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14958899-DS-9 | 26,351,943 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital due to problems breathing.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- While here, you were found to have decreased function of your
heart, which was likely the cause of your symptoms.
- Unfortunately, you needed to be intubated to help you breathe.
- We gave you medications to get the extra water out of your
lungs, and antibiotics to help treat for pneumonia.
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.
- Weigh yourself every morning. Call your outpatient
cardiologist if your weight goes up more than 3 lbs in one day
or 5 lbs over three days.
- 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.
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 | Ms. ___ is a ___ year old woman with history of
hypertension, obesity, asthma, headaches, seizure d/o on
lamotrigine, chiari 1 malformation s/p surgical decompression,
and chronic mobility and social issues, presenting on post
partum day 6 after C-section for twins with respiratory distress
s/p intubation, found to have low ___ transferred to ___ for
further management of peripartum cardiomyopathy. ___ ___ showed
LVEF 15%, severe global LV hypokinesis c/w non-ischemic
cardiomyopathy, RV free wall hypokinesis, mild MR, and high PA
systolic pressure. She was extubated on ___ and was actively
diuresed and started on PO meds. New discharge meds included:
torsemide 10mg qod, metoprolol XL 200mg qd, Entresto 97mg-103mg
bid, spironolactone 25mg qd, apixaban 5mg bid for cardioembolic
prophylaxis given global LV hypokinesis. She will follow up with
outpatient PCP, ___, and Dr ___ with f/u ___
at that time.
ACUTE ISSUES:
=============
# Hypoxemic respiratory failure
# Peripartum cardiomyopathy
# Acute systolic HF exacerbation
# RML consolidation
Presented with sudden onset dyspnea and hypoxia requiring
intubation at OSH. This was ___ pulmonary edema in setting of
peripartum cardiomyopathy ___ edema, elevated BNP, orthopnea at
home) as resp status improved with diuresis. She was
successfully extubated on ___. CTA was negative for PE. She
received ceftriaxone for coverage of possible pneumonia, though
this was discontinued. She was started on apixaban 5mg bid for
cardioembolic prophylaxis, given EF<15%, global LV hypokinesis.
She was discharged on torsemide 10mg qod, metoprolol XL 200mg
qd, Entresto 97mg-103mg bid, spironolactone 25mg qd.
Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan: torsemide
10mg qod).
# RUE Swelling
Noted to have tense and significant RUE swelling following
admission. RUE U/S unremarkable. Surgery consulted, and felt
this likely was related to her PIV. Her exam improved following
removal of PIV and elevation of the arm.
# Seizure disorder
Has history of seizures transitioned from oxcarbazapien to
lamictal, prior history of setting house on fire with seizure.
Seizures are usually absence, not generalized tonic clonic.
Stable since ___ on current lamotrigine dosing. Continued home
lamotrigine.
# Thrombocytosis
# S/p C-section and post-partum hemorrhage
# Normocytic Hypochromic Anemia
Recently underwent massive transfusion protocol in setting of
hemorrhage complications during delivery. Continued to have
slowly downtrending Hgb during admission, thought secondary to
continued slow post-partum hemorrhage. DIC labs negative. ___
consulted who felt no surgical intervention was required.
# Social
Estranged from parents, lives in public housing, concerns for
neglect on recent admission, father of baby is currently
imprisoned. SW was consulted.
# Asthma
Continued home inhalers, advair as symbicort not on formulary.
TRANSITIONAL ISSUES
====================
[]Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan:
torsemide 10mg qod).
[]Has ___ and outpatient f/u scheduled with Dr ___
(Cardiology).
[]Discharged with life vest given low EF and recurrent episodes
of NSVT. Consider EP follow-up.
[]Recommend minimizing or d/c'ing use of albuterol given
recurrent episodes of NSVT (though pt on this for asthma). | 213 | 464 |
15398908-DS-19 | 22,328,509 | Dear Ms. ___,
You were seen here at ___ for a small bowel obstruction
causing nausea, vomiting, and abdominal discomfort. A
nasogastric tube was used to suction out some of the contents in
your stomach/bowel and you were given IV fluids to prevent
dehydration. You have recovered well and we wish you all the
best when you return home!
As you prepare to leave, please remember to 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. | Ms. ___ presented to the ED on ___ with acute onset
epigastric abdominal pain and emesis. CT showed small bowel
obstruction. Given her history of liver transplant in ___, Ms.
___ was admitted to the transplant surgery service for
management of her SBO, which was medically managed with NPO
status, an NG tube for suction, and IV fluid resuscitation. Ms.
___ continued to received her tacrolimus while inpatient. Her
stay was uneventful and she was hemodynamically stable
throughout her hospitalization. NG tube was dc'ed on ___ and
she was advanced from NPO to a clear liquid diet. Her pain
lessened and resolved with medical management-she did not
require pain medications during her hospitalization. She was
advanced to regular diet with appropriate return of bowel
function.
During this hospitalization, the patient ambulated early and
frequently, and actively participated in the plan of care.
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. | 222 | 199 |
14403089-DS-4 | 23,017,750 | You were admitted to the hospital for evaluation of your
weakness and difficulty walking. We believe that this is related
to arthritis in your neck and lower back causing compression of
your nerves and weakness. Your myasthenia appears to be stable.
We made some changes to your medications to try to reduce the
diarrhea. You will follow up with your outpatient neurologist.
When you arrived we saw that you were dehydrated, likely due to
the diarrhea. This improved with fluids and while you were here
the diarrhea improved in frequency. It will be important for you
to keep drinking fluids, especially if the diarrhea worsens, to
protect your kidneys.
We saw that you had a urinary tract infection and we have been
treating you for it. You will need to take oral antibiotics at
home. We are giving you a medication, fosfomycin, which you take
once. You should take this on the morning of ___ ___.
THIS MEDICATION CAUSES DIARRHEA IN SOME PEOPLE. It is not a
dangerous side effect, but please make sure to continue to have
water and salty foods if this happens.
We sent stool samples to the lab to look for an infectious cause
of diarrhea. We did not see one and we believe this is most
likely an effect of your medications.
It was a pleasure taking care of you. | ___ was admitted for management of his myasthenia
___ and chronic diarrhea and workup of his progressive lower
extremity weakness and worsening gait, which was persistent
despite treatment for his myasthenia with 3 days of IVIG
treatment (___) and numerous changes in medications
(___). His examination is notable for mild myasthenic symptoms
(ptosis, fatiguable upgaze, minimal facial and neck flexion
weakness, and fatiguable weakness of proximal muscles). However,
on admission he was found to be weak in a cervical and
lumbrosacral radicular pattern and bilateral upper motor neuron
pattern lower extremity weakness in a distribution atypical for
NMJ disease. He was thought to have a multifactorial etiology of
his weakness with majority of his functional decline more
attributable to cervical spondylosis and stenosis, rather than
acute myasthenia flare. The neuromuscular service was consulted
and through discussions with his outpatient neurologist his
cellcept was decreased and prednisone was increased. His
myasthenic symptoms were stable after the change. His diarrhea
improved; he still had intermittent loose stools. He was found
to have a urinary tract infection and was treated with
ceftriaxone (4 days). His culture grew pansensitive klebsiella
and ecoli resistant to ampicillin and cefazolim and he will
complete his course of treatment with fosfomycin based on
sensitivities and his myasthenia. | 221 | 209 |
18856222-DS-9 | 23,046,124 | You were admitted for a bowel obstruction and are now ready for
discharge. We managed your obstruction with bowel rest and IV
fluids. During your hospitalization your obstruction resolved.
Your diet was also been advanced and you are now tolerating a
regular diet. Please give us a call if you develop fevers,
chills, nausea, vomiting, or your abdominal pain returns. You
can follow up with your primary care doctor. Please let us know
if you have any questions. It was a pleasure taking care of you. | Mr. ___ presented to ___ Department on ___ as a
transfer from an OSH. He had initially presented to OSH with
nausea/vomiting and intolerable abdominal pain. CT scan was
concerning for a small bowel obstruction, especially given Mr.
___ past surgical history of an exploratory laparotomy this
past ___ for a renal laceration s/p traumatic fall. An NGT was
placed at the OSH and he was transferred to ___ for further
care given his surgical history at this institution.
Given findings and the lack of peritoneal signs, the patient was
treated conservatively with NPO/IVF, NGT for decompression, and
awaiting return of bowel function. His pain was treated with IV
pain medications, and his nausea was addressed as well. With the
NGT decompression, he began to experience return of bowel
function on HD#1 with a KUB showing resolving ileus vs. SBO. On
HD#2, the NGT was D/C'd, he was passing flatus, and tolerating
full liquid diet with no nausea or vomiting. He was discharged
on HD#3, tolerating regular diet with no nausea/vomiting,
continuing to pass flatus, and with resolved abdominal pain.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 86 | 255 |
10742136-DS-2 | 22,002,679 | Your admitted to the hospital with respiratory failure and
cellulitis. Your breathing improved and we are ultimately able
to wean you off of oxygen. We also treated a skin infection
called cellulitis with 2 antibiotics, called cipro and
vancomycin. He received 7 days of antibiotics but we extended
your course after discharge from the hospital. | ___ woman with a complicated PMH including bilaterally
TKR's, morbid obesity, and recent bilateral breast cancer (R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who is admitted after presenting to the
ED in the evening ___ with fever to 102, encephalopathy, and
leukocytosis
#Acute metabolic encephalopathy
#Severe sepsis with unclear source
#Left-sided weakness, aphasia, dysarthria
There was initially concern for stroke or TIA on the second
hospital day, but these findings were not noted when she was
initially admitted or in the ER. At the time of discovery, she
had dysarthria, aphasia, and left-sided weakness (___), but she
was out of the window for possible tPA. Head CT ___ did not
show any acute process. She received ASA 325mg PO ___
MRI/MRA head and neck ___ showed no acute process either. (She
needed large MRI which caused 1-day delay). LP attempted on
___ AM out of concern for meningitis, but unsuccessful. In
particular, excess soft tissue made this difficult. ___ was then
consulted, but said that after someone has full ASA, they are
ineligible for LP for 5 days. At 5 days, study would be
non-diagnostic, so will not be pursued. Thankfully, towards the
end of the day on ___, the symptoms had largely resolved.
She was placed on Vancomycin and Cipro on ___ out of concern
for possible meningitis. Cellulitis was very notable on her LLE,
and there was possible PNA on CT (not very convincing) and no
evidence of UTI. Blood cultures were drawn and showed no
growth. Her WBC was as high as 22.6, but improved to normal
after receiving antibiotics. Ultimately, the possibility of
bacterial meningitis was low, so after receiving Vancomycin and
Cipro, this was changed to keflex and doxy on discharge for
extended course for cellulitis. Swallow consult for diet safety
had no issues on ___. With thrombocytopenia, viral illness is
also on the differential, but LFTs normal. Flu swab was
negative.
#Acute hypoxemic respiratory failure
She presented requiring 4L of nasal oxygen. CTA negative for PE
but did show atelectasis and possible aspiration or infection.
She received standing Duonebs, which seemed to help. OSA/OHS
and atelectasis were the likely largest culprits. She was able
to wean O2 to RA several days prior to discharge.
#Hx of bilateral breast cancer
Diagnosed late ___ with R stage 1 invasive ductal cancer and L
DCIS), now s/p lumpectomies/partial mastectomy (___) and now
on letrozole given cancer was ER-positive. Per review of
records,
patient was not recommended chemotherapy or radiation therapy.
Followed by Dr. ___ at ___ On___ (___). Last
seen in ___. She continued home letrozole 2.5mg daily
#Hypophosphatemia and hypomagnesemia - replaced
#Hypertension - continue home at atenolol 50mg daily
#Fungal skin rashes - skin care and anti-fungal cream ___
changed to Fluconazole 200mg PO x1 on ___ and then 100mg PO
daily ___.
# Morbid obesity - outpatient exercise program
# Gout - She continued home allopurinol ___ daily
#Outstanding issues
[]changed to keflex and doxy on discharge for extended course
for cellulitis (total duration of treatment ___ days)
[] For fungal rash started Fluconazole 200mg PO x1 on ___ and
then 100mg PO daily ___.
>30 min spent on discharge planning including face to face time | 58 | 541 |
12949794-DS-12 | 23,555,901 | Your dressing may come off on the second day after surgery.
Your incision is closed with sutures. You need suture removal.
Please keep your incision dry until removal of sutures.
Please avoid swimming for two weeks.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
for 2 weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation. | ___ y/o F with history of spinal cord stimulator presents with
wound drainage. Patient is other intact. Cultures were obtained
on admission and vancomycin was started. On ___, she was
consented and pre-oped for the OR for wound washout and removal
of spinal cord stimulator. ID was consulted who agreed with
continuation of vancomycin.
On ___, the patient was taken to the OR for removal of spinal
cord stimulator and wound washout. Intraoperative cultures were
taken. ID continued to be involved.
On ___ She continued on vancomycin. A PICC line was ordered.
On ___, the patient was stable from a neurologic persepctive.
Infectious disease adjusted the patient's antibiotics based on
sesitivities and switched her to cefazolin 2g Q8h. She had an
episode of chest pain that did later resolve. An EKG was
ordered which was found to be unremarkable. Cardiac enzymes
were ordered as well which were unremarkable. DC was planned
___ after her AM dose of antibiotics. ID follow up was
scheduled. | 186 | 170 |
16693049-DS-17 | 21,394,627 | Ms. ___, you were admitted to ___
___ shortness of breath. While you were here, a chest
Xray showed you had some fluid in your lungs. You were given
Lasix (furosemide) to help with this, and were started on
antibiotics for your cough and bacteria in your urine. | Ms. ___ is a ___ yof with a history of mild mental
retardation, HTN and newly diagnosed CHF presenting with hypoxia
with pulmonary edema on CXR.
# CHF: Diagnosed ___. BNP elevated. Echo ___ shows
diastolic dysfunction, Mild to moderate (___) aortic
regurgitation and preserved EF.
-continued Lasix 20mg po daily, discharged on 40mg and should be
adjusted at next PCP visit pending lytes and volume status
-continued home Lisinopril
-We could not completely wean oxygen so was discharged with home
oxygen. Patient desatted to <88% on RA with ambulation. This was
discussed with family, and there is obvious concern with her
smoking at home. She agreed to stop, and lives with Nephew who
was going to be there as well. Patient and family was repeatedly
warned of risks with going home with O2, but this was preferred
to rehab by patient and family.
# Recent Fever: No fevers since admission. Possibly pneumonia
given productive cough with R>L lung sounds although not seen on
CXR. Repeat CXR after diuresis negative for PNA. UA negative but
urine cx ___ growing E.coli 10,000-100,000.
-completed 5 day course Levofloxacin (day 1 = ___
-completed Bactrim 3 days (day ___ for urine since E.coli
resistant to fluroquinolones
# Hypertension
-continued home Lisinopril
-continued Lasix
# Mental Retardation: Maintained at baseline mental status per
family.
# COPD
-continued home Combivent
# Hyperlipidemia
-continued home Simvastatin
# Social: Per sister, patient lives alone and likely requires
home care. Sister may try to be her full time caretaker.
-___ consult
-Case Management involvement
# CODE: Full-confirmed with HCP
# CONTACT: ___ (sister/HCP) ___
___son) ___
## TRANSITIONAL ISSUES:
-will follow up with PCP and check electrolytes
-please consider decreasing home Lasix from 40mg to 20mg at next
office visit pending her creatinine, electrolytes, and clinical
appearance on exam
-please re-eval need for home O2 at future visits, and discuss
risks with continued smoking | 48 | 338 |
12071526-DS-4 | 20,843,157 | Dear Ms ___,
You were admitted to an outside hospital after being found at
home looking to your left side with loss of motor function on
your left. You had a witnessed seizure at that hospital and were
transferred to ___ for seizure management. You were treated
with a large amount of anti-seizure medications. This made you
very drowsy for a couple of days but eventually it left your
system and you started to act more like your self. We started an
anti-seizure medication called dilantin and we would like you to
continue this medication as an outpatient. You were evaluated by
___ who recommended discharge to a rehab. We recommend you
follow up with your PCP as needed. You were discharged in stable
condition to the rehab. It was a pleasure caring for you during
your stay. | ___ lady with HTN and HLD who presents with left side gaze
preference and left hemiparesis which progressed to
unresponsiveness. She was taken to OSH where workup was
unrevealing but reportedly was noted to have a tonic clonic
seizure. She received Ativan and Keppra and was transferred to
___. At ___, the patient was unresponsive to vocal stimuli,
eyes were shut and there was no gaze deviation. There was
spontaneous movement of the right arm but none on the left
although she did localize, grimace and moan to pain. Pupils were
1mm and minimally responsive. CT head was negative for acute
bleed or loss of gray white differentiaton and CTA head and neck
did not reveal any major vessel cuttoff. Lumbar puncture did not
reveal any signs of infection. She was initially drowsy, likely
secondary to medication effect, but eventually regained her
baseline level of arousal. She was started on Dilantin and had
no other seizure activity. She evaluated by ___ who
recommended discharge to a rehab. | 138 | 168 |
19751571-DS-10 | 24,540,241 | Dear Mr. ___,
It was a pleasure to take care of you at the ___
___. You were admitted because there was
fungus in your blood, which can be a very dangerous situation.
You were started on anti-fungal medications, and we monitored
you for fevers and other signs of infection. You will need to
continue this medication for roughly one more week.
During your hospitalization, you were also noted to have a
possible urinary tract infection, which you were treated for.
You had also had diarrhea prior to coming to the hospital which
was caused by a bacteria known as "C. Diff". You will continue
to receive antibiotics for this process.
You also were switched to a different seizure medication, as our
testing showed you may have some activity related to seizures
during your hospitalization.
You had received a tracheostomy during your prior
hospitalization. The lung specialists put a cap on the
tracheostomy, and you were able to breathe well without it.
After watching you for 2 days, you were safe to have the tube
taken out. We now have it covered with a dressing, and the vast
majority of patients have natural closing within a few weeks. | ___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications including cardiac arrest,
respiratory failure s/p trach/peg admitted with recurrent
candidemia and diarrhea.
Active Diagnoses
# Candidemia: Found on surveillance cultures from rehab. The
patient's HD catheter was pulled in the ED as a likely source
(he had not required HD since discharge in early ___. CXR did
not show evidence of pneumonia. TEE was negative for
bioprosthetic valve vegetation. Ophtho was consulted and were
not concerned for endophthalmitis. The patient was treated with
iv Micafungin ___. He was switched to po fluconazole ___,
once weaned off Dilantin for his seizures. Per ID
recommendations, he will have a 7 day course of fluconazole
which should continue through ___ (to end on ___.
Blood cultures were negative for fungemia while in house. He
will need repeat fungal cultures one week after discontinuation
of fluconazole (to be drawn on ___.
# Possible Coag Negative Staph bacteremia: Grew out on ___ BCx
on ___. While it was possibly a contaminant, the patient was
started on iv vanc for a 7day course given his complicated
recent course of infections per recommendations of ID. Repeated
blood cultures did not grow out any bacteria.
# Seizures: Patient had EEG significant for epileptiform
activity with bitemporal activity. Neurology was consulted, and
they recommended weaning of phenytoin in favor of Keppra. He was
started on Keppra while weaning off of phenytoin without any
seizure-like activity during the bridging process. Last dose of
phenytoin was ___. The patient will be continued on Keppra 500mg
po bid.
#C. difficile colitis: This was thought to be likely secondary
to C. diff. Although it was not documented, the patient was
started on vancomycin PO at the rehab on ___, and is planned to
have a course to complete ___ after iv antibiotics complete
(this course should be continued through ___. Symptoms
mildly improved since initiating antibiotics though he continued
to have intermittent loose stool during the hospitalization.
# S/P hypoxic Respiratory failure: Patient was trach'ed during
prior hospitalization. Lasix held starting day 2 of admission
out of concern for impending hypovolemia. Per interventional
pulmonary consult, the cuff was removed and the trach was capped
on ___. After tolerating this for 48 hours with O2sat>96, the
trach was decannulated. The site was dressed with care. Healing
and improvement of the patient's voice is expected over the next
several weeks.
# ___: Last admission complicated by ___ secondary to
hypotension requiring HD, which he has not required since prior
hospitalization. He was noted to have residual impairment of
renal function on admission. Creatinine has improved throughout
hospitalization.
# Malnutrition: Patient with poor nutrition since his prior
complicated hospitalization course. During the hospitalization,
he has been on G-tube feeds at night. Speech and swallow cleared
the patient for regular diet, although he was fearful of
aspiration. Nutrition followed the patient throughout
hospitalization. As the patient continues to bolster his PO
intake, he tube feed requirements will need to be readdressed.
He should be evaluated by nutrition while in rehab.
# S/P cardiac surgery: Patient had recent complicated and
prolonged hospitalization course. After admission for bacterial
and candidial endocarditis c/b mitral flail, he had a CABG/MVR
complicated by respiratory failure and cardiac arrest. Staples
were removed from abdominal incision. Patient will need to
follow-up with Dr. ___. He was continued on his daily statin
and aspirin therapy.
CHRONIC DIAGNOSES
# Depression: Patient has been previously diagnosed wth
depression, and he noted difficulty coping with his complex
medical situation. In latter stages of hospitalization, the
patient's mood improved, as he expressed hope to regain mobility
and to be near his wife. He was continued on quetiapine.
#Atrial fibrillation: Patient had history of atrial
fibrillation. He was kept on amiodarone. He was monitored on
telemetry until ___, and he was in sinus rhythm without notable
events. Given prior GIB, the patient is not being started on
anticoagulation beyond aspirin.
#Asthma: Patient has been on steroids long-term for asthma. This
was continued at 10mg ___ and 5mg ___. There
was no asthmatic exacerbations during hospitalization. It is
recommended that the patient eventually undergo a long steroid
taper in the future.
#History of chronic hyponatremia: The patient had chemistries
trended with normal serum sodium throughout hospitalization. | 202 | 730 |
14030381-DS-8 | 22,022,625 | Dear Mr ___,
It was a pleasure having you here at the ___ ___
___ ICU. You were admitted to the ICU from your
rehab after you were found to have a fever and increased
secretions through your tracheostomy. You were found to have a
pneumonia which required a prolonged course of antibiotics.
You will need to continue the Bactrim for another 10 days and
the Ceftazadime for another 12 days.
We wish you the best in your recovery.
Sincerely,
Your ___ Team | This is a ___ year old gentleman, with a history of Down Syndrome
w/ trach, G-tube and foley, stage 4 sacral decub, who is
presenting from nursing home with fever and increased secretions
from his trach.
#SEPSIS: Patient's Tmax in the ED was 102. Patient meeting SIRS
criteria with likely source of infection. Given that he is
having increased secretions and CXR shows evidence of right
lower lobe consolidation, patient likely has new pneumonia.
Patient also tachypneic to the ___. CURB 65 score of 2, but
given increased secretions he required admission to ICU given
level of care. Patient placed on vancomycin, cefepime and flagyl
(given hx of prior resistant organisms), Day 1= ___. BAL
studies grwoing GNRs which speciated to Acinetobacter Baumannii
and Psuedomonas Aeurginosa. The Acinetobacter was found to be
multidrug resistant. Infectious Disease was consulted for
recommendations in antibiotic management. He was started on IV
Bactrim for the Acinetobacter for a planned ___dditionally, Ceftazadime was started for Psuedomonal coverage
for a planned 14 day course. The patient remained afebrile and
showed some evidence of improvement in respiratory status
(slight decrease in frequency of suctioning). He was
transitioned to oral suspension Bactrim given that he was
clinically very stable.
#SECRETIONS: Patient is s/p trach and G-tube on ___. ICU
transfer for increased secretions. Patient underwent frequent
suctionning and managed with scopolamine patch. Glycopyrrolate
was additionally added given that secretions are thick and
persistent.
#SACCRAL SORE: Stage 4 ulcer. Wound care advised was consulted
and recommended packing loosely with Aquacel Ag rope and
covering by 4x4's and an ABD. | 86 | 270 |
12318912-DS-13 | 29,583,044 | Dear Mr. ___,
You were admitted to the hospital with acute uncomplicated
appendicitis. You were taken to the operating room and had your
appendix removed laparoscopically. You tolerated the procedure
well and are now being discharged home to continue your recovery
with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Sincerely,
The ___ Care Team | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed WBC was WNL at 7.9. The
patient underwent laparoscopic appendectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, and took
oxycodone for pain control. The patient was hemodynamically
stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
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. | 735 | 202 |
10193065-DS-25 | 20,678,041 | Dear Mr. ___,
It was a pleasure caring for you at ___!
Why was I admitted to the hospital?
-You were admitted to the hospital because your weight had
increased
-You also had a blood clot in your lung
What happened while I was in the hospital?
-You received medicine to remove fluid and decrease your weight
-You received medicine to thin your blood
What should I do after leaving the hospital?
- Continue to take your medicines as prescribed. The people at
your rehab facility will help you with this.
- Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ healthcare team | ___ male with a history of HFrEF (EF 40%), HTN, HL, DM,
AFib not on AC d/t hemorrhagic stroke, CKD, and dementia
admitted for CHF exacerbation and new R subsegmental PE.
#ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: After
last discharge in ___ gained approx. ___ pounds with
increasing edema and JVD. Despite cardiology instructions to
increase diuretics, it appears there were concerns about nursing
home medication compliance and dietary adherence. On admission
BNP 1600, stable from ___ admission for CHF. Patient was
diuresed with IV Lasix and transitioned to PO regimen of
torsemide 40 mg BID. For afterload, patient discharged on
lisinopril 30 mg (previous dose 40 mg; decreased for lower blood
pressures). Metoprolol succinate XL was increased from 75 mg
daily to 75 mg QAM and 50 mg ___ for better heart rate control.
Discharge weight 91.9 kg.
#R SUBSEGMENTAL PE: New subsegmental PE seen on CT angiogram
performed in the Emergency Department. He has atrial
fibrillation but has only been on aspirin due to a history of
cerebral hemorrhage ___. HDS, no O2 requirement, no signs of R
heart strain on ECG on admission. Neurology was consulted given
history of intracranial hemorrhage. Recommended heparin drip w/o
bolus and MRI to help in determine risks of longterm
anticoagulation. However, based on discussions with patient's
outpatient cardiologist (Dr. ___ and patient's son, the
decision was made to defer antiocoagulation due to patients CVA
hemorrhage and frequent falls. Patient remained HDS throughout
hospital course.
# UTI: Patient had complaint of abdominal pain in RLQ to
suprapubic region. UA, UCx revealed E. coli and proteus. Patient
initially started on IV ceftriaxone ___ but narrowed to
ampicillin when sensitivities resulted. He will complete course
of ampicillin ___.
#AFIB: History of afib, recently persistent. CHADSVASC of 6,
however has not been on full anticoagulation given history of
intracranial hemorrhage in ___. Patient was monitored on
telemetry during hospital course and had rates up to 140s. The
decision was made to increased Metoprolol succinate XL from 75
mg daily to 75 mg QAM and 50 mg QPM for better rate control.
#RIB FRACTURE: Reported frequent falls at rehab, and per OSH
records no bed alarms at rehab facility. s/p rib fracture from a
fall. Stable R rib fracture with pain on exam. Pain controlled
with Tylenol and lidocaine patch as needed.
___ on CKD stage 3: baseline 1.1-1.6. Cr monitored while
inpatient. Did have rise in Cr to 1.9. Improved by withholding
Lasix dose. Cr on discharge 1.7. Please check BMP day after
discharge and fax to ___ clinic: ___. | 111 | 423 |
14217106-DS-13 | 27,197,410 | Dear Ms. ___,
You were hospitalized due to symptoms of confusion and left
sided 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.
Given your large stroke burden and other medical problems, it
was decided to make you comfortable and stop all tests and
therapies.
We are changing your medications as follows:
- Discontinued all home medications
- Provide comfort medications (please see med list)
Please take your medications as prescribed.
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ woman with COPD, CAD s/p CABG, and
HTN who was found down and was confused and had left-sided
weakness. She was taken to ___ where a ___
showed a right basal ganglia infarct with hemorrhagic
conversion. EKG at ___ also showed diffuse
hyperacute T waves, deep TWI in leads V1, V2 and aVL, QTC 516
mSec. She was transferred to ___ on ___. In the ___
emergency room, EKG confirmed results of previous EKG and she
was noted to have elevated CK 3005, mild elevation in troponin
T(0.07) and elevated CK-MB (98+) revealing evidence of
rhabdomyolysis and NSTEMI. Cardiology was consulted and ECHO
showed EF>75% without evidence of thrombus. CTA head and neck
showed right M1 & M2 defects of MCA suggestive of emboli,
hemorrhagic transformation in right basal ganglia, and complete
occlusion of right ICA. MR ___ confirmed a large R MCA
territory stroke, hemorrhage of right putamen, foci of infarct
involving the left centrum semiovale, and infarct of the genu of
the left corpus callosum, old right occipital lobe infarct, and
extensive chronic small vessel ischemic disease. Although
atheroembolic disease would explain the R MCA stroke, it would
not explain the left-sided infarcts. Therefore, a more proximal
source (cardioembolic) is likely. Her mental status
progressively worsened. A Doboff was placed for feeding and
medication due to AMS and swallowing deficits. A family meeting
including HCP resulted in the choice to make her comfort
measures only. Medications and Doboff were discontinued. She was
kept very comfortable and discharged to hospice. | 146 | 256 |
11774442-DS-13 | 26,494,857 | Dr. ___
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were constipated, vomiting and required oxygen
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Because of your recent abdominal surgery, there was concern
that you had an obstruction in your belly, however a CT scan of
your belly did not show any obstruction. You were given
medication to treat your nausea and pain. You were also given
medication to have a bowl movement. You improved and where ready
to leave the hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Ms. ___ is a ___ year old female with recent SBO s/p ex-lap
with extensive lysis of adhesions on ___ who presented with
abdominal pain, emesis, and constipation with concern for SBO.
TRANSITION ISSUES
=================
[] 9mm stone noted on RUQ, consider additional biliary workup if
patient experiences RUQ pain
[] Consider outpatient sleep study to evaluate for OSA, new O2
equirement on admission
[] A1c 9.3 on admission, continue to titrate insulin and
consider swallow study for possible gastroparesis if
nausea/abdominal pain persists.
#CODE: FULL CODE presumed
#CONTACT: ___ ___
ACUTE ISSUES
============
# Nausea, vomiting, and constipation
# Recent SBO s/p ex-lap w/ LOA
CT a/p showed post-surgical changes but no acute abnormality and
no evidence of obstruction. She had enema in the ED with
significant bowel movement so presumably does not have
significant constipation on arrival to the floor. Likely some
contribution for gastroparesis given poorly controlled diabetes.
In addition, ___ have had mild ileus. Of note, she is also on
chronic prednisone for her rheumatoid arthritis so may have
secondary adrenal insufficiency with inadequate response to
stress. She takes Tylenol at home for pain but has not been
taking any constipating opioids. She does follow a bowel regimen
at home. RUQUS with so evidence of cholecystitis or biliary
dilation but does have a 9mm stone lodge in the neck. Started
with clear liquids now advanced to full diet. Due to wound
deheisence, a wound vac was placed. She was treated with IV
zolfran and prochlorperzine for nausea and emesis along with
agressive bowel regimen, which included enema. Pain control was
achieved with tylenol 1g and low dose oxycodone.
Has wound vac in place per surgical service.
#Hypoxia
#New O2 requirement
Patient found to be hypoxic while in the ED, but she was
reportedly asymptomatic and awake. CTA PE showing no PE but
showing nonspecific opacities and ground glass changes. She
denies any cough or respiratory distress. Differential includes
atelectasis (recent long hospital stay) vs. obesity
hypoventilation syndrome vs aspiration pneumonia vs. pneumonitis
in the setting of recurrent emesis vs. underlying sleep apnea
that may not have been diagnosed (reports history of snoring).
She has no known COPD but did smoke for ___ years in the past.
Patient iniately required 3L NC, but was quickly wean to RA
without much difficulty.
# Rheumatoid arthritis
- Continued home prednisone 10mg daily
- Note that she has not had any stress dosing. If her abdominal
discomfort, nausea and emesis persists, consider stress dosing
for relative adrenal insufficiency with prednisone 30mg x 3 days
and then re-evaluate
# Diabetes: Her A1c is 9.3 on this presentation
On insulin at home: Humalog ___ 54U breakfast and 26U dinner;
initially held given poor PO intake and stable sugars. Restarted
on Insulin and titrated back to home regiment prior to
dishcarge.
TI: Needs close follow-up on discharge
CHRONIC ISSUES
==============
# History of PE, lupus anticoagulant syndrome: Last event ___.
Previously on warfarin but this was discontinued about ___ years
ago.
# GERD
- Continued omeprazole
# Hypertension
- On lisinopril at home; initially held given recurrent emesis
and relative soft blood pressures, restarted prior to discharge
# HLD
- Continued rosuvastatin
Patient seen and evaluated in the morning. Reports feeling
well. No nausea vomiting abdominal pain today. Ambulating
independently at her baseline. Wound VAC functioning fine,
replaced with a portable unit. Medically stable for discharge
today. Discharge plan discussed with patient in detail, she
understands and agrees. | 157 | 546 |
18128311-DS-15 | 24,786,747 | Dear Ms ___,
It was a pleasure taking care of you at ___
___.
You were in the hospital because you had multiple seizures. We
believe these were caused by your sodium level being very low.
Your sodium was most likely low because of your blood pressure
medication (HCTZ) as well as dehydration.
In the hospital, we gave you fluid to bring your sodium level
back to normal. You also developed a condition called
rhabdomyolysis, which refers to muscle breakdown, likely caused
by the seizure. We treated this with IV fluids.
When you leave the hospital, you should stop taking your HCTZ.
This can cause a low sodium level. We are also holding your
blood pressure medications until you see your PCP.
According to ___ state law, you are not allowed to drive for 12
months following a seizure. You should also avoid swimming or
bathing unsupervised, as well as heights including ladders.
Best wishes,
Your ___ team | Ms ___ is a ___ year-old R-handed F who presented with
multiple seizure-like events. Her evaluation was notable for
hyponatremia to as low as 119 on admission, which is the most
likely cause of her seizure. Seizures consisted of episodes of
an aura of "strange thoughts" and gustatory sensation, followed
by UE tremors w/ fixed gaze, then eyes rolled back. Postictally
she had lethargy/confusion.
# Seizure: Likely provoked by hyponatremia, although her family
history of seizure as well as prior episodes of "strange
thoughts" does raise concern for a primary epilepsy. MRI showed
no structural cause for seizure. EEG has been normal with no
epileptiform discharges. She did not have any further seizures
during admission. As this is felt to be a one-time, provoked
seizure occurrence, she was not started on anti-epileptic
medications.
# Hyponatremia: as above, this is felt to be the most likely
cause of her seizures. Her urine Na on admission was <20, with
initially concentrated urine, suggesting hypovolemia as the
cause of her hyponatremia. Her diuretic use as well as extensive
time spent outside in the hot weather may explain the
hypovolemia. After volume replenishment, her Na corrected to 130
on ___. This was slightly quicker than the recommended
correction of 8mEq in 24 hours, so D5W was started to prevent a
rapid rise in her sodium. Her sodium afterwards remained stable.
Furthermore, her blood pressure was persistently in the low 100s
early on in her hospitalization, despite all of her
anti-hypertensives being held. This again argues for significant
volume depletion.
# Rhabdomyolysis: On ___, CK was noted to rise, with subsequent
myoglobinuria on UA. Her renal function remained stable. She had
significant thigh pain but was otherwise asymptomatic. She was
hydrated as above with D5W. CK peaked at ___ and then
downtrended to ___ prior to discharge. Etiology is likely
seizure. | 152 | 305 |
13894222-DS-5 | 29,072,025 | Dear Mr. ___,
You were admitted to ___
because you were feeling short of breath and more tired than
usual. While you were here, your care team found that your heart
was not beating in a coordinated way, which might have been
causing your symptoms. We discussed all of your options, and you
opted to have a pacemaker put in. The pacemaker acts as a backup
for your heart, to help make sure that it beats fast enough. You
tolerated the procedure well and you were discharged with the
following changes to your medications:
- Increased statin from pravastatin 20mg daily to atorvastatin
40mg daily
- Stopped lisinopril. Do not restart this medication until you
see your doctor as an outpatient.
- Please take Keflex, the antibiotic, for your new pacemaker.
It was a pleasure caring for you!
Your ___ Care Team | Mr. ___ is an ___ year old male with PMH notable for HTN, HLD,
DM2, and history of paroxysmal complete heart block presenting
with dyspnea and fatigue and found to be in 2:1 AVB.
#) SYMPTOMATIC BRADYCARDIA: Most likely etiology at his age is
senescence of conduction tissue. Despite provocative maneuvers
at bedside (bearing down, carotid sinus pressure), arm exercise,
there was no effect on AVB, and PR interval appeared constant on
telemetry. Patient has evidence of other conduction disease with
incomplete RBBB and LAFB and has relatively preserved PR
interval (226 ms), which is suggestive of infranodal block. TSH
was within normal limits and lyme serologies were negative.
Given concurrent symptoms, patient was considered a candidate
for permanent pacemaker, which was placed on ___.
Post-procedurally patient was stable, unremarkable interrogation
by EP, without events on telemetry, and a CXR confirmed
placement of permanent pacemaker. | 138 | 147 |
12406109-DS-6 | 26,286,595 | 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.
- Please take the full course of antibiotics as prescribed.
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in the right upper extremity.
- Range of motion as tolerated in your right upper extremity.
Physical Therapy:
Activity: Activity as tolerated
Right upper extremity: Full weight bearing
Sling: when OOB
WBAT, ROMAT right upper extremity, sling for comfort.
Treatments Frequency:
Site: R elbow
Description: surgical incision covered with DSD
Care: Change dsg daily and prn. Assess surgical incision for s&s
of infection. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. A joint aspiration was
performed and the patient was found to have right elbow septic
arthritis and was admitted to the orthopedic surgery service.
He was started on empiric vancomycin, and he was taken to the
operating room on ___ for irrigation and debridement of
right elbow infection, 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. Blood cultures
drawn at the time of presentation were positive for beta
streptococcus group b, and the infectious disease team was
consulted. Per the recommendations of the infectious disease
team, the patient's antibiotics were changed to Nafcillin and a
TTE was obtained that showed no cardiac involement. The
patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right upper extremity with range of motion as tolerated. The
patient will follow up in two weeks with Dr. ___ 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. | 213 | 303 |
18638427-DS-20 | 29,774,757 | Dear Ms. ___,
It has been our pleasure to care for you at ___.
You were admitted to the hospital with anemia (a low blood
count). For your anemia you received a blood transfusion and
responded well. Since that time your blood counts have been high
enough that you have not needed another blood transfusion. Your
doctor with continue to follow your blood counts after you are
discharged.
You have chronic liver disease called cirrhosis. As a result,
you may bleed more easily and for longer. To treat your
bleeding, you were given transfusions of platelets and Fresh
Frozen Plasma.
Also as result of you liver disease, you collect fluid in your
abdomen and chest chronically. To treat this, you get the fluid
removed every ___ weeks. While you were in the hospital, you got
fluid removed from your chest by a procedure called a
thoracentesis.
During your hospital stay we put in a special intravenous line
called a PICC. A PICC is a tube that goes into your arm and to a
major vein just above your heart. The PICC can stay in for a
long time and you will go home with your in place. You PICC line
will be used for giving medicines and transfusions of blood
products. Your PICC line will require daily flushes and dressing
changes. A ___ service will help you do this at home.
Thank you for choosing to get your medcial care here at ___.
Sincerely,
Your ___ Care Team | ___ w/ h/o EtOH Cirrhosis c/b diuretic-resistant ascites,
diuretic-resistant hydrothorax, SBP, hepatorenal syndrome, HE,
and esophageal varices, who presents with acute on chronic
anemia now s/p PRBC tranfusion, thoracentesis and PICC line
placement. | 240 | 33 |
19014044-DS-7 | 21,501,382 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because of a urinary tract infection. You were treated with IV
antibiotics and improved. Please continue taking your oral
antibiotics at home.
Please call the kidney ___ at ___
immediately if you develop any recurrence of symptoms of your
urinary tract infection (burning on urination, increased
frequency, increased hesitancy, or dribbling).
All the best,
Your ___ Team | Mr. ___ is a ___ year old male s/p DDRT ___ here with
fevers and symptoms of urinary tract infection, possibly
pyelnephritis versus cystitis.
ACTIVE ISSUES
# FEVERS/DYSURIA
Patient presents with positive UA, fevers consistent with UTI.
Pt with pain over grafted kidney so pyelo is a possibility
however he says this is baseline and CT scan from OSH negative
for pyelo. Urine culture had no growth. Was initially treated
with ceftriaxone and transitioned to cefpodoxime with clinic
improvement and a plan for 1 ___HRONIC ISSUES
# S/P DDRT
Creatinine appears to fall within the range of his normal over
the past few years. It is elevated from two days ago, likely
reflecting some ___ in response to systemic inflammation.
Continued CsA, MMF, and prednisone.
# HTN
Continued home amlodipine.
# HYPERPARATHYROIDISM
Continued home sensipar. | 77 | 136 |
18050171-DS-17 | 20,266,674 | YOU ARE LEAVING AGAINST MEDICAL ADVICE. WE RECOMMEND THAT YOU
STAY BECAUSE YOUR SODIUM IS LOW (120). WE DISCUSSED THAT LOW
SODIUM CAN LEAD TO MENTAL STATUS CHANGES. WE DISCUSSED THAT YOU
SHOULD RETURN TO THE ED IF YOU EXPERIENCE MENTAL STATUS CHANGES.
WE ALSO DISCUSSED THAT YOU NEED TO RESTRICT FREE WATER
CONSUMPTION. PLEASE FOLLOW UP WITH YOUR PCP AS SOON AS POSSIBLE.
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 left upper extremity w/ no shoulder range of
motion; in sling and swathe at all times; range of motion as
tolerated in wrist, digits
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.
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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off. | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left dislocated shoulder and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a closed shoulder reduction 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's preoperative Na was 124. His home HCTZ was
held and he was advised to not take it until he follows up his
PCP. His postop Na was 119. He was free water restricted and
given a sodium tablet. His Na was rechecked 3 hours later and
found to be 120. Throughout, he had no changes in mental status.
Of note, he drank lots of alcohol two days prior and drinks ___
drinks daily.
The plan for the patient was to continue free water restriction
and start IV NS at 75cc/hr. The patient declined to stay and
wanted to leave against medical advice because he runs a local
newspaper and could lose thousands of dollars if he did not get
home tonight. It was explained to the patient in detail why we
thought he needed to stay in the hospital. The patient still
wanted to leave. He was advised to follow up with his PCP as
soon as possible regarding his HCTZ and low sodium. He will
follow up with Dr. ___ in clinic in 2 weeks. | 260 | 272 |
17047736-DS-9 | 24,039,986 | Dear Mr. ___,
You were admitted to ___ and
underwent lysis of a blood clot in your right leg, and placing
of a stent in your right popliteal artery. You have now
recovered from surgery and are ready to be discharged. Please
follow the instructions below to continue your recovery:
MEDICATION:
Take Plavix (Clopidogrel) 75mg once daily for 1 month
After you finish your course of Plavix in 1 month, restart
taking Aspirin 81mg once daily
Start taking Xarelto. You will take 15 mg twice a day for the
first 2 weeks, and then 20mg once daily after that
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Mr. ___ was admitted from clinic with a three day history
of new-onset RLE claudication and R popliteal artery occlusion
demonstrated on duplex US. He was taken to the endovascular
suite and underwent an arterial angiogram which confirmed the
popliteal occlusion and also showed some collateralization
suggecting acute-on-chronic disease. A tPa pulse spray and
angiojet thrombectomy x2 was performed, followed by an
angioplasty and stenting of the right popliteal artery. The
procedure was uncomplicated and Mr. ___ tolerated it
well. The post-intervention angiogram demonstrated an open
politeal artery, a ___ open to the foot, diminutive AT occluding
above the ankle and a peroneal occluding at the midleg,
consistent with his pre-operative status. Following the
procedure he was loaded with 300 mg of Plavix and restarted on a
heparin drip. He recovered quickly from surgery and by POD 1 was
eating, walking and voiding. He had no hematoma or bleeding
from his groin puncture site and his pain was well controlled on
PO medication. With all goals of care met and doing well
clinically, he was discharged on a 1 month course of Plavix and
a new ongoing regimen of Xarelto. After 1 month he will replace
the Plavix with Aspirin and will be on a Aspirin/Xarelto regimen
indefinitely. | 420 | 209 |
12419181-DS-12 | 24,034,327 | Dear Ms. ___,
It was a pleasure to care for you during your hospitalization at
___. You were admitted for
confusion we believe is due to worsening of your dementia. Your
recent head injury, bladder infection that required antibiotics,
and problems with regulating the sodium level in your blood may
have also contributed. We checked a CT scan of your head and
you had no bleeding. During your hospitalization, we stopped
your antibiotics, and gave you IV fluids while carefully
monitoring your sodium levels. Your confusion improved during
the hospitalization we believe your dementia is continuing to
worsen. You worked with physical therapy while you were here,
and enjoyed playing your word finding games.
You had a fall overnight during your hospitalization while
getting up to go to the bathroom. Your physical exam was
normal, and you did not appear to be more confused. A head CT
scan showed no bleeding in the brain or any new abnormalities.
We recommend that you have someone help you in and out of bed
and to the bathroom to prevent any more falls or injuries, and
continue to work with physical therapy.
Your salt levels were low, but were carefully monitored to
ensure it did not fall lower to worsen your confusion. We
restricted the amount of water you drank to 1 liter (4 cups).
You should continue drinking no more than 4 cups of water at
home and eat foods that are high in salt. Your daughter and
nurses ___ help you with this.
It will be important for you to follow up with your physician
and have your sodium level monitored as well as any signs of
headache or changes in neurologic function. | ___ year old woman with history of subdural bleed, cognitive
decline, afib on metop and amiodarone, presenting with cognitive
decline secondary to worsening dementia and hyponatremia. | 294 | 27 |
17924725-DS-14 | 28,377,516 | Dear Ms. ___,
You were admitted for symptoms of progressive memory loss and
visual hallucinations. You have been diagnosed with ___ Body
Dementia. Your MRI did not show lesions in your brain, and a CT
scan showed two hemangiomas (groups of blood vessels) between
your skull and your brain. Your EEG was normal. Your spinal
fluid analysis did not show infection or autoimmune disease in
your central nervous system. Additional tests for Alzheimer's
disease are still pending. You were started on donepezil to
treat your dementia. You will have outpatient Neuropsychiatric
testing and will follow up with Cognitive Clinic (Dr. ___
and with your Neurologist Dr. ___.
You have REM sleep behavior disorder, and you were started on
trazodone at night to help suppress REM-type sleep, to improve
the nightmares and behaviors you have at night. We will also
taper off your venlafaxine, because this could be making your
REM sleep behavior disorder worse.
You have a high white blood cell count, with many eosinophils.
This could be due to infection, allergic reaction, or cancer.
You have been evaluated by Infectious Diseases and you have many
tests pending to check for infection. You will follow up with
your PCP and your PCP will need to refer you to Infectious
Disease clinic if any of your tests for infection return
positive. You will also have an appointment in ___
to assess for cancer as a cause for eosinophilia. It is less
likely that this is due to an allergic reaction, but if all of
the tests result as negative, drug allergies will need to be
investigated.
It was a pleasure taking care of you during this admission. | Ms. ___ is a ___ yo RH F with migraines and possible
prior TIA (L sided weakness at the time) who was referred by Dr.
___ for workup of rapidly progressive cognitive
decline. In fact, the patient's cognitive decline is less
rapidly progresive than initially thought. She has reported
memory loss over the past ___ years, hallucinations of
women/children smaller than true size for the past ___ year, and 3
falls within the past 6 months. The patient's memory problems
include remote and recent memory and word finding difficulty.
The hallucinations do not have an auditory component, do not
interact with the patient, and after the initial surprise of
having hallucinations, do not bother the patient. However, she
has called the police at night because she gets confused and
thinks she is unsafe. The falls are a combination of
unsteadiness and accidents (slipping on ice, etc). EEG showed
diffuse slowing but no epileptiform discharges, and LP was
bland, so this is unlikely to be seizures or
infectious/autoimmune encephalitis. The diagnosis for her memory
loss and hallucinations is ___ Body Dementia, although patient
does not have Parkinsonian symptoms at this time.
NEURO:
- MRI brain with contrast: some atrophy, extraparenchymal masses
possibly hemangiomas. Masses confirmed as hemangiomas on CT
___. Initial concern that these masses could be causing
seizures (manifesting as hallucinations) in this patient, but
this was not corroborated by EEG. cvEEG shows diffuse slowing
but no epileptiform activity.
- LP - traumatic tap but bland. CSF cx neg. A-beta and tau
pending.
- Effexor 75mg daily - will taper off this medication, as per
outpatient psychiatrist Dr. ___ (___), by
reducing dose by 50% for 1 week and then stopping, as this
medication can be worsening the patient's REM sleep behavior
disorder. SSRIs and SNRIs can exacerbate dementia in this
patient. In the future, her psychiatrist would like to consider
seroquel for hallucinations if not well controlled on donepezil.
- Continue donepezil 5 mg for dementia with memory
loss/hallucinations
- Continue trazodone 25 mg qhs to suppress REM sleep in this
patient with REM sleep behavior disorder
- will arrange for outpatient Neuropsychiatric evaluation
- will follow up in cognitive clinic with Dr. ___ and with
neurologist Dr. ___ (___)
HEME/ID: labs show WBC ___, with 40-60% eosinophils. She does
report recent UTI which was treated with an unknown antibiotic
which she believes begins with a "B". If she received Bactrim,
this could be sequellae of having a Sulfa allergy. Can also be
seen in some leukemias and lymphomas (but she has no other sx),
allergies and allergic reactions, and parasitic infections.
Since the eosinophilia has persisted since admission, drug
reaction may be less likely. Last CBC in ___ showed only
3% eosinophils, but there is concern for parasitic infection in
this patient with recent travel to ___ ___ and
3 days of diarrhea in ___ (although self-limited). There is
also concern for HIV, since patient has had new sexual contact.
- WBC count persistently elevated with eosinophilic
predominance.
- ID was consulted and recommended the following tests, which
are pending: ESR pending, CRP 4.6, HIV pending, ANCA pending,
cortisol 9.5, strongyloides pending, HTLV I/II pending, LFTs
elevated and should be followed as outpatient, stool O&P - 3
samples sent and ___ is negative with next 2 pending, CDiff
negative
- Serum tox negative
- UTox negative
- UA bland, urine cx neg
- will refer to ___ clinic as outpatient for continued workup
of eosinophilia, possibly to include bone marrow biopsy since
malignancy is a consideration in a patient of this age,
especially if ID workup results are negative (currently pending)
and AEC>1500
- will need follow up in ___ clinic if infectious workup returns
positive - PCP ___ need to refer patient.
CHRONIC PROBLEMS:
- Hyperlipidemia: continue simvastatin
- h/o TIA: continue clopidogrel
***Transitional Issues***
- taper off effexor in 1 week
- follow up neuropsychiatric evaluation
- may need referral to ___ clinic if infectious workup positive
- may need bone marrow biopsy for evaluation of eosinophilia | 272 | 650 |
19817441-DS-11 | 27,669,615 | You came in with chills and jaundice. We found that you had
some gallstones blocking your bile ducts. We did a procedure
called an ERCP with sphincterotomy to relieve this blockage and
you tolerated this procedure well.
Please discuss with your PCP and your ___ regarding
timing of a cholecystectomy or a surgery to remove your
gallbladder.
Please return if you have worsening abdominal pain,
nausea/vomiting, jaundice, fevers/chills, or if you have any
other concerns.
It was a pleasure taking care of you at ___
___. | ___ male with medical history notable for afib and tachybrady
syndrome s/p PPM, HTN, aortic stenosis s/p AVR, CAD, non-hodgkin
lymphoma on surveillance who presents w/x1 week of decreased
appetite and po intake, fatigue, generalized weakness, and
chills found to have choledocholithiasis.
#Choledocholithiasis vs. cholangitis
Pt presented with chills, leukocytosis, and found to have
elevated LFT's, bili. CT a/p showed biliary sludge with mild
gallbladder wall edema. He was started on IV
zosyn->cipro/flagyl x7 day course for presumed cholangitis. He
underwent ERCP on ___ which showed multiple stones and
sludge in the CBD, removed and sphincterotomy performed. Pt
tolerated the procedure well with no post-procedural pain or
nausea. He was counseled to hold his xarelto for 1 week
post-procedure or unless otherwise directed by his Cardiologist.
He ___ also d/w his PCP and ___ prior to deciding on
ccy.
#Afib
#Tachybrady syndrome s/p pacer placement
Xarelto held for procedure and pt got 1x dose of 5mg IV vitamin
K and FFP for elevated INR: 2.9 prior to ERCP. Xarelto also
held for 1 week post-procedure unless otherwise directed by pt's
Cardiologist. Pt's HR controlled with Metoprolol.
#Hyponatremia: Mild. Likely in the setting of poor po intake,
hypovolemia, vomiting. S/p IVF in ED. Now resolved.
#CAD: Continued simvastatin
#HTN: hold valsartan
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. | 85 | 229 |
18323260-DS-23 | 25,270,775 | Dear Ms. ___,
You were admitted to ___
because you were experiencing episodes of losing consciousness.
You care team at the hospital looked carefully at many possible
causes of these episodes. We monitored your heart closely, and
found that your heart rate was too slow. This slow heart rate
could contribute to passing out, especially if you are not able
to eat and drink enough. One of your medications (nadolol) works
by slowing your heart rate, and we stopped this medication while
you were in the hospital. We closely monitored your heart rate,
which improved when we stopped the nadolol. Your blood pressure
remained stable.
While you were here, we performed an MRI of your ankle, which
showed that you have a fracture of your heel bone. We spoke with
your orthopedist, who recommended that we set you up with a
special boot and have you go to a rehab facility.
We also evaluated your abdominal pain, and imaging and
laboratory results were reassuring. We are discharging you on
your home pain regimen, with plan to follow-up with your PCP.
It was a pleasure caring for you!
- Your ___ Care Team | Ms. ___ is a ___ with PMHx of EtOH cirrhosis, RNY gastric
bypass (___), and chronic abdominal pain who presented with
multiple episodes of syncope and stable shortness of breath x ___s left ankle injury.
Syncope thought to be due to a combination of bradycardia (on
nadalol for BP control, no evidence of varices on imaging, prior
documentation of HR in ___ and orthostatic hypotension
(history of gastric bypass and chronic abdominal pain, which
limits PO intake). Question remains regarding why LOC episodes
are so prolonged. Patient remained on telemetry for >48 hrs with
no events. Remained asymptomatic during hospitalization, and
heart rate improved to ___ while holding nadolol. Remained
normotensive.
Additionally, had sudden worsening of her chronic abdominal
pain; this was investigated with labs and a CTAP W IV contrast,
which did not show any acute findings. We continued her home
narcotics and ensured bowel regimen titrated to soft BM daily.
Had MRI this admission for ankle to determine disposition, as ___
felt would be safe for home if WB and would need rehab if NWB
LLE. MRI showed calcaneal fx; pt discussed with her outpatient
ortho, who recommended NWB, CAM boot, and outpatient follow up
with him in several weeks.
Re: ETOH cirrhosis, continues on home lactulose and rifaximin.
No hx varices (last EGD ___. D/c'ed nadolol and
spironolactone as above. Needs GI follow-up. | 189 | 225 |
17454372-DS-15 | 25,977,265 | Dear Mr. ___,
You came to our hospital for rapid heart rate, and was found to
have a heart rhythm called atrial flutter. We gave you
medication to slow down your heart rate, which you responded
very well. You also underwent an ultrasound of your heart (aka
ECHO), which did not show evidence of structural heart disease.
The blood work did not reveal reversible cause of your atrial
flutter either. This condition most likely occurred from your
COPD.
.
Please note the following changes to your medication:
- Please STOP taking aspirin
- Please START to administer lovenox ___ mg (one injection)
subcutaneously daily. You will need to continue doing that
until your INR > 2.0 for at least 24 hours
- Please START to take warfarin 2.5 mg tablet by mouth daily
with your dinner
- Please START to take diltiazem ER 120 mg tablet by mouth daily
- Please continue to take the rest of your medication
.
We have made the following arrangements:
- There will be a visiting nursing coming to your home to make
sure everything is well.
- Please go to the ___ at ___ for blood draw on
___.
- We have also arranged an NP appointment in your PCP's office
on ___.
- You will be notified for the cardiology appointment.
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery. | ___ yo male with history of COPD who presents with new onset
a-flutter.
. | 237 | 13 |
17552191-DS-17 | 28,774,317 | You were admitted to ___ on
___ after you sustained a fall at work. On further
evaluation, you were found to have the following injuries:
- Left small subarachnoid hemorrhage
- Left proximal humoral head fracture
You were seen by the Neurosurgery service. There was nothing to
do for your subarachnoid hemorrhage. You should follow up with
their office in one month (see appointment below). Because you
had a small amount of blood in your head, you are taking Keppra,
which will prevent potential seizures in this situation. Take
all medication until it is finished.
For your left arm (humoral head) fracture, you were seen the the
Orthopedic Surgery team. They recommend that you wear a sling
at all times (other than for hygiene), do not bear weight using
that arm, and follow up with their service in two weeks
(appointment below).
Lastly, you were seen by Physical and Occupational therapy.
Both services felt you were safe to be discharged home. There
is no further follow-up needed.
Please continue to take any medications you were taking prior to
this admission. You are being give a prescription for pain
medication. Take as needed. Do not drive or operate heavy
machinery while taking those narcotics. If you become
constipated, you may take colace (stool softener) daily and a
laxative as needed. | Mrs. ___ was admitted to ___ on ___
after you sustained a fall at work. Per medical records, she
was observed to have seizure-like activity after falling down
approximately 10 stairs. She had also lost consciousness for
approximately five minutes. Upon further evaluation, she was
found to have a small left subarachnoid hemorrhage and a left
proximal humerus fracture. She was transferred to ___ for
further evaluation and management.
One at ___, Mrs. ___ was seen by Neurosurgery and
Orthopedics for her injuries. From a neurosurgical standpoint,
the patient did not require a surgical procedure. Her repeat
head CT was stable. She was started on Keppra for seizure
prophylaxis. She will follow-up in their office in one month.
Mrs. ___ did not require an operative procedure for her left
humerus fracture. She was instructed by Orthopedics to keep the
arm in a sling and not bear any weight with that extremity. She
will follow up with that service in approximately two weeks with
an x-ray prior to her appointment.
The patient's pain was managed well with oral narcotic and
non-narcotic analgesics. She was tolerating a regular diet
well. She was hypertensive at times with systolic pressures in
the 150 to 160s and diastolic pressures between 80 and 90. She
was instructed to follow up with her PCP to address this issue,
although the new onset pain could have exacerbated her blood
pressure.
Lastly, Mrs. ___ was seen by Physical and Occupational
therapy. Both services felt that she could be discharged home
with no additional services.
At the time of discharge, the patient was afebrile,
hemodynamically stable and in no acute distress. | 225 | 284 |
16468462-DS-13 | 28,711,673 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came in following a fall and broke your
femur. You had some bleeding so you were given several blood
transfusions. You had surgery and there were no complications
with the procedure. Your blood counts stabilized so you were
discharged to rehab.
While you were here we discontinued your coumadin because you
needed surgery. You were restarted on your coumadin at
discharge. Your INR needs to be followed up. | ___ y/o female with past medical history of DVT on coumadin,
COPD, GERD, dementia, PNA who sufferred from a mechanical fall
at home and is s/p ORIF for a right femur fracture performed on
___.
ACUTE ISSUES
# Femur Fracture - Patient suffered from a mechanical fall on
___ and was transferred to ___ for surgery. Surgery was
postponed until ___ due to elevated INR while on coumadin.
Admission INR was 2.7. Patient received 5 U FFP with appropriate
normalization of her INR. Patient went to the operating suite on
___ for an ORIF of her right femural shaft which included
lateral plating with a 16 hole plate secured with cortical and
locking screws. There were no complications during the
procedure. Patient returned to the floor and was transferred to
the medicine service for management. Pain was adequately managed
with acetminophen 1 g PO TID scheduled, oxycodone 2.5mg po TID
PRN for post op pain, and Morphine ___ mg IV q4 hrs for
breakthrough pain. Ortho monitored the wound daily and felt the
wound was healing appropriately. ___ was consulted on ___.
Lovenox 30 mg subcutaneous daily was given to the patient for
DVT ppx. Patient to be discharge to rehab facility and will
followup with ortho as outpatient.
# Fever, Leukocytosis - Patient had fever and leukocytosis
post-op. Patient denied chills, diaphoresis, cough. Most likely
post-operative findings. Had CXR which was wnl. Increased
pulmonary toilet and pulmonary ___. Patient was not able to
adequately use the incentive spirometry. Patient was afebrile on
discharge. WBC 9.6.
# Dementia - Patient was at risk for delirium given history of
post-op delirium. Patient did not become delirious during
hospitalization. Pain was managed adequately. at risk for
delirium
# Post Op Pain - Pain adequately controlled with the above
regimen. Will continue the acetaminophen 1 g PO TID scheduled
and oxycodone 2.5 mg po TID prn pain. Will not continue morphine
as outpatient.
# DVT history on coumadin - Patient was therapeutic on warfarin
on admission. Required 5 units FFP to normalize INR. Coumadin
was discontinued prior to surgery. Received lovenox 30 mg daily
as prophylaxis. Warfarin was restarted on ___ at 3 mg. Warfarin
was d/c on ___ due to drop in Hct from 27 to 20. Warfarin
restarted on ___ at 3 mg daily with lovenox 30 mg daily bridge.
INR 1.7 at discharge.
# Anemia - Patient required 3 units PRBC on ___ for Hb 6.5. Hb
normalized following transfusion. Received 2 units on ___ for
Hct 20. Post-transfusion Hct 29. Anemia most likely related to
blood loss during surgery and poor bone marrow response. Patient
did not have any signs of overt bleeding. Hemolysis labs (LDH,
Bili, haptoglobin, retic) were wnl. Hb 9.8 and Hct 28.4 on
discharge.
# Oliguria - Urine output declined after surgery. Foley catheter
was in place for UOP monitoring. Received IVF and urine output
increased. Renal function wnl. UOP decreased yesterday. Received
mainteance IVF. F/c was d/c on ___. Required 1 straight cath
was PVR 430cc. Patient was able to void on own at discharge.
CHRONIC ISSUES
# COPD - Patient has a diagnosis of COPD based on imaging. No
smoking history. Received duonebs q8h for post-op wheezing.
Patient was encouraged to use incentive spirometer multiple
times a day. Supplemental O2 was d/c within 12 hours post-op.
Sats >96% RA at discharge.
# HTN - Blood pressure stable during hospitalization. Held home
lasix. Continued home lisinopril.
# Osteoporosis: Ca and vitamin D administered as inpatient.
Continue as outpatient. Recommend outpatient DEXA scan.
# Nutrition - patient was able to eat a regular diet. Ensure
supplementation was given.
TRANSITIONAL ISSUES
- please check daily INR until therapeutic (goal 2.0-3.0)
- please continue lovenox as bridge to therapeutic coumadin at
30mg subcutaneously daily
- please evaluate volume status daily and restart home lasix
dose (20mg daily) if patient develops signs of volume overload
(lower extremity edema, pulmonary rales) | 82 | 646 |
19747913-DS-21 | 23,900,180 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for abdominal pain related to
your stomach hernia. You had surgery on that hernia, but
unfortunately it did not improve your symptoms. We had a feeding
tube that bypasses the stomach placed which also did not help,
and the feeds actually seemed to make your symptoms a lot worse.
Therefore, we continued to feed you through your PICC instead.
After talking with you and your family, it was decided that it
would be best to transition to hospice in order to shift the
focus of your care to maximize your comfort and quality of life.
We wish you the best of health,
Your ___ Care Team | ___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital for repair of a
large paraesophageal hernia, s/p MICU course after tx of PNA,
now s/p modified post-pyloric feeding tube but w/ worsening
abdominal pain and respiratory status despite all interventions.
SURGICAL COURSE
===============
Ms. ___ presented to ___ after an episode of apnea
in the setting of known large paraesophageal hernia with
previous episodes of apnea and planned repair on ___ ___. At ___, she had a CT chest which showed the hiatal
hernia, pleural effusions, and moderate pericardial effusion.
Her apnea resolved spontaneously, without intervention but
previous episodes she has required CPAP. She was transferred to
___ on ___ for interval management and operative
planning.
Medicine was consulted for risk stratification and medical
optimization in light of comorbidities and new pericardial
effusion. She was assigned intermediate risk of <5% for cardiac
complications, but surgery was not contraindicated. A TTE was
performed ___ that found mild mitral valve prolapse, mitral
regurgitation, and mild pulmonary artery systolic hypertension
with a small pericardial effusion and no signs of tamponade
physiology, please see report for further details.
Cardiology was consulted for pericardial effusion, and after
completion of TTE and evaluation of EKGs, recommendations were
made to discharge with ___ of Hearts monitor for one month
for a possible atrial fibrillation versus sinus rhythm with
multiple PACs on an EKG from ___. Also recommended was a one
month follow up TTE to evaluate for expected effusion
resolution, breast cancer follow up and monitoring, TSH
evaluation, and followup with cardiology in 2 months. There was
concern for possible malignant effusion.
In addition to consulting cardiology and medicine, she was
continued to be monitored on telemetry and continuous oxygen
saturation monitoring with surveillance labs. She was tolerating
soft mechanical regular diet, was ambulating with a walker, and
did not have further nausea, vomiting, chest pain, dyspnea, or
apnea episodes while planning for an operation.
On ___, her WBC 16.7, and she had a repeat pre-operative CXR
that found stable pleural effusions (moderate on left, small on
right) with a top normal cardiac size and previously known
hernia. She was taken to the operating room, and had an
exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous, endoscopically guided gastrostomy tube placement.
She tolerated the procedure well, and after her stay in the PACU
was transferred to the floor after prolonged fatigue from
anesthesia. She was continued on telemetry and oxygenation
monitoring.
On ___, patient was transferred to the SICU for increased
work of breathing and found to have a RUL consolidation with WBC
of 24. A CTA was also done to rule out a PE, which was negative,
but was concerning for a RUL consolidation. She completed a
course of cefatzadime. The patient continued to have hypoxic
episodes w/ respiratory distress c/f multiple aspiration events,
went back and forth between the medicine floor and ICU for these
events. The surgery team saw her and felt that she might need
advancement of her G-tube to a G-J tube.
MEDICINE COURSE
===============
# Hypoxic Respiratory Failure
Reported baseline history of tachypnea prior to surgery thought
to be potentially related to large hiatal hernia but also has
known history of BOOP and restrictive lung disease ___ her prior
history of radiation for breast cancer therapy. Had multiple
aspiration events, completed a course of ceftaz for possible PNA
as above. Was seen by speech and swallow multiple times, was
ultimately cleared for just clear liquids for comfort. Patient
had worsening respiratory status every time tube feeds were
started, prompting discontinuation. Patient complained of
difficulty breathing throughout hospitalization w/ interval
CXR's demonstrating worsening paraesophageal hernia causing a
mediastinal shift to the left. Patient placed on low-dose
morphine w/ some improvement in symptoms.
# Abdominal pain/distension
# Hiatal hernia s/p plication and GJ tube placement: Patient
continued to have abdominal pain after the plication procedure.
G tube was modified to a GJ to allow for post-pyloric feeds
while simultaneously allowing for G tube venting, but did not
help symptoms. Tube feeds were attempted 3 times, and even
though they were started at very low rates, her pain and
abdominal distension would worsen w/in 24 hours of starting.
During hospitalization, was noted to have urinary retention, but
no pain relief from straight caths PRN, and retention
self-resolved after home oxybutynin was d/c'd. Patient was also
given aggressive bowel regimen. Despite all interventions,
patient continued to suffer from significant pain. Ultimately
decided to d/c tube feeds. Continued to leave G tube to vent,
morphine as above. Once tube feeds started, patient was placed
on TPN; however, given concerns for volume overload as well as
overall goals of care, this was stopped prior to discharge.
Family wishes to continue ongoing discussions re: TPN at ___
facility.
# Malnutriton: Pt with poor PO intake this admission ___
expansion of hernia with PO and resulting respiratory distress
as described above. Holding TFs as above, can get clear liquids
for comfort per speech and swallow recs. As above, TPN was
stopped prior to discharge.
# GOC: Patient w/ worsening respiratory and nutritional status
despite all interventions over this long hospitalization.
Multiple GOC discussions had w/ patient and family, they are
aware that further medical interventions are limited and likely
not to help. Ultimately decided on transitioning patient to
hospice care and comfort measures only. However, patient's
family not ready to d/c TPN, they are still discussing this
issue amongst themselves. Therefore, the patient was transferred
with a ___ line in place in case they opt for TPN moving
forward. Patient very lethargic during these meetings, and could
not offer much insight into how she would like to be treated.
# HTN: Continued home amlodipine
# Bipolar disorder: Continued home ___ (level 0.5), olanzapine.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES
===================
[ ] patient has been transitioned to ___, hospice care
[ ] family still undecided on whether to continue TPN, please
continue ongoing ___ discussions, specifically regarding this
issue
[ ] continue to keep G tube to vent, ok to clamp for 30 minutes
if administering meds
# Communication/HCP: ___ (daughter, ___)Phone
number: ___ Cell phone: ___
# Code: DNR/DNI, confirmed with patient and subsequently HCP | 122 | 1,060 |
18890285-DS-22 | 29,842,619 | You were admitted to the hospital after a fall in which he
sustained right sided rib fracutures. Because you were on
coumadin, there was concern for bleeding. You were admitted to
the intensive care unit for monitoring. Your rib pain has been
controlled in pain medication. Your vital signs have been
stable and you are preparing for discharge home with the
following instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old female who was walking at home when she misstepped
and fell on top of a chair striking her right ribs. She did not
strike her head or lose consciousness. She later developed
significant pain in the right ribs and presented to an OSH where
she underwent CT scan which demonstrated right-sided rib
fractures. She was transferred here for management. The patient
was reportedly on coumadin.
Because of her multiple rib fractures, she was admitted to the
intensive care unit for monitoring. Initially she was
hypotensive. Her oxygen saturation was closely monitored and her
hematocrit remained stable. She clinically improved within 24
hours of admission and was transferred to the floor once her Hct
remained stable at ___. Her INR continued to rise following
admission despite holding of coumadin. Max INR was 4.0 on
___. Her only complaint at this time was urgency and
frequency with voids. UA was sent and found to be contaminated,
thus UA obtained via straight cath was resent and found to be
WNL. UCx was pending at the time of discharge, however her
urinary symptoms had already begun to subside at this time. Once
she met the appropriate criteria, Ms. ___ was discharged home
with the understanding that she would follow up with her PCP
___ 24 hours of discharge for INR check as well as per her
appointment scheduled with the cardiology and general surgery
clinics. On the day of discharge (___) her INR was 2.9 and
she received 1mg of coumadin. | 84 | 250 |
18460016-DS-9 | 28,453,453 | Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted with 1 day of nausea, diarrhea, and difficulty eating
food and taking medications. We treated you with IV fluids and
monitored you closely. You did well during your hospitalization
and were able to eat regular foods the next day. You were
discharged on ___ in improved condition.
Please continue taking all of your medications as prescribed,
and attend all follow-up appointments.
Again, it was a please participating in your care. We wish you
the best.
Sincerely,
Your ___ care team | Ms ___ is a ___ F with CML vs PH+ALL s/p allo matched
unrelated donor SCT who presented to ___ on day +100 with 1
day of inability to tolerate PO, 1 episode of vomiting, and 1
episode of watery non-bloody diarrhea, with notable
post-transplant history of possible mild gvhd of colon and
c.diff colitis.
#) Nausea/Vomiting: Improved following 1 day of bowel rest,
zofran, ranitidine, and IVF. C.diff toxin result was pending at
time of discharge but clinically ruled out given formed stool.
Fecal cultures were pending at time of discharge but as she was
clinically improved, tolerating regular diet, she was cleared
for discharge. This episode was felt to be less likely GVHD or
infection given rapid improvement. She has chronic GI symptoms
of IBS-like complaints since her youth.
#) CML vs PH+ALL: She presented on day ___ s/p allogeneic
matched unrelated donor SCT. She is on dasatinib 100mg qhs at
home and tacrolimus 2mg PO q12h. On a clinic visit the day prior
to admission she was seen at Dr. ___ and had been
doing well with no new complaints. Her tacrolimus had been
increased from 1.5mg q12h to 2mg q12h. During admission, her
tacrolimus was continued at the new dose and trough levels were
monitored daily. Dasatinib was temporarily held as it interacts
with ranitidine. She was continued on prednisone 10mg PO for
history of possible mild GVHD of gut. Upon discharge, ranitidine
was discontinued and she was instructed to resume dasatinib. Her
tacrolimus serum level was 2.4, 4.6, 4.7 during this admission.
# Latent TB Infection: She was continued on isoniazid with
pyridoxine
# Citalopram: She was continued on citalopram 20mg PO daily. She
follows with Dr. ___. | 92 | 279 |
11588913-DS-12 | 22,226,854 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | The patient was admitted to Dr. ___ service from the
___ ED for overnight observation, pain control, and IV fluids.
He was continued on ceftriaxone for a UA with >182 rbc and
nitrite positive. On the morning of HD2 his pain was well
controlled and nausea had resolved. His wbc had declined from 19
to 9 and his creatinine had also declined from 1 to 0.7. Given
stone size and location as well as his UA and admission
leukocytosis and hydronephrosis, the decision was made to go to
the operating room for stent placement. He underwent cystoscopy,
right ureterscopy and laser lithotripsy with right ureteral
stent placement. There were no complications; please see OR
dictation for more detail. Post operatively, his diet was
advanced, pain was controlled on PO medications, and he voided
without difficulted. He was given 5 days of cipro, flomax for
stent discomfort, and nacrotics for pain control. He is given
explicit instructions to call Dr. ___ follow-up for
stent removal in 1 week. | 466 | 167 |
13048188-DS-11 | 24,316,457 | Dear Mr. ___,
It was a great pleasure taking care of you. As you know you were
most recently discharged from ___ after your left lower
extremity bypass, and returned from your facility because of
fatigue and slight interval decrease in your hematocrit.
You received one unit of blood during your admission and your
hemoglobin has remained stable:
Hgb
___
It will be important to discuss with your primary care physician
regarding having ___ colonscopy done since it might provide an
additional explanation for your low blood levels.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Take all the medications you were taking before surgery,
unless otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
What to report to office:
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
We did the following changes in your medication list:
- Please START PLAVIX as anti-platelet agent for your bypass
graft (1 month through ___
- Please START VANCOMYCIN every 48 hours (next doses are ___
and ___ for wound drainage/infection
- Please DECREASE NPH at bed time to 14 units. You can increase
this 2 units every 3 days or as directed by your physician as
___ based on your fingerstick blood sugar levels
- Please INCREASE your nifedipine from 60 mg to 90 mg due to
high blood pressure in the hospital.
Please continue taking the rest of your home medications the way
you were taking at home prior to admission.
Please follow up with your appointments as illustrated below.
You will also have a repeat blood count and chemistry panel on
___ at your rehab. | ___ year old gentleman with DM2 complicated by neuropathy, HL,
HTN, PVD s/p L CEA in ___, CAD, CKD, CLL among other conditions
presenting with fatigue and low hematocrit (Hct 22, recent
discharge Hct 23.4). He was re-admitted to the ___ vascular
surgery service after recent discharge the previous day after an
uncomplicated left common femoral endarterectomy and left
femoral to above-knee popliteal bypass with Dacron graft on
___ for continued left lower extremity rest pain and
non-healing arterial ulcer. The patient is s/p radical
nephrectomy for renal cancer, has CLL with anemia of chronic
disease with biweekly injections of procrit. He had been
transfused 5 units of packed red blood cells prior to discharge,
with hematocrit upon discharge of ~23. He was discharged to a
rehabilitation facility in the interim; the facility had drew a
CBC without clear reason, with hematocrit noted to be 22. This,
in context of the feelings of weakness and fatigue, prompted
transfer of the patient back to ___ for further evaluation.
# Anemia: The patient presented with a hematocrit of 22 from
discharge of 23; he received one unit of packed red blood cells
as the patient was symptomatic. Hemolysis labs were not
suggestive of hemolysis. His reticulocyte index was 1.8
suggestive of hypoproliferation. Recent nutritional studies
including iron and B12 were within normal limits. His stools
were hemoccult positive on testing, but this is unclear if a
false positive in the setting of iron therapy. There were no
signs or symptoms of an occult or frank GIB. Overall, it was
favored that the patient's anemia was likely secondary to
hypoproduction related to chronic kidney disease among other
factors. His symptoms of fatigue are likely multifactorial and
not solely related to anemia. He had no active chest pain or
other disconcerting signs while hospitalization suggestive of
poor tissue oxygenation. He should have a repeat CBC and
chemistry panel on ___. If his Hgb is less than 7, chest
pain or other concerning symptoms, or evidence of frank blood or
dark stools, he should return to ___ for further evaluation.
His Hgb on discharge was stable at 8.6. In addition, he should
have updated healthcare maintenance including colonoscopy and
perhaps EGD to explore if a slow GIB could be contributing
factor. He should continue Epo injections as well. The patient
has a history of CLL and chronic anemia requiring intermittent
blood transfusions while taking Procrit once every two weeks. He
received 5 units total of blood during his admission for
hematocrits of ___. His procrit was resumed at 24,000 prior to
discharge, and increased to 30,000 units per recommendations by
his nephrologist; his hemoglobin was improved as above with his
last unit of blood transfused on ___. His last procrit
injection was on ___, Next ___.
# CAD/PVD:
The patient has a history of hypertension, hyperlipidemia in
addition to extensive peripheral vascular disease and was
resumed on his statin, beta-blocker and aspirin. He was started
on plavix for 30 days for anti-coagulation for his new left
lower extremity graft (end date: ___. The patient was
otherwise stable from a cardiovascular standpoint; vital signs
were routinely monitored. ASA 325 mg to be continued lifelong.
The patient is s/p left femoral endarterectomy and femoral-above
knee popliteal bypass with PTFE graft. Throughout his
hospitalization, he had good dopplerable signals bilaterally,
with a dopperable graft, and was weight-bearing as tolerated on
both extremities.
# ___ cellulitis: He developed some serous drainage
from his incision with mild erythema, for which he was placed on
bactrim in his previous admission, which was continued early in
his re-admission course, then switched to IV vancomycin for a
recommended one week course through ___. He also had a ?
surgical site infection at his graft site for which he was given
initially bactrim and changed to vancomycin. His vancomycin
level was drawn at the incorrect dose but the level is
suggestive that with another dose that his level will be
correct. He will receive two more doses as noted ___ and
___. His wound appearance has improved as documented in the
physical exam section.
# Hypertension: It was noted during his hospital to be
hypertensive. He is already on valsartan 320 mg daily in
addition to nifedipine 60 mg daily. In addition, he is on
carvedilol 6.25 mg twice daily. We did not uptitrate carvedilol
given HR 50-60's most of the time. Nifedipine CR was increased
to 90 mg daily. Change might be needed based on BP readings.
Hydrochlorothiazide was initially held given the increase in Cr
however this was restarted in the last 2 days of his hospital
stay.
# CKD, Stage 4: The patient has a history of renal insufficiency
s/p left radical nephrectomy, CLL with subsequent anemia of
chronic disease. The patient is also reliant on torsemide daily
for renal insufficiency; this was held in his previous admission
in light of a rising creatinine from his baseline of 3 to 3.7 at
its peak and was 3.6 prior to discharge, and was held again
during his current admission for similar reasons. Routine
electrolytes were followed, and his urine output remained
marginal ~25cc/hr in the absence of diuretics. Intake and output
were closely monitored. At discharge, he will continue his home
diuretics and regimen. His labs are stable with no acute
indications for dialysis. Of note, at this creatinine level, his
fluctuation is likely trivial given that eGFR remains the same.
He will follow-up with nephrology as scheduled for continued
planning for hemodialysis initiation.
# Diabetes type 2 complicated by neuropathy and nephropathy: The
patient has history of diabetes, with blood glucose levels
between 104-400 within his previous hospitalization. He was
restarted on his home dose of NPH in addition to an adjusted
insulin sliding scale. Due to hypoglycemia, his NPH was
decreased to 12 units with SSI.
# Fall: ___ ~ 4:30 pm patient had a fall in the bathroom
which seems mechanical per patient's description. He hit the
posterior portion of his skull. He denied palpitations, chest
pain, light-headedness, syncope or any other symptoms. He was
able to get up afterwards without any issue. His neuro exam was
non-focal. CT head without contrast didn't show intracranial
bleed (he is on aspirin and plavix). He remained asymptomatic
after the fall. He remained alert and oriented x3 with normal
vital signs. No apparent trauma. Telemetry did not reveal acute
events.
# Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
# CODE STATUS: Full
# CONTACT/ HCP: ___ SPOUSE Phone number: ___ | 642 | 1,095 |
15878172-DS-10 | 28,392,561 | You were hospitalized at ___.
The following is a summary of your hospital visit and
instructions for hospitalizations.
Reason for hospitalization: gastrointestinal bleed
Treatment: Blood transfusions, EGD
Instructions for after hospitalization:
1) Stop aspirin.
2) Stop eliqius.
4) Follow up with Palliative Care at ___.
5) Continue antibiotics for infection.
While you were here with us, you had indicated that you were
very sad and frustrated with repeated hospitalizations, and you
were no longer interested in further invasive procedures or
repeated hospitalizations. Your goal was to stay at ___ for
as long as possible, surrounded by your ___ community, but at
the same time, you were still interested in your current
medications as well as your antibiotics. We believe that the
palliative care team will be able to help you best achieve these
goals, and encourage you to continue to engage with them.
Your weight on discharge was 123.9 lbs, and you are on torsemide
120 mg daily. If you have further dyspnea or painful edema this
can be uptitrated to twice daily if needed and add metolazone if
needed as well.
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ year old man with a history of recent
admission for enterococcal bacteremia, CAD s/p CABG, severe TR
s/p TV clipping (___), AF on eliquis, who presented from an
OSH with melena and hemorrhagic shock. The patient was
transfused total 4U pRBC. EGD revealed multiple non-bleeding
erosions of stomach. Home aspirin and Eliquis were discontinued.
Father ___ unfortunately had ongoing episodes of melena, and in
the setting of his advanced heart failure as well as ongoing
GIB, we held family meetings with regard to goals of care. At
the time of discharge, Father ___ expressed wish for no further
escalation of care, as well as no transfer to hospital. His goal
was to stay at ___ for as long as possible, surrounded by
his community, and to be comfortable. At the same time, he
continued to be interested in continuation of his current
medications, including antibiotics and cardiac medications. He
welcomed involvement of palliative care team and ___ and
further discussions regarding transition to hospice.
# Goals of care
Multiple family meetings were held with Father ___, his HCP
___, as well as niece ___. Father ___ expressed sadness
and frustration with his repeated hospitalizations. He shared
that he was tired of being in and out of the hospital, and that
his goal would really be to stay at ___ for as long as
possible, surrounded by his community. He would like to focus
his care on comfort at this time, and would not want further
invasive procedures; he also would not want to be back in the
hospital (even if this means that he should pass away sooner).
He notes that previously hospice had been mentioned, and he is
interested in hearing more- although isn't quite ready for this
yet. He remains interested in his current oral medications as
well as IV antibiotics.
Specifically, with regard to his GIB, he is not interested in
repeated endoscopies or transfusions. He would also like to
limit blood draws. We discussed his anticoagulation, and given
that he has ongoing bleed with no plan for intervention, this
will be held, understanding the risk of clots/stroke given
atrial fibrillation.
He is confirmed to be DNR/DNI, no invasive procedures, no
transfer to hospital. He would be interested in further
discussion with the palliative care team at ___, with
potential for eventual transition to hospice. MOLST form was
filled out with these wishes.
# Hemorrhagic shock
# Likely UGIB from erosions in stomach
Presented with most likely UGIB with multiple small nonbleeding
erosions seen in the stomach on EGD ___ which is most likely
source. S/p 4u pRBC total per prior notes, including total of 2u
pRBC here. Family meeting was held, during which we discussed
best way forward for management of his GIB. As above, he was not
interested in repeated endoscopies, blood transfusions, and
wished to limit blood draws. After discussion of risks/benefits,
home apixaban was held, understanding risk of stroke given
underlying atrial fibrillation. Last Hgb was 7.2.
# Atrial Fibrillation
Patient was frequently tachycardic. Home metoprolol and digoxin
were initially held due to hemorrhagic shock, restarted once BP
stabilized. Apixaban held due to GI bleed. He was sent home on
fractionated metoprolol 6.25 mg BID with holding parameters,
would continue to discuss need for this medication.
# Delirium
Patient noted to have mild hyperactive delirium post-extubation
with agitation. Resolved. He was maintained on half of home
quetiapine.
# ___
Creatinine 2.3 on admission from baseline ~1.6. Likely pre-renal
in setting of hemorrhagic shock. Improved to 1.4 at time of last
check.
# HFpEF
Home torsemide and Metolazone were initially held in setting of
hemorrhagic shock. When restarted at 120 mg torsemide BID,
patient was net negative ___. Hence this was restarted at
lower dose of 120 mg daily, on which weight was stable and net
negative 300 mL. Discharge weight is 123.9 lbs.
# Enterococcal bacteremia
# C/f new infectious source
Recent admission for enterococcus faecalis bacteremia (blood cx
+ @ BI-N on ___, negative since ___. Etiology unclear at last
admission given CT A/P unremarkable and no obvious GI/GU source
and TEE without obvious endocarditis/vegetation. Given recent TV
clipping, ID plan to treat for endocarditis/clip involvement and
OPAT orders for IV ampicillin 2g q6h and CTX 2g q6h through
___.
- Continue ampicillin and ceftriaxone till ___ to complete 6
week course (he is still interested in this)
# Type II NSTEMI
# CAD s/p CABG (___)
# Transaminitis
Trop on admission to 0.09 although denies any chest pain. Likely
Type II NSTEMI in setting of hemorrhagic shock and demand
ischemia also with elevated LFTs (now downtrending) likely
related to hypotension. TTE reassuring. trops stable. Restarted
atorvastatin at low dose of 20 mg, but ongoing discussion wrt
medications given overall goals of care. Aspirin discontinued
(discussed with cardiology).
# B/l ___ pain
Reported some b/l thigh pain x ___ year with weakness. Also
endorsing b/l calf pain. B/l LEs are warm with 2+ pulses. LENIs
negative for DVT. B12 normal. | 176 | 811 |
14643554-DS-8 | 28,137,438 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet when out of bed at all times.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may 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 | ___ is a ___ year-old woman with HTN who presents
with acute onset dizziness followed by fall found to have large
left temporoparietal ICH at OSH that increased on repeat imaging
here at ___ with rightward midline shift and subfalcine
herniation, s/p decompressive craniectomy on the left ___.
#Left Intraparenchymal Hemorrhage
The patient was transferred intubated from OSH with a left sided
intraparenchymal hemorrhage with surrounding edema. A repeat
head CT was obtained upon arrival to ___ that showed worsening
hemorrhage with increasing midline shift and herniation. A
meeting was had with the family offering a surgical
decompressive craniectomy as well as discussing her poor
prognosis. It was decided to proceed with surgical intervention.
She underwent an emergent left sided decompressive
hemicraniectomy on ___ and was admitted to the Neuro ICU
post-operatively for close neurologic monitoring. She was
started on Keppra x7 days postop for seizure prophylaxis. Postop
head CT showed minimal increase in IPH, with improved uncal
herniation and MLS. She was started on 3% hypertonic saline for
cerebral edema. She was maintained on hypertonic saline.
Hypertonic saline d/c'd ___. CT torso was done to look for
underlying malignancy, which was negative. MRI performed to look
for underlying etiology of bleed, but was unrevealing. On ___,
the patient underwent a NCHCT and a family meeting was held in
the afternoon, in which patient's prognosis at this point was
discussed. Repeat CT on ___ was stable. On ___, the staples
from the incision were removed. On ___ patient was noted to
have left arm, left shoulder twitching and was restarted on
Keppra 1gm BID. She was placed on continuous EEG for 24 hours
which showed continuous focal slowing over entire left
hemisphere, no seizure activity. On ___, she was again noted
to have facial twitching and left shoulder twitching, concerning
for seizure activity. Keppra was increased to 1250mg BID and
restarted on continuous EEG, which was negative for seizure
activity. EEG was again DC'd on ___ and she was maintained on
Keppra 1250mg BID. Patient's neurologic exam remained stable.
#Embolic Infarcts /Dural venous sinus thrombosis
Neurology was consulted for new right MCA territory
embolic-appearing infarcts and developing venous sinus
thrombosis on MRI ___. Neurology recommended TTE with bubble,
which identified no cardiac source of embolism. Left transverse
sinus VST is small and now flow limiting, thought to be related
to pressure due to IPH and swelling. Anticoagulation was
deferred. CTA Head/Neck from ___ showed multifocal cerebral
arterial narrowing concerning for vasospasm vs vasculopathy.
Cardiology was contacted regarding optimality of TTE study, who
recommended obtaining a TEE, which would be a better study to
further evaluate for possible source of emboli. Family
discussion determined to not proceed with further workup of
infarcts.
#PE
The same CTA head/neck on ___ discussed above also showed a
small PE in the left upper lobe. A CTA chest confirmed
non-occlusive PE in left upper lobe, for which anticoagulation
was deferred because of the IPH and the patient's respiratory
status remained stable. LENIs were negative for DVT. She was
closely monitored for physiologic signs of worsening of PE.
#Hypertension /Intermittent SVT
SBP into the 170s, requiring nicardipine drip intermittently.
Intermittently tachycardic, so given fentanyl boluses for
discomfort and started on metoprolol 25mg Q8H for both blood
pressure control and intermittent SVT. Lopressor was increased
on ___ due to persistent tachycardia. Cardiology was consulted
for recommendations regarding rate control; metoprolol was
adjusted.
#Respiratory Failure
The patient was intubated on arrival and remained intubated
during her ICU stay. Mini BAL was performed on ___ gram stain
grew GNR's. Cultures grew H flu, antibiotics narrowed to
ceftriaxone completed on ___. She failed to be weaned from the
ventilator and tracheostomy was placed on ___ and weaned off
vent. On ___ patient required increased in secretions and
required frequent suctioning. She was started on Glycopyrrolate
with much improvement in secretions. She was noted to have
yellow secretions on ___, sputum culture was collected. Final
results were still pending on discharge however the patient's
respiratory status was stable, WBC WNL, and patient afebrile.
Repeat cultures may be followed-up on as an outpatient if
needed.
#Thrombocytopenia
Per PMD documentation, patient had recent weight loss; could not
obtain recent bloodwork from PCP. Some hematologic abnormalities
were noted, including thrombocytopenia. On admission platelets
100, trended down to ___. She did not require transfusion and
platelet count improved. Outpatient heme records received, show
mild baseline elevation of MCV and thrombocytopenia which was
being monitored outpatient.
#Nutrition
OGT was placed. Tube feeds were at goal, and on ___ she was
noted to have hypophosphatemia; concern for refeeding syndrome
so decreased rate of tube feeds and repleted electrolytes,
contact dietary for tube feeding recommendations. They
recommended titrating up on tube feeds very slowly and repleting
electrolytes as needed. Thiamine and folate were added. On
___, the patient underwent placement of a PEG tube. Tube feeds
were restarted Jevity 1.2 cal. Due to an uptrending serum
calcium level, tube feeds were changed to Glucerna 1.2 cal on
___. She was noted to have skin breakdown at the PEG site with
ulceration and ACS was made aware on ___ and they placed a 2x2
gauze under the bumper. ACS was paged again to re-evaluate the
PEG site as 2 sutures remained in place on ___ and patient
continued with skin breakdown despite 2x2 gauze. 2 sutures were
removed and the bumper to the PEG was rotated. It was
recommended to leave open to air or use a thin gauze if a
dressing was indicated.
#Fever
The patient was febrile intermittently during her ICU stay and
was pancultured. Mini BAL on ___ with GNR's on gram stain. She
was started empirically on vanc/cefepime on ___. Patient with
sputum cultures grew H.influenzae and completed course of
ceftriaxone on ___. On ___ patient was febrile up to 102.4,
urinalysis, chest xray and LENIs were negative. Obtained blood
cultures, PICC line removed and tip of catheter was cultured. On
___ patient persisted with fevers up to 101.9. Infectious
disease was consulted for further management, Vancomycin and
cefepime was started. Two Sputum cultures was obtained, which
were both contaminated with respiratory flora. An induced sputum
culture, suctioned from trach site was obtained, which... She
was febrile again on ___, and UA/CXR were ordered, both
negative for acute process. On ___ ID recommended
discontinuation of antibiotics with close monitoring, for
possible drug fever. She continued to be febrile after
antibiotics discontinued. MRI was obtained ___ which was
negative for infection but showed right embolic infarcts and a
developing dural venous sinus thrombosis. Once PE identified, it
was determined that is the likely cause of her intermittent
fevers. No further fever workup obtained.
#Mucous Plug
Patient underwent a CTA Chest to rule out pulmonary embolism on
___ which revealed no evidence of pulmonary embolism and new
focally dilated subsegmental bronchus in the right lower lobe
with distal nodular opacification possibly reflecting mucous
plugging within the distal airway and upstream dilatation. Chest
physiotherapy and aggressive suctioning ordered, the patients
respiratory status remained stable on discharge.
#Elevated LFTs
Medicine was consulted for elevated ALT/Lipase/Amylase in the
setting of fever on ___, who recommended Hepatitis B/C
serology, Fe/Ferritin/TIBC, TSH/Free T4, and a RUQ ultrasound as
workup. Aside from a slightly elevated Ferritin, this workup was
overall negative for any acute/subacute hepatic process, and the
elevated LFTs were stable on ___. This was attributed to a
medication effect, likely either beta-blocker or cephalosporin.
#Dispo
Patient was evaluated by ___ and OT who recommended rehab. | 501 | 1,237 |
14442035-DS-19 | 23,825,725 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a fever and bacteria growing
in your blood
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were treated with IV antibiotics and had your tunneled
dialysis catheter removed because we suspected that was the site
that caused bacteria to grow in your blood
- You had dialysis performed on the fistula in your right arm
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | This is a ___ year old incarcerated male with past medical
history of ESRD secondary to FSGS, cocaine-induced MI, OSA,
admitted ___ with sepsis and klebsiella bacteremia,
thought to be secondary to his tunneled line, treated with
antibiotics and tunneled line removal, tolerating HD via AV
fistula, able to be discharged back to custody ___
# Klebsiella oxytoca sepsis secondary to acute blood stream
infection
# Complication of indwelling tunneled HD catheter
Patient presented with fever and malaise from his ___ clinic.
Blood cultures from admission on ___ grew Klebsiella oxytoca,
as did blood cultures from ___. He was started on broad
spectrum antibiotics, subsequently narrowing based on
sensitivities. On ___ he underwent removal of his tunneled HD
line. Source of infection thought to be his line. Workup did
not reveal other potential pulmonary, GI, GU sources. TTE was
obtained given concern from one provider for ___ possible murmur,
however no valvular pathology was identified. Subsequent blood
cultures remained without growth at time of his discharge.
Discharged with plan to complete total 2 week course (from last
negative blood culture) of PO Ciprofloxacin.
# ESRD ___ FSGS on HD MWF:
Presenting weight 92kg. Discharge weight 90kg. No evidence of
volume overload on exam. His HD line as pulled as above, but he
was able to be dialyzed via RUE AVF. Continued sevelamer 1600
TID. Continued Vitamin B complex supplementation.
# Hx of MI related to cocaine: Decreased metoprolol tartrate
50mg BID to 37.5 BID as occasional heart rates in ___,
asymptomatic. Continued atorvastatin 10mg daily.
# Hypertension: Continue amlodipine 10mg daily
# Constipation: Continue docusate, senna
# BPH: Still making urine, Continue Tamsulosin, Continue
oxybutynin which was changed from daily to twice daily for
better control.
# Obstructive sleep apnea: Not on cpap. Consider evaluation for
CPAP
====================
TRANSITIONAL ISSUES:
====================
[ ] Please continue Ciprofloxacin 500 daily for EOT date
___.
[ ] Decreased Metoprolol from 50 BID to 37.5 BID as heart rates
were in ___.
[ ] Consider evaluation for CPAP given prior diagnosis of sleep
apnea
[ ] Of note, TTE incidentally showed small secundum type atrial
septal defect with intermittent left-to-right flow. EF of 68%.
Consider outpatient cardiology referral.
#CODE: FULL CODE presumed
#CONTACT: ___
> 30 minutes spent on discharge | 136 | 381 |
17981726-DS-21 | 22,330,763 | Dear ___,
It was a pleasure taking care of you at ___!
Why was I in the hospital?
- because you had belly pain, nausea, and dark stools.
- you were found to have an inflammation of you pancreas, likely
secondary to your alcohol consumption
- you were also found to have liver cirrhosis and bleeding from
your stomach, likely also secondary to your alcohol consumption
as well as a viral infection of your liver (hepatitis C)
- you were treated with fluids and pain medication
What should I do after discharge?
- you should follow up with your new PCP as well as hepatology
as below
- you should take all your medications as prescribed
- you should abstain from alcohol
Your ___ team | ___ male ___ man h/o ETOH dependence and
possible suicide attempts (last hospitalized in ___ for
detox
treated per Valium detox protocol; at that time was also found
to
have BRBPR thought to be iso hemorrhoids; hgb 9.7) who presents
with persistent weakness x 7 days with intermittent abdominal
pain with some epigastric pain, nausea, and fevers for the past
4
days.
# acute pancreatitis
Lipase on admission was 300. In combination with this upper
abdominal pain treatment diagnostic criteria for acute
pancreatitis, most likely in the setting of this history of
significant alcohol consumption. Right upper quadrant abdominal
ultrasound did not show any signs of gallstones or biliary duct
dilatation and a T bili was normal. There were no signs of
endorgan damage. He was aggressively resuscitated with IV
fluids. His pain was well controlled on minimal doses of IV
Dilaudid and quickly subsided with supportive treatment. The
patient was initially kept n.p.o. pending a gastroscopy as
below. Following his procedure, his diet could be advanced with
good tolerance. On discharge, the patient was asymptomatic,
eating normally, and without abdominal pain.
# Upper GI bleed
# hypertensive gastropathy
The patient has chronic anemia with a hemoglobin of ___. This
current presentation with dark stools and an initial drop in his
hemoglobin was consistent with an upper GI bleed. He underwent
an EGD ___, which demonstrated hypertensive gastropathy,
likely secondary to his hepatic cirrhosis as below, as the
source of his upper GI bleed. Hepatology was consulted for
further management and recommended antibiotic treatment with
ceftriaxone until discharge. No need to treat with octreotide
or a prophylactic beta-blocker. No need to treat with PPIs.
Outpatient follow-up with hepatology is recommended (see below).
# liver cirrhosis
Patient found to have positive HCV Ab with elevated viral load
of
7.1 log 10 IU/mL. Unknown transmission without significant risk
factors including no prior history of past transfusions (other
than one ___ years ago), tattoos, or hospitalizations. Likely with
cirrhosis with evidence of portal hypertension with portal
hypertensive gastropathy. ETOH may be playing a component as
well. Outpatient follow up with hepatology is recommended.
Work-up including ___, ANCA, immunoglobulins, Ferritin,
TIBC, Fe, viral hepatitis panel, and HCV genotype was ordered.
The patient was seen by nutrition and social work. The patient
was counseled on the necessity to abstain from alcohol.
MEDICATION CHANGES
==================
*** NEW Medications/Orders ***
Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours
as needed Disp #*100 Tablet Refills:*0 This is a new medication
for pain
FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*12 This is a new vitamin | 116 | 504 |
10998589-DS-18 | 29,071,525 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission RUQ
ultra-sound showed diffusely thickened gallbladder wall and
abdominal/pelvic CT also revealed gallbladder wall thickening
and probable cholelithiasis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. 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. | 729 | 202 |
13188070-DS-18 | 23,961,569 | Dear Dr. ___,
___ was our pleasure to take care of you here at ___
___. You were admitted to the hospital
because of ascites. We treated you with a diagnostic and
therapeutic paracentesis to remove 3.8L of ascitic fluid. There
was no infection in this fluid. We increased your spironolactone
from 50mg daily to 50mg twice a day. We also added furosemide
40mg daily. These two medications are for treatment of ascites.
1) Please maintain a low sodium diet.
2) Please take spironolactone 50mg twice a day and furosemide
40mg daily.
3) Please see below for your upcoming appointments. | Dr. ___ is a ___ with HIV and HCV cirrhosis complicated by
hepatic encephalopathy, variceal bleeding s/p banding, who was
admitted to the hospital with new-onset ascites, most likely due
to increased sodium intake in recent weeks.
ACTIVE PROBLEMS
# Ascites and ___ edema. This is most likely from increased
sodium intake since he has been eating more packaged meals in
past few weeks due to recent car accident. It could also
represent progression of liver disease. Diagnostic paracentesis
revealed no PMNs. US-guided therapeutic paracentesis removed
3.8L of fluid. He received 25g of 25% albumin IV. UA showed no
UTI. His spironolactone was increased from 50mg daily to 50mg
BID. We have added furosemide 40mg daily.
CHRONIC PROBLEMS
# HCV Cirrhosis, complicated by hepatic encephalopathy and now
ascites. Patient is listed for Liver Transplant. We continued
his lactulose and rifaximin, aiming for ___ bowel movements per
day.
# GIB/varices. No esophageal varices in last EGD ___.
Patient's HR was in 80-100 range during admission. We did not
adjust his nadolol since he is already at a high dose of 60mg
and higher dose could cause kidney dysfunction.
# HIV. Patient was continued on HAART medications. No history of
opportunistic infections.
# Maxillary sinus mass. Evaluated by ENT on ___ and felt to
be right maxillary mucopyocele. Recommended removal, but will
need approval from Transplant and ID services and correction of
coagulopathy prior to surgery.
### TRANSITIONAL ISSUES ###
1) Spironolactone increased to 50mg BID. We added furosemide
40mg daily.
2) Please monitor electrolytes.
3) Encouraged low salt diet.
4) Follow up with Dr. ___ Dr. ___. | 96 | 257 |
19962724-DS-4 | 29,247,919 | Dear Mr. ___,
You were admitted to the hospital because of lower abdominal
pain. You were found to have a condition called diverticulitis
that is caused by inflammation in the outpouchings in the large
intestine. You were given antibiotics for this that you will
continue for a full 10 day treatment course. Please continue
with a clear liquid diet within the next ___ days and transition
to a normal diet if you are tolerating fluids without
difficulty. It was a pleasure being involved in your care.
Sincerely,
Your ___ Team | ___ M with a history of HTN presenting with five days of
intermittent lower abdominal pain found to have uncomplicated
sigmoid diverticulitis.
# Uncomplicated Diverticulitis:
Mr. ___ presented to the hospital with left lower quadrant
pain found to have uncomplicated diverticulitis with CT abdomen
showing localized localized diverticular inflammation and is
without evidence of abscess, obstruction, or perforation. He is
also without evidence of leukocytosis though exam was notable
for left lower quadrant tenderness with guarding though no
rebound. Patient's last colonscopy in ___ showed evidence of
sigmoid diverticulitis with polyps with need for repeat in ___
years. Mr. ___ was admitted to the hospital placed on clear
liquid diet, started on PO ciprofloxacin/flagyl with improvement
of his abdominal pain and ability to ambulate easily prior to
discharge. He was discharged with 10 day course of PO
cipro/flagyl, tylenol for pain, and zofran for nausea (Qtc of
418). He was instructed to continue clear liquid diet for ___
days and if tolerating without issue could transition to regular
diet.
# HTN:
Blood pressure remained well controlled and he was continued on
atenolol.
# BPH:
Continued on home tamsulosin QHS
#History of hematuria
Patient with prior history of hematuria that per his report had
resolved after treatement with amoxicillin possible secondary to
nephrolithiasis vs. hemorrhagic UTI. UA currently without
evidence of blood. Follow up with primary care doctor
#Cholelithiasis without cholecystitis
CT abdomen showing diverticulitis above noted cholelithiasis
though no cholecystitis | 87 | 236 |
10941013-DS-18 | 23,594,837 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were having trouble breathing
- You were having blood in your bowel movements
What did you receive in the hospital?
- You received medications for your COPD and your breathing
improved
- You received antibiotics for pneumonia and your cough and
breathing improved
- You received 1 blood transfusion
- You stopped having blood in your bowel movements.
What should you do once you leave the hospital?
- Please take all your medications as prescribed and attend all
of your follow-up appointments as scheduled.
We wish you all the best!
- Your ___ Care Team | Ms. ___ is a ___ history of COPD on 2L O2, HFpEF, CKD
III, CAD, DM II, HTN, bullous pemphigoid on prednisone, beta
thalassemia trait, hard of hearing, recent admission to ___ for
COPD exacerbation and hypercarbic respiratory failure requiring
BiPAP, presenting from rehab facility with BRBPR and respiratory
distress admitted with possible LGIB and COPD exacerbation. | 106 | 58 |
19517966-DS-15 | 21,783,446 | You were admitted to the hospital due to abdominal pain and
three episodes of vomiting, one of which contained blood. Your
blood count and vital signs remained stable and treatment for
your known H. pylori/ anastamotic ulcer was resumed. Also, your
abdominal CT scan was reassuring.
You may continue your recovery at home. | Ms. ___ was transferred from an OSH with complaints of abd
pain, nausea and emesis x 3, one of which contained blood. Upon
arrival, the patient's vital signs and hematocrit were stable
(Hct 44.2); Abd/pelvic CT was unrevealing. The patient was
subsequently admitted to the ___ Surgical Service for
administration of PPIs, carafate, re-initiation of H. pylori
treatment with intravenous levofloxacin and metronidazole.
On HD2, the patient's diet was advanced to stage 3 and well
tolerated. Her H. pylori regimen was transitioned to oral
bismuth, omeprazole, metronidazole and doxycycline (pt w/ PCN
allergy). Gastroenterology was in agreement with these
recommendations, and added that she should get a follow-up EGD 6
weeks after initiation of treatment. Vital signs remained stable
and the patient did not experience any further vomiting. Her
primary care provider was contacted, and he reported that
patient had not followed up with him following her previous
discharge, and that he would be happy to follow her. He also
noted that she had a history of being adherent with only
narcotic pain medication.
At the time of discharge, patient was hemodynamically stable, no
emesis since the unwitnessed episodes at home, with improved
pain and ability to tolerate a diet. She was discharged home on
a 2-week course of h. pylori treatment with follow-up with her
PCP and gastroenterology. | 56 | 223 |
16797701-DS-7 | 27,368,454 | Dear Mr. ___,
It was a pleasure taking care of you while you were a patient at
___. You came to us with
bleeding in your colostomy bag. You were treated with a
procedure called TIPS which you tolerated well. After this
procedure your kidneys were functioning slightly worse than
normally. We treated you with IV fluids which resulted in
improvement in your kidney function.
You were also found to have a small blood clot in your lung. We
could not treat you with blood thinners since your were
bleeding, so you had filters placed in a vein in your abdomen to
prevent more clots from traveling to your lungs.
Please be sure to take all of your medications as listed below.
Please keep all of your ___ appointments. | ___ yo M with PMH of HCV cirrhosis and colon cancer s/p resection
and colostomy ___ years ago who presents on transfer from OSH with
anemia and bleeding concerning for variceal bleed.
ACTIVE ISSUES
# ___ variceal bleeding: Unclear etiology on admission.
EGD and colonoscopy were unremarkable. CTA showed ___
varices which were thought to be the most likely source. Patient
was managed with pantoprazole and octreotide drips and
ceftriaxone for SBP prophylaxis. Frank blood from ostomy on
___ with hypotension. Resuscitated and taken for TIPS on
___. The ___ varices were embolized. Low
post-procedure portosystemic gradient. Observed in MICU
overnight no events. Patient had no further issues with
bleeding. Patient received total of 6 units pRBCs and 2 units of
platelets from ___ to ___. He Hct remained stable after TIPS
and embolization of varices.
# Acute kidney injury: Cr 1.6 on admission. Unclear baseline.
Likely pre-renal azotemia in the setting of acute bleed on
admission. Cr remained elevated after patient was taken for TIPS
and was slow to improve with IV fluids. This was attributed to
contrast-induced nephropathy in the setting of TIPS. Patient was
given more IV fluids and Cr had begun to trend down on
discharge. Home diuretics were held on admission and were
restarted on discharge.
# Pulmonary embolism: RLL pulmonary artery filling defect that
was incidentally found on CTA abdomen/pelvis. Unable to
anticogulate in setting of GI bleed. Bilateral ___ studies
negative for DVT. TTE as part of pre-transplant workup showed no
PFO. Patient had retrievable IVC filter placed with TIPS on
___.
# Hepatic encephalopathy: Patient with mild encephalopathy may
be his baseline. There was no evidence of exacerbation of
encephalopathy after TIPS with the exception of mild asterixis.
CHRONIC ISSUES
# HCV cirrhosis: Reportedly there is no history of SBP or HE;
however, he is on rifaxamin, nadolol, diuretics chronically.
Diagnostic paracentesis was with no SBP. CTA on ___ notable
for ___ varices. Patient underwent TIPS which resulted
in an improved gradient as above. Continued home rifaximin.
Continued nadolol initially but was held in MICU given soft
blood pressures. Restarted on discharge. Diuretics were held in
the setting of unstable blood volume but were also restarted on
discharge. Nutrition was consulted.
# Thrombocytopenia: Likely due to chronic liver disease.
Transfused to Plt > 50. Given 2 units of platelets in the
setting of TIPS.
# Colon cancer: Patient s/p surgery and chemotherapy ___ years
ago. Not being actively treated for this.
TRANSITIONAL ISSUES
- Patient successfully underwent TIPS
- Will need abdominal US every 6 months for ___ screening
- Given Rx for outpatient lab work
- Monitor mental status given risk of hepatic encephalopathy
- PCP ___ scheduled
- ___ Liver Clinic ___ scheduled
- ___ gastroenterologist ___ scheduled | 126 | 441 |
18483975-DS-3 | 22,739,637 | You were admitted to the hospital with appendicitis. You were
taken to the operating room and had your appendix removed. You
tolerated the procedure well and are now being discharged home
with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. 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.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the 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.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mr. ___ was admitted to ___ after having nausea and
vomiting. He was found to have appendicitis. He was taken to the
OR and had a lap to open appendectomy. However, pre op he
developed a-fib with RVR. He was treated pre op and this
continued through out the operation. However, he tolerated the
procedure well. He was admitted to the ICU post op for
management of his a-fib. He was transferred to the floor after
his rate was controlled. He was evaluated by cardiology and he
was continued on IV to PO metoprolol. He had another episode of
A-fib while he was on the floor. He was transferred to a
cardiac floor for a dilt drip. HE was hemodynamiclly stable
during this episode. He continued to have abdominal distention
during his stay and had constipation. He had a repeat CT scan
which showed an abscess. He was continued on antibiotics. He was
discharged with follow up and will follow up with his own
cardiologist. He was tolerating PO, ambulating and doing well at
the time of discharge | 774 | 181 |
18618203-DS-46 | 25,995,908 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital because ___ had fevers, cough and some
chest pain. For your fevers and cough, we thought that these
were likely due to a pneumonia so we started ___ on antibiotics,
which ___ finished while ___ were in the hospital.
For your chest pain, we determined that this was not likely a
heart problem. Please continue to monitor your pain and notify a
nurse or call ___ if ___ have different or worse pain, or sudden
shortness of breath.
___ also had abdominal pain, which we determined to primarily be
due to constipation given that it changed a little bit every
day. However, on CT scan, ___ had a swelling at the end of your
stomach where it meets your small intestines and so ___ had
camera sent into your stomach (endoscopy) to look at the inside
of your stomach. ___ were found to have one ulcer as well as the
swelling at the end of your stomach which was biopsies. ___ can
learn about the results of this biopsy at your follow-up
appointments with Dr. ___ should keep taking your
reflux medication, esomeprazole magnesium, at home.
While ___ were in the hospital, we learned that ___ were not
eating well at home, and ___ levels of some nutrients in your
blood (phosphorus, potassium, magnesium) were low. ___ were
also monitored because your sodium was very low, but it
improved., There was also concern that ___ were aspirating
(swallowing your food into your lungs), which caused occasional
fevers and puts ___ at risk for pneumonia. ___ should only drink
thickened liquids and soft food. Drink 3 Ensures with Protein
each day.
INSTRUCTIONS FOR EATING:
nectar-thick liquids and soft solids
Take pills with whole with nectar-thick liquids or at least in
pureed solids if drinking thin liquids
Do not lay down after eating
Eat sitting up.
Please follow-up with appointments with your primary care
doctor, your gastroenterologist and your vascular surgeon.
Thank ___ for choosing ___. We wish ___ the very best.
Your ___ team. | ___ with COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain
concerning for community-acquired pneumonia, which improved with
CAP treatment; he was then kept for constipation/diffuse
abdominal pain which improved; he then developed SIADH in the
setting of recent PNA and hypothyroidism.
# Hyponatremia/SIADH: initially did not improve despite 1L IVF
challenge initially; Ulytes afterwards were suggestive of SIADH,
likely in setting of hypothyroidism (TSH ~20) and recent CAP;
fluid restriction was started. Pt was euvolemeic. Likely
exacerbated by poor PO intake and alcoholism/poor solute intake.
Renal followed and recommended salt tabs 1g TID with 1L fluid
restriction. Na stabilized to 129 at time of discharge.
# Hypothyroidism: TSH checked ___ given lower BP's and
hyponatremia was 20. Pt's levothyroxine was increased to
150mcg/day; may not have been dosed appropriately at home. Will
need repeat TSH in ___ weeks post discharge.
# PNEUMONIA, community-acquired vs ?aspiration in the setting
of alcohol abuse. His CXR on admission was not entirely
definitive. Presumed CAP given fever, mild tachypnea, and
dyspnea. Note that he has longstanding dyspnea and chest pain
which has been worked up in past without clear cause. Finished
7 day course of oral cefpodox and azithromycin, last day
___.
# Fever, recurrent aspiration: Patient developed temperature to
101.2 in am ___, afebrile afterwards, and 101.3 on ___.
Panculture was unremarkable. Initial fever on ___ resolved
without any intervention. There was concern for recurrent
aspiration and speech and swallow evaluated. Patient aspirating
significantly on video swallow. Isolated fevers thought to be
secondary to aspiration events. Decision made not to treat with
antibiotics as patient was always hemodynamically stable and
events resolved on their own. Felt that adding antibiotics when
he wasn't decompensating, would be putting him at risk for c
diff and resistance. Speech and swallow recommended nectar thick
liquids and soft dysphagia diet. They also recommended SLP ___
and further evaluation and treatment as an outpatient (pt should
call ___. The patient was given packets of information
and individual counseling regarding his diet and how to prevent
further aspiration.
# CHEST PAIN. Tenderness to palpation of ribs/sternum suggests
MSK etiology. ACS ruled out with nonspecific EKG changes,
negative tropx3. Pt has presented with similar complaints in the
past.
# Abdominal discomfort: diffuse and migrating abdominal pain,
most likely due to severe constipation. Had many small bowel
movements during hospitalization but still large stool burden on
CT. CT also showed thickened duodenum and pylorus so EGD was
performed that showed a gastric ulcer and a deformity of the
pylorus (biopsied). Pylors biopsy results were wnl. Ferrous
sulfate stopped as thought to contribute to constipation. Iron
>100.
# Electrolyte abnormalities (hypophos, hyperkalemia, hypomag):
likely due to a "refeeding syndrome" in the setting of chronic
poor nutrition and alcohol abuse. Repleted often during
hospitalization. Encourage nutrition (with ensures) on
discharge. Discharged on magnesium 400mg BID.
#Left arm edema: diagnosed on HD 5. Unclear etiology, upper
extremity US was negative other than for slow flow, so this is
likely a result of blood draw trauma.
# Anemia: Patient with 10 pt hct drop in 36 hours at beginning
of hospitalization. No evidence of bleeding. Most likely due
dilution with underlying bone marrow suppression from chronic
alcohol use + dilutional effect. Retic index was 0.8, Hgb
remained stable. Iron stopped as thought to be contributing to
abdominal pain. Hgb on discharge 8.1. Would consider outpatient
iron infusions. | 343 | 580 |
11749788-DS-7 | 20,506,589 | :
You were admitted to the hospital with abdominal pain after
undergoing a colonoscopy. You underwent imaging and there was
concern that you had a bowel perforation. You were placed on
bowel rest and started on intravenous antibiotics. Your
abdominal pain has decreased and you have been tolerating a
regular diet. You are being discharged with the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness, abdominal pain
*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. | ___ year old male who was admitted to the hospital with abdominal
pain after having a colonoscopy. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging.
A cat scan of the abdomen was done which showed pneumoperitoneum
which was concerning for a bowel perforation.
The patient was placed on bowel rest and started on a course of
ceftazadime and flagyl. After his abdominal pain decreased, he
resumed a regular diet. He was transitioned to a 14 day course
of augmentin. He was ambulatory and voiding without difficulty.
He resumed his home medications.
The patient was discharged on HD #3 with stable vital signs and
a stable hematocrit. He was instructed to follow-up with his
primary care provider and his ___. The patient
was provided with the telephone number to the acute care clinic
with any questions or concerns. | 220 | 152 |
16358853-DS-10 | 21,896,553 | * Your injury caused left rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | The patient was admitted to ___ as a Basic trauma from ___
___. Appropriate primary and secondary survey were performed
per trauma protocol. She was found have the following injuries:
Left scapular fracture
T11 burst fracture with 8mm retropulsion
multiple Rib fractures
chronic T8 & T9 compression fractures.
Orthopedic surgery was consulted for spinal injury and for
scapular fracture. They recommended activity as tolerated and
did not recommend a brace. C spine was cleared with MRI which
was negative for Cspine injury, thus hard collar was removed. IS
was encouraged and pain was controlled with oral pain medication
due to her rib fractures. She was successfully weaned off oxygen
on the day of discharge. Physical therapy and occupational
therapy were consulted and they recommended rehabilitation. Her
diet was advanced and she tolerated a regular diet without
difficulty. The patient was discharged on ___ to rehab. At
the time of discharge, she was off oxygen, pain was controlled
with oral pain medication, and she was tolerating a regular diet
and urinating and stooling normally. She was discharged to rehab
with plan to remain in rehab for less than 30 days, and plan to
follow up with ACS, Ortho spine, and ortho trauma in ___ weeks
after discharge. | 243 | 205 |
15606428-DS-12 | 27,682,261 | You were admitted to the surgery service at ___ for treatment
of your pancreaticocutaneous fistula. You have done well ___ the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
Please call Dr. ___ office ___ if you have ant
questions or concerns. During off hours: call Operator at
___ and ask to ___ service. | The patient well known for Dr. ___ was admitted to
the HPB Surgical Service for evaluation of his new abdominal
wall drainage. On ___, the patient underwent abdominal CT
scan, which demonstrated multiloculated collection between the
pancreas and the posterior wall of the stomach with apparent
track from this new collection traversing into the anterior
abdominal wall (please see Radiology report for details). The
patient was started on IV Zosyn, made NPO and ___ was called for
consult. On ___ patient underwent CT-guided placement of an 8
___ catheter inside the peripancreatic collection. Midline
fistula was covered with ostomy bag for drainage. The patient's
peripancreatic fluid was sent to microbiology for analysis.
Fluid was positive for Streptococcus Milleri group and
Haemophilus species, ID was called for consult. Patient's wound
was packed with dry gauze daily. The patient's WBC started to
downward and he was afebrile. Diet was advanced to clears on
___ and diet was well tolerated. The patient underwent wound,
ostomy and drain care while ___ hospital, and he demonstrated
understanding. Prior discharge on ___, patient's WBC returned
within normal limits, he remained afebrile and fistula/drain
output subsided. The patient was hemodynamically stable.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 63 | 241 |
19629953-DS-11 | 29,333,610 | Dear Ms. ___,
It was a priviliege to care for you at the ___
___. You were admitted for weakness/fatigue. We
performed several tests and the most likely cause of your
symptoms is side effects from your recent chemotherapy. You were
given IV fluids for dehydration and it is now safe to be
discharged home.
Please follow up with your appointment to see Dr. ___
week.
We wish you the best!
Sincerely,
Your ___ Team | ___ with recently diagnosed Stage IVB ovarian adenocarcinoma who
presented to the ED with bilateral leg weakness and difficulty
ambulating 5 days after starting treatment with
carboplatin/paclitaxel.
# Lethargy/generalized weakness:
Patient presented with progressive fatigue and subjective leg
weakness. ___ at OSH prior to admission negative for DVT. Her
exam was reassuring against cord compression and therefore did
not warrant dedicated spine imaging. No major lab abnormalities.
TSH normal. Case discussed with outpatient oncologist who agreed
that symptoms most likely related to her recent chemotherapy,
particularly paclitaxel (initiated 5d prior to admission).
Orthostatics were negative by blood pressure criteria
(borderline
by HR criteria), and her initial symptoms resolved completely
with IVFs. She was asymptomatic with a normal neurologic exam at
discharge, tolerating a regular diet. Followup in ___
clinic
already scheduled for ___.
# Headache:
Endorsed new HAs ___. No other red flag symptoms, but given
known diagnosis of stage IV cancer, MRI obtained to exclude
brain
metastasis that did not identify parenchymal brain mets. There
was a question of an abnormal signal in the skull calvarium of
unclear significance. Per discussion with Dr. ___
imaging either with bone scan or dedicated CT will be determined
on follow up with Dr. ___ as outpatient.
# Ovarian Cancer:
Recently diagnosed and s/p total lap hysterectomy and b/l
salpingo-oophorectomy on ___. Started C1 of ___ 5
days prior to admission. As above, outpatient oncologist (Dr.
___ followed closely, and Ms. ___ will f/u in clinic ___. | 72 | 219 |
12255330-DS-14 | 20,023,932 | Dear Mr. ___,
You were admitted to ___ from ___ due to an
infection in your prosthetic knee. You were started on
antibiotics for your infection. You eventually had the liner
replaced in your knee by Orthopedic surgeons. You improved on
the antibiotics and were discharged home with physical therapy
and home antibiotics. Your transplanted kidney was also not
working properly on admission, though it improved throughout
your stay.
It was a pleasure taking care of you this admission!
Your ___ Team | ___ with history of multiple L TKR and revisions complicated by
MRSA bacteremia also with ESRD now s/p LRRT presenting with MSSA
septic prosthetic joint and bacteremia now s/p I&D. Course was
complicated by ___.
# SEPTIC PROSTHETIC JOINT/SEPSIS: Joint arthrocentesis WBC >100K
with PMN predominance. Negative crystals. Gram stain was
negative, but grew MSSA in joint and blood. In this patient with
a history of MRSA bacteremia, he was initially treated with
vancomycin/cefazolin for MRSA/MSSA coverage, and was
transitioned to cefazolin when his cultures grew MSSA. Patient
underwent TTE/TEE which were negative for endocarditis. There
was initial concern for seeding of his ortho back hardware and
pacemaker, but TEE and physical exam alleviated these concerns.
His CRP downtrended during hospitalization. He was followed by
Ortho, had joint washout and replacement of liner on ___. He was
followed by ID during hospitalization and planned for 6 weeks of
IV cefazolin (ending ___ All Bcx since those taken in the ED
have been negative. Pt underwent vein mapping ___ to kidney
transplant and poor general access, it showed poor venous access
in the upper extremities b/l, with better access on the Lt UE
that is being preserved in case the patient will require a
fistula for HD. ___ was c/s for PICC placement, they were
concerned about future venous access issues in the Rt UE as
well, so they placed a tunneled central line on ___. ID desired
Rifampin on discharge for better biofilm clearance, but since
patient required Tacrolimus for immunosuppression of his kidney
transplant, due to drug interactions, he will have to wait until
he is switched back to Rapamycin to start Rifampin. ID
recommends 6 months of PO Levaquin and Rifampin after 6 weeks IV
Cefazolin to avoid lifelong suppressive Abx therapy. Pt will f/u
at ___ for ID & Ortho and has OPAT weekly labs. ID will
contact ___ IV team over eventual DC of pt's tunneled central
line when it is no longer needed.
# ESRD s/p RENAL TRANSPLANT: Pt's initial renal transplant U/S
was normal. There was never any tenderness over his graft to
suggest infection. Pt was originally on Rapamycin and
Prednisone for suppression, he was switched to Tacrolimus ___ to
better wound healing after surgery. Tacro levels have been high
during his stay as Renal attempted to optimize his dosing (goal
tacro levels of ___, he is being discharged on 0.5 mg tacro BID
and prednisone 5mg daily. He will f/u with Renal Transplant at
___. Patient will likely need to be transitioned back to
rapamycin in the future.
# ACUTE KIDNEY INJURY: Patient presented with Cr 2.1. Pt's ___
was likely pre-renal given his history of poor PO intake and
labs showing urine sodium < 10, FeNa < 1% and urine osmoles >
500. However, the pt did have mildly active urine sediment with
proteinuria, few RBCs and few WBCs. Renal transplant ultrasound
was normal. Pt's Cr slowly improved to baseline over his
admission (baseline around 1.4-1.7). Cr on discharge 1.4.
Nephrotoxins were avoided and medications were renally dosed
over his admission.
# ATRIAL FIBRILLATION: Pt is on his home metoprolol and
apixaban. Apixaban was held briefly in the setting of his joint
I&D, and was restarted after his surgery
# NORMOCYTIC ANEMIA: His anemia is likely secondary to acute
illness, however there are no priors in ___ system. H&H has
been stable over the admission.
# OSA: Pt wears CPAP o/n w/o issue. No SOB or chest pain
overnight while wearing CPAP. | 79 | 586 |
18893199-DS-42 | 22,604,102 | You were admitted to the hospital because you were having chest
pain. We monitored your heart enzymes and EKGs which were
normal. We notified your cardiologist who suggested that you
have a stress test which was completed and normal. Your pain
likely occurred because you were dehydrated. After IV fluid you
felt better and were discharged home.
No changes were made to your medications. Please be sure to take
them as directed | Mr. ___ is a ___ year old gentleman with ___ CAD s/p MI with 7
angioplasties and 5 stents, HTN, HLD, mitochondrial disease,
admitted with intermittent episodes of chest pressure, with no
EKG changes and three negative sets of cardiac enzymes.
.
. | 71 | 41 |
12719678-DS-13 | 29,914,182 | Craniotomy for Hemorrhage
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples. You may wash your hair
only after staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on follow up.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. | Mrs. ___ is a ___ year old female who was punched on the side
of her head and fell striking her head on the ground. A stat
head CT was obtained after arriving at ___ and showed a left
SDH with an 8mm MLS and poor exam. She was emergently brought to
the OR for a craniotomy for evacuation of her SDH. She was
brought to the neuro ICU for recovery, on post op exam she was
moving all extremities and following commands. She was extubated
and placed on nasal cannula. She was very agitated post
extubation and c/o pain, she was restarted on her methadone and
prn morphine.
On ___, she was awake and pleaseant this morning. Overnight she
had several episodes of trainsiently bradycardia down to the
20's with loss of her blood pressure, but spotaneously self
resolved. Since admission her heart rate as been in the 40's to
50's. Cardiology was consulted and reccomended discontinuing her
Methadone since it could cause QTC prolongation. Cardiology
expects heart rate to improve over the next several days. Later
in the afternoon she complained of severe headaches, dilaudid,
fentanyl and tylenol were given with no relief. A stat head CT
was obtained and it showed a small hyperdensity on the left
crani site with improved pneumocephalus and stable MLS. Chronic
pain is also following patient for pain and methadone
management.
On ___, on exam, L periorbital edema was resolved and she was
seen to have a L ptosis, but was otherwise intact. Ophthalmology
was consulted to rule out orbital injury from trauma and they
felt there was no acute itnervention that was required and
recommended outpatient followup. She was restarted on her
methadone at a lower dose after a stable EKG.
On ___ she remaiend stable and continued to have a elft ptosis.
She was trasnferred to the floor with telemetry and her
methadone was again decreased.
On ___ the chronic pain service was consulted. They recommended
decreasing the Methadone to 80mg daily. An EKG was ordered to
assess QTC interval. The EKG was reviewed by the cardiology
service who recommended discontinuing the methadone because of
increased QTC interval to .48. The Valium was discontinued and
the Methadone was changed to 60mg daily. A PICC line was ordered
due to the bradycardia and potential need for medication access.
On ___, The patients QTC was improved at .46. The patient serum
magnesium was low and repleated with 2 gm Magnesium sulfate. The
chronic pain service consulted and continued to have bradycardia
with heart rate at ___ when sleeping. Chronic pain service
recommended decreasing the methadone to 40 mg po qd and changing
the Dilaudid dosing to ___ mg po q 8 hours. and to repeat the
EKG the following morning. The patient had an ECHO which showed
mild aortic regurgitation with normal valve morphology as well
as mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function.
On ___, The EKG QTC was stable. Chronic pain felt that the QTC
was stable and her pain/withdrawal was well controlled. She was
discharged to rehabilitation. | 243 | 523 |
18325012-DS-11 | 20,575,976 | Dear Mr. ___,
You came to the hospital with breakthrough seizures. We
monitored you on EEG and made medication adjustments. Your
keppra has been stopped and you are taking a new medication
called oxcarbazepine. You will continue to take your previous
medications dilantin and zonisamide as well. Please follow up in
neurology clinic.
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ year old man with history of TBI with
subsequent epilepsy who presented with 2 breakthrough seizures
with secondary ___. Admitted for increase seizure frequency and
AED management.
# Epilepsy:
No inciting factors were found for his breakthrough seizures. ___
was monitored on EEG and ___ had multiple partial seizures. ___
continued his dilantin and zonisamide. His keppra was weaned off
and ___ started oxcarbazepine.
# TBI: Continued home Tizanidine. ___ was seen by psychiatry, who
recommended for his behavior, Ativan 2mg IM/IV for acute
agitation episodes only if agitation rises to level of safety
concern. ___ did not require Ativan during admission.
# Pain: Continued home meloxicam
# GERD: continued PPI
# CV: continued aspirin | 55 | 118 |
10893121-DS-9 | 29,390,904 | You were evaluated at ___ for
your increase in seizure frequency which is in the setting of
antibiotic treatment. It is possible that your use of a
cephalosporin antibiotic, Rocephin(ceftriaxone), which was
administered intramuscularly may have transiently decreased your
seizure threshold resulting in your breakthrough seizures.
We recommended no changes to your anti-epileptic regimen; you
were given an additional dose of medication to increase your
blood level of the Phenytoin to theraputic. | ASSESSMENT: The patient presents with breakthough seizures with
a subtherapeutic phenytoin level. He has a past history of
medication non-compliance but states that he has been taking his
correct AED doses. It is unclear how acutely his phenytoin level
has dropped as it was last checked on our system in ___.
# NEURO:
The patient was loaded with IV fosphenytoin with good effect
increasing his PHT level to 25. No further ictal activity was
noted. He will return for labs on ___.
# ID:
No infectious source was identified. | 72 | 89 |
19678952-DS-14 | 20,636,921 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital after having a cough at home, and you underwent
chest imaging which did not show a pneumonia. We were concerned
that you likely have a viral upper respiratory illness, and
started azithromycin to help with inflammation and infection.
Please continue to take this medication as prescribed.
We were also concerned about your ability to swallow and your
risk of aspiration in the future. Please follow up with your
primary care physician and discuss this risk in the future.
Please continue to take your other home medications as
prescribed. Script for wheelchair provided, and this can be
obtained at any medical supply store.
Take Care,
Your ___ Team. | This is a ___ year old male with past medical history of
Alzheimers Dementia, Parkinsons Disease, admitted ___ with
> 1 week of cough, low-grade fevers, CXR with poor visualization
of lung fields, treated empirically for pneumonia with
improvement and discharged home.
.
>> ACTIVE ISSUES:
# Community Acquired Pneumonia: Patient initially presented with
3 days of non productive cough, initially hypoxic in ED; CXR had
poor visualization of lung fields due to body habitus. Patient
was initially treated with IV Ceftriaxone and Axithromycin for
CAP coverage with subsequent improvement in symptoms. He was
transitioned to PO azithromycin. He had mild wheezing on exam,
so was provided albuterol inhaler with spacer with symptomatic
improvement. Team discussed with family re: his risk of
aspiration, and whether patient would benefit from
speech/swallow consultation. Family decided knowledge of
aspiration would not change their management, and they would
prefer to take home without swallow eval, and continue current
feeding regimen with 1:1 supervision. Risks of aspiration were
discussed with family, and voiced back understanding.
.
# Hyperkalemia: Patient initially found to be hyperkalemic,
unclear origin, without EKG changes. With IVF, patient had
repeat labs checked with normal potassium levels. No clear
offenders as far as medications, or renal disease. ___ have been
result of mild prerenal azotemia.
.
# ___ Disease: Patient continued to be at neurologic
baseline per family, and was continued on carbidop-levodopa.
.
# Depression: Patient was continued on paroxetine.
.
# GERD: Patient was continued on omeprazole.
.
# History of constipation: Patient was continued on outpatient
regimen.
.
# Hyperlipidemia: Patient was continued on simvastatin.
.
# Hypertension: Patient was continued on home atenolol.
. .
>> TRANSITIONAL ISSUES:
# Goals of Care: DNR/DNI.
# Contact Information: ___ (daughter): ___ | 128 | 294 |
13731472-DS-17 | 26,365,671 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted to
the ICU for respiratory distress which resolved without
intervention. We monitored your breathing overnight and you did
not have any problems breathing.
You also reported nausea which we treated with medication.
We have prescribed your erythromycin eye drops for eye
irritation.
We are setting you up for followup with outpatient pulmonology
and sleep medicine. | ___ with PMH COPD on ___, obesity hypoventilation syndrome
last FEV1 80%, OSA on BiPAP, morbid obesity, presenting with
malaise and intermittent SOB over the past several days
presenting with nausea and malaise.
# Nausea, malaise: Patient with loss of appetitie and nausea
without vomiting, diarrhea in the few days prior to admission.
Attributed to a possible mild viral illness but without further
symptoms at this time. No known sick contacts. No evidence of
obstruction. She improved with anti-emetics, PPI dosing and
simethicone.
# Obesity hypoventilation syndrome: Given patient's body
habitus, favor obesity hypoventilation as primary cause of her
chronic hypercarbia and hypoxemia. She uses BiPAP when sleeping,
and has ___ ___ and is currently not requiring any more than
that. Following ICU admission, she was quickly transitioned to
her ___ oxygen regimen. Of note, she admitted that she had not
been using her BiPAP regularly over the past several weeks due
to a poorly fitting, somewhat uncomfortable facemask. She
endorsed the mask that we provided in the hospital was more
comfortable, and that she would use that mask at ___. As such,
she was provided that mask to take ___ with her to endeavor to
optimize her compliance with NIPPV at ___.
# COPD: No evidence of acute exacerbation. Patient is without
cough, wheezing, or change in sputum. No leukocytosis or
radiographic changes to suggest acute pulmonary process to drive
exacerbation. Not unlikely that patient has COPD component to
her respiratory disease, but FEV1 in ___ was 82%, suggesting
restrictive rather than obstructive process even then. No
steroids indicated this admission, we continued her inhaler
medications.
# Constipation: This has previously been an issue during her
hospitalizations. Therefore, aggressive bowel regimen to prevent
this with senna, colace, bisacodyl, lactulose.
# Hypertension: Continued ___ amlodipine, metoprolol and
ramipril.
# CHF: TTE in ___ with preserved EF, likely diastolic
dysfunction. CXR on ___ with fluid overload, but no suggestion
of volume overload this admission. We continued her ___
diuretic.
# Gout: We continued Allopurinol ___ mg PO TID.
# Depression: We continued Bupropion.
# GERD: Continued omeprazole as above.
# Hypothyroid: Continued Levothyroxine Sodium 25 mcg PO daily.
# Transitional Issues:
- repeat CT six months, unless clinical suspicion of possible
extrathoracic primary carcinoma is high enough to merit PET-CT
scanning | 67 | 383 |
12909112-DS-8 | 29,479,375 | Dear Ms. ___,
It was a pleasure taking care of you at the ___.
Why was I here?
You were admitted to the hospital for jaundice (yellow skin and
eyes)due to a mass in your pancreas causing obstruction of bile
outflow from the liver.
What was done while I was here?
- You underwent ERCP (endoscopic retrograde
cholangiopancreatography), a procedure in which a camera
(endoscope) is inserted in your esophagus and passed down your
digestive tract to place a stent to restore bile duct flow.
- You were started on oral antibiotics (Ciprofloxacin) to
prevent infection.
- You had an imaging study which showed a mass in the pancreas
enlarged since ___.
- You had an ultrasound and fine needle biopsy of the pancreatic
mass on ___.
- You had bloody stools, so underwent a flexible sigmoidoscopy
(camera study of the left half of your colon) which showed
internal hemorrhoids. You received intravenous fluids and blood
transfusion with improvement in your blood pressure.
What should I do when I get home?
- Please continue taking all medications as prescribed.
- Please get labs done at your primary doctor's office and fax
to Dr. ___ liver doctor.
- Please ___ with your PCP and specialists as an
outpatient.
We wish you a speedy recovery,
Your ___ Care Team | ___ woman with a history of alcoholic and NASH cirrhosis
(liver biopsy ___, pancreatic head mucinous cyst (found in
___, CEA 385, ___ aborted given nodular liver),
hypertension, osteoporosis, and depression who initially
presented to ___ with jaundice, darker urine, and
BRBPR x 2 days, then was transferred to the ___ ED on ___
with CT findings of new 2.3cm CBD dilatation, dilated pancreatic
duct, and enlarging pancreatic cystic mass.
>> ACTIVE ISSUES:
# Biliary Obstruction:
She presented with new jaundice found to have direct
hyperbilirubinemia. OSH CT scan report was notable for intra and
extra hepatic biliary ductal dilation. Abdominal ultrasound here
confirmed biliary ductal dilation with CBD dilation up to 2.3
cm. This also showed interval increase in size of pancreatic
head/uncinate process cyst, 5.3 x 5.6 x 5.9 cm from 2.6 x 2.7 x
3.5 cm in ___. AFP was normal. CA ___ was elevated at 115. She
underwent ERCP on ___ which revealed a 3 cm tight, distal CBD
stricture with severe post-obstructive dilation. Sphincterotomy
was performed, brushings were obtained of the distal CBD
stricture which showed rare atypical glandular epithelial cells,
and a ___ Fr x 8 cm straight plastic biliary stent was placed
across the stricture. Given rising bilirubin levels post-ERCP,
MRCP was performed on ___ which showed enlarging pancreatic
mass since ___, a side-branch IPMN, and acute interstitial
edematous pancreatitis secondary to recent ERCP. She underwent
EUS with FNA of the pancreatic cystic lesion on ___. Forty cc
of fluid was drained from the pancreatic cyst and sent for
cytology which was pending on discharge. Fluid CEA was 244 and
Amylase was 4205. Her total bilirubin levels were downtrending
and she had improving jaundice, icteric sclera, and sublingual
jaundice prior to discharge.
>> RESOLVED ISSUES:
# Hypotension: Patient initially had BPs to the ___ in the
ED unresponsive to IVF so was admitted to the ICU. Her blood
pressures improved with 2U pRBCs and she did not require
pressors or any additional transfusions. Her hypotension was
felt to be secondary to hypovolemia from blood loss.
# Anemia, Hemorrhoidal Bleeding:
She reported intermittent bright red blood per rectum at home.
She was found to have a drop in Hgb from 11 to 9. She was
transfused 2U pRBC. She underwent EGD and flexible sigmoidoscopy
in the ICU which were notable for portal hypertensive
gastropathy and oozing internal hemorrhoids, not requiring
intervention. She was initiated on IV Pantoprazole 40mg Q12H,
which was transitioned to PO Pantoprazole 40mg QD on discharge.
She continued to have minimal bleeding from her internal
hemorrhoids during this hospital admission, though with stable
Hgb 9 and no additional blood transfusion requirements. She was
started on a hemorrhoidal suppository with good effect.
# Acute Kidney Injury: Patient initially presented with Cr 1.5,
which resolved to 0.9 with intravenous fluids and transfusion of
2U pRBCs. Post-ERCP, she had a Cr bump to 1.4. She received
100g total of 25% albumin on ___, with normalization of Cr to
her baseline of 1.0.
>> STABLE ISSUES:
# EtOH and NASH Cirrhosis:
___ Class B, MELD 10. Patient has biopsy-proven cirrhosis
with a combination of alcoholic (3 glasses of wine/day for 30+
years) and NASH etiology. For volume, the patient had no signs
of ascites and did not receive diuretics. For infection, she was
started on PO Ciprofloxacin 500mg BID x 5 days for
intra-abdominal infection prophylaxis after her ERCP on ___ and
after EUS on ___ (antibiotic course will be complete on ___.
For bleeding, the patient had decreasing episodes of BRBPR
during her admission (please see Anemia, Hemorrhoidal Bleeding
above). For encephalopathy, the patient was alert and oriented
without asterixis and did not receive Lactulose or Rifaximin.
# Coagulopathy:
Patient had a supratherapeutic INR of 1.5 on admission. She
underwent an IV vitamin K challenge with 5mg QD x 3 days with no
change in INR. Therefore her supratherapeutic INR is thought to
be secondary to synthetic dysfunction from cirrhosis.
# Hypertension: Patient's home Verapamil 120mg twice a day,
Valsartan-HCTZ 320-25mg daily, and Atenolol 25mg daily were
initially held in the setting of initial hypotension. BP meds
resumed at discharge with stable Blood pressures.
# Cardiomegaly: Patient has known cardiomegaly on CXR but no
history of heart failure, denying dyspnea and syncope. ___ TTE
showed LVH and "systolic anterior motion of the mitral valve
with significant outflow tract gradient." No history of heart
failure. Can consider cardiac MRI as outpatient to distinguish
hypertensive myopathy from hypertrophic obstructive
cardiomyopathy.
# Osteoporosis: Patient continued taking her home Raloxifene
60mg daily.
# Depression: Patient continued taking her home Escitalopram
10mg daily.
>> TRANSITIONAL ISSUES:
[ ] Repeat ERCP in ___ weeks (___) for removal of PD and
biliary stents and reevaluation: ERCP will contact patient to
schedule follow up
[ ] Repeat CA ___ in 4 weeks.
[ ] Given cardiomegaly, consider cardiac MRI (___) as
outpatient to distinguish hypertensive myopathy from
hypertrophic obstructive cardiomyopathy.
[ ]Follow up pancreatic mass FNA pathology results
[ ]Ciprofloxacin given prophylactically post EUS X 5 DAYS | 209 | 821 |
17180509-DS-21 | 24,247,204 | Mrs. ___,
___ was our pleasure caring for you at ___
___. You were admitted with concerns for low blood
sugar. Your blood sugars were within normal limits while you
were in the hospital. It is possible that changes in your body
since your gastric bypass are causing some of your symptoms.
You need to follow up with bariatric surgery along with a
nutritionist and your primary care physician to create ___
lifestyle plan that will work for you.
Your second urine sample returned clear without signs of
infection and you do not need antibiotics.
If you feel lightheaded or shaky, please eat something with
sugar immediately or drink orange juice or cola. Take your blood
sugar by finger prick, if less than 70 then consume juice or
cola and let your regular outpatient doctor know.
___ wishes,
Your ___ Care Team | ___ w/ ___ ___ gastric bypass, opioid abuse, depression
p/w recent increased fatigue and found to be hypoglycemic.
# HYPOGLYCEMIA: Likely secondary to recently decreased intake;
pt endorsed trying to reduce "junk foods" immediately prior to
onset of symptoms. HbA1c <6, indicating pt has not developed
DM2. Various endocrine pathologies considered included cortisol
deficiency, insulin antibodies, insulinoma, or ___
hyperplasia secondary to gastric bypass surgery
[nesidioblastosis], which appeared much less likely given
glucose stability in the hospital. AM cortisol WNL. Did not
become hypoglycemic on admission so no labs for insulin,
___, or ___ were drawn.
- STARTED ___ and cyanocobalamin 100 mcg PO/NG DAILY
___ ___ bypass
- Rx given for glucometer, lancets, and testing strips to
monitor FSBG when symptomatic
- Follow up with surgeons for further management of diet, workup
of NIPS
# Contaminated urinalysis: intially treated with nitrofurantoin
for ?UTI, though repeat without epis did not show e/o infection.
# NARCOTICS ABUSE: Lives in sober home. Has not used Percocet in
over one year and has agreements on her ___
medications. No narcotics, muscle relaxants, or benzos in the
house. Ibuprofen 600 mg Q8H:PRN pain.
# DEPRESSION/ANXIETY: H/o. Continue home citalopram 40 mg PO QD.
# MIGRAINES: H/o. Home ___
mg oral TID:PRN migraine, can get one/day here. Ibuprofen 600 mg
Q8H:PRN migraine.
# RIGHT HIP, LEG PAIN: H/o. Has had several imaging studies. No
narcotics, muscle relaxants, or benzos in the house. Ibuprofen
600 mg Q8H:PRN pain.
# CANDIDAL DERMATITIS: Physical exam shows erythematous, itching
rash below pt's inferior pannus. Pt describes long history of
rash, occasionally flaring. Candidal dermatitis thought most
likely given high incidence among obese patients and appearance
of rash. Miconazole Powder 2% 1 Appl TP BID
# TRANSITIONAL ISSUES:
- Dental hygiene is poor, needs f/u with dentistry
- Morbid obesity: needs to see gastric bypass surgeon,
nutrition___
- Blood glucose monitoring supplies given at discharge
- Code: FULL
- Emergency Contact: ___ (dad) ___ and ___
___ (mother) ___ | 137 | 318 |
12575134-DS-7 | 28,188,175 | Dear Mr ___,
It was a pleasure taking care of you at ___
___.
You were in the hospital because you were having nausea and
vomiting at home. We think this was due to a condition called
Cyclic Vomiting Syndrome. We gave you medicines for nausea and
IV fluids.
When you leave the hospital, we will give you medicines to help
control your nausea. It will be important for you to establish
care with your primary care doctor.
If you have any further nausea/vomiting and are not able to
tolerate food or drink by mouth, you should call your doctor or
return to the Emergency Department.
Best wishes,
Your ___ team | TRANSITIONAL ISSUES:
-Patient was counseled and given information on stress
management resources.
-Patient was counseled for marihuana cessation
-Will have PCP and GI follow up in the outpatient setting
___ year old male with history of Horner's syndrome who presented
on ___ with intractable nausea and vomiting over previous
several days prior. On admission he presented with ___
(creatinine 3mg/dL) and several laboratory abnormalities
including hyperphosphatemia, hypercalcemia, and hypokalemia.
These all resolved with IV fluids. His nausea was managed with
IV fluid, Ondansetron, and Lorazepam. By the day of discharge he
was able to tolerate oral food and liquids without signs of
dehydration. He met with a social worker and was given stress
management resources. He will follow up with his PCP and GI in
the outpatient setting.
# Cyclic vomiting syndrome
# nausea/vomiting: No reported history of recent ETOH
ingestion. No diarrhea. We could also consider cannabinoid
hyperemesis, given his marijuana use, but his symptoms are
neither relieved nor exacerbated by marijuana. Episodes likely
triggered by increased stressed as every episode he has had has
been during a time of increased stress at work. He was given
bowel rest, antiemetics and IVF with improvement in his
symptoms. He was discharged home with a short course of
lorazepam (10 tabs) and ondansetron. He was counseled to f/u
with his PCP and to contact stress management resources provided
by ___ while inpatient to possibly help prevent further episodes.
# Acute renal failure: also had hyperphosphatemia,
hypercalcemia, and hypokalemia likely in the setting of his ___.
Creatinine on admission was 3 mg/dL. Renal u/s showed a 4-mm
crystal at the calyx, but he denies any dysuria or hematuria.
Repeat labs showed rapid improvement in Cr after IV fluids.
Creatinine 0.7mg/dL on day of discharge.
# Polycythemia (resolved): Due to hemoconcentration given poor
PO intake. Improved to normal after IVF given for hypovolemia in
the setting of nausea/vomiting from likely ___. | 107 | 318 |
14542380-DS-11 | 22,598,290 | Dear Ms. ___,
You were admitted to the hospital for chest pain and shortness
of breath. We investigated the cause with a cardiac MRI, and
echocardiogram and a cardiac catheterization. None of these
showed any active inflammation around your heart (pericarditis)
or any other potential heart causes for your chest pain, which
was reassuring. We believe that your current pain is likely
coming from your chest wall and may be related to an injury. You
were started on an anti-inflammatory medicine (indomethacin)
with improvement in your symptoms. Please follow up with your
doctor.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | Ms. ___ is a ___ year old woman w/ a hx of pericarditis c/b
pericardial effusion ___ yrs ago p/w worsening CP and SOB x 1 week
and pericardial effusion on echo.
# Chest pain, costochondritis: Pt has reported history of
pericarditis sarting ___ years ago with multiple subsequent
episodes. She presented with chest pain, SOB, and decreased
exercise tolerance for 3 months. She had a cardiac MRI that was
pending from week before discharge that showed small effusion
but no evidence of active inflammation or restrictive heart
disease. She underwent cardiac catherization with right and left
cath which showed no significan CAD and normal filling
pressures. Her left sided chest pain was reproducible on exam on
presentation. She was started on indomethacin with improvement
in her pain. Pain is likely musculoskeletal with costochondritis
most likely. She is being discharged on NSAID regimen. | 113 | 143 |
17721163-DS-10 | 20,719,339 | Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service after your left foot surgery.
You were given IV antibiotics while here and had a PICC line
placed for easier long-term IV antibiotics.
You are being discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your left foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
FOLLOW UP:
Please follow up with your Podiatric Surgeon, Dr. ___. You
will have follow up ___ the Podiatric Surgery Clinic ___ ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge if it is not listed below.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills. | The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have a necrotizing infection of the left foot and was taken
to the operating room immediately on ___. Afterwards, he was
admitted to the podiatric surgery service. For full details of
the procedures, please see the separately dictated operative
reports.
The patient was taken from the OR to the PACU ___ stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor for further management with packed-open
wound. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet by POD#1. On
POD2, ___, he was taken back to the OR for an incision and
drainage.
On ___, he was taken back for a definite left
transmetatarsal amputation, percutaneous tendo Achilles
lengthening with Integra graft to the dorsal foot. He was placed
___ a posterior splint and the dressing was left intact until
POD2, ___.
Initially, he was managed on IV Vancomycin, Metronidazole and
Clindamycin. Infectious Disease evaluated him and recommended a
final home course of 2 grams IV Ceftriaxone daily as well as PO
Flagyl through ___ (3 weeks from last surgical date). He
will have weekly surveillance labs (CBC/Diff, Cr, CRP, LFTs)
drawn weekly and sent to the Infectious Disease office. After
the three weeks of antibiotic treatment and final pathology
results are reviewed, the need for continuation of antibiotic
therapy will be reassessed.
Physical therapy was consulted. The patient worked with ___ who
determined that discharge to home was appropriate. The patient's
home medications were continued throughout this hospitalization.
The ___ hospital course was otherwise unremarkable.
The patient was given anticoagulation per routine for each
procedure and while an inpatient. 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 NWB to the LLE lower extremity. 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. | 470 | 384 |
11270948-DS-10 | 27,493,644 | Dear Ms ___,
It was a pleasure taking care of you. You were admitted to ___
___ for altered mental status and
swelling in your legs. While you were here, you were treated
with IV antibiotics for a leg infection called cellulitis. Your
pessary was removed due to concern that this could be
contributing to your infection. You were also treated with Lasix
to improve the swelling in your legs.
You were evaluated by physical therapy, and you will need
24-hour care as you recover from this hospitalization. It is
very important that you attend all of your follow up
appointments, listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you all the best in the future.
Sincerely,
Your ___ Care Team | ___ w/ dCHF, HTN, prolapsed bladder with pessary, and Afib c/b
SSS s/p PPM who presented with altered mental status, initially
admitted to the MICU for sepsis, thought to be secondary to a
LLE cellulitis. She was treated empirically with Vancomycin ___ - ___ for which a PICC was placed. Following IV
fluid resuscitation, she was subsequently hypoxic, with labs and
exam consistent with acute decompensated heart failure. She was
diuresed with IV Lasix, after which she was resumed on home
torsemide. Given persistent leukocytosis, pessary was removed on
___ due to concern for infection. She will be discharged home
with a foley and will follow up with OBGYN for further
management of her pessary. Pt is ambulatory at baseline and
therefore would benefit from d/c to ___
rehabilitation to maximize functional potential and facilitate
return to PLOF. Family's wishes are for pt to return home with
increased support services.
# ACUTE METABOLIC ENCEPHALOPATHY:
Patient presented with progressive decline over last 6 weeks,
with acute worsening in days leading up to admission. Of note,
she was septic secondary to a LLE cellulitis and was found to be
in decompensated heart failure, which may have caused a
metabolic encephalopathy. CO2 normal on admission. No focal
neurologic deficits. She was initially admitted to the MICU due
to hypotensions requiring pressors. Once blood pressure was
stabalized, patient transferred to the floor on ___. Upon
arrival to floor, patient was alert, but not oriented to place
or time. Per her nursing age, her baseline was much better. She
was treated with Vancomycin IV for 7 days, and white count was
monitored closely. Also monitored for other infections, as
below. Sedating medications were avoided. At time of discharge,
patient is sleepy, but able to wake up. She is oriented to
person, place, and year.
# SEPSIS, LIKELY SECONDARY TO LLE CELLULITIS:
On admission, patient had bilateral lower extremity edema, with
redness, warmth, and erythema in LLE. WBC 30. Was admitted to
MICU, and treated with Vancomycin IV. Persistent leukocytosis is
concerning for another source of infection. Was briefly on
pressors for hypotension. Once blood pressure stabalized off
pressors, patient was transferred to floor on ___. Due to
persistently elevated white count, other infection was
considered. ___ CXR showed possible pneumonia. ___ plain
films tib/fib showed no signs of osteomyelitis. Consulted OB/Gyn
due to concern for pessary infection; appreciate their recs.
OB/GYN removed pessary on ___. Patient also received
Fluconazole for yeast infection. Wound care was consulted for
leg wound, appreciate their recs. Patient completed 10 day
course of Vancomycin (___). C dif was sent, but patient
has not been having diarrhea. At time of discharge, patient has
been afebrile and leukocytosis is downtrending.
# CHF:
Chronic, but with worse B/L ___ edema on exam. BNP ___ on
___, elevated from prior. Was taking Torsemide 20PO BID at
home, had recently changed to Torsemide 40PO qAM. Was net -400
in ICU, so basically euvolemic. Was actively diuresed with Lasix
160mg IV BID until patient received dry weight on ___. Was
placed back on home Torsemide 40mg daily.
# AFIB WITH SSS S/P PPM:
Metoprolol was fractionated to 50mg q6 originally, then switched
to home 200mg daily. On ___, she had episode of RVR with HR
130s, stable BP and subsequently remained rate controlled.
Patient is currently home Metoprolol 200mg daily and Apixaban 5
mg PO/NG BID. Heart rate upon discharge were stable in ___.
# HYPERTENSION:
Home antihypertensives originally held in the setting of sepsis
and subsequent diuresis, however, resumed prior to discharge.
Continued home Pravastatin 20 mg PO. Upon discharge, patient is
normotensive.
TRANSITIONAL ISSUES
- PESSARY REPLACEMENT: Patient has follow up with OB/GYN on
___ for pessary replacement. She will bring pessary to this
appointment.
- FOLEY CATHETER: Foley will remain in place until pessary is
replaced; after which, a voiding trial should be attempted.
- She was actively diuresed and subsequently discharged on home
torsemide; Cr with mild elevation to 1.3 upon discharge; Please
repeat BMP on ___ to ensure stable Cr and fax results to ___
___ at ___.
- Trend weights; further adjustments of diuretic regimen
deferred to PCP | 126 | 684 |
12301582-DS-11 | 21,409,522 | Ms. ___,
You were admitted to ___ for back pain.
WHILE YOU WERE HERE:
- We did images which ruled out dangerous causes of your pain
- Your pain improved
WHEN YOU GO HOME:
- Please take all medications as directed and follow-up with the
below doctors
___ the best,
Your ___ Care Team | ___ year old woman with PMHx of HTN, lumbar radiculopathy,
constipation, and hearing loss presenting with acute on chronic
back pain with radiation into bilateral upper extremities.
# Acute on chronic back pain
# Lumbar radiculopathy
Patient had an MRI 1 month ago after a fall which showed
moderate canal narrowing but no evidence of cord compression and
she has had continuous back pain since that time. On this
admission she presented with worsening of pain and radiation
into the bilateral arms. CT of the C/T/L spine showed no acute
abnormalities but chronic disease (see attached reports). As the
CT ___ showed some edema, MRI was obtained which did not
show any cord compression or acute ligamentous injury. CK
normal. Ortho was consulted and recommended soft collar. Her
pain resolved on her home medication regimen and she was
discharged in stable condition for follow-up.
#UTI
Found to have preliminary urine culture with E. coli, pending
sensitivities. In the setting of a limited history of symptoms
due to memory, the patient was started on a 5-day course of
Ciprofloxacin (END ___ for UTI. Follow-up final urine
cultures. Of note, her foley was discontinued and she was noted
to void spontaneously before discharge. Monitor for signs of
urinary retention.
#R Elbow XR findings:
Some concern for R elbow effusion on plain film. Given
resolution of pain and low likelihood of fracture, recommend
follow-up R elbow XR in 4 weeks.
#Anemia:
Iron studies as attached, with elevated ferritin and decreased
Fe/TIBC. Consider Fe repletion or further workup in the
outpatient setting.
# HTN: continued amlodipine 2.5 mg daily
# CAD: continued ASA 81mg and atorvastatin 40mg daily
# Osteoporosis: continued MVI, calcium, and vitamin D,
alendronate qweekly
# Esophagitis: continued sucralfate 1 gm PO BID
TRANSITIONAL ISSUES:
- Reassess need for soft collar pending improvement in pain, low
threshold to discontinue if not helping or no longer needed
- Started on a 5-day course of Ciprofloxacin (END ___ for
UTI.
- Follow-up final urine cultures.
- Monitor for signs of urinary retention (voiding well at
discharge).
- Recommend follow-up R elbow XR in 4 weeks.
- Consider Fe repletion or further workup of anemia in the
outpatient setting.
#CODE: DNR/DNI based on MOLST in OMR from ___
#CONTACT: ___
Relationship: Step Son
Phone number: ___
Cell phone: ___ | 47 | 370 |
15082603-DS-16 | 24,809,475 | You were admitted after a fall with weakness and were found to
have a urinary tract infection in addition to possible
Aspiration Pneumonia. You have been treated with antibiotics
for a 5day course and will need ongoing rehab at the skilled
nursing facility.
Best wishes from your ___ team | A/P: ___ w/ dementia (nonverbal at baseline) sent in
by PCP after reporting ___ recent unwitnessed fall, found to have
possible RLL infiltrate concerning for aspiration PNA and UTI
# UTI: Urine Cx was positive for Klebsiella and pt was treated
with
levofloxacin and completed a 5 day course prior to discharge.
# Possible Aspiration PNA: Pt had minimal cough and normal O2
sats.
Pt was seen by speech/swallow who recommended a ground dysphagia
diet with
thin liquids. There was no witness aspiration events and pt was
assisted with meals.
Pt was treated with a 5 day course of Levofloxacin.
# Fall: EKG reassuring and unable to obtain additional history
given baseline mental status. No associated trauma on films.
Husband
has noticed generalized weakness over the last few days. TSH
reassuring and this was felt likely related to UTI. Pt was seen
by ___
who recommended temporary SNF for rehab.
# Dementia: Pt has advanced dementia with frontotemporal
wasting. Pt
is followed by Dr. ___ who has been adjusting meds
recently.
She has a stereotyped behavior of tachypnea with pursed lip
breathing
when distressed that seems to resolve when pt is comfortable
and/or needs addressed.
Buspirone was started recently and was not felt to be helping,
this was
discontinued per Dr. ___. Pt was continued on home regimen of
Lorazepam 0.5mg qam, Alprazolam 0.5mg qhs, Donezepil 5mg and
Seroquel 100mg BID.
Pt has outpatient f/u scheduled with Dr. ___ in ___.
# Nocturnal polyuria: prescribed desmopressin for
nocturnal polyuria - will continue but trend Na daily
# FEN: Adv ground diet with thin liquid per speech
# Prophylaxis: Heparin sc
CODE: DNR/DNI - confirmed with HCP husband at bedside, ___
interpreter present
Dispo: likely SNF in ___ days. | 49 | 271 |
10949629-DS-5 | 21,361,636 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
You are cleared to resume your home blood thinning medication
(Aspirin, Coumadin) by the neurosurgeon.
You may take Ibuprofen/ Motrin for pain.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain or swelling.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | Ms. ___ is a pleasant ___ year old female who was
transported to ___ ED on ___ from home by ambulance after a
fall down her cellar stairs, found to have cervical spine
fractures at C1 and C2.
#c1/c2 fracture
She was admitted to ___ service under Dr. ___. She was
initially placed in a c-collar, but this was cleared per Dr.
___ the nature of the fractures and no posterior
midline tenderness. Her neurologic exam remained intact. CTA of
the neck was negative for vascular injury. No operative
intervention was indicated.
#Pain
She developed increased left side skull pain radiating to jaw
and head, and her pain regimen was adjusted with little
improvement. Pain service evaluated her for further
recommendations. New regimen with Tylenol, PO morphine,
tizanidine, and gabapentin was initiated with good pain control.
She was discharged home with Tizanidine, Tylenol, and
gabapentin.
#Anticoagulation
Patient has a pacemaker and h/o Afib, and takes Coumadin at
home. This was initially held, but restarted when determined no
OR will be needed. Coumadin was restarted at home dosing and INR
was 3.0 at discharge. She will continue to follow up with her
PCP for monitoring.
#Hyponatremia
The patient was noted to be hyponatremic during admission and
treated with sodium chloride tabs, which were able to be weaned
to 1g daily at discharge. Her PCP ___ continue to monitor.
She was evaluated by physical therapy, who cleared her for
discharge home on ___. Pain was well controlled on PO regimen,
she was ambulating, and tolerating PO diet prior to discharge. | 155 | 255 |
14894642-DS-19 | 21,850,761 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were having left sided abdominal pain and constipation
What did you receive in the hospital?
- We did imaging of your kidneys and your abdomen, and it did
not show an obstruction.
- We think your abdominal pain is likely from your enlarged
kidneys and constipation. You may also be having some muscle
pain.
- We think your nausea, vomiting, and constipation is from your
bowels slowing down and not moving food through as well as it
should
What should you do once you leave the hospital?
- We are working on scheduling an appointment with Dr. ___.
Please call your PCP's office if you have not heard back by
___.
- An appointment was scheduled with Dr. ___ to discuss your
gastroparesis and chronic constipation on ___ at 1:30pm
- New medications: Simethicone 120 mg PO/NG QID:PRN gas
- Changed medications: Allopurinol to 100mg PO daily (given
kidney function)
We wish you the best!
Your ___ Care Team | PATIENT SUMMARY
================
Mr. ___ is a ___ w/ PMHx of polycystic kidney disease and
probable RCC, CKD stage 5 with left AV fistula, BPH s/p TURP,
COPD, s/p upper
lobectomy presenting with constipation and L flank pain, likely
in the setting of gastroparesis (nausea, vomiting, constipation)
and heavy renal cyst burden (abdominal pain).
ACUTE ISSUES
=============
#Flank pain: Mr. ___ presented with multiple day history of
L-sided abdominal pain, worse with inspiration, that was
intermittent and "sharp" in nature. He also had chronic
constipation, and developed nausea/vomiting while hospitalized.
Underwent a CT on ___ which showed a 1cm increase in R kidney
size and 3mm increase in L kidney size, however no acute
findings to explain his symptoms. Admission renal ultrasound was
without hydronephrosis or obstructing stone. He developed
vomiting on ___, and as such had a repeat CT A/P that did not
demonstrate bowel obstruction. Overall, his symptoms seemed most
likely related to dysmotility (given chronic constipation and
h/o polycystic kidney disease), recurrent pain from cyst burden
iso PKD (pain worsened with increase intraabdominal pressure),
and potentially a musculoskeletal etiology given worsened pain
with palpation of the paraspinal muscles. Was thought to be less
likely to represent intermittent SBO (given no e/o obstruction
on repeat CT A/P), ruptured renal cyst (no free fluid on renal
ultrasound), or nephrolithiasis (no hematuria and no e/o on CT
A/P or renal US). Given concern for gastroparesis, we trialed
Metopclopramide 10mg TIDWM, which reduced his abdominal pain. We
aggressively and successfully treated his constipation during
his hospitalization.
# Polycystic kidney disease and
# CKD: As above, appears to have stable disease. Creatinine has
slowly increased over time, consistent with CKD. We continued
his home Sodium Bicarbonate, Sevelamer, Calcitriol, and
Torsemide.
CHRONIC ISSUES
===============
# BPH s/p TURP: Continued home Finasteride and Torsemide
# COPD: Continued home albuterol, advair, and supplemental O2
(goal SO2 88-92%)
# HLD: Continued home atorvastatin
# Gout: Continued home allopurinol
# HTN: Continued verapimil
TRANSITIONAL ISSUES
====================
[ ] Consider restarting home Verapamil after PCP follow up if
needed for HTN management
[ ] We are working on scheduling an appointment with Dr. ___.
Please call your PCP's office if you have not heard back by
___. You should be seen within 1 week.
[ ] An appointment was scheduled with Dr. ___ to discuss GI
dysmotility related to end stage renal disease and chronic
constipation on ___ at 1:30pm
[ ] New medications: Simethicone 120 mg PO/NG QID:PRN gas
[ ] Patient was encouraged to continue bowel regimen: Colace,
senna, miralax, bisacodyl, suppository and linzess. Home
lactulose was continued as well, though it may be contributing
to abdominal discomfort. Would consider substituting if felt
appropriate.
[ ] Changed medications: Allopurinol to 100mg PO daily (given
kidney function) | 201 | 441 |
17663396-DS-19 | 25,552,259 | Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on CC7 regarding management of
your syncope episode. You were evaluated by the Medicine team
and had reassuring telemetry monitoring and reassuring EKG
findings. Your cardiac biomarkers were negative (two-sets). You
did have evidence of an elevated serum glucose and this should
be rechecked as an outpatient.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* This admission, we CHANGED: NONE
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. | IMPRESSION: ___ with no significant past medical history who
presented following a syncopal episode at a baseball game.
PLAN:
# SYNCOPE - The patient leaned down and reached with his right
arm under his chair and turned his neck inciting sharp pain
without radiation of the right arm while at a baseball game.
Following sitting up he experienced lightheadedness and
dizziness with resulting syncope for ___ sec of LOC following
that. No head trauma or injury. Wife confirms his story. Some
mild bladder incontinence, but this can be seen with
neurocardiogenic syncope. Certainly seizure episode is of
concern given the bladder incontinence, but patient has no
strong family history and no prior seizure episodes. Similarly,
laboratory data reveal no metabolic derangements. He also had no
post-ictal concerns, no paralysis and no tongue biting. A TIA or
stroke is of slight concern in a male with a family history of
cardiac disease, obesity and some hyperglycemia on laboratory
data (without HTN, HLD, diabetes history). He has no focal
neurologic deficits or weakness and no carotid bruit on exam. A
posterior circulation TIA could present with a drop attack and
these symptoms, but again less likely. In terms of cardiac
etiologies, his EKG was reassuring with an isolated TWI in lead
III and sinus tachycardia with mild J-point elevation. He does
have family history of MI in his father, but again no documented
HTN, HLD, or diabetes is noted. Cardiac biomarkers reassuring in
the ED (two-sets) and no chest pain or trouble breathing. CXR
was also negative in the ED. He had no arrhythmia documented on
overnight telemetry and has no family history of sudden cardiac
death or early MI. Hypoglycemia unlikely in this patient.
Overall, this leaves a vasovagal episode (neurocardiogenic)
occurring in the setting of sharp and precipitous pain in the
right shoulder that resulted in hypoperfusion, inciting syncope.
He has had no issues similar to this previously. Of interest,
prior to discharge, his peripheral IV was removed and he
developed sinus bradycardia to 30 bpm with mild hypotension and
lightheadedness that rapidly improved, consistent with
neurocardiogenic syncope. An EKG was reassuring. He was
monitored on telemetry through the afternoon and was discharged
in stable condition.
# RIGHT SHOULDER PAIN - Currently pain free, with complete ROM
of shoulder. No history of trauma. Unclear precipitant though
may have been a muscle strain or outpatient brachial plexus
impingement or transient 'stinger'. No RUQ pain to suggest GB
pathology. We encouraged range of motion exercises and possibly
outpatient physical therapy evaluation
# HYPERGLYCEMIA - No prior history of diabetes or strong family
history. No HTN, HLD reported. Patient has evidence of obesity.
He presented with elevated serum glucose and glucosuria. Will
need outpatient fingerstick rechecked and HbA1c, blood pressure
monitoring and fasting lipid panel as an outpatient. | 247 | 463 |
16046549-DS-21 | 26,745,966 | Dear Ms. ___,
You were admitted with three seizures. We think these seizures
came from the area of old stroke in your brain. You were started
on a medication called Keppra 500mg BID to prevent future
seizures from happening. You were evaluated by physical therapy,
and they felt that you needed rehabilitation. You will go to
rehab at ___.
It was a pleasure meeting you!
Dr. ___ | Ms. ___ is a ___ F with a PMHx of HTN, HL, and
stroke (___) who presented after a fall at home and 3 events
concerning for seizure. On exam, she had facial bruising and was
initially obtunded with less movement of her left size. Her CT
and MRI brain did not show any evidence of new strokes or
hemorrhage, and her CT c-spine did not show any fractures or
acute injury. The following morning, she was alert, following
all commands, answering questions appropriately, and had fluent
speech. Additionally, her left-sided weakness had resolved.
Overall, our impression is that she seizures, and her old stroke
was the seizure focus. The obtundation was likely secondary to a
post-ictal state as well as the receipt of benzodiazepines. The
left-sided weakness was likely due to recrudescence of old
stroke symptoms or a ___.
She was started on Keppra 500mg BID. Her EEG showed evidence of
intermittent right posterior slowing and bitemporal slowing, but
there were no further seizures. She initially failed a bedside
swallow evaluation, but she passed a formal swallow evaluation.
She was continued on fall, seizure, and aspiration precautions.
Her LFTs, utox, stox, UA, and CXR were normal. ___ Dopplers
obtained for ___ swelling were also normal. | 65 | 206 |
12736592-DS-14 | 27,896,326 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions. During your stay, you received lasix for
fluid overload, as you had edema in your extremities and groin.
Please f/u with your PCP for further diuretic management.
Your platelets were trending down so we got a HIT panel which is
still pending. Your blood cultures grew Ecoli at admission so we
started you on Unasyn while you were here. You are being
discharged on Augmentin for 7days.
Please follow up in the Acute Care Surgery clinic. You need to
call ___
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. | Mr. ___ is an ___ who presented to the ___ ED complaining of
lower abdominal pain. He was worked up for MI in the ED and
eventually underwent a CTA of his torso which demonstrated
possible cholecystitis. He became increasingly tachycardic and
hypotensive during his ED course and was started on levophed
prior to admission to the MICU. A right IJ was placed in the
ED.
After further evaluation, Mr. ___ was taken to the OR for
laparoscopic cholecystectomy, which he tolerated without
difficulty. He was admitted to the TSICU postoperatively for
hemodynamic monitoring given his initial decompensation in the
ED.
On ___, Mr. ___ was noted to be increasingly hypercarbic and
had a significant respiratory acidosis, and was intubated. He
required levophed with propofol, both of which were weaned off.
His ventillator support was weaned.
On ___ He was transferred to the floor and advanced to a
regular diet. On ___ his foley was discontinued and he voided.
His platelets were shown to be trending down at a nadir of 49 so
a HIT panel was sent, heparin was stopped and fondaparinux was
restarted. His antibiotics were also changed to po augmentin.
His Blood cultures grew back pansenstive Ecoli so we continued
him on that regimen. He was also shown to be fluid overloaded,
without respiratory compromise so we gave him 10 Iv lasix, which
he responded well. His home meds were also restarted. On ___ he
was dischrged home on PO augmentin. | 784 | 248 |
19798578-DS-33 | 20,033,975 | Mr. ___, you were admitted to the hospital because you had
shortness of breath and chest pressure. You also had some night
sweats. You had a workup in the hospital, which showed that you
did not have a heart attack. You also had no signs of pneumonia
or other infections. You were briefly treated with antibiotics,
which were not continued on discharge. You had a scan of your
lungs, which showed no significant blood clot.
We have not made any changes to your medications. Please
continue to take them as previously prescribed. | Mr. ___ is a ___ man with a history of renal transplant
in ___ and newly diagnosed burkitt's lymphoma who presented on
cycle 1, day 14 of EPOCH chemotherapy with an episode of mild
cough and dyspnea on exertion.
.
#Dyspnea on exertion: Pt has atyical mild chest "pressure" w/
walking down the stairs, which he says was different from his
prior episodes of stable angina. Significantly, he has a history
of clincally diagnosed PE/DVT ___ (no CTA was done given his
baseline renal insufficiency and renal transplant) and has been
on treatment with enoxaparin. There is no significant historical
or physical change to suggest that his cardiac function has
changed from Echo preformed about 2 weeks prior to admission. MI
was ruled out with unchanged ECG relative to baseline and
negative troponins. Pt was started empirically on levofloxacin
for atypical PNA or tracheobronchitis given normal appearance of
chest film w/ only small L pleural effusion. Although he had
leukocytosis this was most likely due to his use of filgrastim
just prior to admission for neutropenia. He remained afrebrile
throughout his stay. He had a V/Q scan done, which showed no
evidence at all of a pulmonary embolism. By the evening of
admission, Pt stated that he felt completely well and had no
symptoms whatsoever. His ambulatory O2 saturation was 97% on
room air. His is unlikely to have any a true pneumonia or
bronchitis, and his antibiotics were discontinued on discharge.
.
# Leukocytosis - most likely due to Pt's use of filgrastim just
prior to admission for neutropenia. This was discontinued given
current WBC counts.
.
# Coronary artery disease status post CABG in ___ and DES; vein
graft in ___. Pt was ruled out for MI (see above). Pt was
continued on his home beta blocker and statin w/out issue.
# Diabetes type 2, complicated by retinopathy and neuropathy.
70/30 insulin BID and sliding scale as per home med.
#End-stage renal disease status post renal transplant in ___.
Continued home tacrolimus, level appropriate at 5.9, avoid
nephrotoxins. Continued home ACE-I and prophylactic bactrim
w/out issue.
# Peptic ulcer disease - continued home PPI | 92 | 347 |
14489759-DS-3 | 24,269,898 | Dear Ms. ___,
It was a pleasure to take care of you during this
hospitalization. You were admitted to ___
___ for low blood count (anemia) and fast heart rate.
Your blood count was monitored and stable when we discharged
you. It is likely that multiple factors are contributing to your
anemia and you should follow up with GI and hematology oncology
as an outpatient.
For your atrial fibrillation with a rapid heart rate, we
restarted you on 2 medications (metoprolol and digoxin) to help
control/decrease your heart rate. You will need to follow up
with your regular doctor.
You are now safe to leave the hospital. Please follow-up with
your doctors and take ___ your medications as prescribed. | ___ with a history of rheumatic heart disease s/p AVR/MVR in
___, Afib on Coumadin, and CKD previously on HD (baseline Cr
1.2-1.6) who presents from nursing home with 5 days BRBPR and
dyspnea.
# Anemia: Patient was transferred from rehab to ___ ED for Hct
drop found at rehab. Repeat Hct in ___ ED was 27.5, showing
stable anemia from prior ___ ___ admission
(Hct ___ for GIB thought ___ to ___ tear.
Throughout this admission, patient was monitored and without
signs of active bleeding. Hct remained stable and was 27 at the
time of discharge. Most likely diagnosis is chronic blood loss
from low-grade GI bleed. Differential also included B12
deficiency (on B12 IM), and myelodysplastic
syndrome/myelofibrosis. Patient will need outpatient Hematology
and Gastroenterology follow-up 1 week after discharge for
further work-up and management of anemia.
# Potential GI Bleed: Patient had a recent admission to ___.
___ ___ for a concern of GI bleed thought ___
___ tear. Upon current presentation to ___ ED,
patient was found to have guaiac=positive stool. Throughout the
rest of the admission, the patient was without evidence of
active bleeding. Anemia was managed and monitored per above.
She will need outpatient GI follow-up for consideration of
EGD/colonoscopy.
# Atrial Fibrillation with Rapid Ventricular Response: During
___ ___ admission, patient received
diltiazem intravenously and orally and digoxin with good hear
rate response but was discharged off all rate-controlling
medications and anticoagulation in the setting of potential
bleed. Upon current presentation to ___ ED, digoxin was
started at 0.125mg daily and metoprolol was started and titrated
to 25mg BID based on blood pressure and heart rate. Heart rate
improved from 140s in ED to 80-100s at the time of discharge.
Her heart rate will need to be monitored as an outpatient.
Aspirin 325mg daily was initiated for anticoagulation, CHADS
score 1.
# Hypotension: Patient developed intermittent asymptomatic
hypotension on ___ and ___ to systolic blood pressure ___,
thought to be a combination of hypovolemia from decreased PO
intake and uptitration of beta blocker. Beta-blocker was
down-titrated (see above) and patient was administered 1 liter
of IV fluids, with stable blood pressure ranging systolic
110-120s at the time of discharge.
# Renal Insufficiency: Patient with unknown baseline renal
function. Creatinine was monitored and improved from 1.4 on
admission to 1.2 at the time of discharge, which was consistent
with recent baseline from rehab laboratory values.
# Thrombocytosis: Patient was found to have thrombocytosis to
platelet count of 600-700k during this admission. Differential
included reactive process vs. myelofibrosis. The patient needs
outpatient Hematology follow-up for further management and
work-up of thrombocytosis.
# Chronic Diastolic Heart Failure: Patient remained without
evidence of decompensation during this admission. She was
started on a beta-blocker per above.
# Schizophrenia, depression, OCD: Patient was continued on her
home psychiatric regimen including trazadone and fluvoxamine.
===================================
TRANSITIONAL ISSUES
===================================
MEDICATIONS
- STARTED Metoprolol tartrate 25mg BID
- STARTED Digoxin 0.125mg daily
- STARTED Aspirin 325mg daily
- STOPPED Potassium supplementation
FOLLOW-UP
- Repeat CBC in on week ___ to assess for stability of
anemia.
- Please monitor digoxin level and for signs of toxicity
- Please monitor patient's heart rate and ensure well-controlled
at 80-100
- Please down-titrate metoprolol to 12.5mg BID if blood pressure
is found to be sBP<90.
- Hematology follow-up needed in 1 week. Appointment needs to be
scheduled, ___ Hematology Department phone number provided.
- Gastroenterology follow-up needed in 1 week. Appointment needs
to be scheduled, ___ Gastroenterology Department phone number
provided.
OTHER
- Please continue goals of care discussion with patient's
gaurdian | 122 | 593 |
16356598-DS-9 | 26,552,874 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for three episodes of uncontrolled left hand
movements that were concerning for seizures.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your anti-epileptic drugs were changed and you were started on
Keppra.
- Your pneumonia treatment was continued with antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
- Please call Dr. ___ office to schedule a follow up
appointment.
Thank you for allowing us to take part in your care.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old female with PMH significant for
ER+/PR-/HER2+ left ductal BrCa on anastrozole, brain lesions s/p
resection of right frontal lesion and prior CK, large left
occipital cystic lesion, recent grand mal seizure associated
with ICH, recent admission for focal seizure and
post-obstructive pneumonia, who presented after 3 self-limited
episodes of left hand focal motor seizures, now initiated on
Keppra (from Topamax) and completed antibiotic treatment for
pneumonia.
TRANSITIONAL ISSUES
===================
[ ] Please continue to monitor for seizures on new AED regimen,
Keppra 1 g BID.
[ ] Recommend continued follow up with Dr. ___ your
seizures and brain lesions.
[ ] Recommend continued follow up with Dr. ___ your cancer
care.
[ ] Patient was offered home ___ services, but declined. She
would benefit from physical therapy if she is amenable.
[ ] She will complete 7 day course of antibiotics with augmentin
on the evening of ___. The final dose will be given prior to
discharge.
ACTIVE / ACUTE ISSUES
=====================
#Focal motor seizure
#Brain metastases
Presents with 3 self-resolving episodes of LUE twitching without
LOC or post-ictal state. There was family report of concern for
cyanosis. No ___ involvement or incontinence. Neurology consulted
in ED, suspect current seizures may be arising from prior R
frontal resection bed given seminology. She was recently
admitted with similar complaints, for which topiramate was
uptitrated to 100 mg BID. Seizure threshold may have been
lowered by concurrent antibiotic therapy. Imaging from most
recent admission with stable findings. Topiramate stopped and
Keppra 1000mg BID started. Has not had involuntary movements
since admission. Will continue levetiracetam 1000 mg BID on
discharge. There was no indication to pursue EEG.
#Ataxia
#Lower extremity weakness
She was noted to have left leg weakness and associated ataxia,
despite ___ motor strength testing on her neurologic exam while
in bed. MRI C/T spine was pursued. Final read pending at time of
discharge, however it was reviewed by attending
neuro-oncologist, Dr. ___ did not find any acute change
to account for her symptoms. Her symptoms improved and she was
evaluated by physical therapy. They felt she would benefit from
home ___, however she declined at this time. She was provided
with information for local ___ and ___ services and she will
pursue these in the outpatient setting on an as needed basis.
#R hilar mass
#Post-obstructive pneumonia
She presented on most recent admission with DOE, cough and
hypoxia found to have post-obstructive changes consistent with
pneumonia. She was discharged on levofloxacin/flagyl with plans
for 7 day course to complete ___. Given concern for
levofloxacin reducing the seizure threshold, she was
transitioned to doxycycline in the ED. She received 5 days of
atypical coverage before admission. Given QTc 512ms, will
complete course with Augmentin through ___ to complete 7 day
course.
#Non-gap metabolic acidosis
#Respiratory alkalosis
HCO3 14 with Cl 109. VBG with pH 7.39/pCO27 suggesting likely
respiratory compensation for metabolic acidosis. She has a
chronic component to non-gap metabolic acidosis, potentially
worsened by topiramate administration which can be associated
with decreased serum bicarbonate. Topiramate was discontinued
and her chemistry panel was trended daily.
#Metastatic HER2+ Breast Cancer
Followed by Dr. ___ T4N2M at diagnosis with
infiltrating, left ductal HER2+ BrCa. Prior treatment has
included taxol/Herceptin, followed by anastrozole/Herceptin and
most recently anastrozole monotherapy due to transaminitis. She
was lost to follow up in ___ after PET scan showed
worsening mediastinal and lung metastases. Upcoming plan was for
cyberknife with Dr. ___ to L occipital cystic lesion followed
by likely consent for study protocol ___ (HER-2 antibody
conjugate). She underwent MRI and CK planning with plans to
initiate CK on ___. She was continued on anastrozole 1 mg PO
daily. Drs. ___ were updated throughout the
admission.
CHRONIC ISSUES
==============
#Thrombocytopenia
Chronic, baseline 100-120. Currently at baseline. CBC was
trended daily.
#Hypothyroidism
Continued levothyroxine 100mcg daily.
#Hypertension
Lisinopril held on prior admission, Continued to hold as she is
normotensive.
#HCP/CONTACT: ___ (husband), ___
#CODE STATUS: Full, presumed | 131 | 642 |
17282608-DS-22 | 20,042,939 | You returned to the hospital perianal discomfort and inability
to void after undergoing a recent incision and drainage of a
perirectal abscess. You were given Augmentin and have not had
any fevers for the last 24 hours. Your white blood cell count is
also decreasing to normal. During this admission, you underwent
exam under anesthesia, abscess drainage, and ___ placement.
You have recovered from this procedure well and you are now
ready to return home. You have tolerated a regular diet and your
pain is controlled with pain medications by mouth. You may
return home to finish your recovery. You will need to take your
oral antibiotics for 12 more days after returning home, stopping
them after ___.
You have small incisions next to your anus, with a drain and two
setons. Your incision is healing well however it is important
that you monitor the area for signs and symptoms of infection
including: increasing redness of the incision line,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incision may be left open to the air.
You have recently been prescribed narcotic pain medication
oxycodone. This medication should be taken when you have pain
and as needed as written on the bottle. This is not a standing
medication. You should continue to take Tylenol for pain around
the clock and you can also take Advil. Please do not take more
than 4000mg of Tylenol in 24 hours. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities | Mr. ___ underwent an ___, drainage of perirectal abscess and
placement of 2 setons on ___ after presenting with urinary
retention and being found to have lateral, anterior, posterior
and deep extension of his perirectal abscess. He tolerated the
procedure well with no complications. He was started on
Augmentin postop and this was continued for a 14 days course
total. A foley catheter was left in postop due to his urinary
retention but it was removed on POD#1 and he was voiding. His
diet was appropriately advanced as tolerated. His pain was
controlled on oral meds. He was deemed fit to discharge home on
Augmentin for 14 day course. | 335 | 110 |
11703010-DS-3 | 26,370,676 | Dear Ms. ___,
It was a pleasure to care for you at ___.
You were admitted for shortness of breath, fever and chest pain
and found to have fluid in your lungs (a pleural effusion) and
signs of pneumonia. You were treated with antibiotics and this
improved. Please follow-up with your outpatient primary care
physicians to ensure that this resolves.
Best wishes,
Your ___ Team | Ms. ___ is a ___ year old woman w/ a PMH of ___ and
multiple recurrent episodes of chest pain attributed to
costochondritis who presented with worsening dyspnea and chest
pain for over 2 weeks prior to admission with 2 episodes of
night sweats and a non-productive cough, febrile to 100.5 in ED,
with significant leukocytosis with CTA chest revealing bilateral
pleural effusions and consolidations consistent with CAP.
#Pneumonia. Pt presented with leukocytosis to 28.5 with
associated fever to 100.5 in the ED. CTA showed pleural
effusions R>L with a consolidative process c/f pneumonia.
Presentation was c/w community acquired PNA. Pleural effusions
are likely reactive ___ PNA and less likely ___ autoimmune
process given ___ weakly positive (1:40) and negative dsDNA,
also less likely malignancy. No c/f TB given no symptoms of
weight loss/hemoptysis and no exposure hx or travel to endemic
areas. Leukocytosis down-trending with antibiotics. Patient
initially treated with ceftriaxone/doxycycline out of c/f
tick-borne illness however given negative Lyme, transitioned to
augmentin/azithromycin for PO regimen 5 days total. Ambulatory
sat was 94% at time of discharge. Of note, interventional
pulmonology was consulted and the decision was made not to do
thoracentesis given small size of effusion on US and therefore
high risk for pneumothorax and patien'ts clinical improvement.
#Elevated ESR/CRP. Despite low c/f autoimmune process as primary
pulmonary process, significantly elevated CRP/ESR (greater than
expected for PNA) and history of
___ costochondritis was concerning.
Would recommend reechecking ESR/CRP after resolution of
pneumonia, consider sending RF, anti-CCP, C3/C4 as outpatient if
ESR/CRP persistently elevated or new sxs develop consistent with
rheumatologic disease.
#RUQ tenderness: Likely ___ rib pain from pleural effusion R>L.
LFTs notable only for elevated AlkP/GGT which is likely acute
phase reactant.
#Pericardial Effusion: Noted on CTA in ED. TTE ___ showed
trivial/physiologic pericardial effusion, thus low c/f
development of tamponade.
#Proteinuria. Resolved. Kidney function normal throughout stay,
BUN/Cr ___ on admission. U/A in ED showed proteinuria (also
hematuria possibly contaminant from menstruation). Repeat U/A on
___ showed no proteinuria or hematuria.
#Anemia: Guaiac in ED was negative and hemolysis labs were
negative. Fe studies c/f AOCD. H/H improving during admission to
___ on ___, though per ___ ___ atrius records she did not
have anemia.
#Coagulopathy. INR 1.4 on admission, improved to 1.2 on ___
#Thrombocytosis. Likely acute phase reactant
#Seasonal affective disorder. Pt was continued on home
fluoxetine | 61 | 392 |
12700774-DS-18 | 21,206,695 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted because of increasing left shoulder/arm pain and were
found to have a non-displaced fracture of your left humerus.
You were given 5 treatments of palliative radiation to the site
as well as conservative management with a sling and pain
control. You were also found to have new clots in the veins of
you legs bilaterally. You were started on a therapeutic dose of
Lovenox (Enoxaparin) to treat these.
We used a number of different modalities to attempt to
effectively treat your pain. Ultimately, we came to the
conclusion that the best treatment for your pain would be to do
a regional nerve blockade to the affected area.
Please make the following changes to your medications:
START Enoxaparin Sodium 80 mg, subcutaneous injection twice a
day
START Miralax one packet every day, as needed, for constipation
CHANGE gabapentin to 300mg twice per day
CHANGE dilaudid to ___, by mouth, every three hours, as needed
for pain
CHANGE dexamethasone from 2mg to 4mg every morning
CHANGE methadone to 40mg three times per day
START tizanidine 2mg twice per day
Please take the rest of your home medications as previously
prescribed.
Below are some important information regarding your infusion
pump:
You or the infusion company should not change the dressing on
your pump. Nobody should change the dressing on your pump. If
you have any numbness around the eyes, ringing of the ears,
palpitations, or seizures, this may be toxicity from the
medication in the pump. You should go to the closest emergency
department. If you have any fevers, chills, swelling, redness
or significant pain around the insertion site of the pump, you
should call your doctor or have it evaluated at the closest
emergency department.
You will be re-admitted to the hospital (___ on ___.
You should arrive to ___ approximately at 9am. Ideally,
the pump will be shut off before you leave your home that
morning. You should STOP taking your LOVENOX on the morning of
___.
If you have any problems or questions with the pump, you should
call your infusion company, or you should call the Anesthesia
nurse ___ (cell ___. If you
are having pain, you should notify your infusion company, and
they will contact ___ for a prescription to go up on
the pump's parameters.
You should continue to take your lovenox twice per day. Know
that lovenox leads to thinner blood, and you are at increased
risk for bleeding. You had a small amount of bleeding from your
hemorrhoids this hospital stay. If you have increased bleeding,
or are feeling unwell such as lightheaded, chest pain, or dizzy,
you should be evaluated by your local emergency department. | BRIEF CLINICAL SUMMARY:
___ yo M with stage IV NSCLC adenocarcinoma with metastatic
lesions to brain and bone, who was admitted with a new
pathologic left humerus fracture. The patient completed a
5-episode radiation therapy protocol, with course complicated by
L arm pain that was refractory to large amounts of narcotic
medications. The patient had a brachial plexus block and
catheter placement by anesthesia/pain medicine, with good
effect. The patient was discharged home with the peripheral
catheter nerve block, with infusion support services. | 464 | 87 |
18846873-DS-5 | 22,613,214 | You were admitted to the antepartum service for observation due
to flank pain, concerning for a possible kidney stone. Your pain
improved and it was felt it was safe for you to be discharged
home. Fetal testing was reassuring while you were here. You have
no activity restrictions at home. | Ms. ___ was admitted to the hospital with acute onset
colicky LLQ pain concerning for nephrolithiasis or preterm
contractions. She had a U/A that was within normal limits and a
renal ultrasound that showed no evidence of hydronephrosis or
nephrolithiasis. A workup including vaginal cultures and urine
culture were all negative.
She was observed and did not have any contractions, vaginal
bleeding, or rupture of membranes. Her pain resolved by HD#2.
After a period of observation, she was deemed stable for
discharge home with precautions. | 50 | 85 |
12178135-DS-5 | 26,277,321 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted for worsening kidney
function. You were evaluated with laboratory testing and a
kidney biopsy which showed BK virus nephropathy. You were
treated with IVIG and we decreased your immunosuppression and
your kidney function improved. You developed low sodium levels
which are improving with fluid restriction.
You should get repeat labwork on ___ and continue your 1.5L
fluid restriction. | Ms. ___ is a ___ year old woman now ___ years s/p LURT who presents
with acute allograft dysfunction in the setting of worsening BK
viremia despite relatively low-dose immunosuppression. She has
no signs of overt bacterial infection, volume depletion, or
evidence of urinary obstruction which would explain her
worsening creatinine. Thus, the most likely causes are worsening
BK nephropathy versus rejection.
#***Please note: after patient was discharged, notified by
infection control that patient's roommate for <24 hours on
___ was found to be FluA positive***
#Acute renal failure- BK virus versus rejection
- Biopsy done ___ showing BK nephropathy
- Hold ASA, NSAIDs for biopsy; no anticoagulation or
antiplatelets for ___ days starting ___
- Hold lisinopril
- Dose medications for GFR < 10 ml/min
#Immunosuppression: Decreased home sirolimus and prednisone in
setting of BK nephropathy.
- Sirolimus 1.5mg and prednisone 4mg to be titrated by
outpatient transplant nephrology.
#Prophylaxis:
- Held TMP/SMX in setting ___ with hyperkalemia. No need for
PJP coverage at this time and was held on discharge.
- continued home vitamin D | 74 | 185 |
10874939-DS-16 | 24,153,301 | Dear Ms. ___,
You were admitted to ___ to determine why you lost
consciousness at dinner on ___. Based on testing that
you received here, we think that you fainted due to a phenomenon
called vasovagal syncope. We know that you have had previous
episodes of vasovagal syncope. Here are some ways that you can
prevent loss of consciousness/passing out in the future when you
start to feel lightheaded:
+Leg-crossing - cross one leg over the other and squeeze the
muscles in your legs, abdomen and buttocks. Hold this position
as long as you can or until your symptoms disappear.
+Arm-tensing - grip one hand with the other and pull them
against each other without letting go. Hold this grip as long as
you can or until your symptoms disappear.
+Water ingestion - drink water when you feel as though you are
going to faint.
It is also possible that you fainted due to an issue with your
heart, although we think that this is less likely given that
your stress test and echo were normal when you were hospitalized
at Mount ___ in ___. However, we still think that it would
be beneficial to do some additional testing as an outpatient
(another stress test and potentially a 24-hour cardiac monitor).
We have scheduled a follow up appointment. Please see below.
It was a pleasure taking care of you!
Your ___ Team | ___ with a PMH of vasovagal syncope who presented after an
episode of syncope.
#Vasovagal syncope:
Patient felt lightheaded and nauseous immediately prior to
episode of syncope. Regained consciousness briefly and began
walking to bathroom when she lost consciousness again; she was
seated in a chair and had a BM. When she regained consciousness,
she threw up several times and felt nauseous, weak, and sweaty.
Denied head strike, tongue biting, post-ictal confusion.
Patient's nausea and weakness subsided after she arrived at
___. Etiology of syncope thought to be vasovagal possibly
secondary to gastroenteritis or viral etiology given dehydration
(lactate 3.4 on presentation), vomiting, diarrhea. Other
possible etiologies include arrhythmia (pulse of 40 could
suggest bradycardia) or atypical angina equivalent. ED EKG
showed NSR with T wave inversion in leads I, II, avL, V2-V6, no
ST changes. Reassuringly, previous EKGs from years past had also
been notable for T-wave inversions. The patient also has a
history of negative stress test (___) and negative carotid
ultrasound. The patient was monitored on telemetry and no
arrhythmias were noted. Her symptoms completely resolved. Urine
and blood cultures showed no growth to date.
# Diffuse T wave inversion
Likely chronic given report of nonspecific T wave abnormality
during ___ admission in ___. Possible diagnoses
includes physiologic precordial t wave inversion, memory t
waves, type II demand ischemia, and LVH (given mild concentric
LVH on echo in ___. | 226 | 229 |
15650925-DS-20 | 26,489,280 | Please take all of you medications as prescribed, keep your
follow-up appointments, and abstain from all drug and alcohol
use. | ___ woman discoid lupus, GERD, ETOH abuse, long QT
syndrome c/b TdP/VF arrest s/p single lead ICD (___), now
with recurrent ETOH pancreatitis and alcoholic ketoacidosis.
She was treated for acute pancreatitis with IVF, bowel rest, and
antiemetics (using benzodiazepines to avoid QT prolonging
medications) with good results. Her ketoacidosis responded to
D5LR, and her alcohol withdrawal was managed by ___ with
diazepam, but she did not have significant withdrawal symptoms.
Throughout her stay she had marked asymptomatic hypertension
(SBP 160-180/DPB 100-130) which improved on an increased doses
of Toprol (25mg>50mg) and the addition of norvasc, but on the
day of discharge her BP was low normal (110/70), and because of
insurance issues requiring out of pocked expenditure and
concerns about noncompliance, she was discharged only on Toprol
(50mg). It may be that her hypertension while hospitalized was
precipitated by ETOH withdrawal, but this is unclear, and she
will need close follow up and monitoring.
HYPOMAGNESEMIA/HYPOKALEMIA: She had marked electrolytes
derangements which required aggressive repletion. | 20 | 162 |
15295867-DS-20 | 20,545,926 | You were admitted with DKA in the setting of a pneumonia as well
as blood infection. You were admitted to the ICU initially. You
were treated with antibiotics you will need to continue
vancomycin for 6 weeks. You also had a feeding tube placed that
you will use for your nutrition. | ___ man, chronically ill, T1DM, multiple toe
amputations, gastroparesis & prior DKA, ESRD (likely ___ DM, no
biopsy on file) on HD, bilateral ___ DVT s/p IVC filter ___, L
non-occlusive jugular thrombus (___), R thalamic bleed in the
setting of HTN emergency w/ residual L hemiparesis (___), &
L hip fracture s/p fixation ___, who presents w/ lethargy,
found to have multifocal pneumonia, Staph bacteremia and DKA.
# PNA:
# MRSA Bacteremia:
Source of MRSA bacteremia felt to be pulmonary. CT A/P without
evidence of abscess. Of note, CT did mention concern for
possible osteomyelitis; however, ortho evaluated the patient and
did not feel that this was consistent. Central line removed
___. The patient was originally treated with vanc/zosyn. Zosyn
was d/c'ed ___, with plan to continue vancomycin for 6 week
course per ID through ___ with hemodialysis.
# T1DM:
# DKA:
Very brittle, in DKA on admission. He is very sensitive to
insulin and has had hypoglycemic episodes in the past. He was
initially treated with insulin gtt in the ICU. ___ followed
closely and made adjustments to his insulin regimen. Please see
discharge medication list for current insulin regimen. Briefly,
he will continue lantus 7 units daily in AM and insulin sliding
scale. His insulin requirement has slightly increased as he has
been cleared for PO intake along with tube feeds and may require
further adjustment.
# Afib:
Appears to be new in the ICU. Was on amiodarone drip and
eventually transitioned to Metoprolol tartrate q6hrs that is now
transitioned to Metoprolol XL (50mg BID). Coumadin was initially
held in the setting of supratherapeutic INR's, has since been
restarted.
-Rate control: HR's have been in the low 100's on long acting
Metoprolol and the dose can be titrated if felt necessary
however he is asymptomatic
-Anticoagulation: he was bridged in the setting of prior DVT and
new AFib to therapeutic INR. His home dose of warfarin is 4mg
but in the hospital he has received 5mg. Heparin IV was stopped
___ after 2 consecutive therapeutic INR's ___ - ___. INR
today (___) is 2.6.
# Hx VTE:
Complicated coagulation history. He had bilateral ___ DVT s/p IVC
filter ___, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___). He has been restarted on Coumadin as
above. Given multiple previous clots, decision was made to
bridge with heparin gtt until INR therapeutic. Notably he has
LLE swelling compared to the right leg; he does have an IVC
filter already and is therapeutic on anticoagulation so an
ultrasound is not likely to change management. He has received 5
days of IV heparin and is now therapeutic on Coumadin.
# Dysphagia
# Aspiration
# Severe Protein Calorie Nutrition
Patient underwent a G-J tube placement ___. After ongoing
discussions with SLP and medical team, pt decided to accept
aspiration risk trial pureed solids with nectar-thick liquids.
His current tube feeding regimen is:
Glucerna 1.5 Cal; Full strength
Tube Type: Percutaneous jejunostomy (PEJ); Placement confirmed.
Starting rate: 50 ml/hr; Do not advance rate Goal rate: 50
ml/hr
Residual Check: Not indicated for tube type
Flush w/ 30 mL water Per standard
Free water amount: 100 mL; Free water frequency: Q6H
Supplements:
Banana flakes: Mix each packet with 120 ml water & stir until
dissolved
Administer by syringe through feeding tube
Flush each packet with 30 ml water; #packets: 1; times/day: 3
-He has had some loose stool in the last 1 week that may be due
to tube feeding. Banana flakes were added ___ but not yet
initiated prior to discharge and can be added if loose stool
persists.
-Sugars have slowly trended up with initiation of PO diet along
with tube feeds, please adjust regimen if needed.
# HTN: Labetalol transitioned to Metoprolol as above. HR's have
been low 90-100s and stable, asymptomatic, in AFib. Can titrate
up on regimen further if needed.
# ESRD: HD MWF. On nephrocaps, sevalamer, low phosphorous diet.
Vancomycin dosed with dialysis (last dose ___, due ___,
dose is given based on vancomycin level per dialysis team).
# Anemia
-H&H noted to drift down slightly. No active signs of bleeding.
Iron studies suggest anemia of inflammation/chronic disease. H&H
8.___.2 at the time of discharge. Suspect also a component of
phlebotomy. Please recheck counts in the next ___ hrs to
ensure stable.
# Incidental Imaging Findings:
- CT A/P showed "Bilateral lower quadrant abdominal wall
heterogeneous fatty lesions may represent complex lipomas.
These were likely present on the CT dated ___ however
appear more conspicuous on the current study given mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely.
Ultrasound and/or MRI is recommended for further evaluation if
clinically warranted."
- CXR ___ showed "Increased soft tissue density medial to the
right IJ central venous catheter may simply be projectional.
However, hematoma cannot be excluded and short interval
follow-up is recommended."
- Continue follow up of anemia/blood counts
#Dispo - discharge to rehab today
#Contact - wife ___ ___ has been updated by case
management
Time spent: 50 minutes | 51 | 826 |
13823917-DS-18 | 23,205,486 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
You were admitted because we suspected you might have pneumonia
given your recent cough and fever.
What was done for me while I was in the hospital?
You received antibiotics and medications that can help you
breathe easier.
What should I do when I leave the hospital?
Follow-up with your primary care doctor within the next week to
ensure your breathing has improved. Continue taking your
antibiotics.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year-old man with congestive heart failure (EF
30%), myelodysplastic syndrome, chronic kidney disease, and
possible interstitial lung disease presenting with subacute
onset cough + fever, found to have multifocal
consolidations on CXR and rhonchi on exam concerning for
pneumonia vs. exacerbation of chronic interstitial lung disease.
ACTIVE ISSUES
======================================
#Cough/Fever
#?Pneumonia
He presented with several days of cough with reported history of
T ___ at home, though with no recorded fevers upon
presentation. His CXR showed multifocal opacities with no lobar
consolidation that may represent progression of chronic
interstitial disease as compared to prior radiograph from ___.
However, given his age, poor lung volumes on film, and history,
we could not rule out community acquired pneumonia and he was
started on IV ceftriaxone and azithromycin. He also received
ipratropium/albuterol duonebs as needed. A sputum culture was
sent after starting antibiotics, but this was contaminated. His
oxygen requirement initially ranged from 90 - 97% on 1L NC;
later, he was 92-94% on room air. He was not symptomatic, and
was more interactive/responsive on day of discharge. He was
transitioned to PO cefpodoxime/azithro to complete a course for
CAP.
#CKD
His creatine was 2.2 on admission from baseline 1.7 - 1.9, but
eventually trended down to 1.8 on HD #2 and HD#3.
#Swallowing:
Nursing expressed concern about his aspiration risk, and speech
and language pathology evaluated patient. They recommend
continuing a thin liquid and regular solid diet, with meds
crushed in applesauce. They believed patient requires assistance
with all meals with standard aspiration precautions (sitting
upright, 1:1 assistance with meals). Patient's wife was
educated on monitoring for swallowing difficulty.
#Elevated troponins:
Troponin 0.3 on admission with EKG stable compared to prior.
Repeat troponins were stable at 0.2. We thought troponins
likely elevated in setting of possible mild demand ischemia in
the setting of infection with poor clearance of troponin in th
setting of CKD. The patient has follow up scheduled with his
cardiologist.
CHRONIC ISSUES
======================
#Hypertension: We continued his home carvedilol, and initially
held his home losartan in the setting of decreased renal
function. Losartan was restarted day of discharge.
#Atrial Fibrillation:
Patient noted to have ectopic episodes of atrial fibrillation.
His wife reports that he was on apixaban for three months prior
to an eye surgery, and taken off thereafter. He has not been
taking it at home per her report. As of the most recent note
___, apixaban was to be discussed with cardiology given the
patient's advanced age. Discussed risks/benefits of long-term
anti-coagulation with his wife. She verbalized understanding of
risk of stroke vs. bleeding with decision to anti-coagulate or
not, and wanted to speak further with outpatient cardiologist
before making decision.
# Pancytopenia:
Patient has had anemia with hemoglobin in the ___ range,
leukopenia in the range of ___, and thrombocytopenia between
___ over the past ___ years. Based on a hematology oncology
note from ___ (reporting a bone marrow biopsy from ___, this
was thought to be due to myelodysplastic syndrome. His CBC on
admission was consistent with his baseline.
#Congestive Heart Failure (EF 30%):
Reported per echocardiogram in ___. He did not complain of any
symptoms, he was euvolemic on exam, and CXR showed no signs of
pulmonary edema. We did not diurese him.
TRANSITIONAL ISSUES
===============================
[ ] Antibiotic Course: Cefpodoxime/Azithromycin for 5-day course
(___)
[ ] Consideration of anticoagulation: after initial discussion,
patient's wife would like further discussion of risks and
benefits with cardiologist given history of atrial fibrillation.
[ ] Aspiration risk: will require 1:1 observation with meals,
and medicines crushed in food per speech and swallow evaluation.
[ ] Blood cx x 2 pending at the time of discharge, will need to
be followed up | 104 | 626 |
15007011-DS-6 | 25,501,058 | You were admitted with a cerbellar stroke. You were started on a
new medication to prevent new strokes. These are Apirin 81 mg
daily and Plavix (Clopidogrel) 75mg daily. You should follow up
with your primary care provider to schedule an echo of your
heart. | Neurologic: Was admitted to Neuro-ICU/Stroke service, Attg, Dr.
___. MRI/MRA brain showed occluded left vertebral artery.
Lipid panel showed mildly elevated TGs, otherwise WNL. HBA1C
WNL. Started ASA on ___. He was transferred to the floor
stroke service later in the day on ___. His headache
resolved and his symptoms slowly improved with respect to his
ataxia and dysmetria. We did not start coumadin given his
current social situation (living in shelter, difficulty getting
to blood draws) and also it's potential interaction with
depakote, so we opted for 3 months of plavix with continued low
dose aspirin. We also started a statin prior to discharge.
Cardiovascular: We allowed BP to autoregulate with goal SBP <
180. TTE w/bubble study was ordered but patient refused to wait
for this study as we could not give him a specific time it could
be done by, so instead of allowing him to leave AMA we
officially discharged him with plans to obtain an echocardiogram
with bubble study as an outpatient. He voiced understanding of
this plan upon discharge and stated he would try to see his PMD
one day after discharge to discuss this. We left a message with
the office of Dr. ___ at ___ about our
recommendations for an outpatient echo with bubble study ASAP.
Resp: We continued home COPD med regimen without changes. His
respiratory status was stable on room air throughout the
hospitalization.
FEN/GI: Bedside swallow study completed while in the ICU and he
was allowed to eat prior to transfer to the floor. Continued to
PO well throughout stay on floor. Colace X1 for constipation.
Chemistry labs stable.
Psych: We continued Depakote ___ mg for bipolar disorder.
Depakote level was stable. Melatonin was given for insomnia. He
did not appear to be at risk for withdrawing and did not require
CIWA scoring. We wrote for a nicotine patch but he refused
this. We do not recommend he start chantix for smoking cessation
due to his risk for further strokes.
Prophylaxis: He recieved DVT boots and subcutaenous heparin
while not ambulating. ___ and OT were consulted and cleared him
for discharge home.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 81) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 45 | 561 |
13254836-DS-7 | 26,983,465 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for fevers.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours as needed for your pain. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fevers and an elevated WBC to 15 and was admitted to the
orthopedic surgery service. The patient was given 48 hours of
vancomycin. An MRI and x-rays showed hardware intact without
evidence of osteomyelitis. His WBC resolved to 9 on ___ and he
was afebrile during his admission. He felt well on day of
discharge. It was determined that he would be discharged home
and return if his fevers persisted.
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
WBAT LLE. The patient will follow up with Drs ___
per 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. | 52 | 184 |
14428832-DS-8 | 20,890,704 | Dear Ms ___,
It was a pleasure taking care of you at ___
___. You came back to the hospital because you had
worsening abdominal pain and nausea. You had an endoscopic
ultrasound that found no cause of your abdominal pain. They took
biopsies during that procedure that are still pending. We found
no abnormalities causing your abdominal pain. You were able to
eat a regular diet and were discharged home safely. You should
follow up with the surgeons on ___ to have your gallbladder
removed.
We are starting you back on your coumadin with lovenox
injections until your coumadin is therapeutic. Please talk to
your primary care doctor to determine when you can stop the
lovenox. You should have your next INR drawn on ___.
Please follow up at the appointments below. | ___ PMH pituitary macroadenoma, HCV, PE who presented with
recent abdominal pain consistent with gallstone pancreatitis s/p
sphincterotomy now representing with abdominal pain.
# Abdominal pain: Patient presented with worsening abdominal
pain. She had an EUS that showed Slightly dilated (4mm) but
otherwise normal pancreatic duct. Dilated (12mm) but otherwise
normal common bile duct. The dilation extended to the level of
the ampulla. No cause for the dilation could be identified. Her
diet was advanced and she was discharged home.
# HCV (genotype 1a) on Harvoni - continued Harvoni
# Recent Pulmonary Embolism: Patient with PE diagnosed in
___. She is currently on Lovenox as a bridge to
warfarin. INR on discharge was 1.
# Pituitary macroadenoma: continued cabergoline 1 mg oral
2X/WEEK
# Fibromyalgia: continue home meds
# COPD: continued Fluticasone-Salmeterol Diskus (100/50) 1 INH
IH BID
# Depression: Held citalopram due to prior concern for erratic
behavior
========================= | 131 | 167 |
15991401-DS-14 | 27,609,814 | You were admitted for chest pain.
Your labwork showed you did not have a heart attack. You had a
nuclear stress test that showed no concerning signs.
Please follow-up with your cardiologist in the next 2 weeks.
Please also find a new primary care doctor to discuss your
symptoms. | ___ hx CAD s/p CABG and POBA, HTN, HLP and recent admission for
NSTEMI in setting of pyelonephritis with sepsis who presents
from home with exertional angina and labile blood pressures
after not following up for a stress test.
#CAD/angina: sx sound anginal although pt with sx overnight and
trops continue to be flat. No concern for UA/NSTEMI at this
time. However she did suffer NSTEMI 1 mo prior and did not f/u
for outpt stress testing; she has known 3VD s/p CABG. Admitted
for nuclear stress imaging over the weekend. During the
weekend, had occ episodes of her described CP; enzymes flat
throughout. Nuclear stress showed no reversible ischemia and
normal LVEF, however her RPP was ___ and she demonstrated
delayed exaggerated BP response to exercise after cessation (no
BP rise during stress). Due to these findings, it was felt that
her nitrates were exacerbating her preload dependent diastolic
dysfunction and as well not helping her symptoms (which were
probably not anginal), so nitrates were discontinued at
discharge with consideration of CCB if BP not controlled. | 51 | 186 |
15440778-DS-22 | 24,206,372 | DISCHARGE TO ___
Physical Therapy:
NWB in ___
Treatments Frequency:
Continued care for infection | Patient was admitted to the orthopaedic service for treatment of
post surgical cellulitis. ___ was initially treated with
vancomycin monotherapy and then subsequently Ancef was added for
better strep and MSSA coverage. ___ did have recession of his
erythema on his leg, but continued to have significant swelling
and erythema around the site of the incision with exquisite pain
and inability to ambulate. During this time, we were in contact
with Dr. ___ at the ___ and plan
to transfer him back to Dr. ___.
___ did work with physical therapy. His DVT ppx was continued per
prior instructions. ___ did have a lower extremity ultrasound
that was negative for DVT. His hospitalization was otherwise
unremarkable. | 10 | 115 |
10999782-DS-9 | 26,654,369 | Dear Mr. ___,
You were admitted to ___.
WHY WERE YOU ___ THE HOSPITAL?
==============================
- You had fevers due to a collection of blood (hematoma) ___ your
right leg that was infected.
WHAT WAS DONE WHILE YOU WERE ___ THE HOSPITAL?
==============================================
- You had the infected fluid drained and a drain was placed ___
your right thigh.
- You were given antibiotics.
- An IV catheter was placed ___ your right arm, which caused a
lot of bleeding. It was eventually removed.
- A number of studies were done to determine why you had the
bleeding ___ your thigh and from the IV.
WHAT YOU NEED TO DO WHEN YOU GO HOME?
======================================
- Please continue to take all of your medicines as prescribed.
- Follow up with the Infectious Disease doctors ___ ___ to
determine how long to continue antibiotic therapy.
- Follow up with the Hematology doctors ___ ___ to complete
the evaluation of your bleeding disorder.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team | Information for Outpatient Providers: ___ with a ___ MDS,
hypothyroidism, hypertension presented to ___ ED with 2 weeks
of intermittent fevers found to have spontaneous right thigh
hematoma and likely abscess. Patient was taken for ___ drainage
and drain placement with removal of 8cc purulent fluid and
report of a multiloculated fluid collection measuring 10x3x6cm.
Patient was treated with empiric vancomycin, ceftriaxone,
clindamycin. Abscess cultures grew staph aureus that was
pan-sensitive. Antibiotics were narrowed to cefazolin for a ___
week course to be determined by ID as an outpatient. A midline
was placed for continued IV abx as an outpatient, which was
complicated by persistent bleeding despite DDAVP x3, topical
thrombin application, and multiple dressing changings. The
midline was removed and hemostasis was achieved. Prior to
discharge, patient was transitioned to linezolid ___ PO BID
for continuation of 4 week course (D1: ___, end date:
___.
# Right Rectus Hematoma/Abscess: Patient presented with 2 weeks
of fevers, right thigh pain found to have spontaneous right
thigh hematoma on CT RLE. He had no hx of trauma/inciting event
for development of hematoma. Given his feers/chills/pain,
hematoma was felt to be infected/developed into an abscess.
Patient was taken for ultrasound-guided ___ of the
abscess with placement of a drain for source control. Given
report of multiloculated collection with purulent fluid, patient
was started on broad spectrum antibiotcs with vancomycin,
ceftriaxone, clindamycin (D1 = ___. Abscess cultures grew
pan-sensitive staph aureus. Right thigh drain drained <10cc
serosanguinous fluid per day. Echo was negative for signs of
endocarditis. ___ drain was d/c'ed on ___. Patient's abx was
narrowed to cefazolin with plan for continued treatment as
outpatient. However, midline placement was complicated by
persistent bleeding despite DDAVP x3, topical thrombin
application, and multiple dressing changes. Midline was removed
and patient was transitioned to PO linezolid to complete 4 week
course of abx (___) with ID follow-up as outpatient.
# Normocytic Anemia: Patient was found to be acutely anemic from
baseline hemoglobin of ___ based on outpatient results. This
was felt most likely ___ spontaneous bleed/hematoma ___ patient's
right thigh. No other clinical evidence of other sources of
bleeding. Patient also has known baseline anemia due to MDS.
DIC/hemolysis was considered, but fibrinogen and other DIC labs
were normal. Patient received 1u pRBCs on ___ for Hb 6.9. Right
thigh drain output was monitored and drained <10cc
serosanguinous fluid per day.
# Unspecified Coagulopathy: Patient presented with spontaneous
hematoma without trauma/injury. He also gave history of
consistent with an unclear bleeding disorder that included
continued oozing from a small incision following cyst removal
and bleeding for days following superficial cuts/abrasions at
home. He also had midline placement complicated by persistent
bleeding. He received DDAVP x3 over three days and multiple
dressing changes with topical thrombin without resolution of
bleeding. Differential diagnosis included a secondary process
to the patient's known MDS vs primary platelet
dysfunction/coagulopathy that had not been diagnosed. Atrius
heme/onc was consulted. Empiric vitamin K repletion was given
for INR of 1.5 with some response. DIC labs (given infectious
presentation) were negative. Platelet mixing studies and factor
levels were normal. ___ studies pending. Patient to
follow up with Hematology as outpatient for further evaluation.
# MDS: Stable. Atrius heme/onc followed. Outpatient oncologist
aware of admission.
# Hypothyroidism: Stable. Continued home levothyroxine.
# Hypertension: Stable. Given infection, held patient's home
chlorthalidone.
# Psoriasis: Stable.
# Hyperlipidemia: Continued statin.
TRANSITIONAL ISSUES
========================
[] Patient on 3 week course of PO linezolid. Please monitor
patient for signs of persistent or recurrent infection and
determine whether patient will need longer course of abx or IV
abx treatment.
[] Patient with MDS and baseline neutropenia. Please monitor
patient's CBC every week while on linezolid.
[] Patient with unspecified coagulopathy. Please follow up
pending coagulation studies and further evaluate. | 165 | 645 |
18243257-DS-9 | 28,979,612 | Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with dissolvable sutures underneath
the skin and steri strips. You do not need suture removal. Do
not remove your steri strips, let them fall off.
Please keep your incision dry for 72 hours after surgery.
Please avoid swimming for two weeks.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
for 2 weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | On ___, Ms. ___ presented to the ED with worsening
mid-thoracic and low back pain and burning. She was taken to
the OR on ___ with Dr. ___ C5 corpectomy and C4-6
anterior fusion. Her operative course was uncomplicated; please
see separate operative note for full details of procedure.
On POD1, patient reported improved pain. Her incision was
intact and there was no underlying hematoma or swelling. Her
strength was full and symmetric, and she denied any sensory
deficits other than subjective numbness in her hands. She
tolerated a regular diet and had sufficient urine output.
She was evaluated by ___, who felt she needed an additional
session prior to discharge. However, patient was adamant about
going home. She felt strongly that she would be safe at home, as
long she could be provided with a rolling walker for some
assistance with ambulation. She stated that she understands the
risk she is taking by going home without being cleared by
Physical Therapy as she is in fact medical school graduate from
___. Hinging on that, she also expressed clear understanding
of precautions she should take to prevent falling and when to
call for help or seek medical care. After discussing with
attending, it was decided that she could be discharged home.
She was provided with a short course of low-dose Valium for
muscle spasms and Oxycodone for breakthrough pain, in addition
to a bowel regimen (Senna/Colace) while on Oxycodone. She was
also provided with longer (>1 month) course of Gabapentin for
which she was instructed to discontinue when no longer needed.
Each of the medications and their risks--particularly as they
relate to impaired mental/physical function--were explained to
the patient and she expressed understanding. She is to follow-up
in clinic for repeat AP/Lateral XR in 1 month. | 239 | 304 |
12151872-DS-15 | 25,825,684 | You came to the hospital after an episode of unresponsiveness.
You were found to have a urinary tract infection. You were
treated with antibiotics, which finished on ___.
While in the hospital, you were observed to stop breathing while
you were asleep for brief periods of time. This is called sleep
apnea. You would benefit from sleeping on your side and not
taking sedating medications prior to sleep. You will need to
follow-up with the sleep medicine doctors after ___ leave the
hospital. Your PCP can make arrangements for you to see a
sleep medicine doctor as an outpatient. | Mr. ___ is an ___ year old gentleman with atrial fibrillation (on
chronic apixaban) complicated by CVA ___/ severe dysarthria
and aphasia and two recent admissions for MDR E coli UTI
presenting from his facility after an episode of
unresponsiveness.
# Sepsis ___ E. Coli UTI:
# Encephaloopathy
He presented with unresponsiveness and sepsis. UA positive and
urine culture growing MRI E. Coli. He was started on Zosyn. He
completed a 10-day course of Zosyn on ___. He will resume
fosfomycin suppression as an outpatient. He will follow-up with
Infectious Disease and Urology for urodynamic testing to ensure
no structural cause for his recurrent UTI as an outpatient. His
mental status improved to baseline and he did not seem confused,
though it's difficult to assess his mental status as he is
aphasic. He follows commands and seems to understand what is
said to him, but cannot communicate back to providers. He had
some episodes in the afternoons/evenings when he would call out
and seem agitated and upset, but this seemed mostly when his
family was not present and at least in part due to frustration
with inability to communicate.
# Pneumonia:
He is at high risk for aspiration. Bibasilar opacities were
seen on CXR. He was treated initially with zosyn and
vancomycin. Vancomycin was subsequently stopped as suspicion
for MRSA PNA was low. He completed the course of Zosyn
(primarily for UTI) as above. He had negative urine Strep and
Legionella antigens.
# Sleep Apnea
He had observed apneic episodes up to 90 seconds while sleeping
overnight. During these episodes he was found to desaturate to
as low as 60%. These episodes were noted to decrease in
frequency and severity as his sepsis was treated. He was seen
by Sleep Medicine who believed he had moderate obstructive sleep
apnea + REM dominant OSA. Sleep recommended that the patient
lie on his side, avoid sedatives, and trial auto-CPAP PRN while
in the hospital. They will follow-up with the patient for
formal sleep testing as an outpatient. He missed his scheduled
appointment due to still being hospitalized, so request that his
PCP's office make sure he gets follow-up with sleep medicine.
# History of Urinary Retention. He was continued on home
doxazosin.
# Stercoral colitis: Evidence was seen on CT abdomen/pelvis. It
was unclear if his bowel regimen had been continued as
outpatient. He was restarted on bisacodyl, Colace, miralax. He
had no GI issues clinically during his hospital course.
# Atrial fibrillation:
# Sinus bradycardia:
His CHADS2VAsC is 5. In his history, he suffered a stroke after
DCCV in ___. He is followed by cardiologist (Dr. ___. He
continues sotalol and apixaban.
# CVA:
He has known CVA after ___ (___) with retrieval of left
ICA/MCA clot with residual R-sided weakness, dysarthria, and
dysphagia s/p PEG. During his hospital course he was maintained
on strict NPO diet with tube feeds. ___ came and did teaching
with his son and wife for administering tube feeds. He was
switched from continuous tube feeds to bolus tube feeds, to
simplify administration, and tolerated this well.
# Renal Cysts:
Incidental finding on CT A/P in the ED: "Bilateral indeterminate
renal cysts of the right lower and left upper poles which may
reflect hemorrhagic versus proteinaceous cysts for which
follow-up nonemergent ultrasound could be obtained, as
clinically indicated." Ultrasound was not obtained while
inpatient, but could be done as outpatient.
Disposition: ___ and OT evaluated him and recommended rehab.
However, the patient's wife wanted to have the patient come back
home with her. Though he was medically stable for discharge for
days, he was unable to be discharged home until his wife/son had
undergone teaching with ___ on giving tube feeds and for a
Hoyer lift to be delivered to their home. He will have ___
services (Art of Care) who will be teaching them how to safely
use the ___ lift.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge
today. The total time spent today on discharge planning,
counseling and coordination of care today was greater than 30
minutes. | 105 | 693 |
13391297-DS-18 | 23,436,324 | Dear Mr. ___,
You were admitted to the hospital for difficulty breatjing. This
was related to your COPD and was similar to your episodes in the
past. We treated you with steroids and an antibiotic called
azithromycin. You should continue taking the steroid called
prednisone and azithromycin for 3 more days after discharge. You
should also continue taking your home inhalers to help with your
breathing. It will be important to see your primary care doctor
to help determine what is caused this episode and if there is
anything to be done to prevent future episodes. It was a
pleasure taking care of you.
Best of luck,
Your ___ medical team | Summary
================================
___ male history of CAD status post MI, COPD (GOLD stage
III, FEV1 38% predicted in ___, hypertension, diabetes
presenting with abdominal pain and increasing dyspnea. He was
found to be in COPD exacerbation and treated with prednisone and
azithromycin. He quickly recovered and was discharged in good
condition. | 108 | 50 |
12478892-DS-27 | 27,712,585 | Dear Mr. ___,
As you know, you were admitted for urinary retention and
abdominal distention and found to have some reduction in your
kidney function and low sodium. A Foley catheter was placed,
allowing you to urinate comfortably, and abdominal distention
likely reflected constipation due to pain medication use after
surgery. Your kidney function and low sodium improved with
fluids. You also were treated for a gout flare in your right
great toe.
Please do not restart your chlorthalidone (diuretic) until your
kidney function is checked on labs on ___ and your PCP
advises you to do so. | Mr. ___ is a ___ with end stage renal disease status post
kidney transplant, prostate cancer, and recent penile prosthesis
insertion on ___ who presented with abdominal distention and
urinary retention. | 96 | 31 |
18072875-DS-12 | 22,443,231 | Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of alcohol withdrawal and low sodium levels.
Your low sodium levels were probably from inadequate diet and
possibly pain and pneumonia causing excessive hormone release.
This level improved with restriction of fluid and nutrition.
You should not take in more than 2 liters of fluid a day at home
for now. It is very important that you follow up to get your
sodium rechecked and focus on eating a balanced diet upon
discharge. You had fallen when you came in likely due to
alcohol intoxication, and you were treated for alcohol
withdrawal during your admission. IT IS VERY IMPORTANT TO STOP
DRINKING ALCOHOL, AS IT IS EXTREMELY DANGEROUS FOR YOUR HEALTH.
If you feel that you are in danger of beginning to drink again,
please call your PCP for further support. You were also found
to have new heart failure, which is likely due to your alcohol
use, and may have had a heart attack during your admission. You
are scheduled to follow up with a cardiologist upon discharge.
Please be sure to make this appointment. Please also be sure to
take all of your medications as prescribed and follow up with
all appointments listed below.
Good luck! | ___ F with hx of alcohol abuse/withdrawal, HTN, PKD who
presents with hyponatremia, alcohol withdrawal, and respiratory
distress.
ACTIVE ISSUES
-------------
# Respiratory distress: likely multifactoral including
multifocal/aspiration pneumonia and asthma exacerbation. Patient
presented with tachypnea, tachycardia, and hypotension, possibly
pointing to sepsis although picture complicated by alcohol
withdrawal and hypovolemia. She was treated for
community-acquired pneumonia with levofloxacin and ceftriaxone,
eventually narrowed to a five day course of levofloxacin. Her
asthma exacerbtaion was treated with 5 day course of prednisone
40 mg daily and nebulizers. Patient was able to wean off oxygen
by discharge. Flu vaccine and pneumovax were administered prior
to discharge.
# Hyponatremia: presented to an outside hospital with Na 106 and
initially improved to 113 after NS boluses as she appeared
significantly hypovolemic on exam. Urine lytes obtained and was
most consistent with a ___ picture with elevated sodium and
urine osmolality. In addition, patient had a very limited diet
suggesting nutritional causes from a 'tea and toast' diet.
Patient was then placed on fluid restrition and sodium improved
to 128 on discharge. Patient had no change in mental status
throughout her hospitalization, thus pointing more to a chronic
rather than acute process. She has been instructed to observe a
2 liter fluid restriction at home and to opitimize her nutrition
through 3 meals per day and Ensure supplementation. She will
follow up with her PCP and have sodium rechecked at that time.
# Alcohol withdrawal: history of withdrawal seizures. Patient
was placed on daily folate and thiamine. She was placed on the
phenobarbital protocol for withdrawal, weaned until the time of
discharge, when she did not have symptoms of withdrawal. Social
work consult was obtained, and patient expressed the desire to
stop drinking after this hospitalization. She will be going to
live with her parents initially after discharge.
# Elevated troponins: troponin 1.07 without any ECG changes. No
previous cardiac history, but has risk factors including
smoking, polycystic kidney disease, and hypertension.
Differential included NSTEMI vs. demand ischemia secondary to
tachycardia and metabolic derangements. Patient had no cardiac
symptoms. Per cardiology, they stated to start aspirin and beta
blocker, as well as lisinopril upon discharge, and she will
likely need a cardiac catheterization on discharge. She will
follow up with Cardiology a month after discharge. TTE was
obtained and showed cardiomyopathy with EF 30%, suggestive of
possible alcoholic cardiomyopathy. She was told of this
diagnosis and that she should cease drinking alcohol. She will
get a follow-up TTE at her Cardiology appointment.
# s/p fall: large ecchymosis post fall. Appears to be vasovagal
as patient felt lightheaded prior to episode. No loss of
consciousness reported. In the ED, CT head and torso and abdomen
negative for acute lesion or bleeding. Pain was treated with
acetaminophen and tramadol. Social work consult was obtained to
determine if there was any abuse, which the patient denied.
# Elevated liver function tests: per CT abdomen, the liver is
diffusely hypoechoic attenuating consistent with hepatic
steatosis which is consistent with her history of alcohol use.
AST was not greater than ALT as would we expect with alcohol
use. Hepatitis panel was negative in ___, and was repeated on
this admission and also negative. Possibly also secondary to
hypovolemia leading to decreased perfusion vs. hepatitis. LFTs
downtrended over her hospitalization. They should be rechecked
at her discharge appointment with her PCP.
# Smoking: smoking cessation was encouraged. Nicotine patch was
offered but patient refused.
# Hypertension: lisinopril was held during most of her
admission, but was restarted at discharge. She will get lab
testing (Chem10) at her PCP ___.
# Polycystic kidney disease: with renal and liver cysts on CT
abdomen. Creatinine was normal during her presentation. She
will follow up with her PCP after discharge.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her PCP and with
___. She will need a repeat TTE in one month to evaluate
her valvular function, given her new cardiomyopathy. She will
need a recheck of her Chem10 and LFTs after discharge,
especially her sodium level. Blood cultures pending at
discharge will need to be followed up.
# Communication: brother (___) ___,
mother (___) ___
# Code: Full | 226 | 716 |
13857066-DS-22 | 24,668,322 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were feeling short of breath and had chest pain, and were
found to have blood clots in your lungs
What did you receive in the hospital?
- You were treated with a blood thinner
- You had a CAT scan that showed your heart function was normal
- You had an ultrasound of your legs which did not show any
blood clots
- We performed blood work and did not find any obvious
abnormalities
What should you do once you leave the hospital?
- Continue to take rivaroxaban 15 mg PO two times per day for 3
weeks total (21 days). After this, you should take rivaroxaban
20 mg PO one time per day, until your outpatient doctor tells
you to stop. (You will likely be on this medicine for ___
months.)
- Take your medications as prescribed and attend your follow up
appointments
We wish you all the best!
- Your ___ Care Team | ___ no significant PMH who presented with several days of chest
pain and dyspnea, admitted for treatment of bilateral PEs.
ACTIVE ISSUES
=============
#Pulmonary embolism
The patient presented with chest pain and shortness of breath.
CTA chest showed left segmental and right subsegmental pulmonary
emboli, and no CT evidence of right heart strain. Given her low
PESI score (39), this is a Class I, very low risk PE, and
outpatient management is appropriate. No obvious reason based on
history to be hypercoagulable, though she did undergo surgery 2
months ago. Doppler US of LEs negative. She was started on a
heparin gtt. Given that she is not tachycardic, had negative
trop, no evidence of heart strain on CTA, hemodynamically stable
and no oxygen requirement, the heparin gtt was discontinued and
she was started on a loading dose of apixaban (10 mg PO BID).
This was changed to rivaroxaban for insurance coverage reasons.
At time of discharge, she was continued on rivaroxaban 15 mg PO
BID for 21 days, which will be followed by rivaroxaban 20 mg PO
daily afterward.
#Normocytic anemia
She was noted to be anemic during this admission. Her anemia has
unclear etiology and is stable from prior. She was noted to have
no signs/symptoms of bleeding.
CHRONIC ISSUES
==============
None
TRANSITIONAL ISSUES
===================
[] She was started on rivaroxaban on ___. She was instructed
to take rivaroxaban 15 mg PO BID for 21 days, followed by
rivaroxaban 20 mg PO daily afterward. Her outpatient provider
should determine the appropriate duration for anticoagulation.
[] She should receive a hypercoagulability work up as an
outpatient. Protein C and S were sent while inpatient, and were
pending at time of discharge. She could also receive factor V
Leiden, cardiolipin, and beta-2 glycoprotein testing.
[] She was noted to have normocytic anemia during this
hospitalization. Her outpatient providers should consider a
workup for anemia (iron studies, B12, folate) and possible
treatment, such as iron supplementation if indicated.
#CODE: Full presumed
#CONTACT: ___ ___ (husband) | 166 | 317 |
17059535-DS-16 | 24,052,846 | Dear ___,
___ were admitted to the hospital after falling and fracturing
your leg. ___ had surgery to fix this. ___ were found to have
low blood counts and a hurt liver, but this was improving by
discharge. ___ were also found to have likely new multiple
myeloma, which the Hematologists are planning on seeing ___ in
clinic for.
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- ___ 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:
-Touchdown weightbearing right lower extremity, range of motion
as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add Tramadol as needed for increased pain (of note, this
did make the patient more tired than usual). 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 ___ are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If ___ require more, ___ 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 ___
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:
- ___ 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, ___ may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever >101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Please follow up with your Orthopaedic Surgeon, Dr. ___.
___ will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills. | Ms. ___ is a ___ year-old-female with mild cognitive
impairment (vs. mild dementia), supraventricular tachycardia vs.
nonsustained VT (unclear history), diet-controlled DM,
spine/hip/knee OA, retinal TIA, remote history of breast cancer
s/p lumpectomy, radiation, and hormonal therapy (in her ___,
prior syncopal episodes and hx SVT on verapamil, cholecystectomy
(___), and bilateral hip replacements (10 and ___ yrs ago
approximately), who presented after a fall with periprosthetic
hip fracture s/p uncomplicated ORIF on ___, and was transferred
to Medicine for thrombocytopenia, hyponatremia, and
transaminitis. | 611 | 83 |
11197922-DS-9 | 27,983,620 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
a dangerously high blood pressure. We treated you with blood
pressure-lowering medications, and your symptoms improved. We
did an echocardiogram of your heart, which showed changes
consistent with high blood pressure.
In the future, if these symptoms return, notify your PCP
___. | ___ with PMH of HTN and hepatitis C presents with SBP >200, HA,
nausea, and diaphoresis.
# Hypertensive urgency:
Pt with SBP >200 at PCP ___ ___, prescribed lisinopril
and HCTZ. Now with refractory HTN to SBP >200 having taken these
new medications. Presented to ED with symtoms and EKG concerning
for ACS. Troponins were negative. He was started on nitro gtt,
and his pressures improved to SBP 150s prior to transfer. His
symtoms resolved as well. He was started on his home meds
overnight in addition to amlodipine 5mg. On the floor, his BP
elevated overnight but resolved with medications again. His
amlodipine was uptitrated to 10mg daily, but he continued to
have refractory HTN overnight. He was then changed to nifedipine
30mg long acting daily. Lisinopril and HCTZ could not be
uptitrated due to elevated Cr. An echo was performed to evaluate
for structural damage secondary to HTN, which showed mild LVH,
normal EF, and mild pulmonary hypertension.
# ___:
Pt with Cr of 1.4, baseline unknown. No known hx of renal
insufficiency per atrius notes, but pt had not been followed by
a PCP ___. Possibly elevated at baseline due to chronic
uncontrolled HTN. UA shows protein in the urine, supporting
chronic renal insufficiency. In addition, could be acutely
elevated in the setting of recently starting HCTZ and
lisinopril. It is also possible that the acute injury is in the
setting of hypertensive emergency, thus reflecting end organ
damage. FeUrea 52%, which is borderline ATN/prerenal territory.
Most likely a mixed picture which will improve with management
of his HTN.
# ACS rule out:
EKG with J point elevations and TWI concerning for ACS first
seen at ___'s office. Pt denies CP or SOB. Not started on
heparin gtt. Trops negative x3. Most likely hypertensive
structural heart changes causing EKG patterns.
# Hep C: stable. s/p interferon-ribavirin therapy with
resolution.
# CAD risk: No family history. Pt risk factors include HTN and
obesity. Last lipid panel ordered in atrius ___, pending. Pt
was started on ___ daily. | 56 | 336 |
13353459-DS-5 | 22,154,641 | Dear Ms. ___,
It was a pleasure to care for ___ at ___. ___
were admitted for decreased kidney function, with a rise in a
blood value called 'creatinine'. We believe that your kidneys
had lower blood flow than they normally do because of two
things: ___ have not been on thyroid medication for a few weeks
and ___ were taking blood pressure medication. Thyroid hormone
helps regulate blood flow to the kidney, without it in your
system they were not able to filter the blood as well. The
medications ___ take for high blood pressure can also lower
blood flow to your kidneys.
Fortunately, there did not appear to be any death of the
kidney cells when we looked at your urine under a microscope.
The lab value (creatinine) improved over 24 hours after we gave
___ intravenous (IV) fluids. Because of the rapid improvement
with IV fluids we do not think that any of the medications ___
take were causing kidney inflammation.
Most of your hypertension (high blood pressure) medications
were stopped in the hospital and your blood pressures were
100-120 systolic. We continued your beta-blocker (metoprolol)
and ___ should continue this at your regular dose. Your primary
care doctor can restart your blood pressure medications when
your thyroid has been treated.
The following medication changes were made:
STOP amlodipine (This is temporary. Please follow up with Dr.
___ to discuss when to restart this)
STOP lisinopril (This is temporary. Please follow up with Dr.
___ to discuss when to restart this)
STOP | Ms ___ is a ___ yo woman with DMII, HTN, papillary thyroid
carcinoma s/p resection in ___, and CKDIII who presents as a
transfer from ___ for acute on chronic
kidney injury likely secondary to pre-renal azotemia.
#Acute on chronic kidney failure:
This patient has a baseline Cr of 1.1-1.2 per her PCP's records
(reviewed over phone) back in ___. She was noted to
have a Cr of 3.5 on ___ then 3.9 at ___
___ yesterday (3.9). She has not had any extra fluid losses
(diarrhea, polyuria, profuse sweating) nor has she had poor PO
intake. However, she has not taken any thyroid medication since
___ and her gland is surgically absent. Clinically she is very
hypothyroid. Despite being without thyroid hormone replacement
she was on multiple antihypertensive medications (HCTZ,
amlodipine, lisinopril, metoprolol, and spironolactone). The ACE
would directly impair renal blood flow and the diurectics could
indirectly cause the same effect through hypovolemia. All of
these together likely caused pre-renal azotemia which explains
her responsiveness to IV fluid (Cr 3.9 > 2.1) with 2L saline.
On urine microscopy today there were no casts or dysmorphic
RBCs, and there were moderate WBC w/o white cell casts. This
non-specific urinary sediment did not suggest acute tubular
necrosis or acute interstitial nephritis.
#Hypothyroidism: This is secondary to surgical removal of the
thyroid in ___ for papillary thyroid carcinoma. The patient
has been off levothyroxine since ___ in order to increase her
TSH prior to a iodine-123 uptake scan which she had during this
admission. She was maintained on a low iodine diet in accordance
with the nuclear medicine protocol. She will resume her
levothyroxine in accordance with their protocol after discharge.
#Hypertension: See above. All of her home medications except
metoprolol were discontinued in the setting of her acute kidney
injury. Her blood pressures were on the low side (93-115/50-72)
in the last 24 hours on a single agent after 3L of IV fluids.
She was discharged on only metoprolol and her other home
antihypertensives can be restarted after she resumes her
levothyroxine by her PCP.
#Obstructive sleep apnea: The patient is on CPAP at home. She
tolerated sleeping without CPAP x2 days.
#GERD: On outpatient omeprazole for GERD. Discontinued in the
setting of possible acute interstitial nephritis, but because of
the sudden overnight improvement in creatinine after IV fluids
AIN was considered less likely as a cause of her acute renal
failure. She was discharged on her home omeprazole. | 255 | 407 |
19614931-DS-16 | 26,324,238 | Dear Mr ___,
You were admitted to the hospital because acute on chronic
liver failure
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We did two paracenteses, on of which found an infection in
your abdomen, this is known as spontaneous bacterial peritonitis
- We had palliative care speak with you and help optimize your
medications to treat your symptoms
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Please follow up with your ___ services. You will also be
seen by the hospice team at your home
- We set up appointments with your primary care physician and
the liver team.
Thank you for involving us in your care.
-Your ___ Care Team | Mr. ___ is a ___ year-old man with a history of alcohol use
disorder, who presents as a transfer from ___ with
jaundice. Overall picture most concerning for severe alcoholic
hepatitis, complicated by SBP and found to be steroid non
responder. | 138 | 41 |
10952156-DS-26 | 26,196,447 | Mr. ___,
You were admitted to the hospital because you felt lightheaded
and had chest discomfort. When you were admitted to the
hospital you were found to be in atrial fibrillation with a fast
heart rate, which means that your heart was not pumping
normally. We think that this is what caused your symptoms.
Your heart returned into its normal rhythm, and you did not have
your symptoms.
You were originally scheduled to have a cardiac catheterization
___. However, after touching base with your primary
cardiologist Dr. ___ was decided that your symptoms
were more likely due to your rhythm and that you would not need
a cath at this point.
Because you were off of your warfarin for a few days, we will
start you on a medication called Lovenox (Enoxaparin) that well
prevent you from having a clot. You will need to take this
medication along with the warfarin until you follow up in your
___ clinic next week. You will also be sent home
with a device called the ___ of hearts" to see if your rhythm
coincides with when you have symptoms. You will follow up with
Dr. ___ with this. Continue to take all of your other
medications as previously prescribed. | Mr. ___ is an ___ year old male with PMH of CAD s/p multiple
stents, with hx of multiple MIs, CVA, DMII, Afib (on metoprolol
and coumadin) who presented with progressive chest discomfort
and lightheadedness and found to be in Afib/flutter with RVR was
rate controlled with diltiazem, metoprolol with self resolution
to sinus rhythm. Previously scheduled catheterization was
deferred given that symptoms were thought to be more likely
related to progressive Afib vs. coronary disease with plan for
further work up and management of Afib.
.
ACTIVE ISSUES
.
# Chest discomfort: progressive over past few months despite
increase in isosorbide mononitrate. Occurs daily at both rest
and exertion. Patient presented with chest discomfort and
lightheadedness in Afib with RVR. Trops neg x2 and mild ST
depression on EKG v5 and v5. Chest discomfort resolved once
patient was back in normal sinus rhythm. Touched base with
patient's outpatient cardiologist and scheduled catheterization
was deferred given symptoms seemed more consistent with Afib
than ACS. Asymptomatic on discharge.
.
# Parox Afib: CHADS2 6. Rate controlled and anticoagulated.
Presented to ED in Afib with RVR to 150s. Beta blocked with
metoprolol and diltiazem. Was been in sinus since arrival to
floor. Warfarin held prior to cath. Patient was started on
lovenox bridge to coumdadin with follow up in ___
clinic. Strategy for rhythm was discussed with outpatient
cardiologist, Dr. ___ @ ___. Unable to use amiodarone
given iodine allergy, decision was made to send home w/ ___
___ to ensure that the lightheadedness and chest discomfort
episodes were related to his atrial fibrillation. Will f/u w/
Cardiology.
.
# CAD: Extensive. Prior cath ___ showed LAD 100% proximal
occlusion, LCx 30% occlusion, 100% occlusion of OM1. Trops neg
x2. Continued with home aspirin, isosorbide mononitrate,
metoprolol, and atorvastatin.
.
# HTN: pressures were elevated to 140s-150s during
hospitalization. Continued home Losartan 25mg, Metoprolol
Succinate 25mg, and Imdur 120 mg.
.
CHRONIC ISSUES
.
# sHF: Etiology ischemic. EF 30% ___. No shortness of breath,
wt gain, orthopnea. Euvolemic on exam. Continued home
metoprolol, losartan. Consider spironolactone given EF < 35%.
.
# Hyperlipidemia: ___ with HDL 48 and LDL of 89.
.
# Moderate AS: ___ of 1.4 and mean gradient of 13 on echo from
___. Patient is not symptomatic. Home Losartan 25mg as
above.
.
# DM2: HbA1c 6.4% ___ on oral agents. No end organ damage.
Held home orals. Insulin sliding scale.
.
# BPH: continued home tamsulosin.
.
# Hypothyroidism: continued home levothyroxine.
.
### TRANSITIONAL ISSUES
- Patient was discharged on ___ of hearts with plan to see if
the lightheadedness and chest discomfort episodes were related
to his atrial fibrillation, will follow up in cardiology clinic.
- Patient was started on Enoxaparin Sodium 150 mg SC daily on
___ as bridge to warfarin with plan to follow up in
___ clinic
- Consider outpatient anti-arrhythmics pending ___ of hearts.
AVOID amiodarone given history of anaphylaxis to iodine. | 215 | 489 |
15970791-DS-18 | 29,174,036 | Dear Ms. ___,
You were admitted to ___ because you became confused and
sleepy. You were found to have a urinary tract infection. Your
confusion improved with treatment of your infection. You should
continue to take Bactrim twice daily (end on ___.
You were not taking your seizure medication (Depakote) before
you came into the hospital. Make sure you take all of your
medications as prescribed with the help of your ___. Please make
sure you follow up with your Neurologist to monitor the level of
this medication.
You were evaluated by our physical therapists and occupational
therapists during your hospitalization. You will receive
physical and occupational therapy at home. You were given a
walker to help with your mobility.
It was a pleasure taking care of you!
Your ___ Team | PCP: ___. ___
Neurologist: Dr. ___ ___, Fax
___
___ yo woman with h/o sz disorder, asthma, migraine, chronic back
pain, depression, gastric bypass and multiple SBOs, p/w vague
sxs including malaise, lethargy, and urinary incontinence found
to have urinary tract infection.
#Delirium
Patient was visiting her daughter in the hospital when she
developed confusion and lethargy. Received head imaging with no
evidence of hemorrhage or infarct including CT head and MRI. Has
a history of seizure disorder, but current episode not
consistent with seizure. She was seen by neurology for stroke
rule out as Code stroke was called; given reassuring neuro exam
and no significant abnormalities on CT head and MRI, she was
ruled out for acute stroke. She was found to have a urinary
tract infection. Her confusion improved with antibiotic therapy.
#Klebsiella Urinary Tract Infection
Patient with urine culture positive for pan-sensitive
Klebsiella. Plan to treat with 5 day course of Bactrim DS BID
(end ___.
#Seizure disorder
Her Depakote level was 44 in setting of two days of missed
medication. Continued on her home dose of Depakote 1500 daily
and 1000 qHS with plan to follow up with Neurologist on ___ to
ensure Depakote is at an adequate level.
#Peripheral neuropathy:
Patient with neuropathy of R lower extremity, which is chronic
in nature. Also with decreased vibratory sensation bilaterally.
Patient will follow-up with neurologist Dr. ___ should get
serum polyneuropathy work-up if not already done as outpatient
given poor vibratory sensation in ___. Continued on home
Gabapentin 300mg QHS.
#Depression vs PTSD: Per ___ patient with recent psychiatric
admission at ___ discharged on ___. Current
symptoms may be related to daughter's illness and diagnosis of
leukemia. History of suicidal ideation and self mutilation.
Continued home Aripiprozole 20mg, Risperidone 2mg qHS and
Sertraline 200 mg.
#Back pain: Holding home Tramadol in setting of confusion,
continue Lidocaine patch.
# CODE: Full presumed
# CONTACT: ___, Relationship: father, Phone number:
___ | 128 | 322 |
17473651-DS-7 | 27,650,598 | Dear Ms ___,
It was a pleasure caring for you at the ___
___!
Why were you hospitalized?
-You were hospitalized because you were having dark stools and
we were worried about a bleed from the GI tract.
What was done in the hospital?
-You were given blood to replete the blood you lost from your GI
bleed
-You had a colonoscopy to find the cause of your bleeding, which
was negative. Your blood counts then leveled off so we think
that the bleeding stopped on its own.
What should you do when you get home?
-Keep track of your stools. If you have red bloody stools or
dark black, tarry stools at home please call your doctor or come
back to the ER. Your stools may be dark from iron supplements,
but they should not come out like tar.
-Continue to take your medications as prescribed.
-Please be sure to go to your follow up appointment on ___ with ___ and Dr. ___. She will check your
blood counts and make sure that you are not having more GI
bleeding.
We wish you all the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with chronic alcohol use
disorder (sober for ___ year), Stage ___ liver fibrosis, stage I
lung cancer s/p RUL wedge resection, multiple colonic polyps and
diverticulosis c/b bleed s/p partial colonic resection, who
presents with a GIB.
GI bleed:
Presentation with very dark stool mixed in with frank blood, as
well as right-sided abdominal pain that started around the time
the bowel movements began. A slower-transit lower
gastrointestinal bleed was deemed most likely. After admission,
the patient continued to have bloody bowel movements, requiring
transfusion of a total of 3u PRBC. Due to difficulty obtaining
and maintaining peripheral IV access, a PICC line was placed on
___. Patient underwent a colonoscopy on ___ that was
negative. Given her presentation, BUN was <3 and stable
hemoglobin from ___ to ___, it was deemed that an upper GI
bleed was unlikely and Upper GI endoscopy was deferred. It was
deemed most likely that the patient had a colonic diverticular
bleed that spontaneously resolved. She was discharged home with
close follow-up on ___ for monitoring of CBC. She was instructed
to monitor for further melena or hematochezia and return if
further bleeding. She was also discharged on pantoprazole 40mg
BID.
Abd pain:
For pain during this admission, patient was given a small dose
of oxycodone as needed, with good effect. This was discontinued
on discharge.
HTN:
Amlodipine was held during this admission in the setting of GI
bleed and normotension. | 180 | 243 |
Subsets and Splits