It will be important for you to
continue to take medications to help move your bowels especially
while taking narcotic pain medicines.
You should not resume taking your sotalol on discharge. You will
need to see Dr. ___ in 2 weeks to address whether you should
restart this or begin another medication.
If you should have worsening shortness of breath, chest pain, or
any other concerning symptom, please let your doctors ___.
Again, it was our pleasure participating in your care.
We wish you the best,
-- Your ___ Medicine Team -- | PRIMARY REASON FOR ADMISSION:
Ms. ___ is a ___ with a history of atrial fibrillation
(recently started on warfarin and sotalol 2 weeks ago) and DVT
many years ago who had a bunionectomy on left foot on ___ who
presented with shortness of breath and evidence of heart failure
on exam. | 177 | 52 |
17008218-DS-18 | 27,364,768 | Discharge Instructions:
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:
-Nonweightbearing right lower extremity in the splint
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 daily for 2 weeks then ASA 325mg for 2
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.
- 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
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
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 any new medications/refills. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right trimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right ankle 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'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
nonweightbearing in the right lower extremity, and will be
discharged on lovenox x2 weeks then asa 325 x2 weeks 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. | 571 | 262 |
17504528-DS-20 | 28,488,247 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | The patient was admitted for further evaluation. Echo done by
Cardiology showed no tamponade physiology. Coumadin continued
for mechanical valve. She developed AFib with rapid response.
EP was consulted. Amiodarone started. She became tachy-brady
and lopressor was discontinued. EP did not recommend a
permanent pacer. She will be discharged with ___ of Hearts
monitor to be managed by Dr. ___. She is discharged on
hospital day five with follow-up instructions. Dr. ___
continue to manage anti-coagulation. | 121 | 86 |
13699514-DS-13 | 29,719,031 | Dear Ms. ___,
It was a pleasure taking care of you.
You came to the hospital because you had a fall.
We did a workup, and you had no injuries.
You were safe to go home.
Please see you Doctor on ___ for followup | Ms. ___ is a ___ year-old-woman in senior living housing
with ___ weekly ADL assistance as well as PMH of HTN, well
controlled Diabetes Mellitus, hypothyroidism bilateral knee
replacement who presents with left knee pain and shoulder pain
after falling while using her walker at home. | 39 | 47 |
13551252-DS-19 | 29,826,935 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You came to the hospital because you had breakthrough seizures
likely due to nausea and vomiting from a gastroenteritis.
Your seizure medicine was switched to IV formulation until you
could tolerate medicine in your enteral tube. You stopped
vomiting and your tube feeds were resumed. Then, your medicines
were switched back to enteral formulation.
Now that you are leaving the hospital, you will continue to take
your medicines as previously prescribed. Please follow-up with
your doctors, as listed below.
We wish you the best,
- Your ___ Team | ___ is a ___ woman with severe intellectual
disability, microcephaly, and spastic cerebral palsy,
intractable epilepsy with frequent seizure clusters and status
epilepticus in the setting of infection (likely
gastroenteritis), now admitted with a cluster of seizures and
vomiting.
#Breakthrough seizures
Infectious workup was unremarkable (UCx, CXR, BCx). She was on
Unasyn for several days but this was stopped given no clear
infectious etiology. Her Keppra 2g BID and Vimpat 150 mg BID
were switched to IV formulation given her emesis. Her zonisamide
400 mg QHS was continued in G tube formulation. Her EEG showed
no seizures, but did show generalized R>L spike and spike and
wave discharges and slowing R frontal central area. Her tube
feeds were resumed and after she tolerated feeds for 24 hours,
Vimpat and Keppra were returned to G tube formulation. She
remained without further emesis throughout her hospitalization.
She has brief eye deviation to the right at times throughout the
day, which her mother reports are seizures. These are at
baseline.
#Constipation
She intermittently had constipation which was resolved with a
bowel regimen (see medication worksheet). She was having near
daily bowel movements prior to discharge.
TRANSITIONAL ISSUES:
====================
Follow-up with epilepsy as an outpatient
No changes made to her AEDs
Ensure daily bowel movement
Check chem 10 once a week to assess need for mag or K+ repletion | 99 | 218 |
11588493-DS-17 | 26,792,245 | Ms. ___,
It was a pleasure caring for you at ___. You were seen in our
hospital for trouble swallowing. We found evidence of a fungal
infection, called "thrush," in your mouth. We also did an EGD
(endoscopy) to evaluate for any obstruction or mass or infection
to cause your trouble swallowing. Fortunately, this test did
not show any abnormalities.
Please continue all your medications as prescribed. Please
continue the Nystatin rinse for 5 more days. Follow up with your
surgeon, PCP, and GI doctors as ___. If you have a
question, do not hesitate to ask. | Ms. ___ is a ___ year-old woman with recent prolonged
hospitalization for abdominal pain, s/p biopsy of benign
abdominal mass, OSA, morbid obesity, asthma, GERD, depression,
and anxiety, who now presents due to odynophagia and inability
to tolerate PO intake.
ACTIVE ISSUES
=================
# Odynophagia
# Thrush
Following a prolonged hospitalization at ___
___, she now presents with difficulty taking PO and
Odynophagia, and a feeling of pills/food getting "stuck" in her
throat. This was new since her last hospital stay, but unlikely
to be related to her abdominal mass. A1C/TSH normal, HIV
negative. In setting of thrush in oropharynx, antibiotic use,
and chronic inhaled corticosteroid for asthma, the dx of ___
esophagitis was considered (also HSV esophagitis given h/o
perioral HSV). She thus underwent EGD with biopsy on ___.
Fortunately, no evidence of esophageal infection or abnormality
was found. She was given Nystatin QID for thrush, as well as
Magic Mouthwash.
# Difficulty taking PO
She was initially resuscitated with 2L IVF, but taking stable PO
intake prior to discharge. Of note, she does have long history
of abdominal pain, thought to be possibly somatoform vs IBD vs
gastroparesis. Also, worth noting low BUN and albumin,
indicating likely poor nutritional status overall.
- Continue home Morphine, Omeprazole, Sucralfate
# Abdominal Mass: She was discussed at a joint GI/Surgery
conference on ___. Plan is ultimately for definitive surgical
management in the future as outpatient, and this appointment is
scheduled. She completed her 14 day course of Cipro/Flagyl for ?
infected mass post-biopsy while inpatient.
# Thrombocytopenia: PLT 125-142, from 150-200's during prior
hospital stays. No evidence of bleeding. Recommend outpatient
recheck
# Coagulopathy: INR 1.3-1.4, from 1.2 last admit. Likely
nutritional given poor PO intake overall. Recommend outpatient
recheck.
CHRONIC ISSUES
=================
# Depression/Anxiety:
- continue home fluoxetine 20mg DAILY, lamotrigine 125mg DAILY,
trazodone 100mg QHS, Ativan 1mg PO BID
- held brexpiprazole 2mg QHS as not on formulary, but OK to
resume on discharge
- continue nighttime Prazosin 3mg QHS
# Asthma
- continue Fluticasone Propionate 110mcg 2 PUFF IH BID
- continue Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
# Obstructive sleep apnea
- continue home BIPAP
TRANSITIONAL ISSUES
===================
- Was previously on Cipro/Flagyl for coverage of a possibly
infected mass that was recently biopsied. Completed this course
in house.
- Discharged on Nystatin oral suspension QID to treat thrush, 5
more days as od ___
- No changes made to any of her other chronic home medications
- EGD biopsy results pending on discharge
- Mild thrombocytopenia, platelets of 142,000 on day of
discharge. Recommend outpatient recheck.
- Mild coagulopathy, INR 1.3 on day of discharge. Likely
nutritional. Recommend outpatient recheck. | 100 | 442 |
10934976-DS-13 | 22,597,409 | #Brain Hemorrhage with Surgery
Surgery:
- You underwent a surgery called a left-sided mini craniotomy to
have blood removed from your brain.
- You underwent a surgery to embolize the vessels contributing
to the bleed in 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.
This is to prevent bleeding from your groin.
- 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.
- You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
- Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
- You make take a shower.
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.
Care of the Puncture Site:
- Keep the site clean with soap and water and dry it carefully.
- You may use a band-aid if you wish.
What You ___ Experience:
- Mild tenderness and bruising at the puncture site (groin).
- 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
- Bleeding from your groin incision
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 | #Moderate TBI
#Bilateral acute-on-chronic subdural hematomas, left > right
___ male transferred from OSH with bilateral
acute-on-chronic subdural hematomas, left bigger than right,
after an intoxicated fall down the stairs. He was found to have
7mm of rightward midline shift on his initial scan. He was
urgently taken to the OR with Dr. ___ left
___ for subdural hematoma evacuation - please see
Dr. ___ report for further details. A subdural
drain was left in place that was hooked up to an EVD set-up and
leveled at the iliac crest. It was removed on ___. He was
extubated and brought to the Neuro ICU for close post-operative
monitoring. A post-operative NCHCT was done on POD1 that showed
expected post-operative changes as well as an improvement in the
rightwards midline shift. Course complicated by ETOH withdrawal
and ongoing nausea for which he was treated with Compazine with
good effect. On ___ patient underwent bilateral MMA coil
embolization for management of his chronic subdural collections.
Patient tolerated the procedure well and was transferred back to
the ICU post operatively. His neuro exam continued to improve,
and patient was called out of the ICU to the floor on ___.
Physical Therapy worked with the patient during his admission
and progressed him for discharge home. Patient was medically
stable for discharge on ___.
#Alcohol use disorder complicated by ETOH withdrawal
On POD1, the patient was scoring on the CIWA scale and received
a Phenobarbital load. He was also started on daily Thiamine,
Folic acid and a Multivitamin and resumed on his home Lactulose
at 30mg TID. Loaded with phenobarb for ETOH withdrawal on ___
and required rescue dose on ___. Addiction consult was placed
for recommendations and recommendations were appreciated. He
remained stable through remainder of admission.
#Afib
Patient continued on his home diltiazem on a split dose of 30mg
Q6 hrs. Upon discharge he can resume his normal home dose of
120mg ER daily. | 706 | 318 |
13047349-DS-22 | 26,366,530 | Dear ___,
___ were admitted because ___ had a severe infection to your
colon. We treated ___ with antibiotics and fluids. ___
fortunately improved and are feeling better.
Please continue your medications as explained further down. We
strongly recommended ___ to have a visiting nurse to help ___
with medications and home safety but ___ declined.
It was a pleasure to take care of ___.
Your ___ Team | PRIMARY ONCOLOGIST: ___, MD
___, MD
PRIMARY CARE PHYSICIAN: ___, MD
PRIMARY DIAGNOSIS: Stage III pancreatic cancer, unresectable
TREATMENT REGIMEN: C3 Gemcitabine/pb-Paclitaxel (d1: ___
Mrs. ___ is a ___ year-old lady with stage III pancreatic
cancer on C3 of
gemcitabine/pb-paclitaxel complicated by PVT on enoxaparin
presenting with fever, diarrhea and found to have colitis on
imaging.
#Sepsis
#Acute Bacterial Colitis
#Hypovolemia
Patient presented with 3 days of high grade fevers, copious and
frequent non-bloody diarrhea with mucus. CT Abdomen/Pelvis
significant for ascending and transverse colitis. C.difficile
NAAT was negative. Differential is broad but there is
significant concern for bacterial etiology given high grade
fevers and colonic
involvement. Thus was covered with ceftriaxone and metronidazole
(d1: ___ diagnoses include viral colitides,
ischemic colitis (increased risk given PVT), idiopathic
inflammatory colitides. Patient with fever, bandemia,
tachycardia, hypotension meeting sepsis criteria. Significant
need for volume repletion given volume loss due to GI losses.
Patient defervesced on day 2 of admission. Diarrhea improved
incompletely on day 3 of admission. Given mild eosinophilia
consideration for helminthic etiology was given. Stool testing
negative for coccidian and O&Px1. O&P#2 pending upon discharge.
Patient was discharged to complete 7 day course of antibiotics.
#Presumed Pancreatic insufficiency: Patient was empirically
started on pancrelipase supplementation with vast improvement
but not complete resolution of diarrhea. She was given a 30 day
prescription for therapeutic trial.
#Chronic hypotension and Orthostatic hypotension: Patient had
BPs in low ___ in most of her clinic visits. At multiple
times during admission dropped BP as low as low ___ while
completely asymptomatic in bed. Upon review of vital flowsheets
from prior admissions the same phenomenon was observed. During
this admission was concurrently hypovolemic due to diarrhea, BPs
responded to IVF boluses initially but not after 3 days.
Cosyntropin stimulation test completed with appropriate response
at 60min (>20). Given intermittent dizziness/lightheadedness
while going to the bathroom and history of previous falls she
was started on midodrine titrated to SBPs>90.
#Anemia: Likely has anemia of chronic inflammation due to
malignancy at baseline. ___ have had some blood loss from
colitis but mostly hemodilution in setting of aggressive fluid
resuscitation. Required 2U PRBC during admission.
#Unresectable pancreatic cancer: On completed C3 of
gemcitabine/pb-paclitaxel (___). Plan for next cycle when
infection resolved and functional status improved.
#Portal vein thrombosis: Like secondary to her tumor pancreatic
tumor. Was continued on enoxaparin 100mg sc daily throughout her
admission.
#Bipolar disease: Well compensated during the admission.
Continued aripiprazole 30mg daily and fluvoxamine 150mg bid.
#Cancer-related pain: Secondary to likely neural invasion of
mass. Was continued on oxycontin 30mg q12h standing and
oxycodone 10mg q3h for breakthrough.
TRANSITIONAL ISSUES:
#Antibiotic course: To complete antibiotic course with
cefpdoxime 400mg bid and metronidazole 500mg q8h through ___.
#Helminth work-up: O&P #2 and Strongyloides IgG. Please
follow-up and treat accordingly if positive.
#Orthostatic hypotension: Discharged on midodrine 10mg tid. ___
be titrated down/off after completing antibiotics and fully
reconditioned.
#Pancrelipase: Discharged on 30-day therapeutic trial, may hold
when diarrhea completely resolved to see if significant benefit.
#Given patient's difficulty understanding medications and
unclear home safety in terms of fall risk we strongly
recommended her having a ___ but she declined. Please consider
discussing this with her.
___ than 60 minutes were spent planning and coordinating the
discharge of this patient. | 65 | 551 |
14720755-DS-12 | 25,788,892 | 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:
-Weightbearing as tolerated left lower 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 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 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.
- 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
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip CRPP, 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 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
weightbearing as tolerated in the left lower extremity, and will
be discharged on home anticoagulation 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. | 503 | 256 |
14541045-DS-21 | 27,660,356 | Dear Ms. ___,
It was our pleasure to care for you at ___.
You came to the hospital because of abdominal pain and low blood
pressures.
WHAT HAPPENED IN THE HOSPITAL?
- you had blood work done which showed a decrease in your liver
function which was suspected to be possibly from your cancer
treatment
- you were started on oral steroids to help your liver function
- your liver numbers started to improve
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with your oncologist
- continue taking all your medications as directed
- please continue taking your prednisone (steroid) at the
current dose until instructed to decrease it by your oncologist
We wish you all the best!
Sincerely,
Your care team at ___ | ___ F w/ a significant PMH of recurrent metastatic SCLC on
nivolumab who presents for eval of worsening RUQ abd pain found
to have significant transaminitis
#RUQ Abd Pain
#Acute Transaminitis
Currently afebrile and HD stable; no leukocytosis; unknown
etiology at this time with concern for worsening metastatic
disease vs. immunotherapy induced hepatotoxicity. Hepatology
consulted with recommendation to pursue ___ guided biopsy of
healthy tissue (non-metastatic dz) to make this differentiation.
___ guided biopsy initially planned, however on additional review
of imaging, ___ feels there is no healthy liver to biopsy.
Further work up with AMA (negative), ___ (weakly positive), and
HCV (negative). Patient was started on empiric prednisone 60mg
qday for treatment of suspected immunotherapy related hepatic
toxicity with outpatient follow up and anticipate prolonged
taper depending on her response to steroids. She was also
started on a PPI and calcium/vit D while on steroids. PJP was
not started in the setting of acute hepatic failure, though
could be considered if she will remain on high dose steroids for
a prolonged period of time.
#Metastatic NSCLC with transformation to small cell lung cancer
- s/p 4 cycles of palliative carboplatin and etoposide
- s/p C2 (of 4) of nivolumab [complicated by rising TSH]
- s/p C3D1 (of 4) of nivolumab on ___
- hepatic and osseous lesions are progressing
- c/w home inhalers and pain control
- will follow up with outpatient Dr. ___ on ___
___ for repeat LFT check and evaluation
#Hypothyroidism
- likely immune mediated adverse event ___ nivolumab
- c/w home levothyroxine 137mcg PO daily
#HLD
- held home Atorvastatin 40mg PO qPM given transaminitis
#MDD
- decreased dose to 20mg fluoxetine PO daily in setting of
hepatic impairment
===================== | 117 | 267 |
16133054-DS-18 | 28,997,921 | Dear Ms ___,
You presented to ___ on ___ after having an abdominal CT
scan at an outside hospital which was concerning for gallstones
and fluid collection. At ___, you had a MRI of abdomen which
was concerning for inflammation of your pancreas. You were
admitted to the Acute Care Surgery team and were transferred to
the surgery floor for further medical management.
On ___, you underwent an ERCP with sphincterotomy procedure
and your gallstones were removed. You tolerated this procedure
well. On ___, you underwent a laparoscopic cystectomy where
your gallblader was removed. You tolerated this procedure well.
You were given IV fluids for rehydration and bowel rest. You
were then advanced to a regular diet which you tolerated. You
tolerated oral medicine and ambulated and are now medically
cleared to be discharged to home to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | ___ year-old female who was transferred from ___ to
___ on ___ with choledocholithiasis and gallstone
pancreatitis. The patient had complaints of nausea and abdominal
pain, as well as diarrhea. At ___ she had CT scan
which was concerning for choledocholithiasis and pericholecystic
fluid. She was given Levo,flagyl and transferred to ___ for
further evaluation. ERCP was consulted and they recommended an
MRCP. She was admitted to the Acute Care Surgery team for
further medical evaluation.
She was made NPO and given IV fluids and antibiotics. On
___, she had an MRCP which revealed choledocholithiasis,
cholelithiasis and mild acute pancreatitis. On ___, the
patient underwent an ERCP with sphincterotomy and stone removal.
She tolerated this procedure well.
On ___, the patient underwent a laparoscopic
cholecystectomy. She tolerated this procedure well. She was
started on a clear liquid diet and was evaluated by the
Nutrition team to aid with increased caloric intake. Her
diarrhea resolved spontaneously and her C. Diff test was
negative. She was advanced to a regular diet and oral pain
medicine which she tolerated.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 824 | 284 |
10608839-DS-9 | 21,703,356 | Dear Mr. ___,
It was a pleasure caring for you. You were admitted because you
passed out. This was likely caused by a dehydration
("hypovolemia") which may or may not have led to atrial
fibrillation with rapid heart rate.
You got better with IV fluids and better oral intake, and
controlling your heart rate.
We wish you the best in your recovery!
Sincerely, your ___ Team | Mr. ___ is a ___ male with afib/aflutter s/p
ablation, anxiety, hx of DVT with new bilateral PEs and newly
diagnosed pancreatic adenocarcinoma s/p duodenal stenting and
ERCP with CBP metal stent placement and duodenal stent placement
with hospital course complicated by recurrent afib w/ RVR and
hypotension requiring ICU admissions, now more recently slow GIB
from tumor eroding into stent, readmitted with syncope
presumably from hypovolemia +/- RVR. | 63 | 69 |
16893819-DS-16 | 21,927,876 | Dear Ms. ___,
You were admitted to the hospital for abdominal pain and
management of your pain medications and constipation
medications. Your regimens were readjusted and you were started
on a fentanyl patch. You should continue to take your pain
medications and constipation medications as prescribed. You are
now safe for discharge home with close follow up.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Oncology Team | ___ w/ recently diagnosed recurrent metastatic high grade serous
ovarian carcinoma w/ diffuse peritoneal disease (initially Stage
IIc s/p total abdominal hysterectomy, b/l salpingo-oophorectomy,
pelvic and paraaortic lymph node dissection, and omentectomy in
___, who presents with chronic crampy abdominal pain
without acute findings as well as alternating constipation and
diarrhea in the setting of pain and constipation medication
management. She had port placed for planned outpt chemotherapy
while in house.
# Abdominal Pain
Etiology is most likely due to extensive peritoneal malignant
disease. As noted on her diagnostic lap on ___, she has
"diffuse peritoneal disease, especially in the right upper
quadrant, diaphragm with central tendon bulky disease, small
bowel disease with adhesions to the umbilical area, left lower
quadrant disease diffuse with adhesions of the large bowel to
the pelvic sidewall." Admission CT did not reveal any acute
process. By history, her pain is concurrent w/ her diagnosis of
ovarian ca and has no provoking factors and constantly present,
suggestive of disease related pain. She has had no acute change
in the quality of her pain. She is moving gas and stool. RUQ U/S
showed No cholelithiasis. Discussed with gyn/onc; no further
role for surgery at this time.
She was given bentyl PRN cramps and continued amitriptyline qhs,
supportive pain control w/ po morphine, apap, avoid IV meds for
dispo pending, and started on fentanyl patch 12 for longer
duration of coverage. continued colace/senna, PRN milk of mag
for constipation. regular diet tolerated well throughout
admission. will follow up with outpatient onc, likely plan
continuing chemotherapy as outpatient now that she is s/p PICC
placement with ___.
# Ovarian Cancer, Metastatic, Recurrent
She is now on C1D12 of carboplatin every 3 weeks. She will be
due for C2 on ___.
Dr. ___ updated, will f/u outpatient.
discussed with gyn/onc; will discontinue estrogen for
optimization of response to chemo. Now s/p port placement ___
while patient inpatient. discharged after port for further
outpatient care. Continued pain management and bowel regimen as
above. | 72 | 331 |
17656673-DS-10 | 25,456,750 | Dear Ms. ___,
You were admitted with heavy vaginal bleeding, likely
attributable to a fibroid. Please take the provera as prescribed
and continue your oral contraceptive pills. You also need to
take iron twice daily. If your bleeding increases or you feel
dizzy or lightheaded, please call your gyn provider or our
office at ___ right away.
You have a follow up appt with your primary gyn on ___, it is
important that you go to this appointment. If you have any
problems with this please feel free to call the ___ clinic at
___.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ presented to the emergency department for heavy
menstrual bleeding she was then admitted to the gynecology
service for observation. Her bleeding had become minimal on
admission. She was monitored and her bleeding stoppped
completely. Her vitals remained stable and she was asymptomatic
from an anemia standpoint throughout her admission. She was
started on iron and provera and discharged with close outpatient
follow up scheduled. | 112 | 66 |
16564743-DS-27 | 26,051,577 | 1. 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.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. 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.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches that need to be removed will be
taken out at your follow-up visit.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. 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. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Sutures will be removed at yoru follow-up
visit.
11. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, PICC line assessment, IV infusions.
Weekly labs - CBC/diff, Chem 7, LFTs and send to ID RNs at
___.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Physical Therapy:
WBAT
Mobilize
Treatments Frequency:
dry, sterile dressing changes daily and as needed for drainage
wound checks
ice
TEDs
**staple removal will be at first follow up appt.** | The patient was initially admitted to the Medicine service for
worsening right hip pain. A CT was performed showing a hematoma
in the right gluteal region. The patient also developed
parasthesias and weakness in the sciatic distribution with a
true right foot drop. At that point he was transferred to the
Ortho service with a symptomatic postoperative hematoma. He was
taken to the OR by Dr. ___ evacuation of the hematoma on
___ at which time cultures were sent. These cultures
ultimately grew MSSA and the patient was started on Nafcillin
and taken back to the OR for ___, hardware removal, ABX spacer,
and wound VAC on ___. These cultures showed proteus in the
tissue and yeast in the fluid so ID recommended switching from
nafcillin to cefepime with initiation of micofungin. Following
further speciation micofungin discontinued & started on
Voriconazole. After sensitivities returned on yeast,
voriconazole changed to fluconazole. He was found to be bleeding
from the wound and required serial transfusions. Postoperatively
his VAC failed and due to persistent bleeding so he was taken
back to the OR on ___ for repeat ___ and VAC placement. He
continued to require multiple transfusions and resuscitation and
ultimately was transferred to the Trauma ICU, with transfer to
floor following stabilization. Patient underwent repeat ___ on
___ and interval repeat ___, antibiotic spacer exchange &
wound closure on ___.
***************
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room on multiple occasions for the
procedures described above. Please see separately dictated
operative reports for details. In general the patient tolerated
the procedures well but had significant blood loss and
ultimately required multiple transfusions and ICU monitoring. He
received antibiotics as directed by the ID team. | 493 | 291 |
19410858-DS-17 | 28,654,269 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for a mass in your pancreas. You had
a procedure to look in your bowels and there was a narrowing
found near your pancreas. This was opened up and sample were
taken. You also had an MRI (picture of your abdomen) to better
look at the lesion in your pancreas. After your procedure, you
had vomiting that was brown and concerning for blood. Your blood
count remained stable and you did not have any further episodes.
Because your blood pressure was well controlled while you were
in the hospital, we are only restarting Doxazosin upon your
discharge. Please talk with your PCP about restarting the other
medications. Please continue to take your current medications as
directed. | ___ year old man with several days of nausea, vomiting, and
epigastric pain, found to have pancreatic lesion & CBD
dilatation. Patient was admitted for ERCP and MRCP to evaluate a
pancreatic mass found on imaging at an outside hospital.
# Hematemesis: Had episode of coffee ground emesis on ___.
Hematocrit remained stable. He was started on an IV PPI.
# Pancreatic lesion/CBD dilation: Appears cystic though concern
for malignancy as well. Based on MRCP findings, the lesion is
cystic. Brushings of the CBD showed atypical glandular cells.
This will require further evaluation to ensure there is no
malignancy.
# Hypertension: Well controlled at this time. The patient's
blood pressure medications were stopped in the setting of
hematemesis, blood pressures remained well controlled. | 134 | 124 |
14257008-DS-11 | 21,826,325 | Return to ED for temperature > 101.5
Take cipro for 10 days | Patient was admitted to the urology service. CTU showed no
signs of obstruction or ureteral leak. Patient was started on
empiric vanc/ceftriaxone and spiked his last fever on the early
morning of ___. He was transitioned to cipro on the morning of
___ after his ___ cultures were found to have
grown 50k E coli sensitive to cipro. Given that he remained
afebrile through the evening of ___, he was discharged home at
that point. At the time of discharge, he was voiding on his
own, tolerating a regular diet, and had pain well controlled.
He was given explicit instructions to follow up with urology.
He was instructed to return to the ED if T >101.5. | 11 | 123 |
10716756-DS-6 | 23,094,962 | Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for recurrent fevers
What was done for me while I was in the hospital?
- You were treated with broad spectrum antibiotics while we
searched for a cause of your infection.
- Your fevers were determined to be caused by your cancer.
- A CT scan of your belly revealed a blood clot in one of your
veins. You were started on a blood thinner to help treat the
clot.
- You had an endoscopic biopsy of your lymph nodes to help guide
your chemotherapy regimen.
- You were started on FOLFOX chemotherapy.
- You were treated with stunting for a blockage in your biliary
drainage system.
- You improved and were ready to leave the hospital. You did
have a fever and elevated white blood cell count before you
left, but we believe this is related to your cancer rather than
a new infection.
What should I do when I leave the hospital?
- Take your medications as prescribed and go to the follow up
appointments that we have arranged for you.
We wish you all the best!
Sincerely,
Your ___ Care Team | SUMMARY:
=========
___ w/ metastatic gallbladder adenocarcinoma now C1D6 on FOLFOX,
PMHx of metastatic neuroendocrine carcinoma of the GB s/p 8
cycles of cisplatin/etoposide (___) and open
resection of gallbladder and liver segment 5 (___), admitted
for FUO with hospitalization c/b partial R portal vein
thrombosis now on Lovenox and atypical chest pain during ___
infusion, now s/p successful ___ challenge, with course further
complicated by thrombocytopenia and hyperbilirubinemia, found to
have biliary stricture, now s/p ERCP with fully covered metal
stent to common hepatic duct on ___. | 206 | 86 |
10515141-DS-3 | 26,282,235 | Dear ___,
___ was a pleasure taking care of your during your stay here at
___.
You came to the hospital because of a headache and high blood
pressure. You were found to have a blood pressure in theh
200s/100s. We gave you medication to lower your blood pressure
which worked. We started you on a new medication which we would
like for you to take every day and follow up with your primary
care doctor about your blood pressure. It is also very important
that you avoid salty foods such as ___ sausage etc.
Please check your blood pressures while at home in the morning.
If the top number is above 180 please call your primary care
doctor.
The following changes have been made to your medication regimen:
START amlodipine | **consider repeat outpt TTE for eval of AS and LVH**
___ y/o woman with PMHx HTN, LVH and mild AS (mean gradient 12mm
Hg) presenting to the ED with hypertensive emergency.
.
# Hypertensive Emergency: Likely related to increased NaCl
intake and undertreated HTN given LVH. Given blurry vision,
concern for end organ damage. When I saw patient she no longer
had headaches. We continued home lisinopril 40 and started
amlodipine 5 and was given IV labetalol (while in ER) and when
on the floors was given PO 100TID. Cardiac enzymes checked adn
were negative. Nutrition consulted to educate patietn about low
salt diet. She is discharged on lisinopril and amlodipine and
will check her BPs at home regularly and follow up with her PCP.
# Aortic Stenosis: Last echo ___. Patient has a cardiologist
who she sees as follow up . Recent echo from ___ showing
Aortic Valve - Peak Velocity: *2.5 m/sec Aortic Valve - Peak
Gradient: *25 mm Hg Mild to moderate (___) aortic
regurgitation was also seen. She also has LVH. Patient will
follow up with her cardiologist, and should have echo done
___.
.
# Positive UA: Given she was asymptomatic, no indication to
treat so we did not start antibiotics.
.
# R Knee Effusion: Likely related to miniscal tear, as patient
endorses swelling after skiing assocaited with "clicking" and
decreased ROM. No erythema or warmth to suggest infection or
crystal arthropathy. ROM is currently back to baseline.
Patient will follow up with ortho
TRANSITIONAL ISSUES
#R knee effusion: patient should follow up with ortho
#HTN: should be followed and amlodipinen should be increased as
needed. | 129 | 281 |
13958446-DS-35 | 28,810,617 | Dear Ms. ___,
You were admitted to the hospital with a fast heart rate,
diarrhea and shortness of breath. It was found that you had some
fluid in your lungs which was drained. This fluid had cancer
cells in it that were consistent with your known lung cancer.
You also had a lung infection which was treated with antibiotics
and your symptoms improved. Your condition has improved and you
can be discharged to your facility. | Ms. ___ is an ___ yo with a history of metastatic NSCLC (mets
to brain and bone), multiple GI bleeds ___ angioectasias,
diverticulosis, CAD s/p CABG, Afib, AVR in ___, ___ (last ECHO
showing EF 50-55% in ___ admitted with acute onset of SOB in
the setting of watery diarrhea found to have pneumonia with
associated malignant pleural effusion. Treated with levofloxacin
and had a thoracentesis for pleural effusion drainage with
symptomatic relief.
# Community acquired pneumonia:
Treated with a 7-day coruse of levofloxacin with symptomatic
improvement. She remained afebrile and hemodynamically stable.
# Malignant left sided pleural effusion:
Underwent thoracentesis on ___ and cytology with malignant
cells consistent with known metastatic NSCLC. Had significant
symptomatic relief after thoracentesis. Repeat CXR on ___
without evidence of reaccumulation of effusion. However, given
that this is malignant it is likely to reaccumulate and has
follow-up scheduled in the interventional pulmonology ___
clinic.
# NSCLC with progression/Goals of care:
Patient has known metastatic NSCLC with right hip metastasis now
s/p XRT. CXR from ___ shows high left lung tumor burden and as
described above also with malignant pleural effusion. After
discussion with patient's HCP and in conjunction with PCP's
notes, goals have been to move patient towards hospice and
___, but was not officially made "comfort measures only".
Several unnecessary medications were discontinued we focused on
pain control. Right hip pain was her primary complaint and
long-acting narcotics were carefully uptitrated with improved
pain control.
# Atrial fibrillation with rapid ventricular rate
Patient has a known history of Afib, not currently
anticoagulated given goals of care. CHADS2 score of 3, was
previously anticoagulated on aspirin but given goals of care
discussion as detailed in patient's PCP note from ___,
unnecessary medications were discontinued. Patient came in with
Afib w/RVR associated with shortness of breath and some
dizziness. Patient did take her Metoprolol Succinate 100mg at
home per report on day of admission and did not receive further
rate control in ED. Was in sinus on transfer to MICU. Was
restarted on home metoprolol and called out to floor where her
rate was well controlled. | 74 | 352 |
19938958-DS-18 | 21,970,619 | Dear Ms. ___,
You were hospitalized for work up of vertigo or dizziness. There
are 2 main reasons for dizziness. One reason is due to the
peripheral nerves in the inner ear and the other reason is due
to the brain such as a stroke. Due to the fact that you have had
many short episodes of dizziness before, it was improved with a
maneuver to dislodge the calcium crystals in your inner ear and
now you do not have any more symptoms, we believe that most
likely the cause of your dizziness is because of a nerve problem
and not because of a stroke. Your MRI did not show a stroke or
blood clot in your head. | ___ is a ___ year-old right-handed woman with HTN, HLD,
inflammatory bowel/diverticulitis s/p resection, strong family
history of hypercoagulability who presents with perisistent
vertigo, acute occipital HA, and episode of confusion.
Initially, her exam is with minimal abnormality-- there is right
torsional nystagmus
on right gaze, +head-impulse to R, and she is falling to R on
exam but has intact cerebellar exam, normal strength, vision,
and
fundi. Her dizziness improved with meclizine and zofran in the
Emergency Room. Her dizziness was resolved with the Epley
manuever in the Emergency Room. Although it appears she has
many symptoms consistent with peripheral vertigo, the acute
occipital HA, episode of confusion and severe vertigo in the
context of familial
hypercoagulability is concerning for possible sinus venous
thrombosis. Ms. ___ has a MRI/MRA/MRV which was showed no
sinus venous thrombosis or stroke. Ms. ___ symptoms
completely resolved. She is able to walk without assistance.
Thus, she was discharged home with meclizine prn and asked to
follow up with her primary care doctor in next few weeks. | 118 | 176 |
19229949-DS-5 | 25,235,460 | Angiogram with Embolization of Right Vertebral Artery Dissecting
Aneurysm
Medications:
Take Aspirin 325mg (enteric coated) 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 activities you can and cannot do:
When you go home, you may walk and go up and down 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 that is draining, as needed
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
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
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 our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room! | Ms. ___ was admitted to the Neurocritical care unit for
close neurological monitoring and critical care in the setting
of Subarachnoid hemorrhage and ruptured aneurysm. She was
started on Nimodipine for vasospasm prophylaxis and dilantin for
seizure prophylaxis. Systolic blood pressure was maintained
less than 140.
She underwent cerebral angiogram on ___ with coiling of the
diessecting right vertebral artery aneurysm. She was recovered
in the ICU on a heparin gtt for 48 hours. Systolic BP post
procedure was maintained strict under 140 to reduce chance of
migration of coils. Plain skull images were done the following
am and were compared to the intra-angiogram images. No coil
migration was noted.
She remained stable neurologically and follow up CT imaging does
not demonstrate any cerebral infarct on ___. Headache
management has been a challenge. There also was concern that
she was exhibiting signs of alcohol withdrawal on hospital day
#5 and small doses of Ativan were given. Her TCD's remained
stable. She remained in the Neuro ICU with a stable exam.
On ___ she had an episode of bradycardia during which she was
normotensive. Followup EKG was normal and she had no further
episodes. On ___ she was stable in the ICU with increasing
urine outputs so labs were done to assess for any endocrinologic
abnormalities that could be causing this and she was placed on
florinef by the ICU.
MRI/A imaging on the ___ was stable. Screening Lower extremity
dopplers were negative for DVT. On ___, dilantin was
discontinued. On ___, patient remained nonfocal on examination
and was transferred to the floor. Her foley was discontinued.
Now DOD, she is afebrile VSSS. She is tolerating a good oral
diet and pain is well-controlled. She is set for discharge home
in stable condition. | 280 | 302 |
10108435-DS-60 | 27,067,429 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ w/ PMH of CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE
c/b chronic venous stasis ulcers (on Coumadin), occluded IVC
filter (since ___ opioid dependence on methadone, CAD s/p
stents, HFpEF, COPD on home O2, recent admission for ___ leg pain
felt to be due to venous stasis presenting again with worsening
bilateral leg pain. | 14 | 57 |
18932912-DS-10 | 28,429,918 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted after your MRI showed
three brain tumors. You were seen by our neuro-oncology,
neurosurgery and interventional pulmonary teams. You had a CT
scan of your body which showed a mass in your lung which is also
suspicious for cancer. You will need to have a sample of the
lung and possible brain surgery. You need to return to the
hospital on ___ at 10am. Do not eat or drink anything after
midnight on ___ night. You also have an MRI scheduled on
___ at 3pm.
Stop taking your Plavix. | ___ yo M with HTN, CAD, DM2 here with new brain lesions
concerning for metastatic disease found to have concerning lung
lesion.
# Metastasis, brain
# Lung mass
Presents with new brain lesions most concerning for metastatic
disease. The patient underwent CT torso for staging. Chest CT
with evidence of suspicious speculated mass and upper lobe,
speculated paratracheal nodal conglomerate. Neuro-oncology,
Neurosurgery and interventional pulmonary were consulted. Given
appearance and location of brain masses, they are amenable to
surgical resection. Given small chance of an alternative
diagnosis, recommendation was made to peruse biopsy of lung
lymph nodes. The patient will undergo EBUS with biopsy. He also
hat CTA brain for neurosurgical planning and will undergo
functional MRI as an outpatient. He was continued on Decadron
4mg TID per Neurosurgical recommendations. Given overall
clinical stability and patient preference, he was discharged
home to complete these procedures as an outpatient. Plavix was
held in preparation for procedures. The patient was advised to
continue baby ASA. The above was communicated to the patient's
PCP by phone on the day of discharge.
# CAD, native vessel
Per note in chart had BMS placed at ___ in ___. Given this
is ___ after ___ placement, plavix was held. The patient
continued ASA 81mg which was OK with Neursurgical attending, Dr.
___. He was also continued on his Statin.
#Hypertension, benign
Continued home medications
#Diabetes, Type II controlled without complications
Continue home medications
#Code - full
#Contact: Niece ___ speaks ___- ___. Patient
says we can communicate with her- Family (daughter, sister and
niece) updated extensively at bedside. All questions answered to
their apparent satisfaction on the day of discharge | 105 | 270 |
13586936-DS-7 | 22,114,434 | It was a pleasure to care for you during this admission. You
were treated for pneumonia. Your blood pressure was low when
you were admitted, and you were sleepy. These things improved
with intravenous fluids and antibiotics. We stopped the bladder
irrigation and this should not be restarted.
Medication changes:
Augmentin 875 mg po bid for 4 more days
Lamictal increased to 75 mg po bid
Keppra decreased to 250 mg/500 mg po bid | Impression: The patient is an ___ year old man with history of
dementia, sick sinus syd s/p PPM, moderate AS, prior MRSA
pneumonia and C. diff colitis, with indwelling catheter, and a
seizure disorder, presenting with sepsis secondary to likely
pulmonary sources. He was initially admitted to the ICU for
early goal-directed therapy for the sepsis, and was later
transitioned to the hospital medicine service once the sepsis
had been stabilized, and continuosly improved until discharge
back to his long term nursing home.
Acute Issues
# Sepsis: Upon admission, the most likely source was the urinary
tract given his chronic 3-way urinary catheter at rehab and his
UA with >182 WBCs. Aspiration PNA may also have played a role
given his RML/RLL infiltrates on CXR and his poor mental status
with high risk for aspiration. There was no report of fevers or
diarrhea at rehab. He was mildly hypotensive on arrival to the
FICU with SBP in the ___ on no pressors. His BP's improved to
the 100-120s after about 1L total of fluids, and he received
empiric vanc/Zosyn for presumed urosepsis as well as MRSA
covereage given the concern for aspiration PNA. Urine culture
was negative, and therefore cause of symptoms presumed due to
aspiration pneumonia. He will complete a course of augmentin at
his facility for pneumonia.
# Acute encephalopathy on admission Patient was reportedly more
lethargic than usual, per direct discussion with the ___ staff.
His baseline MS is ___ to self, thought to be from vascular
dementia. The most likely cause for his AMS was sepsis from
UTI, but may also have been ___ to starting lamotrigine
recently, although it would not have been expected to resolve as
quickly as was noted if due to medications. We held his
seroquel and trazodone initially, but continued Celexa. He was
resumed on home trazodone and seroquel at discharge.
# Leukopenia: Unclear etiology, may be related to Keppra. He
is currently being transitioned from Keppra to lamotrigine in an
attempt to improve his leukopenia. His underlying
infection/sepsis may be acutely lowering his WBC, although he
has evidence of leukopenia prior to his presentation for sepsis.
ANC at admission is 1300 and he is very mildly neutropenic, so
concern for atypical infections was low. The transition off
keppra was continued, after discussion with his neurologist, and
the Keppra was decreased from 500 mg twice daily to 250/500.
The recommended plan was to continue to decrease the keppra by
250 mg a week (ie: next dose would be 250/250) as the
lamotrigine was increased by ___ each week until goal of 150
mg po bid. At this time, we increased his lamotrigine to 75/75mg
doses.
# Aortic stenosis: Valve area 0.8cm2 in ___. He appears
somewhat volume depleted on exam, he has no edema or crackles on
exam. His cardiac exam is consistent with a decreased S2,
suggestive of critical AS. Repeat TTE showed progression of his
aortic stenosis, to severe. As a result, he is likely to be
very sensitive to low blood pressures.
# Hematuria and CBI: Patient presented from rehab with a 3-way
Foley and CBI. His rehab states that he has been on this for at
least a year and plan to continue it indefinitely. He had not
been seen by urology at ___ for ___ years. Has had negative
cystoscopy and CT urogram with no clear cause for his hematuria.
We stopped the CBI, with no hematuria, and changed his foley to
a regular foley prior to discharge. CBI SHOULD NOT BE
RESTARTED. If he develops hematuria after a foley catheter
change, this should be monitored for evidence of obstruction.
If he continues to have hematuria or obstruction, CBI can be
started for ___ hours as needed until his urine clears again,
at which point it should be stopped. He should follow up with
urology as needed if this persists.
# Goals of care: Upon admission, the ___ team spoke with the
patient's brother, ___, who states that he is the
health care proxy and makes decisions for the patient. He
stated that the patient has expressed that he would like
everything done for him, including resuscitation, intubation,
pressors and invasive procedures. This should be re-addressed
with the brother again given severe aortic stenosis, and his
degree of cognitive dysfunction. | 73 | 731 |
11950373-DS-19 | 25,674,864 | Dear Ms. ___,
You were admitted to ___ for
chest pain. In the Emergency Department there were some mild
changes in your EKG, which made us concerned about your heart.
Your chest pain resolved. To further evaluate your heart you had
a nuclear stress test on ___, which showed that some areas of
your heart could be at risk for a heart attack. On ___, we
planned to take you for a cardiac catheterization, however since
your pain had resolved, you preferred to go home. The risks of
not having a catheterization were described to you, however you
still wished to go home. Your medications were adjusted to
hopefully decrease your chest pain in the future.
Please take all medications as prescribed and follow-up at your
scheduled appointments. If you develop any chest pain while you
are at home you should present to the Emergency Department
immediately.
It was a pleasure taking care of you,
Your ___ Team | Ms. ___ is an ___ year old female with a history of CAD s/p DES
(___), DM, and HTN presenting with a history of worsening
chest pain on exertion and decreased exercise tolerance, with
one day of severe chest pain and heaviness found to have
positive stress test. Admitted for cardiac catheterization.
# Unstable angina/CAD: Ms. ___ is an ___ year old female with a
history of CAD s/p DES (___), DM, and HTN presenting with
worsening chest pain on exertion with exercise intolerance, and
one day of severe chest pain. At home on aspirin, ___,
atovastatin, and metoprolol. She presented to the ED and was
found to have initial normal ECG with trops<0.01 x 2. She went
for pharmacologic nuclear stress test on ___, which showed a
reversible, medium-sized, mild perfusion defect involving the
LAD territory. The pt also reported ___ chest pain and was
noted to have 0.5-1 mm of ST segment scooping on ECG. She was
admitted for cardiac catheterization planned for ___ and
placed on heparin gtt. As pt felt well on ___, she declined
the cardiac catheterization as she felt that it took her a long
time to recover from her cath in ___. Discussed at length that
the patient is probably putting herself at increased short term
risk of an MI or urgent revasc without an invasive strategy (the
risk is actual much less clear in women with negative biomarkers
where the benefit of an early invasive strategy is blunted in
clinical trials. Her burden of ischemia on the nuclear perfusion
study is mild to moderate and if in the moderate category revasc
may be more beneficial). She understood this risk and is
requesting to go home. To help with her anginal symptoms, her
metoprolol was increased to 100mg po daily, and she was started
on imdur 30mg po daily and given sublingual nitroglycerin for
home as needed. She was instructed that if she develops chest
pain, she should go to the Emergency Department immediately.
CHRONIC ISSUES
# Hyperlipidemia: Continued on home atorvastatin.
# Diabetes mellitus: At home on glipizide. During
hospitalization started on insulin sliding scale and glipizide
was held. This was restarted on discharge.
# Hypertension: At home on metoprolol succinate 75mg po daily.
This was increased to metoprolol succinate 100mg po daily as
above. Imdur 30mg po daily was also started.
***TRANSITIONAL ISSUES***
- Pt informed that if she has chest pain she should report to
the ED ASAP
- New medications: Imdur 30mg po daily
- Change medications: Metoprolol succinate increased from 75mg
po daily to 100mg po daily
- Code: FULL | 154 | 424 |
16070047-DS-15 | 24,127,201 | Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our institution
for your increased pain and drainage from a collection inside
your abdomen. Your antibiotics and parenteral nutrition were
maintained throughout your brief hospital course. We were able
to drain of your collections and sent the samples for
microbiological analysis. Upon evaluation by Infectious Disease
specialist, it was determined that you were not benefitting from
your current antibiotic therapy. We thus have stopped
antibiotics for the time being.
Upon stabilization and control of your pain, we now feel
comfortable sending you home provided you follow these
recommendations:
-You may resume all your medications
-Please continue TPN
-Follow-up with infectious disease specialists as indicated
-Call or come to the emergency department if you develop fever
to 101.3F, chills, persistent nausea and/or vomiting, increasing
pain not controlled with medications, increased drainage from
your wounds, or any other symptom of your concern. | Mr ___ was admitted to our institution given worsening
abdominal pain and reported abdominal discharge from known
phlegmonous collection in left lower quadrant. The fact that
intraabdominal collections had not decreased in size, as well as
the persistence of symptoms while on antibiotics was concerning.
The interventional radiology team was consulted for possible
aspiration of a small umbilical abscess/phlegmon additionally
noted on imaging studies. Awaiting this procedure, patient was
continued on meropenem and administered total parenteral
nutrition as he had been receiving prior to admission.
An ultrasound-guided aspiration of the anterior abdominal fluid
collection was successfully done on hospitalization day #1. This
yielded roughly 1 cc of greenish purulent material, sent to
microbiology for analysis. Infectious Diseases was consulted for
assistance in determining appropriate antibiotic regimen and
duration in this patient. Differential for persistent
collections included development of drug resistant organisms vs
ongoing source of infection due to anatomical defects that would
require surgical management. Given lack of response to meropenem
therapy, decision was thus made to discontinue antibiotics and
continue nutritional optimization for a planned surgical
procedure in the coming months to attempt control of the source
of infection.
Upon improvement of symptoms, patient was deemed suitable to be
discharged to home. Visiting nurse arrangements were made for
daily TPN administration, and an appointment was made to
follow-up as an outpatient. At the time of discharge Mr ___
was doing well, afebrile with stable vital signs. He was
tolerating a regular 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. | 153 | 267 |
16938575-DS-24 | 25,661,369 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for lower back pain and fainting.
What was done for me while I was in the hospital?
- You had imaging of your spine that showed no sign of
infection.
- You had imaging of your head that showed no sign of bleed.
- The Chronic Pain doctors saw ___ and helped us come up with a
good pain management plan.
What should I do when I leave the hospital?
- Please follow up with your chronic pain doctors ___.
Sincerely,
Your ___ Care Team | Outpatient Providers: TRANSITIONAL ISSUES:
====================
[ ] PCP to adjust pain regimen
[ ] Patient may choose to follow-up with providers from the
chronic pain service to assist with adjusting opioids.
#CODE: FC, confirmed
#CONTACT: Deb(friend): ___.
====================
PATIENT SUMMARY:
====================
Ms. ___ is a ___ woman with history of DMII,
HTN, hypothyroidism, bipolar/depression, recurrent syncope
thought to be vasovagal, hx of sick sinus syndrome s/p pacemaker
___ years ago(taken out because of clots forming on the leads),
L4-S1 laminectomy and recent MSSA bacteremia presenting with
acute on chronic back pain and subjective saddle
anesthesia/urinary incontinence, found to have normal neuro exam
with MRI of her lumbar spine showing a benign paraspinal muscle
seroma from her surgery.
====================
ACUTE ISSUES:
====================
# Acute on chronic lower back pain:
Patient came in complaining of worsening lower back pain, saddle
anesthesia, and difficulty holding her urine. She had been
admitted and worked up extensively during prior admissions. She
has previously had surgery to remove her spinal hardware. During
her last admission, she had an aspiration of paraspinal fluid
collection that showed a benign seroma. In this hospital
admission, MRI lumbar spine showed the seroma is still present
but is smaller. There was no concern for infection during her
admission given the quality of her seroma, lack of fever, normal
white blood cell count. Dr. ___ ortho spine doctor saw
her and had low concern for infection or cauda equina syndrome
given she had full strength and no focal deficits on neuro exam.
Her pain was controlled with her home gabapentin,
cyclobenzaprine, standing Tylenol, and oxycodone as needed.
Although she received morphine and IV dilaudid in the beginning
of her admission, she was taken off of IV pain medications.
Chronic pain also saw her and recommended close follow-up with
her PCP and with the chronic pain clinic. ___ was also consulted.
# Syncopal Episodes
Patient has had multiple episodes of syncope in past weeks in
setting of severe pain. At beginning of hospital admission,
patient was in MRI scanner, and a CODE BLUE was called. Patient
had a vasovagal syncopal episode ___ pain. Pt has long history
of syncopal episodes, etiology attributed to vasovagal
physiology. During prior hospitalization episodes, vitals were
normal and no
events seen on tele, and patient was responsive right after the
event. She did have one staring episode which occurred during
this hospitalization, complained of "feeling off." During this
time, her neuro exam was unchanged other than at first patient
stated she was "in the supermarket." but then quickly corrected
herself, and she returned to her baseline shortly thereafter.
During this admission, she was also continued on tele and no
events were seen, and no syncopal events occurred.
# Reported head strike
In the setting of her syncopal episodes prior to admission, she
reported head strike. She mentated well and had intact CN ___
during admission. CT head w/o contrast ___ showed no evidence
of bleed.
# Diarrhea
Patient reported fevers and loose BMs at home. Stool studies,
O&P, C diff studies were ordered but were unable to be obtained
as she stopped having loose stools during this hospitalization.
====================
CHRONIC ISSUES:
====================
# DMII:
-Held home metformin
-ISS
# Hypertension:
-Continued home enalapril
# Hyperlipidemia:
-Continued home statin
# Hypothyroidism:
-Continued home levothyroxine
# Bipolar disorder/Depression:
-Continued home alprazolam/duloxetine
-Latuda is not on formulary | 116 | 531 |
15325167-DS-18 | 21,214,514 | Dear Mr. ___,
You were admitted to the hospital after havin several seizures
at home. We monitored you on EEG and you did not have any more
seizures. Per recommendation of Dr. ___ outpatient
epileptologist, we increased your dose of Vimpat to 250mg twice
per day.
On discharge, please follow up with Dr. ___ as scheduled
below.
It was a pleasure taking care of you, we wish you all the best! | Mr. ___ is a ___ year-old R-handed man with a PMHx of
seizures who presents with 4 events concerning for seizure.
# NEURO: On day of admission, patient had an episode of diffuse
shaking accompanied by tongue biting and urinary incontinence
out of sleep. Per history, most of his seizures are out of
sleep. He has had episodes of seizures that sound frontal in
etiology with fencing position and head turning but this is not
a consistent seminilogy. Patient is compliant with his vimpat
200mg bid, no recent infectious symptoms, no sleep deprivation.
Mr. ___ did have a leukocytosis on arrival in the ED yet no
infectious etiology, further supporting that above event was
epileptic in nature. Currently, his exam is at his known
baseline and only remarkable for mildly impaired memory and
orientation. He has been monitored on EEG and has not had any
epileptiform discharges. Per discussion with Dr. ___
___ epileptologist) will increased Vimpat from 200mg bid
to ___ bid--he tolerated it well.
# ID: CXR with no pneumonia, UA neg, remained afebrile.
# CODE/CONTACT: Presumed Full; ___ (mom) ___ | 72 | 191 |
14062362-DS-5 | 26,121,908 | Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted to ___ with a fracture of your right hip after you
had fallen at home. You also had low blood counts from bleeding
around the hip. You were evaluated by our orthopaedic surgery
service who felt that you did not need immediate surgery and
should be able to walk with a walker. We noted that your blood
levels dropped during your hospital stay which could be due to
your fractured hip and a collection of blood underneath your
skin which was stable. You were given IV fluids to improved
your blood pressure.
Please take your medications as prescribed and follow up with
your appointments as listed below.
It was a pleasure taking care of you at the ___
we wish you all the best
You ___ team | Ms. ___ is a ___ y/o woman with history of advanced dementia
s/p fall 3 PTA, w/ R pelvic and proximal femur fracture deemed
non-operative. She was transferred to the medical service, where
she was managed conservatively for her pain and R thigh hematoma
suffered during fall. | 142 | 47 |
14186323-DS-3 | 23,381,010 | You were admitted to the hospital with abdominal pain, nausea
and vomiting and were found to have a mass in the pancreas. You
had a biopsy of this mass, and results are pending at this time.
You will followup for this on ___. Please follow up at the
multidisciplinary conference on ___ and with your PCP. Our
palliative care doctors ___ help manage your pain and appetite. | The patient is a ___ year old female with HLD, hypothyroidism
found to have a pancreatic mass with pancreatic ductal
obstruction.
.
PANCREATIC MASS CONCERNING FOR MALIGNANCY Patient under went
CTA pancreas that showed pancreatic mass concerning for
adenocarcinoma. She also underwent endoscopic ultrasound for
biopsy of this mass and result pending at the time of discharge.
She will followup with a ___ clinic on ___ to
obtain results and to discuss next steps in planning and
treatment.
Abdominal pain, Anorexia: Due to presumed pancreatic
malignancy. She was started on oxycontin 20 mg po bid as well
as oxycodone ___ mg every 6 hours as needed for breakthrough
pain. She was given the phone number to call for ___
___ care clinic for them to help adjust medications and
help manage symptoms. She will need assistance from PCP/Pall
care to titrate the dosages of these medications. She was also
started on a bowel regimen and had bowel movements in the
hospital Her appetite remained poor, and outpatient providers
should address this as well.
COLITIS: Seen on CT scan, patient asymptomatic.
ANEMIA: No GI Bleeding, appears to be secondary to
myelosuppresion from presumed malignancy
.
HYPOTHYROIDISM: Continued levothyroxine
.
DEPRESSION: Continued home regimen of SSRI and bupropion.
.
GERD: Treatment continued
COPING: Patient recently suffered death of her mother. She
expressed understandable anxiety and distress over her possible
diagnosis. She is very well supported by husband and sister and
she reported a very good experience with hospital chaplain. | 71 | 263 |
19392911-DS-21 | 20,880,650 | Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you were short of breath and were
found to have excess fluid due to poor heart function and an
abnormal heart rhythm
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You received water pills through the IV to help with the extra
fluid
- You had a shock delivered to your heart to put your heart
back in normal rhythm. You had a special ultrasound (TEE) done
first to rule out the presence any blood clots in your heart
- You had a gastrointestinal bleed for a few days that
fortunately resolved without intervention
- Your heart failure medications were optimized
- You began to feel better and were ready to leave the hospital
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Your weight at discharge is 188 pounds. Weigh yourself every
morning, seek medical attention 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.
- If you are experiencing new chest pain please call the
heartline at ___
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | HOSPITAL COURSE:
=====================
___ year old woman with CAD ___ CABG, CVA, MR ___ bioprosthetic
valve, HTN, DMII who presented to OSH with DOE for the past 3
weeks, found to have new HFrEF (30%) with new aflutter. She was
initially started on diltiazem drip, transferred to ___ CCU
for further management. She was IV diuresed until euvolemic, her
atrial flutter was initially managed with esmolol drip resulting
in low BPs, and she underwent a successful TEE/cardioversion.
Her course was complicated with an UGIB that resolved without
intervention, as well as recurrent episodes of somnolence with a
preliminary diagnosis of OSA. | 267 | 103 |
13173710-DS-31 | 20,586,779 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had high blood sugars,
vaginal irritation, and urinary symptoms
What happened while I was admitted to the hospital?
-Your insulin regimen was adjusted by ___
-You were given antibiotics for urinary tract infection and
completed your course while in the hospital
-Your given a steroid cream for her vaginal irritation
Your given an antifungal medication to treat your vaginal
infection
-Your lab numbers were closely monitored and you were given
medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
-It is very important that you take your insulin as prescribed
and also use your sliding scale as discussed
-If you miss more than 2 doses of insulin or if your blood
sugars are >250 on 3 separate occasions, you should call your
diabetes doctor or your primary care doctor immediately
We wish you the very best!
Your ___ Care Team | This is a ___ woman with PMH of insulin dependent
diabetes, hypertension, CKD, and CHF presenting with multiple
complaints hyperglycemia, dysuria, vaginitis, and weakness,
admitted to medical service for treatment of UTI and vaginitis
as well as management of insulin regimen. | 188 | 41 |
10965697-DS-10 | 25,463,386 | Dear Ms. ___,
It was a pleasure to care for you. You were admitted due to a
fall at home. We did not find a specific cause for the fall.
Imaging and monitoring of your heart did not show any
significant abnormalities. You were given fluids. Your blood
counts were monitored, and you were given blood products to
increase your blood counts. You had a bone marrow biopsy to help
guide future treatment of your leukemia.
Please take your medications as prescribed and attend your
follow up appointments. You should no longer take amlodipine for
high blood pressure. | Ms. ___ is a ___ woman with AML s/p allo transplant in
___ who now has graft failure and recurrent disease,
recently started decitabine chemotherapy, who presented with
presyncopal symptoms and fall.
# Presyncope, fall, ?BPPV:
No loss of consciousness or head strike. ___ have been due to
volume depletion, though pt reported good PO intake and was not
orthostatic. History was not consistent with vasovagal or
cardiac etiology. Telemetry was unremarkable. Echo was
unremarkable. CT head unremarkable. No known infectious
symptoms; urine culture was negative, and blood cultures had no
growth as of discharge. Pt may have BPPV, as reported feeling
dizzy with lateral rotation of head.
# AML, Neutropenia:
S/p allo transplant in ___ who now has graft failure and
recurrent disease. Started recently on decitabine (cycle 1, day
1 = ___. Pt has circulating blasts, indicative of continued
disease. Had BM biopsy ___ to help guide next therapeutic step.
If BM biopsy shows continued disease progression, will consider
cytotoxic chemotherapy. If BM biopsy shows good response to
decitabine, will likely continue decitabine. Continued on
prophylaxis with acyclovir, Bactrim, moxifloxacin, voriconazole,
and ursodiol.
# Anemia, thrombocytopenia:
Likely due to AML and its treatment. GI bleed less likely;
guaiac negative stool ___. Pt received pRBC and platelet
transfusions during admission. Developed hives with platelet
transfusion, which resolved with Benadryl.
# H/o HTN: Pt was on amlodipine 5mg daily previously, while on
cyclosporine which can increase BP. Was normotensive during
admission off amlodipine; planned to remain off amlodipine at
discharge.
====================== | 97 | 246 |
12873584-DS-22 | 28,710,710 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
because you have been having lightheadness, spinning, and blurry
vision over the past few months. You had a scan of your head
done, and this did not show a cause for your symptoms. You were
evaluated by the neurology team (the brain doctors) and there
was no concern for a stroke or head bleed. Your symptoms are
likely a combination of your previous diagnosis of benign
vertigo, along with a side effect of taking extra blood pressure
medications. You should see an eye doctor about your blurry
vision, as you shared with us that you think this is because you
need new glasses.
You were also evaluated by physical therapy, and they determined
it's safest if you go to rehab to gain strength before you go
home. You and your family decided you preferred to go home, and
we strongly recommend you have someone at home with you at all
times.
Please take your medication as prescribed. It may be beneficial
to you to have a pillbox that helps lay out which medications to
take when. The medications alprazolam and meclizine have both
been stopped as these can cause lightheadedness, falls and
confusion.
Please go to your doctor's appointment this ___, this is
very important you follow up.
We wish you the best of luck with your health.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old ___ speaking woman with
HTN, HLD, hypothyroidism, anxiety, BPPV on meclizine, and
admission to the stroke service ___ for lightheadedness with
transient R sided weakness that was thought to be complex
migraine or anxiety provoked, who presented with over 2 months
of lightheadness and vertigo. She was admitted to the hospital
because physical therapy recommended patient be discharged to
rehab for functional conditioning, and she needed placement.
#Lightheadness: patient presented with two separate symptoms of
lightheadedness and vertigo. Patient was not orthostatic in the
ED, and does not endorse symptoms of orthostasis. No reported
carotid stenosis on prelim CTA head/neck read. Patient revealed
she was taking 2x the amount of prescribed hydrochlorothiazide
because she thought one was her synthroid. Therefore, her
symptoms may be a result of too many antihypertensives. Her
symptoms may also be a side effect of meclizine. Neurology was
consulted, and recommended discontinuing meclizine. ___ was
consulted, and recommended patient go to rehab for strengthening
and functional conditioning. Patient and her family refused
rehab, despite being told this was what was recommended by our
___ team.
#Vertigo: patient endorsed vertigo as well, and this seemed to
be a separate symptom, however it was hard to tease out with her
history giving. CTA head/neck with no acute pathology to explain
this symptom, and likely secondary to known diagnosis of BPPV.
As above, neurology was consulted, and meclizine was
discontinued for concern it was causing lightheadness.
#Blurry vision: patient reports worsening blurry vision over the
past few months in her right eye. She is not having blacking out
of vision in this eye, just blurriness. She has no jaw pain or
claudication, and describes global tension like headache.
Concern for temporal arteritis low, but ordered ESR and this
should be followed up as an outpatient. She should have
ophthalmology as an outpatient.
#HTN: Continued home prescribed regimen of hydrochlorothiazide,
verapamil, valsartan.
#HLD: Continued home atorvastatin.
#Hypothyroidism: Continued home levothyroxine. | 238 | 327 |
12158416-DS-9 | 25,758,818 | Dear Mr ___,
It was a pleasure to care for you at ___. You were admitted to
the hospital because you had a drug overdose causing multiorgan
failure and hypothermia. You required a breathing tube for
respiratory failure, and your kidneys and liver failed. You also
had significant muscle breakdown (called 'rhabdo' or
rhabdomyolysis), which made your kidneys worse. You required
dialysis for 9 days, and because you were previously healthy,
you are very lucky, and your kidneys recovered, as did your
liver.
You should continue to eat a low potassium and low phosphate
diet while your kidneys recover.
You will need to follow up with Dr ___ kidney doctor)
in clinic in 2 weeks. They will call you with the follow up
appointment.
We wish you all the best! We hope that you will take care of
yourself.
-Your ___ care team | This is a ___ who overdosed on heroin, cocaine, EtOH, was found
down, and transferred from ___ to ___ for acute liver
injury, cocaine intoxication, and hypotension, and admitted to
the ICU for hemodynamic instability, on pressors. He was
intubated in the ED for hypoxemic respiratory failure secondary
to likely aspiration from emesis, and started on broad spectrum
antibiotics for concern for pneumonia. He was found to have
shock, acute renal failure, rhabdomyolysis, cardiac
ischemia/troponinemia, acute liver failure, and LLE weakness and
sensory deficit. In the MICU, shock resolved, pressors weaned,
and CNS depression resolved. Antibiotics discontinued as no
clinical evidence of pneumonia. Transferred to floor, where he
continued to have volume overload in the setting of oliguria and
acute renal failure. Rhabdomyolysis resolved, with CK<5000, as
did acute liver failure. Initiated hemodialysis on ___ because
still with persistent oliguria and worsening acidemia. Required
9 days of dialysis, but urine output recovered and his dialysis
line was removed on ___, with discharge on ___.
# SHOCK: Patient was initially hypotensive to the ___ on arrival
with elevated lactate. Patient had ___ SIRS criteria placing
septic shock on differential. His H/H was stable but mucous
membranes dry so hypovolemic shock was thought to be
contributing. He was started on broad spectrum antibiotics
(vanc/zosyn), which were discontinued as no infectious source
was identified. His hypotension resolved with aggressive fluid
resuscitation (up +15L in MICU course).
# RESPIRATORY FAILURE: Patient intubated on ___ for airway
protection after oxygen desaturation following an episode of
emesis. Patient was on CMV, FiO2 100%, Tv 500 and PEEP of 5.
Fentanyl/versed used for sedation. Patient was extubated the
morning of ___. He had been empirically started on broad PNA
coverage, but antibiotics were discontinued ___ because he had
no clinical evidence of infection. Likely he had aspiration
pneumonitis given the rapid resolution of hypoxemia. His
persistent oxygen requirement on the general medicine floor was
likely secondary to volume overload in setting of acute renal
failure, and it resolved with hemodialysis.
# ACUTE RENAL FAILURE: Likely secondary to acute tubular
necrosis given urine sediment showing muddy brown casts. He
presented to OSH with hypotension, which is the likely etiology
of the ATN, though likely exacerbated by rhabdomyolysis. His
poor urine output indicated that he was not clearing casts from
his kidneys, and the persistently high CK likely made his ___
worse. Creatinine continued to rise with worsening acidosis,
requiring hemodialysis ___. His urine output recovered with
normalization of his electrolytes and downward trend of
creatinine. HD line removed ___.
# HYPERTENSION: Likely secondary to volume overload in the
setting of persistent renal failure. Asymptomatic. Trending down
with dialysis and subsequent autodiuresis. Did not treat with
anti-hypertensives.
# ACUTE LIVER INJURY: Most likely shock liver in setting of
hypotension with componenent of cocaine toxicity and
vasoconstriction. LFTs trended down to normal range. He
completed a full course of NAC per liver, toxicology recs. His
hepatits serologies, HIV, ___, AMA, Sm were all negative.
# LEFT LOWER EXTREMITY WEAKNESS: Initially with L2 sensory
deficit and left hamstring weakness, but recovered full strength
and sensation. Likely lumbar plexopathy, secondary to
compressive neuropathy.
# THROMBOCYTOPENIA: Likely in setting of acute liver failure,
alcohol intoxication, and profound illness. Platelet count rose
to normal range.
# POLYSUBSTANCE ABUSE: Patient overdosed with intranasal cocaine
and heroin, as well as alcohol ingestion. His overdose resulted
in multiorgan failure and significant medical issues. Seen by
social work. Discussed extensively with patient. Has good family
support, motivation to return to caring for his daughter and to
go back to work. His drug use prior to this catastrophic event
was intermittent. | 139 | 602 |
16727715-DS-3 | 24,682,049 | You were admitted because you became confused and had a fall. We
think your sleep medication dose was too high and made you
confused so we decreased this.
Also, your blood pressure drops when you stand up so we
recommend:
1. Drink eight 8-oz glasses of water daily to prevent
dehydration.
2. Wear compression stockings every day to help improve blood
flow
3. Do simple exercises before you get out of bed to help
increase your heart rate
You can keep these instructions by your bedside so you remember
these tips! We have also decreased your blood pressure
medications to help prevent falls. | Patient is an ___ with PMHx of HTN, hematochezia, history of
cardiomyopathy with recovered EF, CKD, Bipolar D/O, and PTSD
with recent discharge from ___ ___ who presents after a
fall with confusion.
# Encephalopathy: Resolved by the following morning. Medication
effect seems most likely given resolution without intervention.
Unclear how much seroquel patient is taking at home as patient
is a vague historian. Imaging ruled out intracranial process. No
signs of infection. Electrolytes normalized without intervention
though creatinine was initially above baseline. In conjunction
with her outpatient providers, we further decreased her seroquel
dosing to 12.5mg daily and continued palmate. We also
transitioned to blister-packing of her meds to reduce
inappropriate medication administration.
# s/p Fall: Orthostatics were positive and creatinine was
slightly elevated on presentation supporting an element of
hypovolemia. Patient is on BP meds and MAOI which can lead to
postural hypotension. Head CT and cervical spine CT showed no
acute injury as a result of the fall. Beta-blocker was dc'ed and
amlodipine was halved. She was given compression stockings and
given other advice about how to decrease the incidence of
orthostasis.
# CKD: Baseline 1.8. Patient slightly above baseline on
admission though trended down by discharge.
# Tachy/brady: Resolved. Tachycardia and bradycardia documented
on arrival never recurred. Patient had frequent PACs and
sometimes an ectopic atrial rhythm but rates remained normal and
she was asymptomatic. Beta-blocker was dc'ed as above.
# Hypertension: Well-controlled on reduced regimen of 2.5mg
amlodipine. Could likely dc this medication all together to
minimize orthostasis
# Bipolar disease and PTSD: Continued palmate. She will
follow-up with her outpatient psychiatrist
# Code: Full
# Emergency Contact: Guardian ___ (sister in law)
___
___ ISSUES
-Her amlodipine can likely be discontinued as an outpatient if
her BPs remain well-controlled
-She will follow-up with her outpatient psychiatrist for further
titration of her insomnia meds
-2.0 x 1.7 x 1.3 cm right neck soft tissue mass was incidentally
noted on CT and is stable from prior imaging. MRI could be
performed for further characterization.
-CT also noted heterogenous thyroid gland. TSH was normal. | 99 | 346 |
11084812-DS-39 | 25,904,190 | Ms. ___,
It has been a pleasure taking care of you at ___
___. You came to the hospital with symptoms
of a viral bronchitis, as well as increased mucle pain and
weakness. You rheumatologist is working on getting you rituximab
for your polymyositis, but for now we did not change your
medicines. We gave you breathing treatments for your cough,
which seemed to help.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ F with polymyositis, ILD, multiple DVTs/PEs on Coumadin,
morbid obesity who presents with productive cough and muscle
pain and weakness.
#. Polymyositis: Pt currently unable to ambulate ___ weakness.
Pt states she typically gets rituximab infusions q6-8 weeks for
her polymyositis, and it has been 8 weeks since her last
infusion. Pt's case was discussed with rheumatology team. Given
her CKs were in the 700s (rather than the 10,000s like previous
flares), no changes were made to the patient's medications. Her
outpt rheumatologist is continuing to work on getting rituximab
approval. Pt states her pain typically responds well to
ibuprofen, so this was used PRN pain. Her home dose of steroids
and mycophenolate were continued, as was Bactrim for PCP ___.
Given inability to walk, pt will be discharge to rehab for
physical therapy as she is unsafe at home. She will need close
rheum follow up and rituximab infusion when approved (will be
arranged by rheum team).
#. Acute bronchitis, viral: No clear infiltrate on CXR or focal
crackles on exam, although both are limited by body habitus. No
fever or leukocytosis to suggest PNA. Cough improved with nebs
and Guaifenesin PRN.
# Hx of DVT/PE: Pt had been taking 5mg warfarin on ___, and
7.5mg other days. INR was subtherapeutic ___, so she was
given an extra 2mg warfarin that day. Would continue 7.5mg daily
and check INR daily until stable.
# recent unprotected intercourse: 2 weeks ago per pt, hCG
negative in ED. HIV was negative. Urine chlamydia negative at
the time of discharge. Pt should have pelvic exam for gonorrhea
screening.
Chronic and Transitional Issues:
# chronic dCHF: Continued home torsemide and BBlocker to
maintain euvolemia. Pt should follow up with Dr. ___ in
Cardiology (appointment not currently scheduled). Prior to
discharge from rehab, please help patient obtain 2 scales so she
can stand on each and combine the weights. At home, pt should
call Health Care Associates (___) if her weight
increases by 2lbs.
# glucose intolerance, morbid obesity: Per pt she is on
metformin in the setting of high-dose steroids but does not have
DM. Last A1c in ___ 5.9%. Given pt did not appear ill,
metformin was continued in house. Pt would benefit from an
intensive lifestyle modification program as due to her multiple
medical problems, she is not a candidate for bariatric surgery
at this time. Weight loss would significantly improve her
mobility.
# osteoporosis: Pt got her weekly alendronate here. Ca and vit D
supplementation were continued.
# Possible mood disorder: Upon discharge from rehab, pt should
make an appointment for an initial visit with ___ by
calling ___, option #2.
# Home safety: Prior to discharge from rehab, pt needs to obtain
another personal care attendant. Pt's mother is her current PCA
and will soon be having orthopedic surgery and be unable to
perform the necessary duties. | 79 | 488 |
18018352-DS-17 | 27,326,511 | Dear Ms ___,
It was a pleasure taking care of you. You were admitted to ___
___ for chest pain. While you were
here, you were evaluated by our cardiology team; you were not
having a heart attack, and you did not require a surgical
procedure for your chest pain. Your blood counts were very low,
so you received a unit of blood cells, and your counts
improved.
We also had an important family meeting with you, your son, and
our full team. You completed the MOLST form, which expresses
your wishes when you leave the hospital. We will set you up with
services at home so that you can get help with medications and
assistance around the house.
We wish you all the best in the future.
Sincerely,
Your ___ Care Team | SUMMARY: Ms ___ is a ___ woman with stage 4 lung cancer,
severe AS, and chronic anemia, who was admitted for chest pain.
Initially, her chest pain and mild ST elevations were concerning
for STEMI, so she was taken to the cath lab. However, her pain
and ECG changes resolved upon arrival to the cath lab, so she
was admitted to the Medical Wards for further management of her
anemia (Hgb 6.5 on admission) and for goals of care discussion.
She was transfused 1 unit pRBC, with appropriate rise in her Hb,
with improvement in her weakness and dyspnea on exertion. She
was evaluated by cardiology, who felt that her symptoms were not
concerning for ACS. Given her Stage 4 lung cancer, she is not
surgical candidate for aortic valve repair. Team had an
extensive goals of care conversation on ___ with patient and
her son ___ was made Health Care Proxy & patient
completed a MOLST form, and was made DNR/DNI. She will go home
with home hospice.
# CHEST PAIN:
Initially, ST elevations in V1-V4 were concerning for STEMI, so
patient was taken to the cath lab upon arrival to ED. However,
her chest pain and ischemic changes on ECG completely resolved,
so she was admitted to the medical service. Repeat ECG on floor
showed 2mm ST elevated in V2 and 1mm ST elevation in V1. Pt
received ASA 325 mg prior to admission and 81 mg PO x 1 upon
arrival to the floor. She had originally been evaluated for
possible cardiac catherization, however, per the cardiology
fellow Dr. ___ declined all intervention. This decline of
intervention seems consistent with prior desires as indicated in
Atrius notes. Documentation of consent for cardiac cath was
signed by the patient, and the patient endorsed that she "wanted
everything done". Given resolution of her symptoms, she was
admitted to medicine for further management. Given her
downtrending troponins and normal ECHO, chest pain was thought
to be demand ischemia, not ACS. She was monitored on telemetry
and given ASA 81mg daily. Held beta blocker and heparin given
severe anemia. Cardiology consulted, appreciate their recs. Per
cardiology, patient is not a candidate for valve replacement.
# ANEMIA:
Patient has chronic anemia, with most recent Hgb 9.3 in ___.
On admission, Hgb was 6.6. Patient denied signs and symptoms of
bleeding. Per Atrius records, she has a history of a gastric
ulcer and endorsed GERD symptoms. Also has a history of AVM per
Atrius records. Given history of aortic stenosis, checked for
active hemolysis, but hemolysis labs were normal. Hemoglobin
remained stable after transfusion, and is 7.9 on discharge.
# STAGE 4 LUNG CANCER:
Patient has a 60-pack year smoking history, and known stage-4
lung carcinoma. The malignancy is non-operable, and the patient
does not want chemotherapy or radiation. She is not on active
treatment and does not require oxygen at home. Oxygen saturation
was monitored, and remained stable throughout hospitalization.
Goals of care were discussed, as below.
# AORTIC STENOSIS:
Patient has known AS prior to admission, with mean gradient 40
in ___. Per outside records, she had previously declined
intervention; confirmed with cardiology that she declined
intervention. Admission ECHO showed severe aortic valve stenosis
(valve area <1.0cm2). Cardiology evaluated, appreciate their
recs. Per cardiology, given the patient's stage 4 lung carcinoma
and multiple other comorbidities, she would not be a candidate
for valve replacement.
# GOALS OF CARE:
Prior to this admission, patient had multiple discussions with
PCP (latest ___ to discuss goals of care with her metastatic
lung adenocarcinoma. Per Atrius notes, " Adenocarcinoma, lung,
unspecified laterality: Inoperable and she refused
chemotherapy...She refused discussion regarding palliative care
or hospice care and insisted on being full code... Today, I
discussed with ___ the futility of intubation and mechanical
ventilation in someone with inoperable lung cancer and critical
valvular heart disease, yet she elected to be full code".
Patient still has capacity. Team met with patient, her family,
social work, and palliative care; she made her son ___ the HCP
on ___. Had a very productive goals of care meeting on ___,
and patient completed MOLST form; she is now DNR/DNI, and would
not like to be hospitalized unless it is for comfort. She is
very clear on what her wishes are. She would like to enjoy the
time she has left, and would like to spend this time at home,
not in a hospital.
TRANSITIONAL ISSUES
- ANEMIA: Patient has known gastric ulcer, and baseline Hgb
___, requiring 1 u pRBC, with appropriate rise in H/H. H/H
subsequently stable and was 7.9 upon discharge. Can consider
occasional monitoring with pallative transfusions as needed.
- HOSPICE CARE: Patient would like to be comfortable and avoid
future hospitalizations. She completed MOLST form and would like
Home Hospice services.
- GOALS OF CARE: Patient is DNR/DNI. | 130 | 799 |
10695080-DS-6 | 20,952,726 | Dear Mr. ___,
You were admitted with altered mental status and fever.
Your mental status improved after decreasing your pain
medication doses. You were treated with antibiotics for a
possible pneumonia, and should complete a course of
Levofloxacin. You were discharged home with hospice services to
make you more comfortable at home.
The following medication changes have been made to your regimen:
START: Levofloxacin 750 mg by mouth daily until ___
DECREASE: Oxycontin 30 mg by mouth twice daily
CONTINUE: Oxycodone 10 mg every 4 hours as needed for pain
START: Acetaminophen 1000 mg every 8 hours
START: Ibuprofen 400 mg by mouth every 6 hours
STOP: Krill Oil
Please continue all other medication as prescribed.
Please contact your hospice team or primary oncologist if you
have any medical concerns while at home. It is important that
you take your pain medications as prescribed to avoid future
problems with confusion and lethargy. Your hospice team should
be contacted if your pain worsens and is not well controlled
with the current medication regimen. | The patient is a ___ yo with a PMHx of metastatic RCC which has
failed chemotherapy (with Sutent, Temsirolimus, and Bevacizumab)
who presents with altered mental status and fever after going
home ___ on hospice.
.
# Fever: Likely secondary to leptomeningeal disease and extent
of malignancy. Given concern for post-obstructive pneumonia
given CXR, we initially covered for HCAP. Lumbar puncture was
deferred given his prior antibiotic treatment in the ED and low
likelihood of meningitis given the rapid improvement in mental
status and lack of meningeal signs. Vancomycin and ceftriaxone
were initiated for a 7 day course. Urine cultures were no
growth, and blood cultures demonstrated no growth during his
stay, but final results were pending at the time of discharge.
He had no further episodes of fever during his stay. He was
discharged on Levofloxacin for oral coverage of possible
pneumonia since IV antibiotics were not available on hospice.
.
# Encephalopathy: Differential diagnosis on arrival included
cerebral edema vs leptomeningeal spread of disease vs sepsis vs
overuse of narcotics. Cerebral edema was not visualized on
imaging. Upon admission, narcotics were reduced from Oxycontin
40 mg TID to 30 mg BID. By day two of admission, his mental
status had greatly improved. It is likely that the reduction of
Oxycontin resulted in the improvement in mental status.
Antibiotic coverage with Levofloxacin was continued on discharge
since infection could not be completely ruled out. He was
discharged on the reduced dose of Oxycontin with Oxycodone for
breakthrough pain.
.
# Pain Control: He has had difficulty with pain control and
adjustment of his narcotics doses for adequate relief without
over narcotization. His Oxycontin likely contributed to his
altered mental status and lethargy on admission. He was
discharged on the reduced dose of Oxycontin 30 mg PO BID with
Oxycodone 10 mg PO Q4H for breakthrough pain. He was also
started on standing doses of Ibuprofen 400 mg PO Q6H and
Acetaminophen 1000 mg PO Q8H. The addition of these
non-narcotic pain medications appeared to have good effect with
a reduced need for narcotics. His pain was well controlled
without sedation or confusion during his stay, and he was
discharged on this new regimen. He will likely neec close
followup of his pain control regimen after discharge with care
to avoid over escalation of his narcotics doses.
.
# Metastatic RCC: He is status post failure of two regimens, and
per primary oncologist no further anti-neoplastic care is
indicated. He recently went home on hospice on ___.
Palliative care was consulted on admission for further teaching
about the role of hospice and reevaluation for hospice services.
He was discharged home with the same hospice service.
.
# Chronic diastolic CHF: He did not appear fluid overloaded on
exam. His outpatient dose of Furosemide 20 mg PO daily was
continued.
.
# Appetite / Nutrition: Patient was continued on Megestrol
Acetate 400 mg PO BID and Ensure supplements with meals.
.
# DVT Prophylaxis: Heparin 5000 units SC TID
. | 171 | 507 |
15700982-DS-20 | 28,276,266 | Pt was discharged against medical advice. He and his wife
refused to wait for their discharge paperwork. | ___ year old gentleman with PMHx significant for ETOH abuse (hx
of DTs), and htn not currently receiving medical care who
presents with symptoms of fatigue, mild cough and acute onset
substernal chest pain.
ETOH ABUSE: History of significant ETOH abuse with history of
DTs. Unable to wean ativan requirement past q2hrs in emergency
room and therefore not suitable for general medical floor given
nursing requirements for management. Positive ethanol on tox
screen. Last drink at 7pm the night prior to admission. Patient
was placed on CIWA scale with valium. He was scoring ___ on
the night of admission mostly for agitation and tremor. He was
given thiamine and folate supplementation. Valium requirement
was spaced out to q4h and he required a total of 15mg on HD1.
- SW consult obtained and patient appeared pre-contemplative.
He was given information about ___ for the
Homeless Program to locate a caseworker to assist with
findingpermanent housing, be referred to a primary care
physician, and
then be referred to a therapist and psychiatrist.
ACUTE DYSPNEA/PLEURITIC CHEST PAIN: Patient complained of
shortness of breath and pleuritic chest pain on arrival.
Concern was for pulmonary embolism vs ACS/unstable angina.
Cardiac enzymes were negative x 2 and EKG showed no ST
depressions or elevations. Chest xray not concerning for
mediastinal widening or infiltrate. D-dimer elevated concerning
for PE/DVT, however, a CTA was not performed as very low
suspicion for PE. Pain resolved on day of admission, and
patient had no further complaints.
HYPERTENSION: Hypertensive on admission to the FICU,
unresponsive to hydralazine 10mg IV. He was started on a
nitroglycerin drip which was discontinued shortly after arrival.
He was started on clonidine 0.3mg po BID as home
anti-hypertensive regiment was unclear. Patient received an
additional 10mg of IV hydralazine with good blood pressure
response. In addition, his pressures improved following valium
for high CIWA scores. Per home pharmacy, patient is on
nifedipine XR 60mg po daily which was restarted on hospital day
1.
TRANSAMINITIS: Mild transaminitis noted on admission. Etiology
is likely acute alcoholic hepatitis vs chronic viral hepatitis
(history of hepatitis C) vs cirrhosis. Synthetic function was
intact with INR 1.0. CT abdomen and pelvis notable for hepatic
steatosis and hyperdense hepatic lesion.
LIVER NODULE: Nearly 3cm discrete liver nodule seen on CT scan.
In setting of significant etoh hx, poor medical care and recent
fatigue concerning for underlying liver disease/malignancy. Pt
informed of this at time of discharge but declined further
evaluation.
FATIGUE: History of progressive fatigue. Unclear etiology.
Weight loss? Liver nodule concerning for malignancy. Normocytic
mild anemia on admission.
Upon arrival to the floor patient and wife insisted upon
leaving. Despite this author repeatedly asking them to stay
citing his current ___ problems along with the new liver mass
seen on his CT of the abdomen. They both insisted on leaving at
10 pm at night from the hospital. (See OMR note for further
details.) Pt appeared competent. He was able to walk
independently. He was thus discharged against medical advice. | 17 | 509 |
17945610-DS-10 | 27,665,558 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital for coughing
up blood and your pulmonary doctors wanted to take another look
at your lungs with a camera to assess for a source of bleeding.
During this procedure, a few oozing sites of bleeding were
identified and treated with electrocautery.
Each morning, we monitored your labs for signs of worsening
anemia from blood loss. At the time of discharge, we did not
feel that you needed a transfusion. Please be sure to schedule a
___ appointment with your Primary Care doctor within 1
week of discharge. You should have a repeat "Complete Blood
Count" at that visit.
Also, since you recently had bleeding, you should not take your
blood thinner coumadin for one month in order to allow your
lungs time to heal. After one month, it is advised that you
resume this medication due to your long term risk of developing
a clot, which may cause another pulmonary embolism or other
adverse event. Please follow closely with your outpatient
doctors regarding continued ___ of these issues.
Sincerely,
Your ___ Team | ___ year old female with heart block s/p pacemaker c/b
pneumothorax requiring multiple chest tubes, DM, CAD, CKD,
presenting with recurrent hemoptysis since ___ with previously
observed clots on bronchoscopy. Recent bronchoscopy also showed
evidence of large clots in the R mainstem and R middle bronchus
with several areas requiring cauterization.
#Hemoptysis: small volume. Chest film with no evidence of TB or
other cavitary lesion, but demonstrated R. middle lobe
opacification concerning for consolidation vs. atelectasis.
There was also concern that this current episode of hemoptysis
was precipitated by recent anticoagulation with coumadin that
was initiated for treatment of pulmonary emboli discovered
during the ___ bronchoscopy. Thus, her anticoagulation was
held. The patient underwent repeat bronchoscopy on ___ with
removal of clots and cauterization of several oozing areas of
friable tissue. Lavage was performed and biopsy sent to
pathology for further examination with results pending.
#Anticoagulation: Coumadin will be held (per pulmonary) for the
next four weeks until patient follows up with repeat CT Chest
and bronch to allow time for her injured pulmonary tissue to
heal. The tentative plan is to ultimately resume anticoagulation
and complete full treatment of her PE. She has IVC filter in
place.
#Iron deficiency anemia: Hg 9.2 on admission and stable at 8.8
on day of discharge. Patient did not have any symptoms of anemia
and was not transfused pRBCs. She was given a script to get her
CBC repeated within the next week and prescribed oral iron
supplements.
#Stage II Sacral Ulcer: no sign or cellulitis; wound kept clean
and dry. Patient rotated frequently to avoid continuous
pressure.
#Hypertensive urgency: Patient hypertensive to 204/99 in PACU
following bronchoscopy most likely secondary to not receiving
her home meds prior to procedure. Home meds given in addition to
20mg IV Labetalol and 5mg IV Metoprolol. Her blood pressure
responded appropriately with no other episodes of significant
elevations.
*TRANSITIONAL ISSUES:*
- Ms. ___ will ___ with her Interventional
Pulmonologist for repeat CT and repeat bronchoscopy 4 weeks
after discharge.
- Ms. ___ was previously anticoagulated with Warfarin to
treat PE. Per her Interventional Pulmonologist, this
anticoagulation should be held for the next 4 weeks until repeat
imaging and bronchoscopy have been completed at which point this
should be restarted if bleeding risk minimized.
- Please check a CBC at PCP ___ within ___ weeks of
discharge.
- Patient started on 325mg of iron at discharge.
- Ms. ___ has an IVC filter in place. This should be removed
once the patient has been safely restarted on anticoagulation.
- Ms. ___ has a stage 2 sacral ulcer. Please evaluate for
healing.
- Patient's BP consistently in the 160s systolic throughout
hospitalization; consider adjusting her outpatient regimen as
appropriate. | 191 | 446 |
18983696-DS-11 | 26,105,589 | Dear ___,
___ was a pleasure taking care of you. You were admitted to the
hospital with palpitations and found to be extremely anemic.
This is most likely due to slow bleeding from your intestines.
We gave you blood transfusions to treat your anemia. Your blood
counts remained stable throughout your time here.
We did an EGD (endoscopy) that was normal. We also did a
colonoscopy that showed an obstruction at the end of your small
bowel, likely due to your colitis. We are not able to rule out
other causes for the obstruction, including cancer.
We recommended that you remain in the hospital for further
evaluation by the colorectal surgeons, but you declined and said
you prefer to follow up with your gastroenterologist at ___
___ prior to any surgical evaluation. You understood
the risk of leaving prior to completing this evaluation. With
your permission, we have contacted Dr. ___ at ___ to let her
know you were here and the details of your stay.
If you have blood in your stool, shortness of breath, chest
pain, or other symptoms that concern you, please contact your
doctor or return to the hospital for further care.
Sincerely,
Your ___ Team | ___ year old female with PMH of Crohn's disease, who presented
with profound symptomatic anemia, most likely related to
subacute GI bleed in the setting of acute on chronic colitis.
# Iron deficiency anemia, likely subacute,
# Crohn's disease,
# Palpitations:
Patient initially presented with palpitations and was found to
have a hemoglobin of 3.5, down from a baseline of ___. She had
an elevated D-dimer, so a CTA was performed in the ED, which was
negative for PE or other abnormalities. She required 3 units of
PRBCs initially, and her hemoglobin remained stable for the
remainder of her hospitalization.
Patient was found to have profound iron-deficiency anemia,
likely from a subacute GI bleed related to her colitis. She
underwent EGD that only showed nonspecific scalloping of the
antral mucosa, with normal biopsies of the antrum and duodenum.
Patient then underwent colonoscopy that showed a polypoid,
edematous, erythematous and ulcerated lesion in what was thought
to be the cecum/appendiceal orifice. This was biopsied which
show active colitis. TB was considered given her history of
positive PPD and risk factors, but her recent quant gold was
negative.
She then underwent MRE that showed a diffusely enhancing
irregular segment of strictured terminal ileum extending to the
cecum and replacing the ileocecal valve. While this may reflect
masslike chronic fibrostenotic changes related to Crohn's
disease (noting the recent biopsy results), underlying neoplasm
cannot be excluded. It also showed a strictured ileum with
partial obstruction with prestenotic dilation of the small bowel
to 7cm.
The hospitalist and GI consulting team wanted patient to remain
in the hospital for further evaluation, but she insisted that
she be discharged and follow up in clinic with her
gastroenterologist (Dr. ___ at ___. Dr. ___ was
contacted to help arrange for urgent GI clinic follow-up and
colorectal surgery consultation.
At the time of discharge the patient had a stable hemoglobin and
was tolerating a regular diet. She was having formed bowel
movements without evidence of blood. She understood that she
should return to the hospital immediately if she were to
experience any chest pain, shortness of breath, or GI bleeding. | 195 | 346 |
Subsets and Splits