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11279168-DS-34 | 24,825,286 | Dear Mr. ___,
It was a pleasure taking care of you.
Why you were admitted?
-You were admitted to the hospital because you fell.
What was done for you?
-You had a CT scan of your head which showed a bleed in your
head that was stable from your previous CT scan. Nothing needed
to be done. Your asprin was held while you were here.
-You were found to have urinary tract infection.
What should you do when you leave the hospital?
-You should continue taking the antibiotic Ertapenem (last day
___ to complete a 7 day course.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ y/o M with PMhx of CAD s/p CABG in ___, NSTEMI, systolic
CHF (EF 35-40%), PVD s/p bypass, CKD stage III,
history of LLE DVT s/p IVC filter, chronic SDH, dementia and
frequent falls transferred from ___ after a fall with
subacute on chronic SDH and UTI.
#Subacute on chronic SDH Patient presented with fall. Per
neurosurgery who reviewed the CT head: CT head stable with left
subacute on chronic SDH, no new hemorrhage,
no midline shift. They did not feel that he had an indication
for surgery. The neurosurgery team recommended follow up in
clinic with repeat head CT in ___ weeks with Dr. ___
(___). His aspirin is being held until he follows up
with neurosurgery.
#UTI
#Urinary Retention
Patient with admission in ___ for UTI, and was on CTX
until
___ for parapneumonic effusion. He had urinary retention and
had
catheter in place on admission. UTI may be catheter
associated though may have had urinary frequency. Given fall and
?change in mental status causing fall decision was made to treat
his UTI with Ceftriaxone. Unfortunately, micro data from ___
___ grew Proteus with ESBL profile, sensitive to Zosyn,
Ceftazadime, and Ertapenem, so decision was made to switch to
Ertapenem 1 g daily IM (IV access unavailable because patient
continues to rip out IV's) for total of ___ days (___). His Foley was discontinued on admission but in the
setting of likely catheter-associated UTI it was discontinued on
admission. He failed multiple voiding trials and a new Foley was
replaced on ___ prior to discharge. We also continued his
home Finasteride and tamsulosin
#Fall
He ___ had multiple falls recently with most recent fall
witnessed. Unclear if fall was syncope related or not per
history. ___ be vasovagal in setting of bathroom use. Other ddx
includes orthostasis and cardiogenic causes though very low
likelihood. Will discharge back to his long term rehab facility.
#Toxic metabolic encephalopathy
#Dementia/delirium
Patient uncooperative and agitated requiring Haldol at ___.
Per grandchildren, he is known to sundown and ___ difficulty
adjusting to new environments. His agitation was an issue during
last admission and psych was consulted who recommended 2.5mg
Haldol BID. He ___ not required this back at his SNF. His
current
encephalopathy is likely delirium related provoked by his UTI.
Required 1 dose of IV Haldol overnight ___ but stable without
any issues on ___. He required no other antipsychotics for
agitation. We suspect he will return to baseline after treatment
for UTI. AOx3 on discharge.
#LLL opacity
Likely related to his previous parapnemonic effusion. There was
no
indication to intervene on this radiographic finding as patient
was afebrile without dyspnea, cough, and leukocytosis and
imaging
findings can lag clinical resolution. | 105 | 427 |
11008295-DS-17 | 24,923,709 | You admitted to ___. The follow
is a summary of your hospitalization and instructions for after
discharge from the hospital.
Reasons for hospitalization:
1) Dehydration
2) High sodium levels
3) Poor appetite
4) Malnutrition | ___ year old lady with history of Parkinsons disease and
diabetes, who presented with fatigue, somnolence, poor oral
intake, failure to thrive found to have hypernatremia. Now with
plan to transition to comfort oriented care given advanced
dementia.
# Failure to thrive
# Weight loss
# Goals of care
Per review of notes, there has been outpatient discussion with
regard to goals of care "team at ___ has recently
been discussing pt's decline. There was a family meeting and
pt's 5 daughters decided together to make her DNR/DNI, ok for
NIV and ok to hospitalize. They would not want a PEG placed.
There is a MOLST that ___ provides that is signed by HCP
(pt's other daughter is HCP), though not signed by an MD....
___ states family recognizes that pt is in decline but this
has been a difficult process."
During her hospitalization with us, discussed advanced dementia,
patient's failure to thrive/weight loss. Ultimately, decision
was made by family to focus on patient's comfort, and in
particular reiterated that they would not want a feeding tube
placed. We discussed that that was consistent with geriatric
society recommendations: "feeding tubes are not recommended for
older adults with advanced dementia. Careful hand feeding should
be offered because hand feeding has been shown to be as good as
tube feeding for the outcomes of death, aspiration pneumonia,
functional status, and comfort. Moreover, tube feeding is
associated with agitation, greater use of physical and chemical
restraints, healthcare use due to tube-related complications,
and development of new pressure ulcers."
Family met with ___, and will be discharged on
hospice for advanced dementia.
# Hypernatremia
Na peaked at 160. Likely secondary to poor PO intake. Resolved
with D5W. Oral intake was continued to be encouraged in the
hospital. After goals of care discussion with family, it was
decided that tube feeding was not within her goals; please see
above.
# Atrial fibrillation: New diagnosis. CHADS-Vasc of 5. Rate
controlled in 50-70s without medications. Anticoagulation was
not started due to transition to comfort oriented care.
# Hypertension
Home valsartan was held. Home amlodipine was continued; SBP
120-140s on this medication. Please have ongoing discussion with
family with regard to this medication given transition to
hospice care.
# Parkinsons
Home Sinamet was continued. | 29 | 365 |
15461505-DS-5 | 23,152,119 | These are the discharge instructions for post-operative
discharge instructions.
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, severe increase ___ pain to operative site or pain
unrelieved by your pain medication, nausea, vomiting, chills,
foul smelling or colorful drainage from your incisions/wounds,
redness or swelling around your incisions, or any other symptoms
which are concerning to you.
Diet: regular diet
Medication Instructions:
Resume your home medications.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. If you were prescribed antibiotics, it is critical for you
to take them as prescribed and for the full course of the
regimen.
Activity:
Please, remain nonweightbearing to your right foot. This is
crucial to increase healing potential.
Wound Care:
You may shower but please keep dressings clean, dry, and intact.
Do not submerge your foot/leg ___ water.
Please call the doctor or page the ___ pager, if you have
increased pain, swelling, redness, or drainage to the operative
sites. | The patient presented to Emergency Room on ___. After
thorough evaluation, it was deemed necessary to admit the
patient to the podiatric surgery service and bring her to the OR
for a right foot I&D. For operative details, please see the op
note ___ OMR. Three days later, she was taken back to the OR for
a debridement, partial closure, and VAC placement. Afterward
each procedure, pt was taken to the PACU ___ stable condition,
then transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled with IV pain medication
that was then transitioned into an entirly oral pain medication
regimen on a PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged while remaining
nonweightbearin to her right foot.
The patient was subsequently discharged to home on HD5. She was
sent home on clindamycin and ciprofloxacin for 10 days. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 202 | 189 |
14400660-DS-27 | 28,243,401 | You were admitted to ___ after having been found a falsely
abnormal lab value and worsening left arm pain at site of your
graft. You were treated with antibiotics for suspected
infection in your arm. You were found to have enlarging fluid
collections at your arm which were felt to be seromas.
Aspiration of fluid from the collection closest to your arm pit
did not show infection. You were treated for cellulitis
(infection of the skin) over your graft.
In addition, you had worsening fluid swelling and low sodium due
to having taken too much fluid by mouth. In addition, there was
scrotal and penile swelling. This resolved with dialisys and
fluid restriction. Please do not drink more than 1.5 liters of
fluids daily.
The following changes were made to your medications:
STARTED:
- Sevelamer
CHANGED:
Sirolimus 1mg every ___
STOPPED:
None
You were discharged home.
Should you develop any symptoms concerning to you, please call
your liver doctor, primary care doctor or go to the emergency
room.
You underwent hemodialisis during your hospital stay. | ___ yo man with HIV, HCV cirrhosis, s/p OLTx2, latent TB with
recent hospitalization for suspected graft infection (LUE
AVgraft placement ___ and fevers, found to have b/l psoas
fluid collections concerning for abcesses, treated with
vancomycin/zosyn terporarily, admitted to medicine service per
request of hepatologist in setting of hyperkalemia and worsening
left arm pain. Hyperkalemia was a spurious findging.
# LUE AV cellulitis at site of Left axilla. Site was
erythematous and TTP with thrill. Patient was started on
vancomycin 1g with HD for suspected cellulitis. Repeat US of
both AV sites in ___ showed shrunken fluid collections at AC
fossa, but increased in size in the axilla. Tenderness
progressed throughout hospitalization requiring increased pain
regimen. Patient had a difficult cannulation episode in the AC
graft with clot removal and successful subsequent HD session.
BCx remained negative and patient was afebrile while on
vancomycin IV. Throughout his stay, he was monitored by
Transplant Surgery Service, who felt his graft was not infected.
In agreement with infectious dsiease, there was significant
concern for endovascular infection given increasing fluid
collections as well as cellulitis over the graft.
Patient's proximal fluid collection was aspirated per discussion
with ID and Renal. This revealed 2+ PMNs, serous fluid w/
negative cultures consistent with a seroma. Patient's pain was
felt to be due to expansion of the seroma and improved with
drainage (self drainage occured prior to aspiration). Patient
was discharged home after completion of vancomycin IV with HD.
Pain improved at time of discharge.
Given episodes of clot aspiration from graft, patient was
arranged for outpatient evaluation of AV fistulogram per
discussion with renal.
# Cough, chest pressure, chronic. Was found to have an
incidental finding of RLL infiltrate on ED CXR. Started
empirically on cefepime for HCAP, CT chest revealed near
resolution of prior infiltrate and a small effusion. Cefepime
was discontinued.
# Hyponatremia/volume overload. While awaiting HD session over
the weekend, patient developed worsening hyponatremia (119) and
was found to be whole body volume overloaded (scrotal edema)
with mild encephalopathy. Infectious w/up was unrevealing. It
was felt, that patient had took in a grossly larger amount of
free water. As HD was performed, volume status normalized and
hyponatremia improved to baseline (high 120s). On day of d/c Na
was 125 prior to HD. Patient's scrotal edema resolved, ___ trace
edema was present bilaterally and encephalopathy had resolved.
He was discharged on 1.5L fluid restriction.
# ESRD on HD: ___. Maintained on home regimen, sevelamer
an low P diet was started for hyperphosphatemia and he was
started on Sevelamer. No other changes were made.
# HCV cirrhosis s/p OLT x2: HCV VL > ___. At this point no
evidence of cirrhosis clinically. Sirolimus level was 4.1 on
admission and 6.6 at discharge. He was maintained on current
dose, however timing had to be changed to ___ given changes in
HD schedule due to hyponatremia. Continued on other
immunosuppressants w/o changes in dose.
# HIV. Neg. VL and last CD4 count > 1000. Continued on home
ARV regimen. | 172 | 544 |
17399675-DS-5 | 27,753,441 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted for right sided chest pain. This was likely due to
your resolving pneumonia. You were treated with antibiotics and
were feeling better.
Please see below for changes to your medications and
appointments. | ___ gentleman with a history of multiple myeloma s/p
auto transplant in ___, most recently on Revlimid, who
presents with ongoing pleuritic right sided chest pain in
setting of recent treatment for bacterial pneumonia.
# Chest pain: nonexertional, right sided, EKG was not suggestive
of cardiac ischemia. Patient underwent extensive workup for PE
during prior hospitalization (V/Q scan, MRA, LENIs) which were
negative. ECHO was done this hospitalization, negative for right
sided valve vegetations. Rib films were negative for fracture.
CT thorax showed persistent but resolving right sided pleural
effusion, likely due to recent pneumonia. Patient was placed
back on ceftriaxone/levofloxacin. His pain gradually improved
over hospital day ___. He did require nightly doses of
oxycodone for pain control. Given his ongoing pain, pulmonology
service was consulted who recommended pain control and incentive
spirometry. He completed 5d of ceftriaxone and will be
discharged with an additional 5d course of levofloxacin. His
pain was largely resolved by day of discharge, will go home with
small supply of oxycodone to take as needed.
# Multiple myeloma s/p transplant: currently treated with
revlimid and dexamethasone as an outpatient. Patient did not
continue revlimid while in house, further management as per
outpatient oncologist.
# CKD: Patient presented with Cr of 2.4, slightly increased from
his recent baseline of 2.0-2.2. His lisinopril was held on
discharge as his creatinine was still elevated to 2.5. This can
be restarted based on further assessment of kidney function.
# Hx. aflutter: patient was sinus on admission, continued
metoprolol and diltiazem
# HTN: lisinopril was held as above
TRANSITIONAL ISSUES
- patient has f/u with ___ clinic to address resolution of
pleuritic chest pain
- patient will complete 5d course of levofloxacin
- patient's lisinopril is on hold pending improvement in kidney
function
- patient remained full code | 50 | 308 |
15376117-DS-7 | 22,438,366 | 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:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity with minimal
abduction of the leg until follow up.
Physical Therapy:
Weight bearing as tolerated in left lower extremity with
restrictions on abduction of the leg until follow up due to
greater troch fracture
Treatments Frequency:
None | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left greater troch fracture and was admitted to the
orthopedic surgery service. The injury was determined to be non
operative on initial imaging and assessment. The patient worked
with ___ and was able to bear weight and mobilize on the left
lower extremity so ___ determined that discharge to home with
home ___ was appropriate. The patients home medications were
continued throughout this hospitalization. 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, and the patient was
voiding/moving bowels spontaneously. The patient is weight
bearing as tolerated in the left lower extremity with
recommendations of minimal abduction of the leg until follow up
due to having the greater troch fractured. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. | 161 | 188 |
19653430-DS-5 | 29,512,330 | Dear Ms ___,
You were admitted for seizure. You were started on a new
anti-seizure medication called Keppra. You should continue
taking this everyday to help prevent seizure.
You were also found to have a pneumonia while you were in the
hospital. You will take 2 more days of antibiotics at home to
complete your treatment course.
Memantine was stopped during this hospitalization due to
ineffectiveness.
There were no other changes to your medications. You should
follow up with your neurologist, Dr. ___.
It was a pleasure caring for you.
Sincerely,
___ Neurology | ___ is a ___ year old woman with PMH of frontal dementia,
HTN, HLD, and depression who was admitted to the neuro ICU due
to
concern for seizure s/p intubation. CT/CTA/CTP only revealing
for potential PNA. MRI wuthout stroke.
Per discussion with daughter and review of EMS records,
patient's presentation could be consistent with a secondary
generalized seizure, but this is questionable as other "drop
attacks" reportedly may have been worked-up to be syncopal in
nature. LP reassuringly bland. She is now at neurological
baseline. Impression is seizure vs rigors provoked by community
acquired pneumonia vs progression of frontotemporal dementia.
Given the fact that she is certainly at risk for seizures, opt
to continue treatment with keppra indefinitely.
# Neuro:
- EEG IMPRESSION: Occasional rhythmic delta activity in the left
temporal region, consistent with LRDA. Intermittent polymorphic
delta slowing over the left temporal region, indicative of left
temporal focal cerebral dysfunction. Diffuse background slowing
and disorganization, indicative of mild diffuse cerebral
dysfunction. No electrographic seizures or epileptiform
discharges.
- Continue Keppra 1g PO BID
- She was continued on home Donepezil
- Memantine was held and in conjunction with OP neurologist,
plan to discontinue this medication as it has not been hepful.
# CV/Pulm:
- Continued on home ASA and statin
# ID:
- treated with CTX and azithromycin for community acquired PNA.
- She completed 5d of azithromycin in the hospital
- CTX was transitioned to cefpodoxime while inpatient, she has 2
days left to complete 7 day course. | 88 | 237 |
19460922-DS-17 | 20,981,118 | Dear Ms ___,
You were hospitalized due to symptoms of headaches and
resulting from an acute brain hemorrhage likely due to a
syndrome called reversible cerebral vasoconstriction syndrome.
Reversible cerebral vasoconstriction syndromes (RCVS) are a
group of conditions characterized by reversible narrowing and
dilatation of the cerebral arteries. The cause of this syndrome
is unknown, though the reversible nature of the vasoconstriction
suggests an abnormality in the control of cerebrovascular tone.
RCVS can cause brain hemorrhages and cerebral edema. You have
received supportive therapy directed towards managing your
intracranial pressure, blood pressure and headaches. We have
started you on oral calcium channel blockers to treat
vasoconstriction. Recurrence of an episode of RCVS is rare. You
require rehabilitation with physical-, occupational and speech
therapy to recover from your neurological deficits.
Please continue taking nimodipine, the last dose is on ___.
Please continue taking amlodipine and lisinopril
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | In brief, Mr. ___ is a ___ right-handed woman with a
past medical history of hypothyroidism and GERD who presented
with recurrent thunderclap headaches was found to have a new
left parietal intracranial hemorrhage and mass-effect on the
left ventricle and subarachnoid bleed. She was also noted to
have a 6 mm aneurysm of the left M1. Presentation is found to
be most consistent with reversible cerebral vasoconstriction
syndrome. Reversible cerebral vasoconstriction syndromes (RCVS)
are a group of conditions characterized by reversible narrowing
and dilatation of the cerebral arteries. The cause of this
syndrome is unknown, though the reversible nature of the
vasoconstriction suggests an abnormality in the control of
cerebrovascular tone. RCVS can cause intraparenchymal
hemorrhages, subarachnoid hemorrhages and cerebral edema.
Several other differential diagnoses were ruled out. An MRI
with MRV did not show any evidence of venous thrombus. A
cerebral angiography did not show any vascular spasms or
vascular malformation. Inflammatory markers were negative
making a vasculitis unlikely. A trans-thoracic echocardiogram
was negative for any cardioembolic source or evidence of
endocarditis.
Ms ___ received supportive therapy directed towards managing
her intracranial pressure, blood pressure and headaches. She was
started on oral calcium channel blockers to treat
vasoconstriction (nimodipine and amlodipine). She will finish a
20-day course of nimodipine on ___ and will continue
amlodipine. She was started on a prednisone taper which was
completed on ___. She was started on lisinopril with a goal
blood pressure in the normotensive range. For symptomatic
treatment of headaches and neck pain she received Tylenol,
lidocaine patches and Flexeril as needed. Zofran was given
scheduled to help mitigate nausea associated with taking
nimodipine.
+++++++++++++++++++++++++
Transitional issues
-Continue nimodipine until ___
-Continue amlodipine
-Continue other antihypertensive agents
-Consider starting a statin if LDL continues to be elevated
(here LDL was 155)
-Follow up in our stroke clinic
-Please call ___ for a Neurosurgery follow-up
appointment with Dr. ___ in 3 months.
+++++++++++++++++++++++++++
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) | 291 | 437 |
12836888-DS-19 | 28,565,789 | Dear Mr. ___,
it was our pleasure caring for you during your admission to ___
___ ___. You were admitted for shortness
of breath. We think this was due to extra fluid that collected
in your lungs from your heart disease. We treated you with a
water pill and this resulted in an improvement in your symptoms.
Your discharge weight was 95.2 kg. You should weigh yourself
daily. If you notice weight gain of 3 lbs in 2 to 3 days you
should call your doctor.
We also noticed a rash on your buttocks that was concerning for
shingles. We sent a few tests to confirm this diagnosis. We are
giving you a prescription to treat shingles called valacyclovir.
We will have the results of the tests we sent in the next ___ to
48 hours and we will call you with the results. You should take
this medication as prescribed until we call you with the
results.
We wish you the best.
- Your ___ Care Team | ___ yo male with CAD (cardiac catheterization in ___ showing
occluded LAD), CHF (normal EF, mild to moderate AR, increased
pulmonary artery systolic pressure), last echo ___,
atrial fibrillation since ___ (rate controlled and
anticoagulated) presents with dyspnea.
ACUTE ISSUES:
=============
#Goals of Care: Patient's family expressed desire to transition
to hospice care. Patient was discharged to hospice care.
#Rash: New rash noted on L buttocks on day of discharge. Papular
with rare vesicles concerning for zoster (slight dermatomal
distribution, initial report of pain) versus contact dermatitis
versus satellite lesions from candidate dermatitis. VZV swab and
culture were performed. Patient was discharged with empiric
treatment of acyclovir. After uninterpretable test results
resulted for VZV direct antigen test, patient was called to
discontinue treatment given absence of pain and thus lowered
suspicion for shingles, in light of potential renal adverse
effects of valacyclovir.
#Dyspnea: Patient reported to have increased dyspnea and
wheezing since ___. Had been evaluated at ___ for this
on multiple occasions prior to admission at which time diuretics
were intermittently increased with variable relief of symptoms.
Patient with new oxygen requirement at time of admission.
Dyspnea felt to be due to volume overload. Echocardiogram
revealed moderate regional left ventricular systolic dysfunction
c/w CAD (LAD distribution) with remaining segments contracting
vigorously (LVEF = 35-40 %) increased PCWP, and mild to moderate
aortic regurgitation. This was a newly depressed EF when
compared to ___ echocardiogram noted in ___ records
that reported EF of 55-60%. Patient was diuresed with IV
diuretics during hospital stay and discharged on bumetadine 1mg
daily in addition to carvedilol 12.5mg BID. Hydrazine 25mg TID,
imdur 20mg TID, amlodipine, ibesartan were discontinued given
palliative goals of care. Discharge weight was 95.2 kg. Patient
breathing on room air at time of discharge.
#Hypernatremia: Hospital stay was complicated by hypernatremia
that improved with slow administration of D5W.
#Urinary tract infection: Leukocytosis on admission to 11.7.
Patient denied dysuria but found to have coagulase negative
staphylococcus on urine culture. Initially was treated with
ceftriaxone/vancomycin that was broadened to
vanc/cefepime/flagyl after patient spiked temperature on initial
therapy. Given goals of care and based on culture sensitivities,
patient was transitioned to oral levofloxacin Q48H that patient
was to continue on discharge. Leukocytosis stable at 12.0 at
time of discharge. Blood cultures were all no growth final read.
#Atrial fibrillation: Occurring since ___. Atrial fibrillation
was rate controlled on metoprolol 125mg per day and
anticoagulated on warfarin. Warfarin was discontinued given
goals of care. Aspirin 81 mg was continued. Metoprolol was
discontinued and patient was discharged on carvedilol 12.5 BID.
#HTN: amlodipine, ibesartan, hydralazine 25mg TID and imdur 20mg
TID were discontinued given GOC. Patient was discharged on
carvedilol 12.5 BID
#CAD: Per atrius notes, cardiac catheterization in ___ showing
occluded LAD. Patient with rising troponin during hospital stay,
felt to be due to demand ischemia. Given that patient was
DNR/DNI and was not a candidate for catheterization, further
troponin checks were discontinued. Simvastatin was discontinued
at time of discharge. Aspirin 81mg was initially discontinued at
time of discharge but patient's wife was called following
discharge and told to continue it.
#CONCERN FOR DYSPHAGIA: Family and nurse note occasionally
coughing/having trouble swallowing salivary secretions. S/S
evaluated patient with video swallow ___ year ago at which time
had evidence of aspiration to thin liquids and nectar thick as
well. Discussion of risks/benefits with wife/HCP ___ was
performed with plan to continue feeding during hospital stay.
CHRONIC ISSUES:
===============
#PSYCH: Donepezil 10 mg PO/NG QHS
#URINARY RETENTION: Finasteride 5 mg PO DAILY
Transitional Issues:
======================
- needs Q48h levofloxacin until ___
- discharging on 1mg bumex daily. Should increase to 1mg BID if
patient noted to have increasing shortness of breath. Can return
to 1mg daily as breathing improves
- noted to have papulovesicular rash on buttocks. Swab and
culture for zoster were pending at time of discharge. Patient
was initiated on empiric treatment with valacylovir BID and will
be called with results. Treatment will be discontinued if
results are negative.
- dysphagia: risks of aspiration with po intake including both
thin and nectar thick liquids were discussed with patient's wife
and son and discussed need to balance this risk with patient's
comfort and goals of care at this time. | 168 | 702 |
15838283-DS-13 | 22,385,472 | You presented to the hospital with poor sleep and agitation. You
were treated initially with Haldol and then transitioned to
Seroquel. You were seen by the neurologists and the
psychiatrists. Many of your sedating medications, including
Xanax and Ambien, were stopped. You were also seen by the sleep
specialists for your central sleep apnea and will follow up with
them as an outpatient.
You were also found to have new atrial fibrillation, for which
you were started on metoprolol with improvement in your heart
rates. You were started on a blood thinner, called Apixaban, to
help prevent strokes. Your aspirin and Plavix were stopped to
decrease the risk of bleeding. You had an ultrasound of your
heart which showed no concerning findings.
You were also started on Flomax for symptoms of urinary urgency.
You were seen by our physical therapists. Your oxygen levels
were noted to decrease significantly with walking; however, you
reported that this is not very different from your baseline. We
recommended that you be discharged to rehab; however, you
insisted to be discharged home. It is very important that you
follow up with your physicians as instructed below. | ___ yo M with history of COPD (On ___ O2 at baseline), OSA on
CPAP, CAD who presents with subacute agitation and nighttime
hallucinations and acute on chronic dyspnea.
#Agitation, anxiety, hallucinations: Has several week history
of agitation, particularly at night. During first 24 hours in
hospital he required 12 mg IV Haldol. Subseuqently his mental
status improved and he was calm/alert/oriented, however
subsequent exam was notable for pillrolling tremor, masked
facies, cogwheeling raising question of Parkinsonism. This
diagnosis was particularly interesting given that it could
explain central sleep apnea and autonomic dysfunction
(hypotension, changes in urinary fx) as well as intermittent
agitation and hallucinations. Neurology was consulted and felt
that the symptoms of cog-wheeling and pill-rolling were likely
related to heavy Haldol exposure on admission. They were
concerned for possible REM behavior sleep disorder. It was also
possible that progression of his central sleep apnea was causing
agitation/delirium particularly at night. A head CT was obtained
that showed no bleed but significant small vessel disease. MRI
head with and without contrast to evaluate for stroke revealed
no acute changes. B12 and TSH were normal. RPR was nonreactive.
Given possibility that polypharmacy (esp recent initiation of
benzos) was contributing, home benzos were stopped as was home
ambien. On HD2 given parkinsonism on exam he was changed from
Haldol to Seroquel for agitation. He had no further episodes of
agitation and no further notable Parkinsonian symtoms after
transfer to the floor.
# Leukocytosis
# LUL infiltrate
Presented with leukocytosis to 36 concerning for acute
infectious process, and with LUL opacity c/f PNA on CTA chest.
This LUL infiltrate had previously been noted on a ___t OSH. He had no other localizing s/s of infection aside from
dysuria (but only 2 WBC on UA) and diarrhea (c diff negative,
started after initiating abx). He was treated with ceftriaxone
x7 d and azithromycin x 5 d for CAP. Plan was for PET-CT as an
outpatient given possibility that LUL infiltrate represented
malignancy in this former cigarette smoker. Discussed with
radiology - will have to wait 1 month following resolution of
PNA to pursue PET scan.
#Atrial fibrillation: New diagnosis during this hospitalization,
possibly precipitated by infection. He was started on
metoprolol, which was uptitrated to provide adequate rate
control. Coreg was discontinued. Given his high CHADS2 score,
he was also initiated on Apixaban. Aspirin and Plavix were
stopped after discussion with his PCP and cardiologist to
decrease risk of bleeding while using Apixaban. TTE was done
which was limited study but largely unremarkable.
#Aniscoria: Patient noted to have aniscoria with possible mild
right sided weakness. He underwent CTA head to evaluate for AVM
which revealed none. MRI head with and without contrast showed
no acute changes.
#Lactatemia:
#Hypotension: He was hypotensive overnight ___. This was
most likely mild hypovolemia from poor intake while delirious
and from GI losses (diarrhea). Hypovolemia was further supported
by accompanying rise in BUN/Cr. BPs and lactate improved with
gentle IVF bolus.
#Acute on Chronic Dyspnea: Presentation was consistent with
progression of his COPD rather than exacerbation as no clear
worsening in dyspnea, no wheeze on exam or change in VBG,
slightly worse cough but no new sputum pdt. He was clinically
euvolemic pointing against CHF exacerbation. CT negative for PE.
Given leukocytosis and LUL CT findings, he was treated for CAP
as above. Suspect that anxiety was also contributing to
intermittent sensation of dyspnea. He remained stable on his
home O2 ___ L NC) throughout his stay. Pt seen by ___ who noted
that he desatted to the 70's with ambulation even with O2. Pt
noted that this is not far from his baseline given his
significant COPD and is insistent on d/c home. Discussed with
patient that our recommendations would be for rehab to build up
his strength and optimize his pulmonary status prior to going
home. Pt refuses rehab and opted for d/c home.
#Central sleep apnea: He had an incomplete sleep study in
___ that was most suggestive of a central (rather than
obstructive) etiology for sleep apnea. He was fitted for CPAP
but did not tolerate the mask, possibly b/c central OSA can be
worsened by CPAP. As above he underwent CT head and neurologic
eval to help w/u for neuro cause of central sleep apnea. While
inpatient he was put on NC rather than cpap at night. Plan is to
follow up with ___ (sleep specialist) who saw him
inpatient in the FICU regarding his sleep apnea.
#Voiding difficulty: Reports sensation of difficulty voiding
(sensation that he frequently needs to void but unable to pass
urine). This was of unclear chronicity but worse over past few
weeks. UA was negative. ___ represent progressive BPH or from
neurologic process as above with autonomic dysfunction. NPH
unlikely given CT head findings. Started on tamsulosin. | 195 | 802 |
19827413-DS-11 | 29,957,587 | Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted for an expedited workup of multiple issues,
including your shortness of breath, elevated ALP, and for fluid
around your heart. You underwent several diagnostic tests,
including a liver ultrasound, an MRI of your liver, an
echocardiogram, and x-rays of your foot. These showed that you
do not have any life-threatening conditions that we can
identify. You were also evaluated by our rheumatology team, who
did not believe your symptoms were related to your underlying
rheumatoid arthritis. We sent a number of studies that are
pending at discharge. Please follow-up with your PCP within the
next week to continue monitoring your symptoms.
Please continue to take your aspirin three times a day for 2
weeks and colchicine twice a day for 3 months to help with the
chest pain. Please have your labs drawn on ___ next week so
your PCP can closely monitor your progress.
We recommended iron supplementation to help with your anemia but
understand you do not wish to take it. Please re-consider this
decision as treating your anemia may make you feel better and
less tired.
It was a pleasure taking care of you.
Best wishes,
Your ___ Team | Impression: Ms. ___ is a ___ lady with h/o seronegative
RA presenting with DOE and cough in the setting of recently
diagnosed pleural and pericardial effusions, most likely due to
viral process.
# Pericardial effusion: Outpatient CTA showed moderate-sized
pericardial effusion and patient presented with pleuritic,
positional chest discomfort suggestive of pericarditis. There
were no EKG changes c/w pericarditis and patient remained stable
with normal BP and pulsus. Echo showed a small pericardial
effusion without any tamponade physiology. Given the presence of
both a pericardial effusion and pleural effusion, rheumatology
was consulted for possibility of serositis complicating an
underlying rhematologic disorder. They did not believe her
symptoms were consistent with either RA or lupus. Diagnostic
tests were sent and pending at discharge, including ___, anti-Sm
Ab, anti-dsDNA Ab, RNP Ab, anti-CCP Ab, Ro & La. Patient treated
with aspirin 650mg TID and colchicine 0.6 BID and will continue
these for 2 weeks and 3 months respectively.
# Dyspnea: Outpatient CTA noted a small left-sided pleural
effusion and patient had persistent dyspnea for 3 weeks. She
completed a course of azithromycin and trial doxycycline and
augmentin and was started on levofloxacin in the ED. Antibiotics
were held and repeat CXR as well as bedside ultrasound did not
show any effusion. Dyspnea most likely multifactorial from body
habitus, pericardial effusion, and atelectasis.
# LFT abnormalities: Patient presented with mild transaminitis
with markedly elevated alkaline phosphatase and GGT on
admission. RUQ ultrasound showed mild central intrahepatic
biliary dilatation and thus, MRCP was performed. This study
showed minimal intra and extrahepatic bile duct dilation without
any obstructing stones or mass lesions. ALT/AST/ALP trending
down at discharge.
# Leukocytosis: Patient with increasing leukocytosis as
outpatient to peak of 17.2 and on admission was 13.1. Most
likely due to a viral process such as ___ virus, leading
to systemic inflammation and pericarditis. CRP also elevated to
250 and ferritin as high as 1100. Leukocytosis downtrending on
discharge to 11.
# Chronic Normocytic Anemia: HGB on admission noted to be 9.4 on
___ from prior baseline 10.7 as of ___ per ___ records. Iron
studies consistent with iron deficiency but patient refused iron
supplementation.
# Rheumatoid arthritis: Patient with history of seronegative RA
followed by ___ Rheumatologist ___. She was previously
on methotrexate which is being in the setting of PNA.
Rheumatologic evaluation recommended x-rays of the foot to
evaluate for bony erosions, but only showed mild degenerative
changes. Per our rheumatology colleagues, we would recommend
re-evaluation of the diagnosis of RA. | 206 | 411 |
12872769-DS-18 | 25,839,039 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain after a recent laparoscopic procedure. You
were found to have a bleed in your abdomen. Initially we
attempted to monitor the bleed and slowly restart your
anticoagulation medication. Unfortunately you continued to bleed
and therefore you were taken back to the operating room and an
arterial bleed was found and stopped. After surgery your blood
levels were closely monitored and remained stable. Your
anticoagulation was again restarted which you tolerated well.
You are now doing better, tolerating a regular diet, and ready
to be discharged to home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Please follow-up with your PCP ___ 24 hours after discharge to
review Coumadin dosing
If you have any questions about your recovery, please call the
Acute Care clinic at ___ | Ms. ___ is a ___ year old was admitted to ___ ___ post-operative day 10 from a laparoscopic cholecystectomy
at ___ ___ with concern for a post-operative
bleed. She originally presented to ___ prior to
___ where a CT was performed and showed an enhancing
focus/contrast blush adjacent to her surgical clips within the
gallbladder fossa and given blood products to stabilize her
bleeding. At ___ she underwent an ___ that showed
no evidence of pseudoaneurysm or active extravasation. She
underwent serial H/H checks while in the ICU that were stable
and was subsequently started on a heparin gtt 24 hours after
last known administration of blood products. On ___ the
patient was hemodynamically stable and transferred to the
surgical floor.
Her heparin drip was titrated to goal PTT and Coumadin therapy
was resumed on ___. On ___ she had sudden onset abdominal
pain radiating to her back and repeat hematocrit showed a
significant drop in hemoglobin/hematocrit. During this event she
also had increased heart rate to 130 in atrial fibrillation and
hypotension to the 80's systolic. She was given IV fluid bolus
and 1 unit packed red blood cells. The patient was then
transferred to the ICU for close hemodynamic monitoring and
management of acute bleed.
On ___ patient was transferred back to the ___ with RUQ
pain, hypotension, A-fib w/ RVR, decreased HCT, and radiologic
findings significant for perihepatic hematoma. CTA showed no
active extravasation from previously noted hepatic laceration or
interval worsening of hemoperitoneum. ___ was notified with
concern for venous bleed however ___ decided to take patient to
OR ___ for ex-lap/washout where a small arterial bleed was
found and controlled. ___ patient HCT has remained stable and
was restarted on a clear liquid diet and heparin drip. ___ her
HCT was stable and the decision was made to transfer her out of
the ICU, begin a regular diet, and transition over to home
Warfarin.
The patient was hemodynamically stable on continuous telemetry
monitoring during the remainder of her hospital course. Her
Coumadin was dosed daily while maintaining therapeutic
anticoagulation with heparin drip. On POD4 surgical drain was
removed. She tolerated a regular diet and had adequate pain
control. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. Her INR at discharge was 2.3 and
heparin drip was discontinued. The patient was instructed to
resume 2.5 mg Coumadin at home and follow-up with PCP ___ 24
hours for ___ monitoring. 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. | 432 | 479 |
17727506-DS-17 | 22,288,380 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. As you know, you were hospitalized for nausea
and abdominal pain. We consulted our gastroenterology team who
recommended we checked a barium swallow with small bowel follow
through as well as a gastric emptying study. Both of these were
normal, and did not provide an explanation for your nausea and
abdominal pain. Our gastroeneterology team's recommendation is
that you follow up as an outpatient for continued investigation
and management of your nausea and abdominal pain. At the time of
discharge we have controlled your symptoms adequately with oral
medications.
You should follow up with your GI doctor as directed. Our GI
team will attempt schedule you an appointment with one of our GI
specialists, here at ___ who may be able to evaluate your
symptoms better. They will also contact you to set up an
appointment in our GI Clinic with one of our Gastroenterology
Fellows in the next ___ weeks to check up on your symptoms.
We have made the following changes in your medications:
START
Ondansetron (Zofran)
lorazepam (Ativan)
Oxycodone
Acetaminophen
STOP
hydromorphone (Dilaudid) | The patient is a ___ woman with a recent history of
nausea, vomting, and diarrhea who is presenting for continued
work-up of these chronic symptoms after extensive work-up at
outside hospital failed to yield diagnosis.
#) ABDOMINAL PAIN with NAUSEA, VOMITING, DIARRHEA: Patient has
had extensive work-up at ___, which appears to
rule out pancreatic, liver, and biliary etiologies, although the
transaminases are still elevated (may by sequelae of
cholecystectomy). Tissue transglutaminase reportedly performed
there as well. Patient has yet to have gastric emptying study,
and presentation is suggestive of gastroparesis. Abdominal
migraine and cyclic vomiting still on the differential, however.
In addition, it is unclear if gynecological causes of abdominal
pain, outside of pregnancy, have been worked up. Multiple
attempts were made to secure a full copy of her workup from ___
___, but only a portion of the record was obtained. GI
was consulted for their input into remaining components of her
workup that could be investigated during this hospital course.
Stool studies were sent to rule out occult infectious sources,
and were negative. The patient was kept NPO and her opiate
analgesia discontinued leading into HD#3 in preparation for
obtaining a barium swallow with small bowel follow through on
HD#3 and gastric emptying study on HD#4. Both of these studies
were reported as normal. Throughout her hospital course, she did
not develop any fevers, vomiting, peritoneal signs, or diarrhea.
Her nausea was controlled on ondansetron IV with lorazepam IV
for breakthrough nausea. Her pain was controlled initially on
hydromorphone IV, which was discontinued in preparation for her
GI studies. At that time she was controlled on around the clock
acetaminophen and toradol. After her studies were completed she
was restarted on oxycodone PO with adequate relief of her pain.
On HD#4 discussion was had with ___ that there were no further
components of her workup requiring hospital admission, and that
further testing could be completed as an outpatient. At this
time it is unclear what is causing Ms. ___ symptoms, and
she will potentially need further workup as an outpatient. She
is to follow up this coming week with her gastroenterologist in
___ for ongoing symptomatic management, and our GI service
will coordinate follow up for her in clinic with one of the
Fellows. At the time of discharge, she was afebrile with stable
vital signs, her nausea was controlled with ondansetron and
lorazepam as needed, her pain controlled with oxycodone as
needed, and she was able to tolerate adequate PO intake.
#LEUKOCYTOSIS: The patient had a leukocytosis on admission lab
testing. Subsequent testing showed that this resolved. She
remained afebrile throughout her hospital course.
#DEPRESSION/ANXIETY: The patient was continued on her home dose
of Prozac.
TRANSITIONAL ISSUES
The patient is to follow up this coming week with her
gastroenterologist in ___ for ongoing symptomatic
management, and our GI service will coordinate follow up for her
in clinic with one of the Fellows.
She has been instructed to attempt to collect her pertinent
records from ___ in order to expedite her future
workup and ongoing management. | 180 | 508 |
16623173-DS-3 | 26,859,594 | Dear Mr. ___,
You were admitted to ___ with
acute appendicitis. You were taken to the operating room and
had your appendix removed laparoscopically. This procedure went
well. You are now tolerating a regular diet and your pain is
better controlled. You are now ready to be discharged home to
continue your recovery. Please note the following discharge
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 You have Dermabond adhesive applied to your incisions and this
will dissolve on its own over the next couple of weeks.
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 a ___ y/o M who was admitted to the General Surgical
Service on ___ for evaluation and treatment of abdominal
pain. Admission abdominal US revealed acute, uncomplicated
appendicitis, WBC was elevated at 18.2. 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 on IV fluids, and oxycodone and acetaminophen.
for pain control. The patient was hemodynamically stable.
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. | 722 | 197 |
15192197-DS-24 | 24,119,275 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had extra fluid in your body related to your heart
disease. We gave you medicines through your IV to take that
fluid off. It is very important that you take all of your
medicines as prescribed and go to all of your follow up
appointments.
We wish you the best of health,
Your ___ Care Team | Mr. ___ is a ___ year old M w/ PMH diet-controlled DM, HTN,
chronic Afib on apixiban, HFrEF (EF 35%), moderate to severe MR,
HLD, s/p ischemic CVA, severe mixed sleep-disordered breathing,
CKD; and OA who presented with chest pain and dyspnea I/s/o
medication non-adherence, who was found to have acute
decompensation of his heart failure s/p IV diuresis, now
euvolemic. | 71 | 61 |
15890202-DS-9 | 29,646,832 | Dear Mr. ___,
You presented to the ___ on
___ after with abdominal pain and were found to have a
small bowel obstruction. You were admitted to the Acute Care
Surgery team for further medical care. You were taken to the
Operating Room and underwent surgical repair of your bowel
obstruction. You tolerated this procedure well and were
transferred to the surgical floor for pain control and to await
the return of your bowel function.
You are now tolerating a regular diet, you pain is well
controlled and you have worked with Physical Therapy. The
Physical Therapy team evaluated you and recommended that you
continue your recovery at a rehabilitation facility.
You were also evaluated by the Medicine team given that you
reported fainting and losing consciousness at home prior to
being admitted to the hospital. There are no acute concerns and
it is recommended you
follow-up with your outpatient Cardiologist and have an
outpatient ECHO.
You are now medically cleared to be discharged. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your follow-up appointment. | Mr. ___ is a ___ year-old male who presented to ___ on
___ with complaints of abdominal pain. He was found on
imaging to have a small bowel obstruction. He was admitted to
the Acute Care Surgery team for further medical management.
On HD1, the patient was taken to the operating room and
underwent an exploratory laparotomy with lysis of adhesions.
The patient tolerated this procedure well and there were no
adverse events (reader, please see operative note for details).
The patient was extubated and transferred to the PACU. The
patient was noted to have low urine output and was hypotensive
with systolic blood pressure in the ___ and he was bloused
with 500ml IVF with good effect. Once stabilized in the PACU,
was transferred to the surgical floor for pain control and to
await return of bowel function.
The Medicine team was consulted to evaluate the patient for his
syncopal episode prior to his hospital admission. His EKGs were
unconcerning and he remained stable from a cardiovascular
standpoint. His syncopal episode was most likely vasovagal from
an episode of emesis. It was recommended he receive an ECHO with
his outpatient cardiologist.
The remainder of the ___ hospital stay is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral pain medication once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. His home
metoprolol was held as he was normotensive.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On POD2, the
patient had +flatus. On POD3, he had a bowel movement and was
advanced to a regular diet which was well tolerated. Patient's
intake and output were closely monitored. His foley catheter was
removed and he voided independently.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient worked with Physical Therapy who
recommended his discharge to rehab. The patient declined a
prescription for oxycodone as he stated his pain was
well-controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled with the Acute Care Surgery team. | 458 | 475 |
14219521-DS-6 | 21,894,526 | You were admitted to ___ with worsening chest pain and
shortness of breath. You were found to have blood clots in your
lungs. You were started on a medication called warfarin to thin
your blood and prevent the blood clots from getting worse. It
takes at least ___ days for this medication to work properly, so
you need to take an additional injectible medication called
enoxaparin (Lovenox) until your blood levels of warfarin are
appropriate.
You will take 5mg of warfarin daily. You need to have your
bloodwork done on ___ to see if the warfarin levels become
therapeutic. At that time, the ___ clinic
nurses ___ advise you if you need to change this regimen.
You should not get your tooth pulled for at least the next month
while your blood thinner dose is being adjusted. Overall, you
will need to take the warfarin for ___ months. | Mr. ___ was admitted with chest pain and dsypnea and
found to have lobar and segmental pulmonary emboli, likely in
setting of immobility at home. No ECG changes or evidence of
right heart strain, was started on a heparin drip, transitioned
to enoxaparin to bridge to warfarin for at least 3 months of
anticoagulation. He was discharged without chest pain or
dyspnea.
ACTIVE ISSUES
# Pulmonary Emboli
Only risk factor is being completely sedentary while at home -
no known malignancy, no weight loss or night sweats, no recent
surgery, no history of blood clots. ECG without evidence of
right heart strain, TropT negative. Was initially started on a
heparin drip, but transitioned to enoxaparin to take while
bridging to warfarin. He will continue anticoagulation for at
least 3 months. He will be followed at the ___
clinic.
# Dyspnea
Most consistent with pulmonary emboli. No evidence of PNA on CT,
no fevers or elevated WBC either, not typical cardiac chest pain
and TropT negative. Does not seem consistent with COPD
exacerbation given no productive sputum. Clinically not
consistent with heart failure. Not anemic. Treatment for PE as
above, discharged without pulmonary sypmtoms.
CHRONIC ISSUES
# Schizophrenia/TBI/seizure d/o
No acute changes in mental status. Is establishing outpatient
care with a new psychiatrist. Continued quetiapine, lithium,
divalproex, lorazepam,
diazepam, doxepin, and lurasidone.
# Hepatitis C
No stigmata of cirrhosis on exam, no evidence decompensation.
Seeing GI/liver as an outpatient.
# Hypertension
Normotensive. Continued HCTZ, lisinopril.
# Diabetes
Continued metformin.
# PUD
Not active, continued PPI.
# COPD
Not active. Continued tiotropium, fluticasone-salmeterol,
albuterol/ipratropium PRN.
TRANSITIONAL ISSUES
- Patient to have ___ checked at ___ on ___ to take 5mg
warfarin from ___ ___s enoxaparin BID
- Was supposed to have a tooth extraction on ___ but high risk
given initiation of anticoagulation. Told patient to defer this
and needs anticoagulation for at least 1 month before we can
bridge again to lovenox and hold for extraction
- Warfarin/divalproex interaction can potentiate warfarin, but
will monitor INR closely during the initiation of warfarin | 151 | 324 |
19550378-DS-30 | 27,191,438 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with a gastrointestinal infection. You were treated with IV
fluids and nausea medications. Your kidney function was
decreased on admission, but improved with IV fluids. We are glad
you are feeling better.
Best wishes,
Your ___ Team | ___ with PMH significant for DM2, idiopathic axonal
sensorimotor polyneuropathy, SBO, coronary vasospasm who
presents with one day of nausea, vomiting, and loose stools.
# VIRAL GASTROENTERITIS:
Given sick contacts, chills, body aches, the patient's symptoms
were felt to be secondary to viral gastroenteritis. She did not
have any URI symptoms or myalgias to suspect influenza. CT
ABD/PELVIS showed diverticulosis and slight thickening of the
distal sigmoid colon, which may be due to a collapsed segment.
Blood cultures with no growth to date. C difficile was negative.
The patient was treated with IVF and anti-emetics. Her diet was
advanced slowly. Her symptoms improved by day 2 of
hospitalization.
# ACUTE KIDNEY INJURY:
Cr was elevated at 1.8 on day 2 of hospitalization, from
baseline of 0.8. FENa was 0.08%, which was consistent with a
pre-renal etiology. She did not have any episodes of
hypotension. She was not on nephrotoxic medications. She was
treated with IVF.
# CHEST PAIN:
Suspect this may be esophageal irritation in the setting of
vomiting given temporality. Troponins were negative x 2. EKG was
also reassuring. The patient was given omeprazole. She was
continued on medications for CAD/coronary vasospasm. Simvastatin
was switched to atorvastatin given drug interaction with
amlodipine.
# DM2:
HbA1c was 5.4% in ___ without therapy. Her glucose with daily
chemistries were normal.
# CHRONIC PAIN:
She was continued on tramadol and gabapentin.
# SENSIROMOTOR NEUROPATHY:
She will have outpatient follow up with plasmapheresis as
planned.
# DEPRESSION:
She was continued on sertraline.
# HOME MEDICATIONS:
- Continued eye drops.
- Held psyllium. | 50 | 249 |
16030932-DS-23 | 20,017,926 | Dear Ms. ___,
You were admitted for evaluation of a brief episode of
unresponsiveness you had during dialysis. We performed extensive
evaluation and found that you likely had a urinary tract
infection. Your blood pressure was also high, likely as a result
of stopping your clonidine patch recently. We think the
combination of these factors was the likely cause of your
episode, and we treated you with antibiotic medications and high
blood pressure medications.
You should continue dialysis (___) at rehab, and continue
to adjust BP medications in conjunction with the Renal team. | Ms ___ is a ___ woman with PMH signficant for ESRD on HD
___, HTN, DM, HLD who presented with episode of
behavioral/speech arrest during dialysis and a possible facial
droop which resolved. Her mental status waxed and waned in the
hospital (sometimes speaking in ___ some, other times
responding slowly in ___ but language exam showed fluent
speech with intact repetition and naming. TIA or stroke appeared
to be very unlikely given her presentation so MRI was not
obtained. EEG was preformed and showed slowing but no seizures.
The patient and was found to have a UTI, which was the most
likely etiology of her symptoms. CXR showed a questionable
consolidation, but she had no clinical signs or symptoms of PNA.
She was initially treated with CTX/Vanc to cover both possible
etiologies, but when urine culture returned showing a resistant
UTI and she continued to have no respiratory symptoms, she was
narrowed to Cipro on ___ for a 10 day course (last day ___.
Her BP was very high on admission with SBP > 200. HTNsive
encephalopathy was another possible etiology of her symptoms.
She had previously been on a clonidine patch but developed a
rash so the patch was discontinued prior to this presentation.
Thus she likely was having rebound hypertension in response to
stopping clonidine abruptly. Her HTN was treated with
uptitrating labetalol slowly during admission. Her BPs improved
to SBP 160s-180s at the time of discharge. The team was not
overly aggressive in treating HTN at this time given concern for
continued rebound HTN from clonidine, and the potential to drop
lower once this acute period is over. Her BP should be monitored
at rehab and adjusted as needed with input from the Renal team.
Her Nutritional status appeared to be poor and she was started
on supplementation. Swallow felt she required a ground diet with
nectar thickened liquids. Her Nutrition and Swallow function
should continued to be monitored at rehab. | 91 | 325 |
13270054-DS-22 | 21,535,175 | Dear Ms. ___,
You came into the hospital because you were having flushing of
your face and a sensation of fullness in your chest, as well as
difficulty breathing. You were found to have a clot in the main
vein near your heart and in the vessels in your lungs. You had
this clot and your port removed and were started on blood
thinners. Additionally, you had low white blood cell counts ***.
You had some rashes on your legs that suggest an inflammatory
condition. Therefore, you were started on corticosteroids
(anti-inflammatory medication).
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- Clean biopsy site with soap, water, then pad dry every day for
2
weeks. Cover with a thin layer of vaseline and perform dressing
change
every day for 2 weeks. Sutures can be removed on ___.
It was a pleasure taking care of you,
Your ___ Care Team | ___ is a ___ year old woman with CLL c/b DLBCL
transformation s/p Allo SCT on ___ complicated by mild,
cutaneous GVHD who presents from clinic with progressive
headache, dizziness and dyspnea who was found to have a port
associated DVT, PE and potential SVC syndrome. Course
complicated by neutropenia and erythema nodosum.
#PULMONARY EMBOLISM
#PORT ASSOCIATED DVT
#POSSIBLE SVC SYNDROME
#ACUTE HYPOXIC RESPIRATORY FAILURE:
Worsening dyspnea and CT demonstrating right sided PE and
occlusive thrombus by the patient's port-a-cath with findings
concerning for SVC occlusion. Reviewed imaging with radiology
and appears that her obstruction is from thrombus rather than
tumor. After discussion with primary oncologist, ___, and IV
access team, patient underwewnt Port removal, Mechanical and
suction thrombectomy of SVC thrombus, SVC venoplasty w/ ___ on
___ with improvement in symptoms. Patient started on enoxaparin
on admission; transitioned to heparin periprocedurally. Switched
back to enoxaparin thereafter. Underwent TTE ___ did not reveal
intracardiac thrombus, but did show a subaortic membrane.
#DLBCL
#S/P ALLO SCT
#CUTANEOUS GVHD:
Post transplant course complicated by mild, cutaneous GVHD and
BK viruria which have resolved with treatment. CT showed new
T10-12 sclerotic lesions and mediastinal lymphadenopathy
initially concerning for recurrent lymphoma. Continued ACV,
atovaquone, and fluconazole ppx. Stopped ursodiol for VOD ppx.
Obtained PET on ___, which was unchanged from prior; no new FDG
avidity. BM biopsy ___ w/o evidence of lymphoma recurrence or
leukemia but did show some megaloblastic features, so increased
increased dose of b12/folate. MMA level was pending at time of
discharge. Tacrolimus was tapered to 1mg QAM, 0.5 mg QPM.
#NEUTROPENIA
#THROMBOCYTOPENIA:
Previously attributed to Bactrim, which was transitioned to
atovaquone. Developed severe neutropenia of unclear etiology
during admission. Dosed neupogen while ANC < 500. Counts
recovered. Etiology of neutropenia was not clear but though most
likely to be secondary to a viral illness though respiratory
viral panel without detection of common pathogens. A full
infectious workup was sent and pending at time of discharge as
below.
#ERYTHEMA NODOSUM
New erythematous leg lesions noted ___. Biospied ___: c/w
erythema nodosum. Broad ddx, including autoimmune/inflammatory,
infections (viral, bacterial, fungal), and malignant. Given low
suspicion for infection, patient was started on
methylprednisolone 1 mg/kf on ___ and tapered to prednisone 60mg
daily for discharge. Applied topical steroid with occlusive
dressing to EN lesions for symptomatic relief. Infectious
disease was consulted and recommended obtaining
quant gold, viral panel (negative), endemic mycosis labs, ASO
which were pending at time of discharge.
#HYPOTENSION (c/f sepsis; resolved)
Hypotensive to ___ on ___ with sensation
lightheadedness/unsteadiness. Initially started vancomycin and
cefepime (___). Stopped vanco ___ and cefepime ___. Was
prescribed levofloxacin upon discharge.
#DEPRESSION: patient tearful on admission given acute illness.
-continued bupropion
-continued fluoxetine
#H/O GASTRIC BIPASS C/B B12 DEFICIENCY:
-continued home B12
#CANCER ASSOCIATED PAIN: Chronic and stable
-continued home oxycodone
#HCP/CONTACT:
Relationship: Husband
Phone number: ___
Cell phone: ___
#CODE STATUS: Full, presumed
TRANSITIONAL ISSUES:
[] Determine prednisone taper, discharged on prednisone 60mg
daily
[] Skin biopsy sutures should be removed on ___, please ensure
follow up for removal
[] TTE showed subaortic membrane, should have surveillance TTE
[] follow up pending quantiferon gold, endemic mycosis labs,
ASO, MMA, B-glucan, galactomannan | 157 | 510 |
19713771-DS-6 | 22,029,535 | Dear Ms. ___,
.
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. If they are still on
after ___ days from surgery, you may remove them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms | ___ year old female with PMH of rheumatoid arthritis on
rituximab, bipolar disorder and hypothyroidism admitted to
medicine after presenting with 5 days of nausea, vomiting,
diarrhea, poor PO intake and crampy lower abdominal pain found
to have large pelvic cystic mass. Patient transferred to Gyn-Onc
for exploratory laparotomy and left salpingoo-phorectomy for
mesosalpinx inclusion cyst. Please see operative note for
details.
Pre-operative:
*) Pelvic mass/nausea/vomiting: 22 cm abdominopelvic mass. ACS
general surgery and Gyn consulted. Abd/Pelvic MRI and PUS -
likely peritoneal inclusion cyst or a large left ovarian cyst
with plan for removal given patients symptoms. Nausea and pain
improved with IVF, pain meds and anti-emetics.
*) ___: Pre-renal acute kidney injury due to dehydration. Had
very limited PO intake over 4 days prior to presenting with
slightly elevated lithium level potentially contributing to ___.
No evidence of obstruction on CT. Creatinine 2.9 on admission,
improved to 0.9 on day of discharge after IV fluid
resuscitation.
*) RA: Currently asymptomatic, last received rituximab on
___. Patient discharged with instructions to f/u with
rheumatology.
Post-operative:
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with IV dilaudid and
toradol. Her diet was advanced without difficulty and she was
transitioned to oxycodone, acetaminophen, and ibuprofen. On
post-operative day #1, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously.
By post-operative day #1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. | 270 | 263 |
12839207-DS-13 | 25,885,048 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had 2 days of cough,
fevers/chills, malaise, worsening fatigue as well as chest pain
and worsening shortness of breath.
What happened while I was in the hospital?
==========================================
- We did blood work and imaging to figure out what might be
causing this and found out you had the flu as well as a lung
infection.
- You were initially admitted to the intensive care unit for
close monitoring in the setting of infection but improved and
were on the regular hospital floor.
- We started you on antibiotic and antiviral and monitored your
heart.
- We manged your lack of sleep and nausea with medication.
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team | Patient summary statement for admission:
=========================================
___ year old male with PMHx of HFrEF (EF ___ w/ ICD/AID,
HLD,
HTN, CAD s/p CABG, T2DM, obesity, depression/anxiety, GERD,
psoriasis presenting with dyspnea, malaise in the setting of
influenza with superimposed bacterial pneumonia. Patient
clinically improved with treatment of above infections and was
able to be discharged with plan to complete a PO antibiotic
course. Hospital course complicated by insomnia and long qtc
interval. | 181 | 69 |
14978865-DS-21 | 26,433,136 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for shortness of breath. We
believe your shortness of breath was due to your heart not
working as efficiently as it used to. This caused fluid to back
up into your lungs, making it difficult for you to breathe. We
gave you a water pill to help remove this extra fluid in your
lungs. However, because your kidney function worsened, we
stopped giving you the water pill. Your breathing improved and
you did not need any extra oxygen by the time you were ready to
leave the hospital. We put in a catheter to help empty your
bladder and monitor your urine output. You developed a fever on
a few occasions. Because of your loose stools, we thought your
fevers were due to a infection in your bowels but we did not
find one. We initially treated you with antibiotics but stopped
them since we did not find an infection. Your left knee pain and
neck pain improved with pain medications and were not concerning
for any infection. Due to your chronic anemia, we gave you two
units of blood. Once your kidney function returned to normal and
your left knee and neck pain improved, we discharged you to
rehab. It will be important to see your primary care doctor
within ___ weeks of leaving the hospital. You should also ask
your primary care doctor about seeing a cardiologist to better
manage your heart conditions. Please remember to weigh yourself
at home everyday and let your primary care doctor know if you
have unexpected weight gain.
Thank you for letting us take part in your care. | Ms. ___ is a previously highly functional ___ year old female
with history of HTN, HLD, polyvalvular heart disease, and
chronic anemia who presented with worsening dyspnea over the
past week. | 285 | 32 |
16332866-DS-9 | 23,963,056 | Dear Ms. ___,
You were admitted to ___ on
___ after you developed fever and headache at home and
subsequently developed seizures. You were found to have
bacterial meningitis, an infection in the membranes surrounding
your brain. You were admitted to our ICU for close monitoring
and improved with antibiotics and anti-seizure medications.
We made the following changes to your medications:
Keprra 1000 mg twice daily to continue for 6 months.
Trazadone was also added as needed for sleep. You may not need
this outside of the hospital.
You have been treated for back, leg pain and headache with
muscle relaxants (tizanidine) and ibuprofen. You were given
tylenol, but had an increase in your liver function tests,
therefore you should avoid taking tylenol for the time being.
Instructions for Rehab:
1. Please treat headache, back and leg pain with tizanidine 4 mg
three times daily as needed or ibuprofen 600 mg every 6 hours as
needed.
2. Please avoid tylenol.
3. Reserve oxycodone for severe pain only and avoid if possible.
4. Please continue Ceftriaxone 2 grams twice daily through ___, to complete a 14 day course. The PICC line may be pulled
following the last dose of ceftriaxone. | ___ yo woman with a history of TBI from an MVA in ___ with
resultant R frontal encephalomalacia and prior seizures (on
dilantin for 6 months following TBI, none since then), who
presents in status epilepticus in the context of fever and
headache. She developed a headache and some flu-like symptoms on
the am of ___ but appeared well throughout the day until she
was found around 4pm with generalized convulsions. EMS was
called and she was given ativan en route to an OSH. She received
further ativan there and was intubated. A head CT showed stable
R>L encephalomalcia, ethmoidal sinus mucosal thickening, and a
frontal skull fracture consistent with her prior TBI. She was
transferred to ___ and started on a midazolam drip. Initial
exam was significant for fever to 101.6 and nuchal rigidity. Off
sedation she did not open her eyes to sternal rub and had roving
eye movements when eyelids held open. Corneal, gag, and cough
were present. She had some spontaneous movements of all
extremities but localized only with LUE. Hyperreflexia L>R, toes
downgoing.
An LP was performed and she was started on vancomycin,
ceftriaxone, and acyclovir for empiric meningitis coverage. She
was also placed on decadron 8mg Q6hrs in addition to Rifampin
600mg daily. ID was consulted. She was loaded with Dilantin and
admitted to the neuro ICU. She was connected to EEG monitoring,
which initially showed burst-suppression pattern. Occasional
bifrontal sharp transients but no definitive epileptic
discharges.
CSF returned with a protein 670, glucose 1, WBC 29 (98% polys),
RBC 61, consistent with bacterial meningitis. Gram stain grew
out streptococcus pneumoniae, sensitive to ceftriaxone. Her
antibiotics were narrowed. Blood cx from the outside hospital
also grew strep pneumoniae.
She was continued on Dilantin 100mg IV Q8hrs. Levels were
monitored with a goal of ___. An MRI brain was performed on
___ and showed diffuse enhancement of the leptomeninges and
along the margins of the lateral ventricles with fluid-fluid
levels in the occipital horns showing slow diffusion, concerning
for intraventricular pus.
She was extubated on ___ and did well. She was transferred to
the Neurology floor. She was monitored on tele and was initially
hypotensive to 80's/50's but improved with IVF. A TTE was
performed which was normal without vegetations.
The patient did well on the floor and received ___ who deamed her
an appropriate rehab candidate. Her AEDs were switched from
Dilantin to Keppra as the patient had previously developed a
rash while on the Dilantin. She was continued on ceftriaxone to
complete a 14 day course. She had some pain associated with
meningeal irritation with head and back pain that was treated
symptomatically with ibuprofen and muscle relaxants. Her pain
was specifically increased in the late afternoon and
prophylactic treatment with tizanidine should be considered
around that time.
Of note her LFTs were mildly elevated, this was attributed to
the high doses of tylenol she was receiving as they drifted down
when the tylenol was removed. On discarge her AST was 113 (down
from 141) and ALT was 47 (down from 75).
She is being discharged to ___ for a short rehab
stay. She will continue the ceftriaxone through ___,
afterwhich her PICC line can be removed. | 198 | 536 |
10619824-DS-12 | 24,677,749 | You were admitted to the hospital with abdominal pain. CT scan
revealed a left inguinal hernia. You were taken to the operating
room and had a left inguinal hernia repair with mesh. 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 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. | ___ with hx of AL amyloidosis s/p autologous stem cell
transplant, chemotherapy in remission, DM2, presenting with an
incarcerated left inguinal hernia, unable to be reduced at
bedside. The patient was hemodynamically stable. The patient
underwent left inguinal hernia repair with mesh, 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. | 690 | 201 |
15907539-DS-9 | 28,846,269 | Activity
- Please wear your TLSO brace at all times when at edge of bed
or out of bed, Please ___ your brace at your bedside.
- Ok to take TLSO brace off when lying in bed
- Please shower while wearing your TLSO brace
- 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.
Pain Control
· 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, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs. | Mr. ___ is a ___ who presented with a L1 superior wedge
fracture after an MVC on ___. Neurosurgery was consulted
for further recommendations or evaluation. He was admitted to
the floor for TLSO brace fitting, but was unable to be fitted
for a brace due to his body habitus. Due to holiday, pt was
unable to be fitted until ___. Pt was made strict bed rest
until brace fitting on ___. He remained neuro intact
throughout his hospital stay. He received his brace on the
evening of ___ and had AP/Lateral X-rays performed while
standing in the brace. Prior to discharge he ambulated
independently with the RN. He was cleared for safe discharge to
home and instructed to follow up in 6 weeks w/ a CT scan w/o
contrast of his lumbar spine prior to his visit. | 189 | 138 |
19935359-DS-21 | 23,033,564 | It was a pleasure looking after you, Ms. ___. As you know, you
were admitted with shortness of breath and was found to have an
acute pulmonary embolus (clot in the lung). You were treated
with lovenox to help thin the blood and prevent progression of
old clot or development of new clot.
To identify a reason for why this clot developed, a lower
extremity ultrasound and abdominal CT scan was performed. It
did not show a clot in the legs - moreover, there was no sign of
recurrence of cancer which would potentially increase the risk
of developing a pulmonary embolus. You did not require oxygen
during this hospitalization.
You also had left knee pain. MRI of the knee revealed a tear
in the lateral meniscus - and this will be managed
conservatively (physical therapy). Please continue with home
physical therapy. You can continue to take ibuprofen as needed
for pain, but please use this sparingly as this can cause
stomach ulcers which would put you at risk of bleeding while you
are on Lovenox. You can also take vicodin as needed for pain. | ASSESSMENT & PLAN: ___ h/o breast CA on hormone therapy,
esophageal CA s/p chemo/XRT, prior PE admitted w/SOB due to
acute PE.
# SOB/Dyspnea, cough: Ms. ___ was admitted with SOB and chest
CTA showed extensive bilateral pulmonary emboli with negative L
LENIs. During this stay, there was no O2 requirements: no
desaturations with ambulation, no hypotension or concern for RV
strain (based on CT scan). This episode represented her ___ PE
- as a result there was concern for a hypercoagulable state in
setting of adenoCA x2.
For this reason, she was treated with lovenox BID and will
likely need this medication indefinitely. To evaluate for a
possible recurrence of cancer as an etiology, an abd/pelvic CT
scan was performed. It showed no evidence of recurrence. She
may obtain a PET scan as an outpt to further delineate the need
for lovenox (if negative for recurrence then possibly
coumadin?).
She was seen by ___ and she was mildly orthostatic by pressure
(but asymptomatic). She was cleared for home with ___. There
was no drop in O2 with ambulation.
# L knee pain: Ms. ___ had L knee pain. LLENI and knee x-ray
revealed no dislocation, effusion or fracture. The exam was
suggestive of possible infrapatellar tenderness possibly ___
___ disease, infrapatellar bursitis/tendinitis. Ultimatley,
L MRI knee was obtained and this showed a tear in lateral
meniscus. It was otherwise unremarkable. She was treated with
NSAIDs, ice pack, vicodin PRN with good effect. Again, she
should continue with home ___
# Esophageal and Breast Cancers: no active treatment
- cont exemestane
- abd/pelvic CT scan without any signs of recurrence
# Chronic Back Pain: cont home meds
# OTHER ISSUES AS OUTLINED.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: on Lovenox
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: pt
#CONSULTS: ___
#CODE STATUS: [X]full code []DNR/DNI
.
#DISPOSITION: d/c home with home ___ | 199 | 356 |
18969321-DS-19 | 23,223,591 | Dear Ms. ___,
It was a pleasure taking care of you while you were a patient at
___. You came in because of
shortness of breath and cough. We performed a CT scan of your
lungs to make sure there was no pneumonia or blood clot. We
didn't find anything concerning on the CT scan. This suggests
that your symptoms were due to temporary worsening of your COPD.
We treated you with steroids, antibiotics, and breathing
treatments which significantly improved your symptoms.
At home, please remember to take your fluticasone inhaler twice
a day. You are being discharged with a prescription for more
albuterol which you should use when you are short of breath.
In terms of follow-up, please be sure to keep your appointment
with Dr. ___ on ___. We are working on getting
you an appointment in the Pulmonary Clinic. It is very important
that you follow-up with Dr. ___ in the next few weeks
about your breathing. | ___ yo F with PMH of COPD, HTN, DM, and multiple psychiatric
comorbidities who presents with worsening dyspnea c/w pneumonia
vs. COPD exacerbation.
Acute Issues
# COPD exacerbation: Given tachycardia and hypoxia on admission
there was concern for PE for which CTA chest was obtained. It
showed no thrombosis or pneumonia making COPD exacerbation most
likely diagnosis. Patient was started on prednisone,
azithromycin, standing albuterol/ipratropium, and albuterol nebs
PRN. Supplementary oxygen was titrated to baseline of 92% on RA.
These interventions resulted in rapid improvement in patient's
symptoms. By HD#2 she had no SOB. Ambulatory O2 sats were
obtained to assess readiness for discharge. O2 sats consistently
above 95% with ambulation. Patient was discharged with
prescriptions for home inhalers and with instructions to
follow-up with ___ pulmonary clinic.
# Cocaine abuse: Since recent discharge from psychiatric
hospital patient endorsed one use of cocaine. She had no
symptoms that were concerning for cardiac ischemia. Troponin on
admission was negative and remained negative on cycling.
Chronic Issues
# Hypertension: Continued home lisinopril.
# Hyperlipidemia: Continued home rosuvastatin.
# Diabetes, type 2 uncontrolled: Patient hyperglycemic to 417 on
transfer to floor for which she was given Humalog 10 units.
Continued home Lantus and managed sugars with low dose Humalog
sliding scale. Oral hypoglycemics were held.
# Bipolar/Depression/PTSD: Continue home psychiatric regimen.
# Anemia: Continued home ferrous sulfate.
# Glaucoma: Continued home eye care regimen.
Transitional Issues
# Patient needs follow-up in ___ pulmonary clinic. Given phone
number but it is unlikely she will call to make appointment. Is
scheduled to see PCP ___ ___ who can help facilitate f/u in
pulmonary clinic. | 159 | 258 |
13995632-DS-4 | 28,171,085 | Dear Ms. ___,
You were transferred to ___ from ___ Hospital
after you fell at your nursing facility. There was concern that
you had bleeding inside your brain, for which you were worked up
with a CT scan. The scan showed no acute bleeding. You were
however found to have a urinary tract infection for which you
were treated with antibiotics. | Ms. ___ is a ___ F with severe dementia and history of
a-fib who presents from ___ after witnessed fall,
also found to have probable UTI. | 61 | 26 |
15589519-DS-14 | 27,638,855 | Dear Ms. ___,
It was a pleasure taking care of you.
You were admitted to the ___
for shortness of breath. You were treated for fluid overload
and underwent a cardiac catheterization which you tolerated
well. You were also seen by the lung doctors who ___
and ___ continue to follow you as an outpatient. You will be
visited at home by nurses who will come to draw blood to monitor
your comadin levels, and they will ensure that you received your
lovenox injections as prescribed until the shots are no longer
needed. Weigh yourself every morning, call your primary care
doctor if your weight goes up more than 3 lbs. | []BRIEF CLINICAL HISTORY:
Ms. ___ is a ___ year old woman with COPD and recent AVR/MVR
and CABG (___) who presented with dyspnea on minimal
exertion worsening over last several days and sharp,
non-exertional, intermittent chest pain. Notably, patient was
hospitalized ___ to ___ for lightheadedness and fall, presumed
from overdiuresis. Of note, she complains of dyspnea on
exertion since CABG/AVR/MVR in ___, but notes acute worsening
over last several days following recent discharge. She was
re-hydrated during that admission and her lasix was held on
discharge. Over the subsequent few days she developed worsening
edema and called her PCP who restarted lasix.
.
[]ACTIVE ISSUES:
# DOE: During this admission, her DOE was thought to be
multifactorial, with COPD and deconditioning also contributing
to her acutely worsening CHF, along with known restrictive lung
disease. A TTE was done which showed EF of 25% (down from 55%
in ___ and severe pressure and volume overload of right
heart consistent with symptoms of heart failure. On exam, lungs
were diffusely wheezy and rhonchorous with fair air movement,
though no rales were appreciated. Given high right heart
pressure and volume, V/Q scan was obtained to rule out PE (did
not get PE CT due to CKD) which was low to intermediate
probability for PE. Diuresis was initiated ___ with 40 mg IV
lasix and she proceeded to diurese - 2.7 liters overnight.
Ultimately, patient was transferred from medicine to ___
cardiology service for further care. Weight on ___: 156.2
lbs. Once on ___, the patient continued to complain of DOE and
SOB despite O2 sats of >95% on RA. The patient underwent a
right heart cardiac catheterization which revealed elevated
right heart filling pressures that improved significantly with
supplemental oxygen. Based on this, the patient qualified for
home O2 for symptomatic relief as an outpatient. She was seen
by the pulmonary consult service; however, as the patient has
restrictive lung disease and was already on optimal therapy,
further treatment was deferred to the outpatient setting.
.
# Chest pain: Patient reports intermittent, sharp,
non-exertional chest pain since her sternotomy. She reports it
is unchanged in character during this time. EKG unchanged, trop
negative x 2. This pain is likely musculoskeletal in origin
related to prior sternotomy. This pain is likely
musculoskeletal in origin related to prior sternotomy. She was
continued on home metoprolol, rosuvastatin, and aspirin 81 mg
daily. Given that she is likely ___ class III, she was started
on lisinopril 2.5 mg daily. Patient had been complaining of
chest pain since sternotomy in ___ (above), but this is
unlikely cardiac as it is non-exertional and ECG was stable and
troponins were flat. She was started on gabapentin for presumed
neuropathic pain with significant improvement in symptomatology.
.
# Elevated INR: INR was 5.9 on admission (goal of 3.0 to 3.5
given mechanical valves). According to patient, her coumadin
dose was increased on last hospitalization. She was previously
alternating 1 mg and 2 mg daily, and was discharged on 2 mg
daily. She has remained hemodynamically stable without evidence
of bleeding. Her coumadin was held until INR entered the
therapeutic range then restarted with lovenox bridging to be
followed up as an outpatient.
.
# Hyponatremia: Sodium 130 during this hospitalization, likely
secondary to CHF. Hyponatremic to 128 last hospitalization,
urine Na<10 and Osm 148 indicative of hypovolemia. Responded to
IV hydration, and was 136 on DC.
.
# CAD s/p CABG and AVR/MRV: She was continued on home
metoprolol, rosuvastatin, and aspirin 81 mg daily. Given that
she is likely ___ class III, she was started on lisinopril 2.5
mg daily. Patient had been complaining of chest pain since
sternotomy in ___ (above), but this is unlikely cardiac as
it is non-exertional and ECG was stable and troponis were flat.
.
# Hypothyroidism: Euthyroid on exam. Synthroid was increased
last hospitalization to 100 mcg daily due to TSH of 6 which was
continued on this hospitalization.
.
# DM: Stable. Patient was placed on humalog insulin sliding
scale during hospitalization with good blood glucose control.
.
# Hypertension: Stable in house with BPS 110s-130s/60s-80s. She
was continued on home metoprolol as above.
.
# Asthma/COPD/RLD: Likely contributing to exertional dyspnea
(above). Her exam was consistent with obstructive lung disease
with diffuse wheezing. V/Q scan also revealed evidence of
possible mucous plugging. She was continued on home regimen of
Albuterol prn, fluticasone inhaler, montelukast, and salmeterol,
salmeterol inhaler.
.
# GERD: Stable on home regimen of pantoprazole 40 mg PO Q12H and
lubiprostone 24 mcg PO BID.
.
# Depression/psych: Stable on home regimen of sertraline,
Seroquel, lamotrigine, and clonazepam.
.
# Pain: Complaints of diffuse chest and abdominal pain at
baseline. This was well controlled on home regimen of oxycodone
5 mg PO Q6H prn.
.
[] TRANSITIONAL ISSUES:
- next INR check is ___, along with routine electrolytes and
CBC which will be arranged by ___ services and sent to her PCP.
- the patient should have her TSH and FT4 checked by PCP | 112 | 870 |
17852933-DS-12 | 27,850,448 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with a small bowel obstruction. You had an exploratory
laparotomy with lysis of adhesions. You are have recovered in
the hospital, are now tolerating a regular diet, and ready to
be 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.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient presented to the Emergency Department on ___ with progressively worsening abdominal pain and associated
nausea and vomiting. Upon arrival, she was placed on bowel rest
and given intravenous fluids and pain medication. She underwent
an abdominal/pelvic CT scan, which confirmed presence of a small
bowel obstruction prompting placement of a ___ tube for
decompression. She was subsequently admitted to the Acute Care
Surgery service and taken to the operating room where she
underwent an exploratory laparotomy with lysis of adhesions;
please see operative note for details. The patient was
extubated in the operating room and brought to the recovery room
in stable condition.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and
intravenous acetaminophen. Once tolerating a po diet, she was
transitioned to oral oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. However, on
POD3, she did report chest discomfort. An EKG was obtained and
troponins were negative x 2.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored and she was
weaned from supplemental oxygen on POD4. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD4, the
patient began passing flatus and tolerated an NGT clamping
trial, therefore, the tube was removed and her diet was advanced
to sips. Her diet was subsequently advanced as tolerated to
regular and well tolerated. She continued to pass flatus and
moved her bowels. Additionally, her abdomen be came
progressively less distended throughout her hospitalization.
Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
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. | 343 | 395 |
15783916-DS-55 | 23,539,358 | Dear Ms. ___,
You were admitted to the hospital with cough, muscle pains and
low grade fevers. We gave you cough medications and your
symptoms improved. These symptoms are likely due to a virus and
should continue to improve. You do not need antibiotics at this
time.
At home, you can use the following medications to manage your
cough:
-Tessalon pearls three times daily
-Guaifenesin cough syrup as needed
-You can also use your Combivent inhaler (previously prescribed
by your primary care doctor) if you feel short of breath or
wheezy
It was a pleasure taking care of you during your hospitalization
and we wish you a speedy recovery. | Acute issues:
# Cough and myalgias: Clinical picture consistent with viral
syndrome (including myalgias and possible costochondritis). No
signs of pneumonia on CXR, WBC not elevated, patient afebrile
throughout admission, so antibiotics were not started. Patient
treated symptomatically with guaifenansin, tessalon pearls,
tylenol and albuterol and reported symptomatic improvement.
# ESRD: Patient on MWF dialysis schedule, received dialysis on
___ as scheduled.
# Hypertension: Patient hypertensive to the 170s on admission,
likely due to the fact that she missed her morning meds on the
day of admission. She had no signs or symptoms of malignant
hypertension. She was continued on amlodipine. | 103 | 102 |
14877326-DS-24 | 27,348,099 | You were admitted with bleeding from your rectum. During your
hospitalization, we checked your blood counts multiple times
found them to be low, so we gave you a blood transfusion. A GI
consultation felt the bleeding was related to hemorrhoids.
Furthermore, we found that you were suffering from an infection
in your intestines called C. Diff. We are treating you with oral
antibiotics for this infection. It is very important that you
complete the course of antibiotics in order to eliminate the
infection. Additionally, the ulcers on your finger tips were
evaluated by our rheumatology department, and it was felt that
the cause of the painful ulcers was related to a chemotherapy
drug you have been receiving called gemcitabine. One of your
blood tests, the anti-nuclear antibody, was positive and may
provide additional information as to the cause of these ulcers.
We have set you up with a rheumatology appointment for
follow-up, and we have started you on a medication which may
diminish these effects, nifedipine. Finally, we noted that your
kidney function was abnormal. A renal ultrasound was done, which
only showed two simple cysts, which do not explain the cause of
the kidney dysfunction. We recommend that you see a
nephrologist as an outpatient and have made an appointment for
you with Dr. ___ below). We also recommend you see a
rheumatologist and have made this appointment as well.
Please note the following changes to your medications:
Start baby aspirin (for your finger ulcers)
Start Nifedipine (for your finger ulcers)
Start Vancomycin (for your C diff infection) - for 12 more days
Start Zofran for Nausea (as needed) | FAX DISCHARGE SUMMARY TO PCP'S OFFICE
#Bright Red Blood Per Rectum (BRBPR)--The patient initially
noted the bleeding, a few tablespoons over three different
instances, the day prior to admission. Throughout the remainder
of her hospital course, she noticed passing a couple of small
clots. Her hematocrits were trended throughout and slowly
declined (possibly related to multiple lab draws), and she
received 1U PRBC. The GI team was consulted, and they felt the
most likely cause of the bleeding was from hermorrhoids. They
felt there was no need for a sigmoidoscopy at this time given
her recent scope which showed no correctable anatomic lesions.
They recommended steroid suppositories which the patient was
started on. Given C.diff infection, they recommended stopping
the suppositories especially as her bleeding had improved.
#C. diff colitis--the patient showed a marked leukocytosis from
admission (WBC on admission 10, peaked at 17), and a C diff PCR
assay showed a positive C diff infection. She was initially
treated with IV flagyl, but ultimately developed
nausea/vomiting. The IV flagyl was discontinued and she was
transitioned to PO vancomycin. The GI team was consulted to
ensure that the PO vancomycin would provide adequate intestinal
coverage given that the patient was in discontinuity, and they
commented that the infection was likely in the small bowel
(given that the sample was sent from the ostomy) and that PO
vancomycin would provide adequate treatment. She was continued
on PO vancomycin and ___ need continued therapy through
___.
#Abdominal pain/nausea/vomiting--The patient was initially noted
to have exquisite tenderness in her LLQ upon admission. This
pain ultimately shifted to the LUQ, and the LLQ was no longer
painful. Her CT scan showed no acute intraabdominal process such
as diverticulitis or obstruction. Notably, the pain was only
present upon palpation of the abdomen and not present at rest.
On hospital day 3, after starting on IV flagyl, she developed
nausea and vomiting. She received a KUB, which showed a normal
bowel gas pattern. She was started on an anti-emetic regimen
including ondansetron and prochlorperazine, with good effect.
Her ostomy output during this time was entirely normal. Upon
discharge, she was no longer nauseous or vomiting and was taking
a regular diet.
#Acute on Chronic Renal Failure--Creatinine upon admission was
3.0, up from a baseline of 2.5 on ___. Urine studies were
sent and her FENa was 2.0%, indicating an intrinsic renal cause.
She received a renal ultrasound, which was negative. Her renal
function ___ need continued follow-up upon discharge, as it
appears to be continuing to decline. She was set up with a
nephrology follow-up here at the ___.
#Skin Ulcers--The patient was suffering from severe skin damage
and pain on her distal finger tips with ulcerations on many of
her fingers. It was further noted that the patient's hands may
also have sclerodactyly. Accordingly, a rheumatology consult was
order, and they felt the lesion was more consistent with
gemcitabine induced digital ischemia and necrosis. A dermatology
consultation was ordered and concurred that the most likely
etiology was gemcitabine induced condition as reported in the
literature ___ et al, Radiol Oncol ___ ___ et
al, Anticancer Drugs, ___. An extensive rheumatologic
serological work-up was ordered to rule out any alternative
rheumatologic causes, the results were pending up until right
before the patient was discharged and ___ was found to be very
positive with high titer. Rheumatology recommended the patient
follow up as an outpatient with the first available appointment.
She was started on nifidipine TID and aspirin 81 mg to relieve
the vasospastic component of the skin necrosis. The patient
reports significantly improved feeling in her fingers upon
discharge. | 267 | 600 |
17660131-DS-36 | 28,385,164 | Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you were fatigued and had abdominal
pain as well as diarrhea
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- We ran tests which showed you did not have an infection.
WHAT DO I NEED TO DO AFTER DISCHARGE?
- Please have close follow-up with your transplant doctors
- Please stop taking any form of laxatives, and discuss this
with your PCP.
Thank you for choosing ___ for your care. We wish you luck for
the future. | ASSESSMENT & PLAN:
___ woman with ESRD s/p living donor renal transplant
(___), CKD II, recurrent C. difficile, and history of Ga___'s
disease on cerezyme infusion, presenting with one bloody bowel
movement, loose BMs, and weakness. | 89 | 33 |
10677944-DS-7 | 21,828,824 | Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your fall and
because of confusion. We evaluated you with a CT scan of your
head and xrays of your chest and spine which showed no acute
changes. We also evaluated your electrolytes and your blood
counts which were normal. We also checked your B12 level and
your thyroid function. The results of these tests are still
pending. We also evaluated you with urine culture. These results
are still pending as well. We believe your fall and your
confusion may have happened because of the medications you are
taking. We stopped your mirtazapine and your busiprone and we
decreased your duloxetine.
After discharge, you should follow up with your primary care
physician for further management of your medical conditions. You
should follow up with your psychiatrist for further management
of your psychiatric medications and for further management of
your confusion.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ y/o male with a past medical history of dementia, ADHD,
depression and anxiety who presented from his ALF with
confusion, failure to thrive, and s/p fall.
# Depression with SI: The patient has a long standing history of
depression, requiring inpatient hospitalization and ECT. On
presentation, the patient reported sadness and desire to go to
sleep and not wake up. The patient was found to have flat affect
with psychomotor slowing. The patient was evaluated by
psychiatry who recommended 1:1 sitter and placed patient under
___. It was thought that the patient's depression may be
contributing to his worsening confusion. The patient's
psychiatric medication regimen was adjusted as below. The
patient was discharged to an inpatient psychiatric facility and
should follow up with these psychiatric providers for further
titration of medication regimen and further management.
# Confusion: The patient reported progressively worsening
confusion, which was corroborated by his sister whom he speaks
to on the phone nearly daily. The patient was evaluated with a
CT head which showed no acute changes. Similarly, electrolytes,
UA, Utox and serum tox were found to be within normal limits.
TSH, B12 and urine culture remained pending at the time of
discharge. The patient's confusion was thought to be due to his
worsening neurocognitive condition (Alzheimer's disease versus
vascular dementia versus mixed) vs. worsening depression vs.
polypharmacy. The patient was evaluated by psychiatry who
recommended discontinuation of buspar, and mirtazapine as well
as reduction in duloxetine dosing. They recommended discharge to
inpatient psychiatric facility at ___. The patient
should f/u with psychiatric providers for further evaluation and
management.
# s/p fall: The patient reportedly had a fall prior to
admission, in which he fell onto his lower back. Though the
patient did not recall the exact circumstances of his fall, it
was suspected to be mechanical in origin given his history of
unsteady gait and possible peripheral neuropathy. The patient's
ECG showed sinus arrhythmia and the patient reported no history
of chest pain, lightheadedness or dizziness. The patient was
evaluated as above and his medications were adjusted as above.
CT Head, CT C-Spine and CXR did not show any acute changes or
injury. The patient was evaluated by physical therapy who felt
that intermittent gait disturbance was likely secondary to his
underlying medical and psychiatric conditions.
# DM: the patient was restarted on his home metformin and
glipizide at discharge (he was managed on ISS while in the
hospital)
# HLD: continued home statin
# CAD: continued aspirin, metoprolol
# h/o EtOH use: The patient reported his last drink was years
prior. He was continued on thiamine, folate, MVI | 173 | 439 |
18964284-DS-18 | 22,857,936 | Dear Ms. ___,
You were admitted to ___ because you were having abdominal
pain, adn you were found to have a partial blockage and
increasing fluid. You had a procedure known as a paracentesis to
remove the excess fluid in your abdomen. You initially needed an
tube in your nose to help relieve the blockage in your bowels.
This was removed and you tolerated eating solid food and then
had bowel movements. If you develop this issue in the future,
you should discuss with your palliative care doctors having
something called a venting g-tube placed to help relieve the
pressure.
Please follow up with all appointments and take all medications
as prescribed. If you develop any of the danger symptoms below,
please seek medical evaluation immediately.
We wish you the best.
Sincerely,
Your care team at ___ | ___ PMH of metastatic mixed carcinosarcoma/serous endometrial
cancer (on supportive care, awaiting hospice initiation), PE
(Xarelto), Depression, presented with abdominal pain/distension,
found to have partial SBO and ascites.
#Abdominal Pain:
#Partial SBO:
#Ascites
Presented with abdominal pain, nausea, and abdominal distension
noted to have partial SBO and worsening ascites on CT abdomen.
Initially requiring NGT for decompression but removed shortly
after admission. Patient also underwent LVP with improvement of
her pain/distension. Per Gyn-onc, not a surgical candidate. Diet
was slowly advanced and she was tolerating multiple small meals
and having regular BMs prior to discharge. Discussed with
patient, the possibility of recurrence and whether a venting
g-tube should be placed. The patient elected to defer this
palliative intervention on this visit but will consider it again
if her symptoms recur. On this admission, patient confirmed her
preference for DNR/DNI and MOLST was completed. She is being
discharged with home hospice.
#PE:
On Xarelto at home transitioned to heparin gtt in anticipation
of LVP. Given her toleration of diet on discharge, she was
resumed on her home Xarelto.
#Metastatic mixed carcinosarcoma/serous endometrial cancer:
As above, not a surgical candidate. Patient now being discharged
on home hospice but will see her oncologist, Dr. ___, in follow
up after discharge.
#Depression -Continued lexapro.
TRANSITIONAL ISSUES:
==================
[] If patient develops recurrent obstructive symptoms, would
again recommend venting g-tube for palliation.
> 30 mins spent on discharge coordination | 133 | 234 |
10804747-DS-8 | 26,246,594 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with shortness of breath
which was likely due to a combination of pneumonia, COPD
exacerbation and fluid in your lungs. You were treated with
Antibiotics, steroids and diuretics and you improved. You were
started on an oral diuretic which you should continue on
discharge. It is important that you follow up with your
cardiologist and pulmonologist after discharge
We wish you the best,
Your ___ care team | Ms. ___ is a ___ year old lady with history of HFpEF, mild to
moderate pulmonary artery systolic hypertension, chronic hypoxic
respiratory failure (multifactorial- COPD, possible interstitial
pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at
home, DVT on warfarin, who is admitted to the ICU for hypoxemic
respiratory failure found to have pneumonia and right heart
failure.
=================
ACTIVE ISSUES
=================
# Hypoxemic respiratory failure/Pneumonia: Pt p/w patchy left
basilar opacity in setting of cough and low grade temperatures,
concerning for pneumonia. She has resided in nursing home for
greater than ___ years, which places her at risk for resistant
organisms. She has not improved with levofloxacin in outpatient
setting. Antibiotics were broadened to
vancomycin/ceftazidime/azithromycin (___), vancomycin was
discontinued when MRSA swab returned negative. Likely
respiratory distress worsened by baseline pulmonary
hypertension, COPD and HFpEF. Pt was gently diuresed out of c/f
pulmonary edema and also received a prednisone 40 mg burst (___) out of concern for COPD exacerbation given wheezes on exam.
She will require slow prednisone taper 10mg daily to start in AM
___ to complete her taper in addition to indefinite
azithromycin. TTE showed RV volume overload, discussed below.
# Right Heart Strain. Pt p/w new TWI in inferior leads as well
as ___, rightward axis in addition to an elevated BNP, all c/f
TV strain iso known pulmonary HTN. TTE showed e/o right heart
volume overload, no sign of new ischemic changes and mild
admission troponin of 0.05 ___. Etiology of right heart
strain is unclear as it is out of proportion for underlying
pulmonary hypertension. As discussed, ischemia is unlikely and
PE is unlikely given that pt presented supratherapeutic on
warfarin. Cardiology was consulted and recommneded starting 10
mg torsemide. The patient has follow up scheduled with
cardiology.
# ___: Pt presented with ___ likely ___ given sodium avid
urine lytes. Improved with IVF.
# Supratherapeutic INR: In setting of decreased PO intake d/t
esophageal dysmotility, also possible drug interaction as she
was recently on levofloxacin. Warfarin was held while patient
was supra therapeutic and resumed while hospitalized. INR was
2.1 on discharge. Coumadin will be resumed at 3mg daily.
===============
CHRONIC ISSUES
===============
# Esophageal dysmotility: Per GI, nonspecific dysmotility and
would attempt treatment for spasm, with suggestion for SL nitro
prior to meals. After TTE could consider this w/ close
monitoring of BP as well as swallow evaluation.
# Hypothyroidism: Continue home levothyroxine.
# Depression/anxiety: Continue home sertraline and clonazepam
# Constipation: Continue home linzess 290 mcg daily, senna 2
tabs every 3 days.
====================
TRANSITIONAL ISSUES
====================
CODE: DNR/DNI
HCP: ___ (son) | 84 | 428 |
12148218-DS-4 | 24,191,722 | Dear Mr. ___,
You were admitted to ___ with acute appendicitis. You were
managed non-operatively with IV antibiotics and bowel rest. You
have recovered well and are now ready for discharge home. Please
follow the instructions below to ensure a speedy recovery.
ACTIVITY:
-no restrictions
-resume your normal activity as tolerated
DIET:
-no restrictions
-resume your normal diet as tolerated
MEDICATIONS:
-you may continue to take Tylenol as needed for abdominal pain
(do not take more than 4000 mg daily)
-You are being discharged with a prescription for antibiotics
(Ciprofloxacin and Flagyl). You should take these for 10 days.
It is important that you finish taking these as prescribed.
FOLLOW-UP:
-Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
-At follow-up appointment, can discuss scheduling of
laparoscopic appendectomy 6 weeks from date of diagnosis.
Contact your surgeon or present to the ED if you experience any
of the following:
- 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
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery Team | Mr. ___ presented to the ___ ED on ___. CT imaging and
physical exam were consistent with acute appendicitis and he was
admitted for non-operative management with IV antibiotics
(Cipro/Flagyl) and bowel rest. He continued to spike
intermittent fevers and white count continued to increase (max
18k) until ___ when WBC decreased, pain improved, and he
remained afebrile.
Diet was advanced to regular on ___ and he was transitioned
to PO medications once tolerating oral intake. IV fluids were
discontinued once oral intake was adequate.
He was discharged home on ___. At the time of discharge, WBC
was normalized, he was ambulating independently, voiding
spontaneously, tolerating a regular diet, and abdominal pain had
resolved. He was instructed to follow up in ___ clinic on
___ to discuss interval appendectomy in 6 weeks. | 201 | 132 |
17066802-DS-12 | 26,586,156 | Ms. ___, you were admitted to ___ with cholecystitis.
You underwent percutaneous cholecystostomy tube placement.
Please, follow up these instructions
-the drain will stain ___ weeks. Please, follow these drain care
instruction
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Please, follow these general instructions
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Ms. ___ presented to the emergency department on
___ with abdominal pain. Right upper quadrant ultrasound
as well as Ct abdomen/pelvis were obtained showing acute
cholecystitis. Acute Care Surgery service was consulted for
further work up and treatment. Given her extensive medical
history she was deemed not to be a surgical candidate therefore
percutaneous cholecystostomy was planned. She was admitted to
the hospital on ___ under Acute Care Surgery Service.
Intervantional radiology was consulted for percutaneous
cholecystomtomy placement. She was made NPO and prepared for the
procedure. On hospital day 1 she developed atrial fibrillation
with rapid ventricular response requiring ICU transfer and
treatment with amiodarone drip and digoxin. Once she was
stabilized she underwent perc chole tube placement on
___. She tolerated the procedure well without
complications. Her diet was advanced to sips to clear liquids on
___. She tolerated it well. On ___ the the foley came out,
she voided without issues. Intravenous antiarrhythmics were
switched to oral, her heart rate was well controlled. Her diet
was advanced to regular. She tolerated it well. The patient
received intravenous vancomycin and ceftriaxone. IV Vanc was
discontinued on ___, IV ceftriaxone was doscontinued on ___
___. The patinet was dischagrged with 5 day course of Augmentin.
On ___ she reported increased episodes of loose bowel
movements, c.diff was sent which came back negative. Her Ins
and Outs have been recorded throughout the hospital day which
remained adequate. She received subcutaneous heparin three times
a day.
On ___ she was discharged to a rehab clinic to continue her
treatment. | 410 | 259 |
11654306-DS-7 | 25,153,515 | Dear Mr. ___,
You were admitted for what was likely early appendicitis. You
infection has cleared and you are cleared to be discharged home
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | The patient presented to the emergency department and was
evaluated by the Acute Care Surgery Team. The patient was found
to have possible appendicitis and was admitted to the Acute Care
Surgery Service. The patient was given IV cipro/flagyl.On
re-read of the CT scan, the patient was deemed to not have an
evidence of appendicitis and would not need antibiotics on
discharge.
The patient will follow up in Acute Care Surgery Clinic in 2
weeks. 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. | 172 | 127 |
18039824-DS-12 | 27,191,038 | You were admitted to the hospital with a flare of your
ulcerative colitis. This improved with use of two doses of
infliximab. you are also on steroids at discharge with
prednisone.
If you have new GI symptoms you can contact the GI on call ___ such as new abdominal pain, fever, chills, bloody
stools, worse diarrhea.
We wish you the best in your recovery,
Your ___ Team | ___ y/o F h/o of UC and C. Diff presenting with blood diarrhea
from UC flare.
#Colitis
#UC Flare
#Leukocytosis
Started Solumedrol 20mg IV q8 on ___. She received her first
dose of infliximab 10mg/kg (700mg) on ___ and received a second
dose indicated for signs of inflammation w initial elevation in
CRP on ___ with another 10mg/kg. She was didscharged with a
steroid taper starting with prednisone 40mg daily to be reduced
by 10mg every three days. By the time of discharge her stools
were less frequent, not bloody and more formed than on admission
(described as many pea sized particles)
She had no known Tb risk factors though her quant gold was
indertimanante and her CXR was clear. Hep serologies show
immunity to HBV. TPMT activity is pending at discharge. She
did have leukocytosis at time of discharge so repeat CBC as
outpatient is indicated.
Hyperkalemia likely relates to elevated platelet count. whole
blood K 4.5 WHole blood potassium can be checked to monitor
actual K level if elev plts persist.
-
#Positive blood culture ___ - micrococcus, repeat cultures
negative. contaminant suspected. | 68 | 189 |
13166547-DS-12 | 23,040,941 | Dear Ms. ___,
You came into the hospital because you were having double
vision, dizziness, and sensory changes. You are admitted to the
hospital to have a lumbar puncture and additional imaging. You
received 2 doses of steroids.
When you leave the hospital you should:
- Take all of your medications as prescribed. You should
complete your steroid course as an outpatient.
- Attend all scheduled clinic appointments.
It was a pleasure taking care of you,
Your ___ Care Team | ___ is a ___ woman with a history of relapsing
remitting multiple sclerosis currently on Tecfidera who
presented with 2 weeks of sensory changes, vertigo, and
diplopia.
Her exam was notable for a partial right ___ nerve palsy and
left hand dysesthesia. Her MRI revealed multiple new and more
confluent abnormal flair hyperintensities suggestive of
progression of her underlying multiple sclerosis. There were
some new ring-enhancing lesions. She had a lumbar puncture that
was mostly bland (6 nucleated cells and 44 protein with 77
glucose).
Given her history of treatment with natalizumab there was some
concern initially that she may have progressive multifocal
leukoencephalopathy with immune reconstitution. However, after
reviewing these images at neuroradiology conference, these were
felt to be more consistent with progression of her underlying
multiple sclerosis. Toxo PCR and ___ virus PCR were sent from the
CSF (results pending at discharge). She was treated with 2 doses
of 1 g IV methylprednisolone.
Transitional issues
===================
-Patient will complete outpatient course of prednisone as
dictated by her multiple sclerosis doctor.
-___ virus and toxoplasma gondii PCR pending at discharge | 76 | 176 |
15835317-DS-17 | 21,996,884 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for evaluation of shortness of breath and had a
catheterization - you were found to have a blockage in of the
arteries in your heart. You had a stent placed to open the
blockage. You were started on plavix. It is VERY important that
you DO NOT stop this medication unless you are told do so by
your cardiologist. Please be sure to consult your cardiologist
before stopping plavix.
This helped your breathing. You were also given lasix to get
extra fluid off of you and help your breathing. Your oxygen
levels improved.
You were also found to have a urinary tract infection and you
were given antibiotics.
You worked with physical therapy who felt that you would benefit
from rehab to improve your strength.
Your kidney function worsened a little bit while you were in the
hospital. Please try to drink fluids at home to keep hydrated
(no more than 1.5 liters)
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | ___ with history of CAD s/p NSTEMI (___) - medically
managed, HTN, diastolic CHF, hypothyroidism, anemia, and
neuropathy who presents from assisted living with dyspnea and
URI, had episode of hypotension and episode of delirium, both
resolved.
.
# NSTEMI/Dyspnea: Given findings on cardiac cath with 90%
lesions, acute symptoms can likely be explained by ischemic
cardiac disease. Lung exam on full review of chart and
discussion with outpatient provider has been abnormal prior to
initiation of amiodarone, and ___ evals have also shown
desaturation with ambulation in the past. She was weaned off of
O2 without any recurrence of her shortness of breath. She should
follow up with pulmonology and further imaging as outpatient.
She was started on Plavix after placement of BMS to LAD. She was
continued on lisinopril, metoprolol, aspirin was increased to
325mg. Atorvastatin 80mg was initiated but switched to 40mg
given interaction with amiodarone. She was started on Imdur as
well.
- follow up with Dr. ___ in ___ weeks
.
# Atrial fibrillation: She completed amiodarone load while in
the hospital and switched to 200mg daily dose. She is also rate
controlled on metoprolol. Per previous discussions with
outpatient cardiologist, no acticoagulation will be pursued due
to history of falls. She was switched to aspirin 325mg daily.
- follow up with Dr. ___ in ___ weeks
.
# Diastolic CHF: Presented in decompensated heart failure in the
setting of ischemia. Initially not on home lasix. She was
diuresed and shortness of breath improved, after cath and BMS to
LAD it had completely resolved. She was started on lasix PO
prior to discharge.
.
# Delirium: Resolved. Episode of decreased level of arousal
though remained AxOx3. Infectious workup negative, CT head
unremarkable and within a few hours patient was at baseline.
Neurology consult also in agreement that this was likely
hospital-induced delirium. Seizure was considered but no
evidence of ictal event or post-ictal state, only possible
contributing medication was cipro which can cause delirium in
the elderly. This was switched to bactrim to complete course of
treatment for her UTI.
.
# UTI: Last UTI was citrobacter sensitive. No recent organisms
in the past. This would be ___ UTI in one month, found to be
ceftriaxone resistant, so patient was switched to cipro
(sensitive), however in the setting of deliriuos episode she was
switched to Bactrim to complete full course of treatment.
- continue bactrim until ___ (treated ___
.
# Hypotension: Resolved. She had episode of hypotension after
aggressive diuresis on admission. Resolved with IVF. Lisinopril
was initially decreased and returned to home dose prior to
discharge.
.
# Hyponatremia: Resolved. Patient admitted with hyponatremia.
Improved with diuresis and euvolemia.
.
# Anemia: Macrocytic. Baseline Hct mid ___. Hemodynamically
stable, no acute issues during this hospitalization.
.
# HTN: Antihypertensive medications were adjusted: metoprolol,
lisinopril were continued. Imdur and lasix were added to her
medication regimen.
.
# HLD: Atorvastatin dose was increased to 40mg PO daily.
.
# Neuropathy: Continued home gabapentin.
.
Transitional Issues:
- CODE: DNR/DNI
- CONTACT: Patient and daughter, ___ (HCP) ___
- patient will require further workup with pulmonology and
further imaging as outpatient.
- follow up with Dr. ___ in ___ weeks
- follow up with PCP | 182 | 530 |
13306806-DS-9 | 23,768,837 | Dear Ms. ___,
You were admitted to the hospital after suffering a motor
vehicle accident. You were found to have multiple left rib
fractures, a sternal fracture, T8 vertebral body (spine)
fracture and a right lateral malleolus (ankle) fracture. You
were admitted to the Trauma/Acute Care Surgery service and
transferred to the Intensive Care Unit (ICU) to help manage your
pain and monitor your breathing.
When medically stable, you were transferred to the surgical
floor. You worked with the Physical Therapy team who
recommended your discharge to a rehabilitation center to
continue your recovery. You are now medically cleared for
discharge. Please note the following discharge instructions:
Rib Fractures:
* Your injury caused left-sided 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).
Spine Injury Instructions:
Please wear your TLSO brace while out of bed
Instructions for your Right Ankle Fracture:
Please wear air cast boot on right foot when out of bed. | Mrs. ___ was admitted to the ___ for monitoring for her
traumatic injuries after an MVC. | 379 | 16 |
17396168-DS-15 | 27,370,180 | Dear Ms. ___,
It was a pleasure participating in your care during your recent
stay at ___. You were hospitalized for lethargy after a fall.
CT and MRI scans of your ___ were taken to look at the
structure of your ___ and showed ___ atrophy with enlarged
ventricles but no acute abnormalities. EEG
(electroencephalogram) testing was performed to look for
evidence of seizures and showed diffuse encephalopathy; your
clinical picture is not consistent with seizures, and you will
not be on anti-seizure medication. You had a lumbar puncture to
evaluate for normal pressure hydrocephalus, and the procedure
was not consistent with that diagnosis. Your final diagnosis is
Alzheimer's Disease, and your increased lethargy is due to UTI,
which has been treated with antibiotics. It will take time to
recover your mental status from this infection, and you may only
experience a partial recovery.
You were also evaluated by physical therapy who felt that it
would be best if you were to go to rehabilitation to help build
up your strength again.
Once again, thank you for the opportunity to participate in your
care. We wish you the best!
Your ___ Team | Ms. ___ is an ___ year old woman with a history of advanced
Alzheimer's Dementia and carotid artery occlusion (unknown side)
who initially presented to ___ on ___ with two days of
lethargy and a change in mental status. | 190 | 40 |
16370208-DS-17 | 22,952,048 | Dear Mr. ___,
___ was a a privilege to care for you here at ___. You were
admitted to ___ due to fevers. Your evaluation revealed
concern for a bladder infection. You were treated with IV
antibiotics (vancomycin) for an enterococcal UTI and then were
transitioned to oral amoxicillin to complete for 10-days. Your
fevers resolved at discharge.
Please keep all your doctors' appointments.
We wish you all the best! | Mr. ___ is a ___ with a PMHx of metastatic bladder ca,
HTN, HLD, Afib and OSA, who presented with fever and
tachycardia.
# Severe Sepsis/Acute complicated cystitis/HCAP: Pt presented
with fever, tachycardia and elevated lactate. Source was not
clear but thought possibly UTI given +UA (though from urostomy)
vs PNA given rhonchi on left. Initially no evidence of pneumonia
on CXR, but on morning of HD one a second x-ray was read as a
right paramediastinal consolidation. He had no clinical s/sxs of
pneumonia and there was previous note of paramediastinal
opacities on CT chest. He was treated empirically with
vancomycin/cefepime. His lactate normalized within 24 hours, and
his tachycardia improved to 90-100s with IVF and beta blockade.
Blood, and urine cultures had not grown by hospital day one, and
he was transferred to the oncology medicine floor with continued
fevers but in stable condition. His urine cultures grew
Vancomycin-sensitive enterococcus. Cefepime was discontinued.
His blood cultures were negative. His fever curve down-trended.
Vancomycin was eventually changed to Amoxicillin x 10days. He
was afebrile at discharge.
# AFib. Pt with known history of afib, not anticoagulated.
Presented with RVR, likely ___ fever/infection. CHADS2 = 1,
though stroke risk potentially higher given severe sepsis. Pt
was fluid resuscitated and given metoprolol 25mg po q6h with
good response in his heart rate. He was switched to home
Metoprolol succinate 100mg daily at discharge. Atenolol was
discontinued.
# Bladder Ca. no active tx while in-house
# CKD: Cr at baseline. Lisinopril initially held in setting of
sepsis. Restarted at discharge.
# Anemia. Chronic, likely ___ malignancy. At baseline, no
evidence of bleeding.
# HTN: Held lisinopril and amlodipine in setting of sepsis.
Resumed upon discharge. SBP running in the 120's to 150's.
# Hyperglycemia. Hyperglycemic during ICU admission. On no orals
or insulin at home. Maintained on insulin sliding scale. BS
better controlled with infection source control.
.
# GERD. Continued omeprazole at home dose.
# HLD: Held simvastatin during ICU admission. Resumed
# Depression. Held citalopram in setting of Afib with rvr and
concomitant zofran use, given potential for long QT. Resumed
upon discharge | 67 | 354 |
12318435-DS-20 | 23,952,398 | Please call Dr ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by your pain medication,
swelling of the abdomen or ankles, yellowing of the skin or
eyes, inability to tolerate food, fluids or medications,
incisional redness, drainage or bleeding, or any other
concerning symptoms.
You may shower. Allow water to run over the incision. Pat the
area dry, do not apply lotions or powders to the incision area.
No lifting more than 10 pounds
No driving if taking narcotic pain medication | ___ woman with DMI and bipolar disorder admitted for abdominal
pain, found to have cholecystitis and multiple hepatic adenomas
and FNH.
1) Cholecystitis: noted on MRI abdomen. Initially started on
ceftriaxone and flagyl. Surgery consulted. HIDA scan was also
positive.
2) Hepatic adenomas: OCP stopped.
On ___ the patient was taken to the OR for cholecystectomy
by Dr ___. At the time of surgery the gallbladder was
noted to be very distended and inflamed. There was also a very
large gallstone impacted in the infundibulum. Due to the degree
of inflammation and the difficulty in locating the cystic duct,
the decision was made to convert to an open procedure. Intra-op
cholangiogram was performed assuring no bile duct injury. A
subtotal cholecystectomy was then completed, and the gallstone
had also been removed.
The patient was extubated and transferred to the PACU in stable
condition. Please see the operative note for surgical details.
Post operatively the patient initially did have pain management
issues and was using a dilaudid PCA with only moderate success.
Adjustments were made and tylenol scheduled which seemed to
improve her pain management. She did have a fever to 102. Blood
cultures were sent which have been no growth to date. A chest
xray was done showing very low lung volumes. Spirometry was
encouraged. She did have a desaturation into the 80's on POD 1
evening. She was encouraged to increase the use of her
spirometer and this did not occur again.
The JP drain was sero-sanguinous, with no evidence of a bile
leak. Her diet was advanced from clears to a regular diet with
good tolerance. No nausea or vomiting. And once on a regular
diet she was tolerating PO oxycodone with improved pain
management such that she was ambulating. | 90 | 289 |
11624928-DS-13 | 29,237,076 | * You are advised to stay home from work for at least 2 weeks.
* You are advised to avoid any contact sports or any activity
that may involve impact to your abdomen, for at least ___ weeks.
* 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.
* 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 antiinflammatory 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 presented as above to the ED at ___ ON ___.
On arrival the patient's vitals were within normal limits. His
OSH imaging (CT head/neck/Chest/Abdomen) was reviewed and it was
decided that a SAH was unlikely. CT neck was negative. CT chest
revealed a small left apical pneumothorax while the CT abdomen
demonstrated a Grade 2 splenic laceration, L lobe liver
laceration without any ___ fluid and a R adrenal
hemorrhage. Subsequently, the patient was admitted to the ICU
under the Acute Care Surgery Service.
Neuro: The patient was alert and oriented throughout
hospitalization. He was kept on Q4H neuro-checks in the ICU
which were negative so they were discontinued when the patient
was transferred to the floor in the evening of HD1. His pain was
initially managed with IV narcotics and then transitioned to
oral medication when his diet was resumed. His C-collar was
cleared after the CT neck was confirmed to be negative and the
patient was transferred to the floor on HD1 when he was deemed
to be stable.
CV: The patient remained stable from a cardiovascular
standpoint; he was kept on telemetry in the ICU which was
discontinued when he came to the floor.
Pulmonary: The patient remained stable from a pulmonary
standpoint; he had a small L apical pneumothorax on admission
which remained stable on repeat am CXR. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On HD1 his diet
was advanced sequentially to a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
The patient refused a Foley on admission so his urine output was
closely monitored and was adequate.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: We held SQH until intracranial bleeding was
definitively ruled out and the patient was encouraged to get up
and ambulate as early as possible.
MSK: The patient had complained of L shoulder and wrist pain on
admission so we obtained X rays which were negative for any
fractures or dislocation.
At the time of discharge on HD2, 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 cautioned against
partaking in any activity that involved contact with his abdomen
or heavy weights for at least ___ weeks and was advised bed rest
until clinic follow-up in 2 weeks. The patient received
discharge teaching and follow-up instructions and verbalized
understanding of and agreement with the discharge plan. However
he left without his paperwork so efforts were made to fax the
paperwork to him. | 211 | 463 |
14768521-DS-3 | 27,814,840 | Dear Mr. ___,
You were admitted to ___ for
evaluation of rectal bleeding and were found to have a
gastrointestinal bleed which required many blood transfusions.
You were evaluated by the interventional radiology and
gastroenterology teams and were closely monitored in the
intensive care unit. Your blood counts (hematocrit and
hemoglobin) have been stable and you are recovering well. You
are now ready for discharge. Please follow the instructions
below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You are dizzy, overly fatigued or weak.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Patient is a ___ year old male with pmh significant for CAD, AAA
repair, and diverticulitis s/p open sigmoidectomy that presented
to OSH ER with complaints of acute onset of bright red bleeding
from the rectum. At the OSH, he was given 5U RBCs, ___ and
1Plt. Imaging was completed and CTA demonstrated many
diverticuli with
enhancement in the diverticular lumen. Therefore he was
transferred to ___ for definitive care. Once at ___, massive
transfusion protocol was activated and he received additional 4U
RBC, ___ 1Plt. He was then admitted to ___ for further
evaluation and management.
Interventional Radiology was consulted for mesenteric
angiography, but on ___, ___ could not find active extravasation,
therefore, no embolization/intervention completed. The patient
continued to bleed via his rectum and his Hct dropped from 28 to
21 which brought total transfusion numbers to 12PRBC, ___,
4plt, 2cryo. EGD was then completed on ___ with no clear source
of an upper GI bleed. The surgical team requested for a tagged
RBC scan which also came back negative and partially low yield
because the patient was not actively bleeding. He was then
transferred to the inpatient unit when his hct was noted to be
stable. Once on the inpt unit, he developed increased work of
breathing for which he received tiotropium and albuterol
nebulizer with good effect and one time dose of 10mg labetalol
for HTN.
Once stable, his diet was advanced as tolerated to regular.
During this hospitalization, the patient voided without
difficulty, was adherent with respiratory toilet and incentive
spirometry and actively participated in the plan of care.
Venodyne boots were used during this stay.
At the time of discharge, the patient was doing well. He was
afebrile and his vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and his pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement. | 296 | 327 |
12628647-DS-19 | 27,837,815 | 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:
-Right lower extremity 50% partial weightbearing
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
TREATMENT/FREQUENCY:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be left
open to air unless actively draining after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever greater than 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right midshaft femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right femur osteotomy and ORIF,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. During hospitalization the
patient was intermittently tachycardic. This was consistent
with prior hospital admissions. The patient remained
asymptomatic. EKG showed sinus tachycardia. She was treated
with IV fluids. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
___ weightbearing in the right lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 610 | 295 |
19491686-DS-8 | 21,089,334 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service with right
upper quadrant pain. You had a CT scan and ultrasound of your
abdomen that showed acute cholecystitis and a gallstones causing
an obstruction. You had an ERCP procedure and had three stones
removed. You were given antibiotics and taken to Interventional
radiology for placement of a tube to help drain the infection
from your gallbladder. You tolerated the procedure well and are
now ready to be discharged to home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Mr. ___, an ___ w h/o bladder and prostate CA s/p
cystectomy/prostatectomy, presented from ___ several
days of N/V and nonbloody emesis, with abdominal pain on
___. His labs notable were for 24 WBC, LFT and lipase wnl,
and imaging demonstrating acute cholecystitis. He underwent EUS
to evaluate CBD stones, of which there were. Therefore, he
proceeded with ERCP for sphincterotomy and stone extraction on
___. Subsequently, in order to manage his cholecystitis,
patient underwent percutaneous cholecystostomy drain placement.
A ___ ___ was placed with 120cc of turbid brown purulent
material drained. This was sent for microbiology eval
(preliminarily GNR and GPC). After normalizing him to his normal
regimen, diet, home medication, and pain control, Mr. ___
was discharged with a course of augmentin for 8 days. He had a
foley catheter up until discharge due to his bladder history. He
reports self-catheterization at home and we felt comfortable for
him to continue to do so. His foley was therefore removed upon
discharge.
Upon d/c, pt was doing well, afebrile, and hemodynamically
stable wnl. pt received discharge instructions and teaching,
along with follow up instructions. pt verbalizes agreement and
understanding of discharge plans. | 417 | 193 |
17668699-DS-6 | 29,270,463 | You wee admitted to the hospital with an abscess on your right
flank. You were started on intravenous antibiotics. You
underwent a cat scan of the pelvis and the abscess was found to
have a localized collection which was drained. Your vital signs
have been stable and your white blood cell count normal. You
are being discharged home on 7 days of antibiotics. So your last
day of antibiotics will be on ___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day. Narcotic
medication can make you constipated so take over the counter
colace as instructed on the bottle if you do take the narcotic
pain medication.
The packing in your wound will need to be changed once a day.
You will be set up with a visiting nurse to help with this. | ___ year old female admitted to the acute care service with right
hip lump. Initial aspiration was done at an OSH, but reported
recurrence of mass size. Incision and drainage done at OSH
which grew strept. Upon admission, she was made NPO, given
intravenous fluids and started on pippercillin and vancomycin.
During her hospital course, she remained afebrile with a white
blood cell count of 5. She underwent a cat scan of the pelvis on
HD #2 to assess progression of the fluid collection. It was
determined that the fluid collection was superficial and and
incision and drainage was done. wound was packed with nugauze
and she was sent with ___ services for packing wound and will be
continued on 7 day course of Augmentin.
She was discharged on a 2 week course of augmentin with
follow-up appointment in ___ clinic. | 187 | 145 |
17228108-DS-40 | 22,683,098 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with fever. You were
started on antibiotics. Blood and urine cultures did not show
any bacteria. A chest x ray and ultrasound of your liver/gall
bladder were also negative for signs of infection. Antibiotics
were discontinued and you will follow up with Dr. ___ as an
outpatient in the liver clinic.
Sincerely,
Your ___ Treatment Team | ___ hx OLT ___ for ___ c/b recurrent HepC cirrhosis s/p
Harvoni, recurrent cholangitis requiring multiple drain
placements, p/w fevers without other infectious symptoms
concerning for possible biliary source.
# Fevers. He was afebrile the entirety of his admission (Tmax
100.1). Given his history of recurrent cholangitis from infected
bilomas, the initial concern was for repeat cholangitis. RUQ
ultrasound on admission showed stable ductal dilation without
evidence of focal liver or splenic lesions. He was started on
Cefepime and Daptomycin for empiric GN and Enterococci
treatment. Daptomycin was selected given his history of "Red
Mans Syndrome" with Vancomycin. Abx were discontinued after 48
hours of no growth on cultures. He was monitored for 24 hours
off antibiotics and discharged to home in stable clinical
condition. His WBC trended down and he did not endorse any
infectious symptoms on discharge. CXR was clear, urine cx was
negative and blood cultures were NGTD at the time of discharge.
# HCV cirrhosis with h/o OLT in ___: He remained
well-compensated without ascites or hepatic encephalopathy. His
LFTs, Tbilli, and Albumin were trended and remained within
normal limits. Tacrolimus level was 4.2 and he was continued on
home tacrolimus dosing without adjustment. Home ursodiol and
bactrium were continued.
Chronic
# Osteopenia: Continued alendronate
# Anxiety and depression: Continued citalopram, lorazepam, and
zolpidem
# Cardiac: Continued ASA
Transitional Issues
- Tacrolimus level: 4.2 on ___. Continued on home dosing
without changes.
- Patient will continue with monthly lab draws with results
faxed to Dr. ___ office as previously arranged.
# CODE: Full
# CONTACT: Wife, ___, ___ | 77 | 266 |
11459120-DS-25 | 20,060,241 | Dear Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted because you had difficulty breathing and low oxygen. We
treated you with IV antibiotics for several days and gave you
water pills to help you urinate. After several discussions, you
stated to us that you would not want to be re-hospitalized under
any circumstances, would not want to return to the hospital for
antibiotics, IV lines, or diuretics, and that you would rather
stay at home and focus on being made comfortable. We are sending
you home to continue this transition towards being comfortable.
Your ___ and case manage will continue to work with you to make
sure your care is within your goals.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old lady with PMH asthma (one 1.5 L at home), afib, PEs
on xarelto, CHF w/ pacemaker p/w dyspnea and hypoxia ___ CHF
exacerbation and atypical pneumonia. We treated with an 8 day
course of vancomycin and cefepime, augmented by azithromycin. We
placed a PICC, and treated with IV diuretics which were
bothersome. She explained to us that she would not want to be
rehospitalized under any circumstance, be treated with
antibiotics, diuretics, get a PICC line, or receive aggressive
care. After discussion with her PACT team, palliative care she
was sent home with ___, with plan to transition to hospice care
as an outpatient.
ACTIVE MEDICAL ISSUES
================
# Healthcare associated pneumonia and mild diastolic CHF
exacerbation. She presented with dyspnea and hypoxia. HCAP was
likely primary cause of hypoxia and dyspnea (dced from rehab ~6
weeks PTA), with some contribution from CHF exacerbation. By
imaging pneumonia appears atypical (legionella negative),
repeated pneumonias likely related to tracheobronchomalacia.
Less likely bronchoalveolar carcinoma given only one episode
hemoptysis. PE ruled out by CT-A but hepatic reflux suggestive
of R heart dysfunction w/ a primary lung process.
- Consider 3 month short term follow for posterior RUL lesion vs
biopsy if admitted.
She appeared euvolemic with 80 mg PO furosemide daily (avoided
BID dosing as patient not compliant with it). She received
vancomycin/cefepime/azithromycin x8 days via ___, which was
dc'ed. Course ended ___. Per IP, there are no further
management strategies for her TBM.
Asymptomatic. Bacteriuria: Had this in the past. Notable history
of ESBL EColi UCxn included meropenem. Asymptomatic, so did not
treat with broader spectrum antibiotics.
# Arm rash/ contact dermatitis from ___ site tegaderm. Consider
alternative bandage for ___ site in future. Attempted to
control discomfort with fluocinolone and low dose
diphenhydramine.
# DIASTOLIC CHF: TTE ___, LVEF >55%, moderate MR. ___
home beta blockade, initially diuresed with IV furosemide, then
switched to PO furosemide as above. She is incontinent, would
monitor daily weights and exam.
# Goals of care: She repeatedly expressed that she wanted to go
home, not a rehab or long term care facility. She has had
discussions about hospice in the past, but has been ambivalent
about it. She intermittently endorsed wanting to go home with
hospice and asking "what is hospice?" after long discussion
(patient not confused), re-demonstrating this ambivalence. She
initially agreed to go to rehab but then did not want anybody to
enter her home to retrieve her checkbook, as such she remained
at ___ throughout her antibiotics course. The ___ care
team, PACT, and her ___ case manager were all closely involved
and after several discussions, she noted that she would consider
transitioning to home hospice in the future, would probably want
hospital re-admission if dyspneic, but would not want to go to a
facility.
CHRONIC ISSUES
===========
# ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RESPONSE:
Stable during admission. She is s/p pacer which intermittently V
paces. Anticoagulated with rivaroxaban. CHADS2 score is 3
(CHF,HTN, age). Continued home rivaroxaban 20mg and metoprolol
succinate 25mg XL.
# Tachy-___ syndrome: s/p pacer which intermittently V paces,
monitor on telemetry.
# OSA. On 1.5L O2 at night at baseline. Not on CPAP.
# Depression: Continued home sertraline.
# Hypothyroidism: Continued home levothyroxine.
# Chronic hip pain: Continued home tramadol. Consider restarting
NSAIDs if patient prefers comfort.
# CKD, stage 3: No longer trending as kidney function had been
stable.
# History of pulmonary embolus- b/l PEs, dx in ___ on therapy
for 6 months---> warfarin was d/c'ed due to recurrent falls;
recurrent PE in ___ w/ saddle embolus thus restarted warfarin,
now on rivaroxaban. Continued rivaroxaban.
# Hypertension: Normotensive.
TRANSITIONAL ISSUES
===================
- Code status: DNR/DNI, do not rehospitalize. Confirmed with
patient.
- Emergency contact:
- Studies pending on discharge: None.
- Please consider checking chem-7 at f/u.
- Please discuss transition to hospice w/ patient and care team. | 133 | 628 |
16696377-DS-18 | 26,580,477 | Dear Ms. ___,
You were admitted for low blood pressure and found to have blood
clots in your legs and in your lungs. You were started on a
medication to treat these blood clots, called lovenox. You
should continue taking these injections until your outpatient
doctor tells you to stop. You are now safe for discharge with
close follow up. For your blood pressure we are decreasing your
home metoprolol.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Oncology Team | ___ year old female with a history of metastatic RCC with brain
metastasis who is admitted with hypotension and extensive DVTs
found to have bilateral PEs started on lovenox.
Bilateral PE's, Bilateral DVTs: etiology of hypercoagulability
likely malignancy
- Discussed with neuro oncology - given brain metastasis,
patient is at risk for hemorrhagic masses intracranially. CT
head showed no active bleed.
- patient was started on hep gtt no bolus; transitioned to
lovenox BID. will continue this medication at discharge
- considered starting apixaban, but this medication was not
fully covered by insurance. Patient will continue lovenox
instead. Some consideration of restarting patient on Coumadin,
but deferred, chose to continue lovenox instead in setting of
___ brain mets with bleeding risk and Coumadin being higher risk
for intracranial bleeding
Hypotension
- Likely secondary to ___ PE's and poor PO intake.
- IV fluids given as needed.
- CTA Chest as above; treat PE's as above on lovenox
- IJ placed in the ED as no other IV access options were
available. Will obtain PICC if needed
___: Cr 1.2 today. continue to monitor with daily lytes.
encourage PO intake, IVF PRN. renally dosed medications.
#Metastatic RCC
- previously on pazopanib; patient was not tolerating it well.
consider restarting as appropriate
- ___ consult given decreased mobility.
TRANSITIONAL ISSUES
#started on lovenox BID for PE, DVT treatment
#Anticoagulation plan: patient discharged on lovenox BID.
considered starting apixaban, but this medication was not fully
covered by insurance. Some consideration of restarting patient
on Coumadin, but deferred, chose to continue lovenox instead in
setting of ___ brain mets with bleeding risk and Coumadin being
higher risk for intracranial bleeding
#consider restarting on Coumadin with close follow up if patient
is not tolerating SQ lovenox
#Patient had complaints of dizziness with the sensation of room
spinning, which started several days prior to admission. She is
unable to say what triggers the dizziness, no focal neurological
signs or symptoms. should follow up with PCP for further ___ if
necessary
#Metoprolol XL decreased from 100mg to 50mg; should be increased
back to home dose by PCP as appropriate
#EMERGENCY CONTACT HCP:
Husband ___ ___
___ ___
#CODE STATUS: DNR/DNI | 86 | 345 |
15584351-DS-12 | 29,133,358 | Please follow these discharge instructions:
-Continue to monitor your right breast area for continued
improvement. If the redness and swelling increase, please call
the doctor's office to report this.
-Should you have fevers and chills, please call the doctor's
office immediately to report.
-Continue your antibiotics until they are finished.
-You may consider eating a probiotic yogurt daily to replace the
'good' bacteria in your intestinal tract. If you cannot
tolerate yogurt then you may buy 'acidophilus' over the counter
as a supplement choice. Acidophilus is a 'friendly' bacteria
for your gut.
-If you start to experience excessive diarrhea, please call the
doctor's office to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed. | Pt presented w/ fevers and WBC 14, found to have advancing
breast cellulitis and abscess s/p US-guided drainages on ___ and
___. Continued to have fevers with drainage from breast and so
on ___ the patient had bedside I&D with copious purulent
malodorous fluid drained (about 400cc). Cx have grown staph
epidermidis and gram pos rods sent out and awaiting speciation.
ID consult recommended broadening abx to linezolid and clinda
from initial abx of vanc, cipro, flagyl. Patient will be
discharged on PO linezolid and clinda to continue until ___ per
ID recommendations. ___ was consulted for
hyperglycemia and noncompliance with metformin due to metallic
taste. Recommended patient be started on Lantus 10U QAM and
insulin sliding scale QID while admitted and sent home with
Basaglar Kwikpen 10U QAM and Novolog Kwikpen sliding scale with
follow-up at ___ on ___. | 137 | 140 |
19176727-DS-11 | 28,516,599 | You were admitted to the hospital for burning on urination,
fevers, and feeling unwell. You were found to have a kidney and
urinary tract infection, called pyelonephritis. An ultrasound
of your kidneys showed no evidence of a complicated infection,
and antibiotics were started with improvement of your symptoms.
You also had a low blood count and concern for blood in your
stool, and underwent an endoscopy which showed no abnormalities
in the upper gastrointestinal tract. However, you will need to
have a colonoscopy as an outpatient to assess your lower
gastrointestinal tract. Please also follow up with your primary
care physician regarding your low blood counts.
Your liver function tests were abnormal, and you had pain in the
right upper abdomen on exam, which you did not experience when
you were not being examined. An ultrasound of your gallbladder
showed no evidence of gallstones, and your liver function tests
were trending back towards the normal range. Please follow up
with your primary care physician regarding these findings.
The following changes were made to your home medications:
- Ciprofloxacin was STARTED, to be taken for 10 additional days
until ___ | ___ presenting with fevers/chills for 6 days with Tmax 102
concerning for pyleonephritis.
#. Pyelonephritis: The patient presented with dysuria,
fevers/chills, and suprapubic pain. She was found to have left
greater than right CVA tenderness and positive UA which grew
pan-sensitive E.Coli, and was started on Zosyn for
pyelonephritis. Given her fever, white count, and tachycardia
an abdominal ultrasound was obtained to rule out complicated
pyelonephritis, which was negative. She was switched to IV
Ciprofloxacin following the return of the E. coli sensitivity
panel with continued improvement of her signs and symptoms. She
was discharged on PO Ciprofloxacin for a 14 day course of
antibiotics.
#Anemia/Black Stools: The patient was noted to have a hct of
32.5 from a prior baseline of 40. She reports black stool
within the last ___ days in the setting of significant NSAID use
for the pain secondary to pyelonephritis, raising the concern
for NSAID-induced gastritis. She had guiac positive brown
stool, and was started on a PPI and underwent an EGD in-house
which was negative. The PPI was discontinued. T.bili and LDH
were normal on initial presentation, ruling out hemolysis. She
will need outpatient follow-up to work up her anemia with a
colonoscopy and further blood tests when her acute infection has
resolved. H. pylori antigen was negative and EGD was normal
without any abnormalities. Her PPI was discontinued and she was
discharged with instructions to have an outpatient colonoscopy.
#. RUQ Tenderness/Elevated LFTs: The patient does not complain
of RUQ tenderness but on exam, exhibited RUQ tenderness to
palpation. She was also found to have elevated LFT's on initial
presentation with ALT > AST and elevated Alk Phos. She denies
nausea/vomitting and denies alcohol use. Abdominal ultrasound
was negative for cholelithiasis or cholecystitis or fatty liver,
and viral hepatitis studies were sent, which showed positive
Hepatitis B core antibody and surface antibody, negative surface
antigen consistent with prior exposure. Hepatitis C Ab was
negative. LFT's down-trended during her hospital stay. She
will follow-up as an outpatient with her PCP for monitoring of
LFT's and further workup, if necessary.
#. Hypertension: The patient's anti-hypertensives were
initially held in the setting of her acute illness. Her blood
pressures have been elevated in-house and her home
anti-hypertensives were restarted prior to discharge
(Triamterene/HCTZ 37.5/25 mg daily).
#Neck Pain: The patient has chronic neck pain, unchanged from
prior symptoms. No confusion, signs of meningismus, and
headache improved. Her neck pain improved in-house.
# CONTACT: Daughter ___ ___. | 193 | 439 |
13681651-DS-28 | 27,559,017 | Dear Ms. ___,
You were admitted to ___ for a
ruptured abdominal aortic aneurysm. You underwent an
endovascular repair to fix this major blood vessel in your
abdomen.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate, do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery,
unless otherwise directed
Take one aspirin daily, unless otherwise directed
ACTIVITIES:
No driving until postop
visit and you are no longer taking pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate, do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
Purulent or foul smelling drainage from your incision
We wish you the best in your health,
Your ___ Care Team | Ms. ___ is an ___ year old female with history of type 2
diabetes, ruptured AAA s/p EVAR complicated by failure of left
femoral perclose requiring patch angioplasty and ex-lap for
hematoma evacuation (___), PAD s/p L fem-peroneal bypass, who
presented with abdominal and back pain, found to have re-rupture
of her AAA.
She was initially found to be hypertensive to a SBP of 220s, and
an esmolol gtt was started. A CTA was performed, which showed
what appeared to be contained rupture without active
extravasation of contrast. Vascular surgery was consulted for
assessment of surgical repair of ruptured AAA.
She was emergently taken to the operating room for re-rupture of
her AAA, and type 1B bar graft leak. She underwent coil
embolization of the right internal iliac artery, as well as
bilateral extension of previously placed EVAR iliac limbs with
two additional limbs into the iliac arteries on both sides to
reseal her previous EVAR graft. Upon transfer to the PACU, there
was some concern initially for right leg ischemia, but the
ultrasound showed that there was some flow in the superficial
femoral artery distal to the puncture site, and she was
transferred to the ICU for recovery.
Postoperatively, she had initially been doing well, but was
noted to have a cooler right foot over the course of the
subsequent hours and loss of her posterior tibial Doppler
signal. Arterial duplex confirmed occlusion of the right lower
extremity lower leg arteries, prompting concern for proximal
occlusion. As such, the patient was prepped for immediate right
groin exploration. Intraoperatively it was noted that the
Perclose closure appeared to have raised a flap of plaque from
the posterior aspect of the common femoral artery. This
appeared to be the cause of her occlusion. She then underwent
right femoral patch angioplasty with Dacron graft, right femoral
endarterectomy, selective catheterization of right external
iliac artery, second order vessel, and angiogram of the right
lower extremity. It was determined that revascularization had
been successful, as her posterior tibial
artery signal was noted to be strong again intraoperatively and
postoperatively. The patient was transferred to the PACU in
stable condition.
Post-operatively she continued to experience intermittent pain
and anxiety. Her home medications were restarted and she
received medications as needed for adequate pain control. She
was also seen by social work and spoke with her outpatient
psychiatrist, which helped to alleviate her anxiety.
She was discharged to rehab. She should continue frequent
incentive spirometer use daily. Anticipate rehab stay less to be
than 30 days.
She should follow up with Dr. ___ at her scheduled
outpatient appointment. She should continue taking aspirin 81mg
daily as well as her other medications as prescribed. | 363 | 447 |
18556017-DS-32 | 27,265,563 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with nausea, vomiting, and diarrhea likely from gastroenteritis.
You also developed a urinary tract infection. We treated you
with fluids and antibiotics and your symptoms improved. You will
need to continue ciprofloxacin for a two week course (starts
___. We also treated you for low phosphorous in your blood
and decreased your cyclosporine level. Your electrolytes and
phosphorus will need to be checked in the next week or so, at
your appointment with Dr. ___.
If you have questions about your blood sugars, you can call the
___ Nurse on Call at ___.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team | Patient is a ___ woman with a history of left breast ___ s/p
lumpectomy ___ f/b XRT, DMI on insulin pump, s/p renal
transplant ___ and ___ for diabetic nephropathy, presenting
with N/V/D fevers x 1 day, found to have pyelonephritis.
# Gastroenteritis (N/v/d and cough): Likely viral
gastroenteritis given rapid onset and similar symptoms in her
lunch companion after eating suspicious meal. Leukocytosis and
fever without localizing signs and symptoms supports this
diagnosis. Other possibilities included URI or a more serious
infection (ie bacteremia) given her immunosuppression. As her
symptoms were ongoing for 2 weeks prior to presentation, an
acute URI presentation was less likely and respiratory swab not
necessary. She also was recently hospitalized for pneumonia but
CXR was clear and would not explain her cough. Still spiking
fevers on ___ but resolved by ___ on antibiotics. She was
found to have Enterobacter cloacae growing in her urine: was
initially treated empirically with with vanc/cipro for fevers of
unclear origin but suspected GI source, then was switched to
ceftriaxone empirically for UTI, and was ultimately discharged
to complete a course of ciprofloxacin given sensitivity data.
She initially required IVF given poor po intake but fluids were
stopped when the patient was taking good po's. Blood cultures
negative to date, stool cultures also negative to date. By the
time of discharge, her nausea/vomiting/diarrhea had resolved and
she was complaining of some constipation.
#Pyelonephritis: patient's first UA/UCx initially negative for
infection but positive on ___ and growing G+ bacteria. Ucx from
___ grew Enterobacter cloacae per above; patient discharged on
ciprofloxacin.
# ___: RESOLVED. Cr 1.3 up from baseline of 1.0. Likely prerenal
given dehydration from poor po intake/vomiting. Taking better
po's by ___. Creatinine back to normal at discharge.
# S/p renal transplant: Continued cellcept and cyclosporine. Her
cyclosoporine dose was decreased at discharge given high levels.
#Hypophosphatemia: patient had low phos during her hospital
stay, question renal phosphorous wasting. Vitamin D was within
normal limits. Patient was discharged on phos supplementation
with close renal f/u.
#DMI: patient uses an insulin pump at home. She was followed
closely by ___ and was maintained on her basal dose rate from
her insulin pump as well as supplemental SS carb counting with
humolog. Towards the time of discharge, she was switched back to
her pump. | 118 | 380 |
18385158-DS-18 | 26,304,379 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted after you went to
the Emergency Department with shakiness and confusion (due to
your liver) and were also found to have high blood sugar. Your
shakiness and confusion improved with extra doses of lactulose
and does not appear to be due to infection. To prevent this in
the future, we have added a medication called Rifaximin to be
taken twice daily in addition to your Lactulose. Also, if you
feel that your hands are jerking in a similar fashion and you
feel confused, you should take an extra dose of lactulose to
help with this and then call the liver doctors if not improving.
Your high blood sugars were have been a chronic issue and it is
important to follow the new regimen that your outpatient
diabetes doctor prescribed for you.
You also mentioned you have shoulder pain in both shoulders. You
should follow up with your orthopaedist that you have seen
previously because it seems to have gotten worse.
Also, it is important that you follow up with your PCP about the
fall you experienced 10 days prior. Your CAT scan didn't show
any blood in your head but it is important that we try to
prevent this from happening again. If you get dizzy in the
future, try to sit down as quickly and safely as possible.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care team | Patient is a ___ with a h/o ETOH cirrhosis s/p TIPS who
presents with mild confusion and shakes consistent with hepatic
encephalopathy, also found to have hyperglycemia. His confusion
and shakes improved with lactulose administration. Patient also
presented with a recent fall (last 10 days ago) that on history
appeared consistent with syncope.
# Hepatic Encephalopathy: The patients history of TIPS procedure
with current symptoms of shakiness and mild confusion consistent
hepatic encephalopathy. His symptoms improved with lactulose TID
and the addition of rifaximin BID. He had no evidence of
infection.
# Hyperglycemia: The patient presented with severe hyperglycemia
to the 500s without evidence of diabetic ketoacidosis. He is
followed by outpatient endocrinologist. He is currently on
lantus 50U qAM and was told to switch to U500 BID on ___.
Lantus 50U qAM and insulin sliding scale was continued while
inpatient and patient was advised to switch to U500 as
prescribed by his endocrinologist on discharge.
# Shoulder pain: Patient also had bilateral shoulder pain for
the last few weeks. Exam revealed pain with both active and
passive range of motion, positive empty can test on LUE and
restricted active range of motion. Patient has seen ortho as an
outpatient for other injuries.
# GIB/Varices: Patient has a history of variceal bleed, now s/p
TIPS in ___. Last EGD in ___ revealed no evidence of
varices.
# Ascites: Patient has a h/o TIPS in ___ and had no evidence
of ascites on bed side ultrasound in the ED.
# ETOD Cirrhosis: Patient is currently followed by Dr. ___
___ in liver clinic. MELD on admission was 9 and is currently
not on the transplant list. Patient will follow up in liver
clinic in early ___.
# Polysubstance abuse/chronic pain: Patient on methadone which
he gets from ___ in ___, ___).
Patient was continued on methadone while hospitalized.
#Fall: patient presented with fall ___ days ago. CT head
negative. Patient endorsed loss of vision prior to fall and
buckling of knees. Fall was felt to be consistent with syncope. | 252 | 340 |
13902897-DS-10 | 28,147,866 | -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 your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-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. | Patient found to have bilateral ureteral stones in ER on
___. As patient was making urine, renal function was at
baseline, and there were no occult signs of infection, she was
observed overnight on ___ to see if she would be able to pass
as least one of these stones. Repeat labs on HD2 remained
stable. Repeat renal US on HD2 showed persistent mild
hydronephrosis on both sides. Patient was additionally still
having intermittent flank pain, and was thus taken to OR on ___
for cystoscopy and placement of bilateral ureteral stents.
Procedure was uncomplicated and patient was transferred to the
recovery area in stable condition. She was observed in the
recovery area and was discharged after voiding. At the time of
discharge, she was ambulating on her own, tolerating diet, pain
was controlled with oral meds, and was voiding on her own. | 351 | 143 |
12268481-DS-22 | 21,853,594 | It was a true pleasure caring for you at ___!
You were admitted due to bacteria in your bloodstream that
caused a severe illness. In the intensive care unit you were
stabilized and given strong antibiotics which cleared your
infection. We did an MRI and an ERCP procedure to look for the
source of these bloodstream bacteria but found none. You are now
ready for discharge with close outpatient follow-up.
Please continue Cipro (oral antibiotic) for another week.
Please call the Liver clinic to set up an appointment next week
for follow-up as noted below. | ___ female with alcohol-induced cirrhosis, decompensated
with ascites, history of celiac disease presented with 2 days of
worsening RUQ and epigastric pain and admitted to MICU for
hypotension and concern for sepsis.
# Severe Sepsis: Patient met ___ SIRS criteria including WBC of
20 with 6% bands which along with ___ and elevated lactate on
admission suggested severe sepsis. Her blood culture grew GNR
bacteremia. The exact source for infection remained unclear. RUQ
ultrasound and CT abdomen did not reveal any sources. However
given localized RUQ pain there was increased suspicion for
biliary source. Patient also had symptoms of gastroenteritis
prior to admission which may suggest gut translocation. She was
initially hypotensive in the ED and in the MICU and received
total of 6L of IVF and 25 g of albumin with response in her
blood pressure. She was started on cefepime and flagyl and
showed remarkable improvement in clinical status. Her lactate,
___ and ___ WBC count improved significantly. Blood cultures
grew pan-sensitive klebsiella and surveillance cultures were
negative. Ultimately continued on IV cefepime while in-house and
transitioned to oral cipro on dsicharge to complete a 2 week
course. Underwent MRCP and ERCP without clear evidence of
billiary pathology.
# Portal vein thrombosus - Small, partially occlusive portal
vein thrombosis seens on CT and on MRCP. Decision made not to
anticoagulate in house as it was thought this may have been
related to sepsis/low-flow state and could resovle
spontaneously. Will need repeat imaging to ensure resolution as
an outpatient.
# ___: Most likely pre-renal renal. ATN also in the
differential given episodes of hypotension. Her ___ improved
with IVF.
# Cirrhosis: Alcoholic cirrhosis with history of decompensation
with ascites. No hx of SBP, HE. Her diuretics were held in the
setting of sepsis but restarted on the floor with good effect.
# Depression: Continued mirtazapine | 92 | 313 |
12668827-DS-33 | 24,177,613 | Dear Ms. ___,
You came to the hospital with burning with urination and were
found to have a urinary tract infection. We treated you with
intravenous antibiotics and transitioned you to the pill form of
antibiotics to complete a full 7 day course of antibiotics. You
also had lower blood counts so we had a procedure called an
endoscopy and procedure to stop bleeding. We also gave you blood
transfusion with stabilization of your blood counts.
You developed some diarrhea before leaving the hospital so we
sent of a stool test to check you for an infection called c.
difficile colitis that was negative and showed no infection
which is great news.
Your antibiotic will be delivered to your home later today.
Please follow up with your appointments below.
It was a pleasure being involved in your care.
Your,
___ Team | ___ yo F with history of autoimmune hepatitis c/b cirrhosis,
Childs A c/b GI bleeding (last EGD ___ pt has known grade I
varices and portal hypertensive gastropathy vs GAVE causing
significant GI bleed with Hgb dropping to 4 ___ who
presents with urinary frequency and dysuria and found to be
anemic Hgb 6.8. EGD performed showed GAVE which was treated
with APC. Found to have UTI so treated with ciprofloxacin. | 136 | 73 |
15757957-DS-3 | 26,055,336 | Dear Mr. ___,
You were hospitalized due to symptoms of dizziness, nausea and
emesis resulting from an ACUTE HEMORRHAGIC STROKE. We think this
happened due to high blood pressure. In order to prevent another
hemorrhagic stroke we encourage you to take your medication as
prescribed.
We are changing your medications as follows:
-Start Lisinopril 40mg daily
-Start Amlodipine 10mg daily
-Start Labetalol 200mg three times daily
-STOP Aspirin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ man with history notable for hypertension,
hyperlipidemia, and prostate cancer transferred
from CHA after presenting with nausea, vomiting, transient
speech
disturbance, and hypertension, found to have a small right
cerebellar IPH. Etiology thought to be related to hypertension.
CTH showed left small cerebellar IPH. CTA head and neck showed
left M2 focal stenosis. MRI brain again showed the cerebellar
IPH as well as evidence of small vessel disease, and
hypertensive microbleeds.
He was noted to be hypertensive during admission and was started
on the following medications: lisinopril 40mg daily, Amlodipine
10mg daily and labetalol 200mg TID. His aspirin was stopped
given his intraparenchymal hemorrhage, microbleeds seen on MRI.
Of note, he was found to have a UTI on admission for which he
completed a 3 day course of ceftriaxone. He was seen by ___
who recommended rehab.
He has outpatient stroke follow up scheduled.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) | 213 | 256 |
12162956-DS-15 | 20,073,655 | Dear Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted with back pain, weakness, and numbness, and were found
to have a tumor in your spinal canal. You have received two
days of radiation and should return on ___ for the
remainder of your radiation therapy, and for MRIs of your head
and the rest of your spine. You should also continue taking
oral steroids to relieve the swelling around your tumor. | ___ with metastatic RCC s/p left nephrectomy, left VATS
resection for pulmonary nodules, and HD IL-2 who presents with
LBP and perineal sensory loss, found to have L1 intradural,
intramedullary metastatic lesion while staging CT torso on day
of admission showed no other evidence of metastatic disease.
#) L1 spinal met: Has associated radiculopathy and new perianal
sensory loss, fecal incontinence. Pt was seen by neurosurgery
and neurology in the ED and started on dexamethasone.
Neurosurgery has determined that she would not be an optimal
candidate for resection, and so she was started on radiation
therapy on ___ and ___. Per her request, the patient was
discharged home on ___ and will complete the remainder of her
radiation therapy on ___ as an outpatient. She will continue
on oral dexamethasone 4mg q6h for now. She also should make
appointments to follow up with her primary oncologists Dr.
___ Dr. ___ new neuro-oncologist Dr. ___
___ ___ weeks.
#) Metastatic RCC: She has undergone resection for pulmonary
metastases, and high-dose IL-2 systemic therapy, most recently
in ___. There was no other evidence of disease on CT torso
done the day of admission. To complete staging workup, she will
complete an MRI head, C-spine, and T-spine as an outpatient
(currently scheduled for ___, since it could not be achieved
during her inpatient time due to the restriction preventing her
from receiving contrast twice within a 48-hour window given her
GFR<60.
#) Depression: continued on home medications. Patient has a
follow-up appointment scheduled with her psychiatrist. | 80 | 260 |
17060831-DS-6 | 27,037,292 | You were admitted with shortness of breath and worsening liver
function tests. This was thought to be due to your metastatic
rectal cancer. You were given chemotherapy which you will
continue as an outpatient tomorrow. | ___ year old man with metastatic rectal cancer (KRAS wild type,
NRAS mutation, MSS) who was admitted from the ED with right
chest/abdomen pain and rising bilirubin most
consistent with disease progression.
Metastatic Rectal Cancer
- The likely cause of the patients abdominal pain and elevated
liver function tests are due to disease progression. Chest CTA
and RUQ ultrasound done in the ED were unremarkable. He had a
previous oxaliplatin reaction. His primary oncologist decided to
start treatment with FOLFOX. He received oxaliplatin
desensitization with pre-medications per protocol while admitted
and tolerated it well. He will return to clinic tomorrow to
receive the rest of the regimen. His liver function tests will
be followed up by his primary oncologist as an outpatient. | 35 | 119 |
18708817-DS-6 | 22,943,373 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
difficulty breathing. We treated you for a heart failure
exacerbation with diuretics (medicines to increase your
urination). We also monitored your heart rate and blood oxygen
levels in the hospital and they have been stable.
We also noticed that your thyroid function continues to be
decreased despite treatment. Please make sure the thyroid
replacement medicine Levothyroxine is taken on an empty stomach,
as food can impair its absorption.
Going forward, the nursing home should weigh you every morning.
If you gain more than 3lbs in a day, your cardiologist Dr.
___ be notified.
Please START Furosemide 40mg Daily
Please CONTINUE Megase
Please STOP Torsemide | BRIEF HOSPITAL COURSE AND ACTIVE ISSUES
___ year old female with history of non-ischemic dilated CM (EF
25%), DM type 2, and dementia, presenting with hypoxemia,
dyspnea on exertion, and lower extremity edema consistent with a
CHF exacerbation with BNP in 20,000s.
# Acute on chronic heart failure: Pt w/ non-ischemic CMP w/ EF
___ on last TTE in ___. She had been maintained on
furosemide 20 mg daily, but was recently switched to torsemide
10 mg PO daily per outpatient cardiology notes on ___ as she
was volume overloaded at that time. She was further diuresed
with a net total output of about 4.2L over course of admission.
She was continued on her spironolactone and lisinopril. We are
discharging her on Furosemide 40mg with plans for chem 7 draw on
___ and ___ to be faxed to Dr. ___ in cardiology. ON
DISCHARGE HER WEIGHT IS 136 LBS.
# Hypothyroidism: She had an elevated TSH and normal T4 during
last admission and her Levothyroxine had been increased to 150
mcg daily. However on this admission TSH remained elevated at
65. It should be confirmed after discharge that she takes her
levothyroxine separately from her other medications and on an
empty stomach. If TSH remains elevated after these
interventions, her dose should be further uptitrated.
INACTIVE ISSUES
# Asymptomatic Bradycardia: Pt with previous admission for
reported bradycardia to ___ recorded at ECF. Stable for now. Not
AICD candidate.
# Diabetes mellitus: Insulin dependent on home ISS and fairly
well controlled w/ last A1c 6.3% in ___. Metformin was
discontinued during last hospitalization ___ ___ but was
restarted in the nursing home at 250 mg daily. Metformin was
held in-house.
# Hyperparathyroidism with hypercalcemia: Stable. No further
intervention per endocrine.
# CKD: stable
# Dementia: Pt with relatively advanced dementia that has been
progressive. Currently oriented x1 which seems to be new
baseline. Continued on quetiapine and remeron.
# Gout: Stable. Continued on home allopurinol
TRANSITIONAL ISSUES
-- DAILY WEIGHTS, adjust Lasix based on volume status and
weight. ON DISCHARGE SHE IS 136LBS. If >3lb weight gain, call
and let Dr. ___ know at ___.
-- O/P chem 7 on ___ and ___ to be faxed to Dr. ___
in cardiology
-- Make sure Levothyroxine is taken on empty stomach without
other medications
-- Changed ASA to enteric coated | 113 | 381 |
16425412-DS-58 | 27,977,082 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were feeling dizzy and weak at home
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a kidney injury, likely because you
were not drinking enough fluids at home.
- You received intravenous fluids.
- You had imaging of your kidney and lungs.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
- Please weight yourself every day, if your weight increases by
3 pounds or more, please call your healthcare provider.
- Your dose of diuretic medication called Furosemide was
decreased from twice daily to once daily.
- Weigh yourself daily and call your doctor if your weight
increases by more than 3 lbs in 2 days or 5 lbs in 1 week.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[ ] Discharge Cr 1.4
[ ] Patient should have repeat BMP at next appointment
[ ] Patient's home diuretics were held during admission due to
hypovolemia. Restarted at lower dose 40mg PO daily. Likely will
need close titration of diuretics as PO intake improves.
[ ] Patient was noted to be hypoglycemic prior to admission
likely ___ poor PO intake as she was recovering from recent PNA.
Intake increased as appetite improved, will be discharged on
slightly lower dose of insulin but may need further adjustment
as outpatient.
BRIEF HOSPITAL COURSE
=====================
___ woman with a history of ESRD ___ HTN and DM s/p
kidney transplant (___), rectal cancer (s/p resection and
ostomy), HFpEF, COPD, DM2, DVT s/p IVC filter, and multiple MDR
UTIs who presented with weakness, found to be orthostatic and
with ___ likely ___ hypovolemia. Patient had recent admission
for multifocal pneumonia and heart failure exacerbation. She had
little PO intake at home and continued to take her home
diuretics. Patient was given IV fluids and her renal function as
well as orthostatics improved. She was restarted on Furosemide
40mg Once daily down from BID and discharged in stable condition
with improving kindey function, Cr. 1.4.
ACUTE ISSUES
=============
#Weakness
#Orthostasis
Presenting with lightheadedness after trying to get up, in
setting of recent hospitalization and decreased PO intake
coupled with diuretic use. No focal weakness on exam.
Orthostatic vital signs positive on ___. Received 500cc NS on
___ with improvement in symptoms and repeat orthostatic vital
signs negative. Patient discharged on lower dose diuretics.
___ on CKD of renal allograft
#ESRD s/p DDRT in ___
Cr 1.8 on admission (baseline 0.9-1.3). Likely elevated in the
setting of hypovolemia. Renal function downtrended to baseline
after IV fluids and holding diuretics. Seen by transplant
nephrology. FeUrea was oddly elevated at 48% with is borderline
suggestive of intrinsic renal disease but may be impacted by CKD
of renal allograft. Renal U/s also showing "abnormal waveform
within the main renal artery with absence of antegrade flow
during diastole." UA positive for protein. Continued on
mycophenolate 250mg BID and prednisone 5mg daily. She was also
continued on prophylactic Bactrim and valacyclovir. Cr on
discharge 1.4.
CHRONIC/RESOLVED ISSUES
=========================
#Multifocal PNA (resolved)
Recent admission for multifocal pneumonia, completed
levofloxacin course on ___. Still having productive cough but
not hypoxemic during admission. CXR looked improved.
#HFpEF
Mild diastolic dysfunction, EF 65% on last TTE ___. Last
discharge weight 115.7 lbs. On admission, proBNP elevated 1796
and trop x2 flat. Home Lasix held in setting of hypovolemia.
Euvolemic on discharge exam, discharged on 40 mg once daily
diuretic.
#HTN
Initially held home hydralazine given orthostasis, but restarted
as BPs improved and hypertensive to 160-170s systolic. Patient
continued on home carvedilol and diltiazem.
#DM2
Patient reports hypoglycemic episode to ___ at home on recent
70/30 regimen. Discharged on decreased dose of
#COPD
Patient continued home tiotropium. Held home Symbicort as non
formulary.
#Urinary retention
Has required Q6Hr catheterization in the past, although patient
doesn't describe performing at home. Patient urinating well
during admission.
#CAD
Patient continued on home ASA and statin.
#CODE: Full (confirmed)
#CONTACT: ___ (daughter) ___
>30 min spent on discharge planning including face to face time | 165 | 505 |
11971622-DS-18 | 20,373,876 | You were admitted with MSSA bacteremia and found to have a
cavitary pneumonia. You improved on IV Antibiotics and these
were tapered per sensitivity testing. You were seen by
infectious disease consult service and will followed by them
over the next ___ months. You underwent transthoracic and
transesophageal echocardiography without evidence of heart valve
infection. The ID team will establish and contact you with
follow appointment information. You will need weekly labs with
results faxed to ID team ___ clinic) as per paperwork. You
are may not drive yourself home tonight. | ___ year old male with h/o HTN who presents with staph aureus
bacteremia and a cavitary pneumonia.
# PNEUMONIA/FEVERS/CAVITARY LUNG LESION/ S aureus bacteremia:
Placed on Vanocmycin and tapered to Cefazolin 2gm q8hr per
sensitivities. TEE done with mild MR but no obvious ___.
FInal report pending. Has PICC placed. Will go home with home
infusion ABX in place. OPAT will follow labs (BUN, Cr, CBC
w/diff). If final TEE without ___ likely get 4wk IV
ABx (OPAT will determine). Quantiferon gold sent prior to
discharge and is pending (annual PPD negative per his report)
# Transaminitis: elevated ALT on admission and repeat. Imaging
suggested hepatic steatosis and borderlined splenomegaly. No
other clinical findings to suggest occult cirrhosis. HAV and
HBV immune per serology. No HCV exposure. Drinks ___ ETOH
daily which could contribute. Patient will f/u with PCP for
further evaluation -- may be ___.
# HTN: continue chlorthalidone
#Migraines: continue zomeg prn | 94 | 159 |
10670085-DS-26 | 24,878,940 | Dear Ms. ___,
It was a pleasure to take care of you during your hospital stay.
You were admitted to the hospital because you had fever, rigors,
and pain upon urination. You were found to have a urinary tract
infection. At first this was treated with IV antibiotics. After
a few days, you no longer had fevers, your blood pressures
became stable, and you no longer had nighttime sweats or chills.
At this point, your blood cultures were negative, so we felt it
was safe to switch you from IV to PO antibiotics. You will be
discharged with 2 antibiotics: ciprofloxacin and amoxicillin.
Your last day of ciprofloxacin will be ___ for 10 total days,
and your last day of amoxicillin will be ___ for 14 total days.
You were restarted on your blood pressure and heart medications
(lisinopril and metoprolol) before discharge and your blood
pressure was stable. When you are at home, you can continue to
check your blood pressure. If your systolic blood pressure is
less than 100 (the top number) or your heart rate is less than
60, please call your primary care physician to ask if you should
continue taking lisinopril and/or metoprolol.
We also stopped Tylenol while your were in the hospital because
your liver enzymes were high. You should discuss with your PCP
___ you can restart Tylenol.
Please continue to follow up with your primary care physician.
You are now being discharged to home with ___ and ___ services.
Your ___ Team | Ms. ___ is a ___ with history of gastric ulcers, CAD s/p
CABG, sCHF (LVEF 35-40%), AVR with bovine valve not on
anticoagulation, HTN, DM, recent admission for UTI with
resultant e/coli bacteremia, who presented with rigors and
dysuria and was admitted for sepsis with urinary tract
infection. She was stabilized, narrowed to PO antibiotics, and
is now being discharged home on a 10 day course of ciprofloxacin
(ending ___ and 14 day course of amoxicillin (ending
___.
--------------- | 246 | 80 |
13663087-DS-10 | 27,074,369 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because you were
experiencing chest pain. Tests did not show any evidence of
heart attack. Your chest pain seemed to be related to change in
position and could be musculoskeletal in nature.
You were also found to have blood in the urine, which is related
to your recent bladder procedure. You also experienced some
injury from the urinary catheter, which was also contributing to
the blood in the urine. We removed the catheter before your
discharge and treated your bladder spasm with pain medications.
Please remember that you might continue having blood in the
urine because you are on the blood thinner warfarin.
Please make sure to follow up with your doctors as ___ and
take all your medications on time.
Best regards,
___ team | ___ year old man with ESRD on HD TTS, HTN and mechanical heart
valve on Coumadin here with chest pain and hematuria. | 139 | 23 |
18115683-DS-12 | 21,670,199 | Mrs. ___, you were admitted for anastomotic leak. However,
this is a contained leak, and you appeared very well throughout
this hospital admission. We attempted at interventional
radiology drainage, but there is no drainable collection. Thus
you will be discharged with follow-up with Dr. ___.
Warning signs: If you experience fever, chills, nausea/vomiting,
inability to tolerate oral intake, please call the office or
come to the emergency room.
Diet: No restrictions
Medications: You may resume all your home medications. We will
continue oral antibiotics for the next ___ days. Lastly, we will
send you home on Lovenox (therapeutic lovenox) and you can
follow-up with your PCP for bridging to Coumadin. It is
extremely important, for you to follow-up with your PCP for
___ bridging, as you are at high risk for clotting, and
other thromboembolic events. | Patient was admitted after recently being discharged. A CT A/P
was performed in the emergency room demonstrating a phelgmon
proximal to the anastomosis consistent with a leak. However, the
patient appeared very well. She was hemodynamically stable and
denied any abdominal pain. Patient was started on Zosyn and a
regular diet. ___ was called for potential drainage with no
drainable collection.
However, patient continue to do well. Patient did not spike
fever, did not experience nausea/vomiting. She will be
discharged home on a total of 14 days of antibiotics as well as
therapeutic lovenox. We recommend that she follow-up with her
PCP for bridging from Lovenox to Coumadin. | 133 | 107 |
17322687-DS-5 | 24,838,905 | Dear ___,
___ was a pleasure taking care of you at the ___.
You were admitted in the hospital because of weakness in your
left arm and leg which improved on their own. You underwent a
CAT scan and MRI of the head which did not showed a new stroke.
We were concerned that you had not been taking your home
medications and we restarted these during your stay. It is
important to take these medications even while you feel well as
we think these medications will KEEP you feeling well. Please
make sure to take your medications regularly and keep you follow
up appointments with your PCP and neurologist.
It was a pleasure taking care of you at the ___.
We wish you all the best,
Your ___ team. | Mrs. ___ is a ___ with history of stroke and CAE in ___ who
presented with weakness on the left arm and lower limb which
resolved spontaneously by the time she reached the ED (<3
hours). She was seen by neurology and was found to have
reassuring neurologic exam. A CTA head and neck was obtained
which showed no acute pathology. She was noted to be mildly
hypertensive and she reported she had not been taking any of her
home medications for several months as she was feeling well
previously. She was admitted to medicine service for stroke
workup and medication counseling. MRI brain was obtained, which
showed no acute infarct and she was started on her home
medications without issue.
CHRONIC ISSUES
================
# T2DM: The patient has T2DM on oral agents. during her
admission period we held her glipizide/metformin and started her
on ___ while inpatient.
# CV risk modification:
- Continued Aspirin 81 mg PO DAILY
- Continued Atorvastatin 40 mg PO DAILY
# Glaucoma:
- Continued Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES
BID
- Substituted latanoprost for bimatoprost while in house
- Continued Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
- Continued Timolol Maleate 0.5% 1 DROP BOTH EYES BID
# Hypertension:
- Continued lisinopril
TRANSITIONAL:
======================
[] please continue patient medication education and encourage
taking home medications.
[] restarted aspirin 81mg daily which we recommend continuing
indefinitely.
[] recommend outpatient echocardiogram to evaluate for PFO or
valve dysfunction that may lend to embolism.
[] follow-up with neurology.
# CONTACT: ___ (son) ___
# CODE STATUS: Full presumed | 125 | 256 |
10694040-DS-17 | 25,923,519 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You came in due to lightheadedness and dizziness. A CT scan of
your head showed no bleeding or strokes. An EKG showed that you
were in atrial fibrillation, which is a heart arrhythmia you
have a history of. Your blood pressure dropped significantly
when you stood up which is most likely why you felt dizzy. We
also gave you intravenous fluids because we felt you were
dehydrated. Your atrial fibrillation stopped and you now feel
less dizzy and lightheaded.
Please continue to take all of your home medications as
directed.
We also met with you and your family about your care for the
future. Please follow-up with your outpatient providers with
any questions that may come up later regarding medications and
further care.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with PMH afib, dCHF, HTN, prior CVA x2, presenting from
___ with dizziness/weakness. Dizziness described as
feeling "lightheaded" on standing usually in the morning
# Orthostasis/dizziness: Patinet came in complaining of
lightheadedness and the sensation of the room tilting when she
was standing up. This unsteadiness resulted in several falls
over the last few days. In the ED, a head CT was negative for
any acute intracranial process. An EKG showed atrial
fibrillation with rvr (~150bpm) and on orthostatic exam the
patients SBP dropped from 135 to 95 upon standing. Pt responded
well to 100mg of metoprolol and soon converted back into sinus
rhythm. Causes of the patient's orthostasis werer thought to be
related to volume depletion as she has had poor PO intake
recently and her afib . Anemia was also considered as etiology
of symptoms as her admission CBC showed a drop of HCT from 39 to
34 over 3 days. This was felt to be less likelty as patient had
no fatigue/weakness and relatively high hct with no signs of
bleeding or hemolysis. The patient remained in SR for the
duration of the admission and orthostatis removed. She received
several liters throughout admission and showed no signs of fluid
overload. On discharge, her dizziness is greatly improved.
# Polycythemia ___: HCT, while below baseline on ED CBC,
trended up on repeat labs to 38. Hemolysis labs were
unremarkable and there was no signs of bleeding (guiac neg in
ED). Patient's CBC has trended lower over the last year with
fluctuance in HCT. Uncertain cause but may be secondary to
progressive fibrosis. However, other cell lines appear normal.
Hydroxyurea was held throughout admission in setting of low HCT
and should be started back as 2x a week medication instead of 3x
per Heme. She will follow up with them as an outpt next month.
She should have a CBC drawn in 2 weeks prior to appointment. TSH
and B12 were wnl.
.
# Afib with RVR: patient converted back to sinus rhythm soon
after admission. She required 100mg metoprolol for RVR to
150bpm. Pt was maintained on daily dose of metroprolol 75mg BID
throughout the admission without complication. Pt's ECG shows
enlarged P waves making conversion back into afib likely in the
future. Pt will follow up with cardiologist as an outpatient.
Warfarin was restarted after being held for several days for
supratheraputic INR. INR is 2.2 on discharge.
# H/o atypical cells on urine cytology: Found ___ hematuria at
last hospitalization. N hematuria since then or during this
admission. It was believed that with a clean UA, this previous
finding was not contributing to current symtoms. Pt was made an
appointment with urology to follow up.
#Family meeting: Prior to discharge, a family meeting was held
with daughter and 2 sons, ___ (___ work), Dr.
___, and Dr. ___. Pts recent falls
were discussed and ___ were made in her medication to
prevent dizziness and lightheadedness. It was decided to
continue pt on warfarin and make changes in living situation and
family was informed that an added level of care would be optimal
at this time. The pros and cons of wafarin therapy were
discussed. Patient's PVC and atypical urine cytology findings
were also discussed and a follow up plan was established. | 152 | 541 |
17866076-DS-2 | 20,683,261 | -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 your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-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.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-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 from the ED and was taken urgently to
the OR for ureteral stent placement. The procedure was
uncomplicated. Please see dictate operative report for full
details. After the procedure, she was returned to the floor and
monitored for signs of sepsis. No complications were encountered
and the patient remained afebrile. At the time of discharge, she
was tolerating a regular diet, her pain was well-controlled, and
she was ambulating without aid. The patient was discharged on a
14 day regimen of antibiotics due to her positive UA and concern
for infection. She will follow up with Dr. ___
definitive stone management. | 377 | 106 |
12669784-DS-4 | 22,155,964 | Mrs. ___,
___ were admitted to the hospital with confusion and mental
status changes following a recent surgery. ___ were treated for
alcohol withdrawal syndrome and are now ready to be discharged
home to complete your recovery there.
Please make sure to follow these instructions after your
discharge to assure timely recovery.
DIET:
___ may continue a FULL LIQUID DIET until ___ are seen by Dr.
___ in clinic and are instructed to advance your diet. All
medications and pills must be crushed in apple sauce, yogurt or
other soft creamy foods. There is a risk they will get stuck in
your esophagus if taken whole. The only pill ___ may take whole
is your levothyroxine (synthroid).
ACTIVITY:
___ may resume regular activity without restrictions.
FOLLOW-UP:
___ should follow up with Dr. ___ as instructed. ___ have an
appointment set up for ___.
MEDICATIONS:
___ are being discharged on your home medications plus several
new ones. ___ no longer need to take acid reflux medications
like omeprazole or nexxium. Because ___ had atrial fibrillation
or afib in the hospital, and ___ cannot take pradaxa for now (it
cannot be crushed and ___ are not allowed to take pills for the
next two weeks), ___ are leaving with a prescription for
Coumadin. This is a blood thinner similar to pradaxa, but
requires monitoring, which your primary care physician ___
provide. It is imperative that ___ call and set up an
appointment with your primary care doctor within 2 days of your
discharge from the hospital.
ALCOHOL:
___ should refrain from alcohol at all costs. A medication ___
were given to treat alcohol withdrawal (phenobarbital) will
remain in your system for a week after ___ stop taking it. When
mixed with alcohol, it causes a high risk of respiratory
suppression which can be life-threatening. Make sure ___ report
any urge to drink to a physician or relative who can help ___.
We recommend social work and withdrawal counseling services.
Thank ___ for letting us participate in your care!
Good luck! | Patient was admitted to the ICU from the ED for management of
her altered mental status. Her ICU course by systems is the
following:
Neuro: She was placed on a phenobarbital taper for potential
alcohol withdrawal. Toxicology screens were negative, including
an ETOH level. Her source of her mental status decline was not
fully diagnosed. Her CT head was normal. Her mental status began
to improve and by transfer, she was AAOx3 without any deficits
CV: She was in rapid afib upon arrival and started on a
diltiazem drip with IV metoprolol for breakthrough. Cardiology
was consulted who recommended cardioversion with a TEE
before-hand. Given her recent surgery, it was decided to forgo
the TEE. A TTE was obtained which showed preserved EF with some
moderate pulmonary artery hypertension. She converted to sinus
on ___ and was transitioned to PO diltiazem and metoprolol.
Resp: She was protecting her airway throughout this time. CT
scan showed b/ pulmonary effusions but she was stable on nasal
cannula.
GI: She was initially made NPO. CT A/P just showed post-surgical
changes, an UGI was negative for a leak and she was advanced to
a mechanical soft diet on ___ and tolerated it well. She
presented with a significiant transaminitis of an unknown cause.
Her enzymes trended down. A liver duplex was negative for any
flow issues.
GU: She had adequate urine output.
Heme: She was initially started on a heparin drip for afib which
was transitioned to pradaxa.
ID: On arrival, there was concern for sepsis given her slightly
elevated WBC, hemodynamic changes, and altered mental status.
She was started on empiric cefepime. Her WBC normalized and her
hemodynamics imrpoved without any signs of a septic source. UCx
and BCx were negative. Her antibiotics were discontinued and her
clinical status was monitored.
On ___, she was stable for transfer to the floor for further
management. | 329 | 312 |
19127408-DS-12 | 29,463,316 | You were admitted for a positive stress test. After discussion
with your cardiologist, we determined that the stress test
result was probably a false-positive. You had cardiac
catheterization in ___ that demonstrated no angiographically
apparent coronary artery disease, and it is unlikely that you
developed coronary disease that needs intervention in the
meantime.
Your pain was likely either A) acid reflux from possible
recurrence of H.pylori or B) esophageal spasm. We are
recommending you see a gastroenterologist for further
evaluation. You can call our GI department ___
and make an appointment.
In addition, please call Dr ___ office at ___ and
make an appointment to be seen this week for follow-up. | ___ yo F with h/o hypertrophic cardiomyopathy, GERD, HTN p-afib
presenting with episode of burning substernal CP consistent with
severe GERD or esophageal spasm, ruled out for MI but with
likely false positive stress test in setting of habitus,
discharged shortly after arrival to cardiology service.
# Abnormal stress test: Patient presented with symptoms typical
for GERD with negative troponins x3 and no EKG changes. Stress
test showed reversible defect that was discussed with her
outpatient cardiologist as well. It was felt that in light of
typical GERD symptoms and negative MI rule out, as well as poor
study due to habitus, this was most likely a false positive.
Additionally, pt with clean coronaries in ___.
# GERD: Patient has severe typical GERD symptoms, was treated in
past for H. pylori but symptoms have recurred. ___ also now have
element of esophageal spasm. Encourage patient to discuss repeat
EGD or referral to GI with her PCP after discharge. Continued
pantoprazole 50mg BID
# Hypertrophic cardiomyopathy: Continued disopyramide,
metoprolol, furosemide, aspirin
#Asthma: continued albuterol PRN. Patient states does not take
fluticasone or singulair this time of year.
TRANSITIONAL ISSUES:
- Hgb A1c pending at discharge
- Patient instructed to f/u with GI or with EGD referral
- Instructed to make cardiology clinic appointment during
business hours to ___ this week | 115 | 216 |
10116621-DS-11 | 28,927,488 | Dear Mr. ___,
You were admitted to ___ due to recurrent chest pain. Your
EKG was reassuring and your cardiac enzymes were normal. This
reassured us that the pain was unlikely to be related to cardiac
ischemia. You underwent a CT scan of your chest that showed
evidence of a small blood clot in the lungs. This may be
contributing to your pain. You were started on anticoagulation
(blood thinner) for the clot and will need to continue on this
for the next few months at least, and follow up with the clinic
in ___. We do suspect that there may be another source for
your pain, so it is important that you ___ with the
gastroenterologists for an upper endoscopy. We have started you
on the medication sucralfate to help with your abdominal pain.
It was a pleasure taking care of you. We wish you all the best. | ___ with CAD (s/p 3 DES in mid-distal AV groove RCA and in the
distal AV groove RCA between the RPDA and RPL1 and DES to mid
RPDA in ___ during 2 successive procedures during the same
day with significant fluoroscopic radiation exposure) presenting
with persistent chest and abdominal pain.
# Chest and abdominal pain: This pain is chronic and did not
improve after ___ in ___. His ECG remained
unchanged and his troponins were negative, arguing against
ongoing ischemia which would be expected to result in cardiac
myonecrosis. Pharmacological vasodilator nuclear stress test
showed small reversible defect that was felt unlikely to be
contributing to chest pain and was more likely a false positive
result from endothelial dysfunction after his recent ___ MI
and from the PCIs themselves. There was no improvement in pain
with SL NTG or other long acting anti-anginal agents. Pain,
therefore, felt to be less likely from cardiac ischemia. Patient
underwent CTA to look for pulmonary embolus or aortic
dissection. A small RUL subsegmental pulmonary embolus was
noted on CTA; given its size, this was again felt to be unlikely
explanation for extent of pain. Highest suspicion is for GI
etiology. He was treated with omeprazole, GI cocktail, and
sucralfate. Sucralfate was most helpful in resolving symptoms
(although not consistently or persistently), so he was given
sucralfate to take as an outpt. He will have a GI work up
(EGD/Colonoscopy) as outpt to further investigate possible GI
etiology of pain.
# Pulmonary embolus: RUL subsegmental PE found on CTA. No
evidence of right heart strain. Normal hemodynamics. Patient was
started on warfarin with an enoxaparin bridge and encouraged to
undergo colonoscopy as part of age-appropriate cancer screening. | 154 | 283 |
11285029-DS-7 | 29,302,201 | Dear Ms. ___,
Please call ___ to schedule an appointment with dr.
___ ___. I know you still don't feel at best and anxious
that those symptoms will be back, but I trust Dr. ___ will
take care of you and come up with plan to address your disease
in the best way available.
Warmest wishes from ___ Medicine team. | #Nausea and vomiting with streaks of blood
Differential includes ___ tear (most likely) vs
bleeding polyp or ulcer. Reassuringly her imaging failed to show
obstruction and she is passing gas, and her Hgb appears stable.
EGD ___ showed multiple polyps without active bleeding or
obstruction, due to persistent symptoms small bowel follow
through was done and also failed to show obstruction.
- PO PPI daily dose
- As inpatient scheduled Zofran, promethazine and
Ativan were used to control symptoms, weaned off to Zofran
before discharge, will continue for 3 days.
- Patient tolerated full diet before discharge without issues,
but she was still very anxious about having the symptoms again
and requested if the polyps could be removed. I discussed with
her in length with help of the GI team that decision for surgery
can't be taken lightly, especially there is no guarantee it will
cure the symptoms. She understood and somewhat accepted the plan
to discuss further management with her GI doctor ___
___ in the clinic. | 61 | 165 |
13091465-DS-22 | 29,869,365 | Hello Ms. ___,
It was a pleasure taking care of you here at ___.
You presented to us ___ night with a one-day history of
throbbing right-sided headache, blurry vision, and left hand
weakness. Your hematocrit count was 57.6 - consistent with your
diagnosis of polycythemia ___. An extensive MRI of the
tissue/arteries/veins in head and neck was normal.
To relieve your symptoms, you were given a therapeutic
phlebotomy, which relieved your right-sided headache, and
brought your hematocrit down to 50.9.
We wish you all the best!
Your ___ team | # Headache:
1-day history of throbbing ___ right-sided headache (different
from her migraine headaches in the past) accompanied by blurry
vision and right hand tingling. She presented to Dr. ___
office, who told her to go to the ED. After presenting to ___,
___ Head without contrast revealed no acute intracranial process.
MRI Head, MRA Brain/Neck, and MRV Head revealed no acute
intracranial process. Hematocrit was 57.6, and the patient's
symptoms were found to be due to her PV. IV fluids were given
and the patient received a 1-unit phlebotomy on ___.
Post-phlebotomy hematrocit was 50.9. By ___, patient's
right-sided headache have resolved.
# Polycythemia ___:
In addition to receiving phlebotomy, patient received baby
aspirin, but did not receive heparin prophylaxis (declined,
stating she preferred to walk and move her legs instead). The
patient will likely need another phlebotomy treatment within the
next week, and should follow-up with Dr. ___.
# Atypical ductal hyperplasia of right breast:
Found on core biopsy after mammogram in ___ showed
calcification in upper outer quadrant of right breast. Nothing
was done for this problem during this hospitalization. Follow-up
with Dr. ___.
TRANSITIONAL CARE ISSUES;
============================
- Follow-up with Dr. ___ need for further phlebotomy
- Follow-up with Dr. ___ atypical ductal hyperplasia
of right breast | 86 | 204 |
17503719-DS-16 | 26,046,499 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Non weight-bearing, left lower extremity | The patient was transferred directly from an OSH and was
evaluated by the orthopedic surgery team. The patient was found
to have left trimal ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left ankle ORIF (with syndesmotic
screw), which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight-bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 142 | 242 |
17573892-DS-2 | 28,447,282 | You were admitted to the hospital because you had a left foot
infection. You were found to have osteomyelitis of the left ___
toe, and underwent surgical ray resection. You were also treated
with the intravenous antibiotics. You will continue to take
antibiotics for another 8 days. Please note that you CANNOT
drink alcohol while taking the antibiotics as you can have a
very severe reaction.
Weight bearing instructions left foot: Weight bearing to heel
___ a surgical shoe | BRIEF HOSPITAL COURSE:
This was a ___ y/o M with DM2, HTN, afib on digoxin, presenting
with 3 month hx left foot infection treated with augmentin for
three months with x-ray evidence of osteomyeltis involving his
fourth left ray.. As he was a diabetic with necrotic ulceration
concerning for pseudomonal involvement, he was treated with
vancomycin and zosyn initially and underwent fourth left ray
resection. He received a picc line for continued outpatient
intravenous antibiotics. He developed thrombocytopenia during
his hospitalization was seen by hematology who felt that the
thrombocytopenia was related to his infection and consequent
inflammation. It is likely that the zosyn also contributed to a
drug induced thrombocytoepenia. He was switched from vanc/zosyn
to vancomycin and cefepime and his platelet count stopped
dropping. He will have vancomycin trough drawn on ___ for
review by his PCP for dose adjustment, as well as creatinine
while on intravenous antibiotics, and CBC to trend his platelet
count. Additionally he will have his INR followed by his PCP
while being treated with coumadin for his atrial fibrillation
with goal INR ___. | 80 | 180 |
12250982-DS-9 | 24,127,380 | Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for shortness of breath initially to the ICU. You were
found to have a bacterial infection of your bloodstream, which
you will need to complete a course of antibiotics for at home
through a special catheter in your arm, and your port was
removed. You also underwent your radiation treatments while you
were here, and we decided that chemotherapy at this point would
probably do more harm than good. We treated your COPD while you
were here, and you should complete a tapered course of steroids
as instructed. Please follow-up with your outpatient providers
as listed below.
We wish you all the best!
Your ___ team | ___ with stage IIIb lung cancer currently undergoing
chemotherapy, COPD on home 2L O2, who presented with SOB and
hypoxia likely due to a COPD exacerbation, found to have GNR
bacteremia. | 122 | 31 |
11945713-DS-3 | 26,231,178 | You were admitted to the hospital after a motor vehicle
accident. You lossed consciousness at the scene but your injury
is a broken collar bone (clavicle). You were evaluated by
orthopedics for this who determined your injury to be
nonoperative. You should remain in a sling and not bear weight
on your left arm for 2 weeks until you follow up in ___
clinic. You remove your arm from the sling from time to time and
perform range of motion exercises.
You will receive a prescription for pain medication to take by
mouth. Take the medication as prescribed as needed. Narcotic
pain medication can cause constipation so it is generally
recommended that you take an over-the-counter stool softener
such as colace or milk of magnesia to prevent this. Narcotics
also cause sedation so do not drink alcohol or drive/operate
heavy machinery while taking narcotic pain medications. | Mr. ___ was admitted on ___ under the Acute Care Surgery
service after his accident. Upon review of his films it was
determined that his only injury was a distal left clavicle
fracture. A spinous process C6 fx was seen but determined to be
old from a prior accident. C-collar was cleared.
Orthopedics was consulted for the clavicle fracture who
recommended nonoperative management with a sling and
nonweightbearing X 2 weeks. Outpatient f/u was scheduled for 2
weeks from discharge.
Occupational therapy was consulted for cognitive evaluation
cognitive + LOC, who recommended that the patient f/u with
cognitive neurology after discharge. Information regarding this
was given to the patient.
On ___ he is afebrile and hemodynamically stable. His pain is
well controlled on an oral regimen and he is able to ambulate
independently. He is tolerating a regular diet. He is being
discharged home with f/u with orthopedics and cognitive
neurology. | 146 | 149 |
17781503-DS-13 | 28,257,141 | Ms ___,
You were admitted to the hospital with leg pain. You were
evaluated for a cause for the pain but unfortunately we could
not find one despite many different images including MRIs and CT
scans. You were treated with pain medication and your pain was
better controlled. Please take your medications as directed and
follow up as directed below. | Ms. ___ is a ___ lady with a PMH significant for colon
cancer with known mets to the liver, bone, and lung who is
admitted from the ED with right leg pain.
# Right leg pain:
Concerning for complication of her known metastatic malignancy.
Ultrasound showed no DVT, and plain films of leg showed no
fracture or obvious lesion. She has known spinal mets and MRI of
the ___ in the last 2 weeks did not show any cause for the
right ___ pain. Had CT scan of ___ to eval for pain but CT scan
showed no fracture or osseous lesion to explain the pain. MRI of
the leg was obtained to evaluate for metastatic disease and was
negative. MRI of the back was obtained to see if any interval
change had occurred in the last 2 weeks and there is mild
progression of disk buldging now touching the thecal sack but
there are no unstable process or any operable features for pain
control. Aldolase level mildly elevated with normal CK and no
muscle enhancement on MRI makes myositis unlikely. She was
started on oxycodone ___ PO Q4 hours, Tylenol, ibuprofen,
and fentanyl patch with the assistance of the palliative care
team who followed the patient while she was in the hospital. She
continued to demonstrate improved pain control requiring only
minimal oxycodone PRNs while on Fentanyl 72mcg Q72H. She will
likely benefit from outpatient palliative care involvement.
# Levido Reticularis
On day prior to admission the patient was noted to have evidence
of levido reticularis of her right thigh which appeared
unchanged over a 24 hour period. She has not had new symptoms
and all of her imaging including LENIs were recently negative
only a few days prior. Given clinical stability, normal labs,
negative imaging and lack of new symptoms I believe it is safe
for patient to be discharged home to continue her maintenance
pain management as directed by oncology and palliative care
consultations. I discussed the plan with patient who is in
agreement to not pursue additional work up in house and she will
discuss with her PCP if she wants to evaluate for underlying
pathology such as embolic phenomena, vascular disease,
rheumatologic disease etc. I also discussed this with the
oncology consultant who is also in agreement. Given her goals of
care and focus on quality of life work up for Livedo Reticularis
may not be warranted at all. However, will defer that final
decision to outpatient providers.
# Metastatic colon cancer:
Most recently on FOLFIRI. Patient has elected to forgo chemo
therapy during last two treatment sessions. Case discussed with
Dr. ___ ___ (primary oncologist).
# Sickle Cell Trait
# Anemia: Stable
# Vitamin D Deficiency: Continued home Vitamin D 1000 units
daily | 63 | 468 |
16880700-DS-29 | 20,647,673 | Ms. ___,
It was a pleasure to participate in your care. You were admitted
for low sodium. You received IV fluids and your condition
improved. You were also treated for a urinary tract infection.
Best Regards,
Your ___ Medicine Team | PATIENT SUMMARY:
================
___ with PMH of angioimmunoblastic T cell lymphoma and Burkitt
lymphoma (on azacitidine ___ and SIADH, who was
admitted from her SNF with reported hyponatremia to 123 from
baseline of low 130s. S/p 1L NS with initial improvement of Na
to 130, uptrended to 134 on discharge. Also found to have
positive UA, started on CTX, with culture and sensitivities
resulting following discharge showing citrobacter sensitive to
cipro. | 38 | 69 |
17330499-DS-21 | 29,517,788 | Ms. ___,
You were admitted to ___ due to symptoms of fever and
confusion in the context of a several day history of productive
cough. Based on these symptoms and clinical findings, you were
diagnosed with pneumonia. We treated your pneumonia with
levofloxacin for 5 days. You completed this treatment on ___.
You tolerated this treatment well and your symptoms improved.
You will be discharged to a rehab facility to continue your
recovery.
During your hospitalization your blood pressure was often high.
To address this we restarted the medication
(hydrochlorothiazide) that you had been taking last year. You
tolerated this medication well and it helped control your blood
pressure. You should follow up with your primary care physician
about your high blood pressure, and the best possible treatment.
It was a pleasure caring for you during this hospitalization and
we wish you the best of health.
Sincerely,
Your ___ Care Team | This is a ___ year old woman with a poorly characterized past
medical history who presents for confusion and delirium in the
setting of cough and fever most concerning for
community-acquired pneumonia and an episode of elevated troponin
in the setting of concern for ECG changes at an outside
hospital. Her hospital course by problem is summarized below.
#COMMUNITY ACQUIRED PNEUMONIA: She had a productive cough with
fever to ___ and WBC 11 at ___, exam with diffuse
wheezing and ronchi R>L, and CXR without clear evidence of
consolidation. Flu swab negative. She was treated with a 5 day
course of levofloxacin for presumed CAP with notable clinical
improvement. She was also treated with duonebs for persistent
wheezing. Early in her stay she required supplemental oxygen but
was discharged to rehab stable on RA.
#TOXIC METABOLIC ENCEPHALOPATHY: Thought to be likely
multifactorial secondary to mild dementia and overlying delirium
in the setting of infection, possible overuse of OTC cold
medications. We held her home amytriptyline.Her mental status
improved over the course of her hospitalization and at the time
of discharge was at her baseline.
#TROPONINEMIA: Elevated troponin at the OSH to 0.11, repeat at
___ was <0.01. There an EKG was taken that was thought to have
lateral ST depressions but this appeared unchanged from prior
ECGs (___) when compared to those available here. Repeat ECG in
the ___ ED was also stable. Denied chest pain throughout her
stay. The troponin leak occurred in the setting of infection,
tachycardia and hypertension and thus the leading cause is
likely demand ischemia that resolved with treatment of her
underlying conditions.
#HTN: Systolic BP as high as 170-180 while at ___. She had
previously been treated for HTN (lisinopril and HCTZ) but was
discontinued in ___ during an episode ___ s/s
dehydration. Her previous HCTZ was restarted during this
admission.
#TRANSITIONAL ISSUES:
- Please consider arranging follow-up with a Cardiologist for
follow-up of this tropnoninemia. | 146 | 317 |
11309536-DS-5 | 28,559,310 | You were treated at the hospital for symptomatic cholelithiasis
with a laparascopic cholecystectomy.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse, changes location, or moves to your chest or back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed Cholelithiasis without
evidence of cholecystitis. 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 on
IV fluids, and IV morphine ___ 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. | 322 | 190 |
12455473-DS-18 | 28,796,880 | Dear Mr. ___,
It was a pleasure to care for you at ___. You came to our
hospital for right arm redness and pain. We evaluated your arm
for a blood clot and it did show a superficial vein blood clot,
but no deep vein clots. This is likely the cause for the pain
and redness and it is likely related to your recent chemotherapy
treatments.
There is no need to treat the blood clot with blood thinners at
this time. Please make sure to call your doctors ___ present to
the emergency room if you have worsening pain, swelling, or
redness, of if you have fevers, chills, or sweats.
Please continue to use hot compresses to your arm, and you can
use Motrin/ibuprofen 600mg up to every 8 hours as needed for
pain. Always take this with food. | Mr. ___ is a ___ male with history of poorly
differentiated adenocarcinoma of gallbladder on neoadjuvant
chemotherapy with gemcitabine and cisplatin (C1D12, last dose
___ who presents with one day of right arm erythema, swelling,
and pain, found to have two tender cords on exam with ultrasound
confirmin superficial cephalic vein clot.
# Superficial Thrombophlebitis: Patient with symptoms
predominantly concerning for superficial thrombophlebitis of the
right upper extremity given palpable superficial vein tender to
palpation. The surrounding erythema is likely related to
inflammation from the phlebitis. Tenderness if over the cords,
but not over skin. He currently has no systemic signs of
infection. Of note, no neutropenia noted on admission. Low
suspicion for septic arthritis of the wrist at this time or for
cellulitis. Right upper extremity venous ultrasound confirmed
superficial cephalic vein thrombus, but no DVT. Erythema
demarcated and patient will be followed in clinic in three days.
Received Vancomycin for initial concern for cellulitis, but this
was discontinued. Will continue warm compresses and will treat
with NSAIDs and close follow up.
# Poorly Differentiated Adenocarcinoma of Gallbladder: Currently
on Gemcitabine/Cisplatin, C1D12. Thrombophlebitis likely related
to Gemcitabine and so discussed obtaining a port to prevent
further episodes.
# Anemia/Thrombocytopenia: Likely secondary to malignancy and
chemotherapy. No evidence of active bleeding.
# Constipation/hemorrhoids: Likely exacerbated by Zofran.
Continued bowel regimen. Patient has hemorrhoidal cream at home.
TRANSITIONAL ISSUES
======================
[] Will need a port placed for further Gemcitabine/Cisplatin
infusions.
[] NSAIDs with food and warm compresses to treat superficial
thrombophlebitis.
[] F/u FINAL blood cultures.
[] EMERGENCY CONTACT HCP: ___ (wife) ___, ___
___ (son) ___ | 136 | 257 |
18058181-DS-24 | 22,586,880 | Dear Ms. ___,
You were hospitalized at ___ after being found confused
with slurred speech. Your doctors think that this was most
likely due to a seizure. You were admitted to the Neurology
Service and monitored for seizures.
While in the hospital, an MRI was done. Your AVM was stable
(no new change or bleed) compared to prior imaging. You were
monitored on EEG. Though no convulsive or clinical seizures
were detected, multiple seizures without clinical correlate
(non-convulsive electrographic seizures) were detected. You had
no symptoms from these. While your anti-seizure medications
were optimized, new agents were not started because these events
were not interfering with your life.
After talking with your daughter, you were felt to be your
normal self and were safe for discharge. Given the change in
your phenytoin dosing however, your doctors request that ___ get
a phenytoin level drawn on an outpatient basis. This should be
a "trough" level, drawn roughly ___ minutes prior to your
morning dose. This was ordered for you and may be done at any
___ lab in ___ weeks.
If you have any questions following discharge, please feel
free to contact ___ 11 or Dr. ___ office.
It was a pleasure taking care of you,
Your ___ Care Team. | Ms ___ is a ___ woman with L AVM s/p embolization and
radiation c/b seizures (on Keppra, phenytoin, and zonisamide);
who presents with slurred speech and confusion. Reportedly she
had been out bowling and was very thirsty but waited for ___
hours until she got home to drink, where she says she wasn't
feeling well and so activated her life alert. Initial exam
largely nonfocal other than waxing and waning altered mental
status, and perseveration. She was admitted due to concern for
seizure (given her history). Her mental status improved by the
next morning. MRI was stable from prior. EEG showed multiple
electrographic seizures over the L occipital lobe that were
without clinical correlate and with normal mental status. She
was loaded with additional phenytoin, with reduction in
electrographic seizure frequency -- but no change in already
normal clinical status. Her home phenytoin was increased to
200/150mg to 200 BID, and zonisamide increased from 100/200mg to
200 BID. She will follow-up with Dr. ___ have her
phenytoin levels monitored to ensure she does not become
supratherapeutic. She was at her cognitive baseline, per family.
Electrographic seizures were discussed with them, and they
agreed to return to the ED if there was any change in mental
status. | 227 | 207 |
14087169-DS-18 | 27,482,267 | Dear Ms. ___,
You were admitted to ___ with severe back pain. Unfortunately
you were found to have a fracture in your back as well as
lesions that were concerning for cancer. You underwent further
workup and testing for these lesions while you were in the
hospital. You were also started on pain medications to help with
your pain. Please do not drink alcohol or drive while taking
oxycodone or MS ___. Please take your medication as
prescribed involved with doctors as recommended below.
We found breast cancer on biopsy that we think has spread to the
spine bone. You will see cancer specialists in follow up.
It has been a pleasure taking care of you and we wish you the
best. | ___ with h/o recent L breast mass (pending workup) who presented
with severe back pain and was found to have multiple lytic
lesions consistent with metastatic malignancy.
#SECONDARY MALIGNANT LESION OF BONE
#SEVERE LOW BACK PAIN
Pt was found to have metastatic lesions as well lumbar vertebral
compression fracture. MRI L spine showed no cord compression.
She was seen by NSG in ED who did not recommend surgical
intervention. Appearance is most suggestive of a metastatic
solid tumor. Metastatic breast cancer was strong consideration
given her known L breast mass. CT torso was performed for
staging which showed enlarged paratracheal LN and RUL nodule as
well. She underwent ___ guided biopsy of L3 vertebral body on
___. Her MRI also shows possible tumor extension vs right psoas
muscle reactive myositis however CK was normal and CT showed no
abnormal enhancement. She underwent ___ guided L3 bone biopsy on
___. She was started on MS ___ and oxycodone PRN for pain
control, as well as APAP and lidocaine patch. She underwent
workup for breast mass as below. SPEP/UPEP negative. ___
consulted and the plan was initial to perform kyphoplasty on
___, but because of another technique with ablation technology
may cause superior pain control, kyphoplasty was deferred. ___
helped arrange follow up for return to hospital for ablation
procedure as this was not available to inpatients. ___ consulted
to help patient mobilize more and work on walking up stairs.
- ___ pathology from vertebral biopsy
#Metastatic Breast Cancer (bone path currently pending): She
underwent b/l mammogram and L breast u/s on ___ that showed 2
masses with associated skin thinking, highly suspicious for
malignancy. The dermal based nodule was not contiguous with
mass, and was suspicious for skin met. She also was found to
have 3 abnormal L axillary LNs. She underwent FNA of breast mass
on ___. Breast surgery was consulted during hospitalization.
Breast path showed: Invasive ductal carcinoma, grade 3,
measuring at least 13 mm in this limited sample, see note.
ESTROGEN RECEPTOR: POSITIVE (>95%, strong)
Internal control: Not present
PROGESTERONE RECEPTOR: POSITIVE (approximately 80%, strong)
Internal control: Not present
HER2/NEU PROTEIN: EQUIVOCAL (2+)
She was set up with Medical oncology, Dr. ___ to see
her on ___. Radiation oncology consulted and will see patient
in ___ and will contact her once they know the bone path result.
#SW Also consulted to assist ___ resources.
Met w/ Ms. ___/ interpreter and ___ ___
Ms. ___ is worried about being out of work and without pay as
well as transportation. Ms. ___ and ___ dtr came to the ___.
___
years ago after her other family members petitioned for their
arrival. She lives with her family and has a strong support
system. She has given permission to speak with her brother
regarding logistics including the ride.
Discussed the RIDE 30 day medical necessity and Ms. ___ is
agreeable to apply. She thinks that her family will help her
with
the cost of $6.30 round trip (caregiver rides free).
Discussed applying to ___ for grocery cards and for
assistance funding the RIDE.
Ms. ___ was tearful as it is her ___ y.o. dtr graduation
today.
Emotional support provided.
Will ___ once RIDE approved and re: ___. Will also
request pt to pt funding.
___
#constipation: pt had not been moving her bowel prior to
presentation due to pain with movement and decreased PO intake.
Now likely worsened by narcotics. She was started on aggressive
bowel regimen of docusate, senna, miralax, bisacodyl
#uterine and cervical lesion: seen on CT torso that was
performed for malignancy workup. Recent pap results from PCP
office performed ___ were obtained and showed no abnormality
other than inflammatory changes. Pt denied any abnormal bleeding
or vaginal discharge. Pelvic u/s was performed and showed no
abnormality.
The nature of hospitalization and pending studies and ___ plans
were communicated to RN at the ___ who
works with patient's PCP ___ : ___. I
provided my phone number and email and received the fax number
to fax over copy of this discharge summary.
>30min on discharge coordination | 121 | 664 |
15532923-DS-22 | 23,720,898 | Dear ___,
___ came to ___ for abdominal pain and were found to have a
stone obstructing one of your bile ducts. ___ had a procedure to
remove the stone, along with symptomatic treatment for pain.
Your liver enzymes were elevated, which is expected when ___
have an obstruction of your bile ducts. Thankfully these liver
enzymes have slowly decreased.
Please follow up with your primary care doctor and also with
your gastrointestinal doctor once ___ have been discharged. ___
and your GI doctor can consider a cholecystectomy to prevent
future episodes of stone pain after discussing the benefits and
risks of each option. Continue ciprofloxacin antibiotic for five
days.
We wish ___ a speedy recovery. It was a pleasure taking care of
___!
Sincerely,
Your ___ team | Mrs. ___ is a ___ year old woman with a PMH of afib (not on
anticoagulation), HLD, GERD, Fibromyalgia, perforated
diverticulitis in ___ s/p sigmoid resection, bowel perforation
from C diff colitis s/p emergent subtotal colectomy with end
ileostomy in ___ and ostomy takedown in ___, IBS and
chronic diarrhea, presenting with abdominal pain triggered by
meals, nausea, vomiting, and elevated LFTs concerning for a
hepatobiliary process.
# Transaminitis/abdominal pain: Patient initially admitted to
___ for concern of cholecystitis. However HIDA scan was
negative. Patient was found to have cholelithiasis and mild CBD
dilation of 9mm. Patient was transferred to medicine for further
management. MRCP showed choledocholithiasis. Patient underwent
ERCP on ___. LFTs continued to downtrend.
- GI consulted.
- Hep panel negative; also not immune to Hep B.
- Pain control w/ Dilaudid, and home gabapentin.
- Pt sent home with plan for elective CCY as soon as possible.
- 10 day course of Cipro for cholangitis ppx after ERCP.
# Lose stools: Patient notes this has been her baseline since
her C.diff colitis and complications. She has seen a
nutritionist and has improved slightly, but still has lose,
watery stools. Rifaximin was started for SIBO. Diarrhea starting
to improve slightly.
- Continue Opium Tincture (morphine) PO ___ PRN TID-QID.
- Continue Diphenoxylate-Atropine 2 tab PO TID.
- Continue Rifaximin 550mg PO TID. | 125 | 217 |
18627390-DS-16 | 24,153,904 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you had Acute Lymphoblastic
Leukemia.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a bone marrow biopsy that showed acute lymphoid
leukemia.
- You were treated with Prednisone and Dasatinib.
- You had a lumbar puncture and received methotrexate.
WHAT SHOULD I DO WHEN I GO HOME?
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors
Thank ___ for letting us be a part of your care!
Your ___ Care Team | Ms. ___ is a ___ female with PMH depression,
anxiety, IBS-C, scleroderma, hypogammaglobulinemia and HTN who
presented as a transfer and was found to have Pro-B Ph+ ALL.
# Pro-B Ph+ ALL:
On acmiddion patient had pancytopenia concerning for marrow
infiltrative process with circulating cells concerning for
blasts. Flow and cytogenetics were consistent with Pro-B
___ chromosome positive ALL (pos CD34, CD19, CD10,
C79a, and Tdt and 9;22 translocation). Patient was started on
prednisone 60 mg BID and Dasatinib 140 mg daily. Patient was
changed to Dasatinib 70 mg PO q12h. On Day ___, patient
had repeat bone marrow biopsy and LP with intrathecal
methotrexate. Per Dasatinib protocol, prednisone was tapered
starting on day 24 and will continue until day 32 (___). She
required platelet and pRBC transfusions during admission.
Patient received ciprofloxacin, Bactrim, micafungin and
acyclovir during her stay. Ciprofloxacin was discontinued when
neutropenia resolved. Micafungin was discontinued on day of
discharge. Patient will follow-up with Dr. ___ as an
outpatient.
# Thrombocytopenia:
Patient developed thrombocytopenia which did not improve despite
multiple platelet transfusions. She received aminocaproic acid
while thrombocytopenic until platelets improved greater than
50K. HLA PRA was 73% and required HLA-matched platelets during
admission. Her last platelet transfusion was on ___.
# Folliculitis:
Prior to admission, patient had ___ days of inflamed groin
nodule and was started on Bactrim. There was concern for abscess
v. leukemia cutis on admission. Dermatology evaluated the nodule
and determined it was folliculitis. Patient was started on
Bactroban with subsequent improvement in nodule.
# HTN:
Home metoprolol succinate was held on admission. Patient will
re-start home metoprolol succinate 12.5 mg on discharge.
# Anxiety/Depression
Patient had anxiety regarding diagnosis during admission. She
received PRN Ativan for anxiety. She continued home sertraline.
# Hyperglycemia:
Patient has known history of prediabetes and has never taken
medication. She had serum glucose ~250 and was started on an
insulin sliding scale. Her hyperglycemia was thought to be due
to prednisone. Prednisone will be tapered and discontinued on
___.
=======================
TRANSITIONAL ISSUES:
=======================
[ ] ___ CT Abdomen/Pelvis w/ & w/o contrast demonstrated
left ovarian cyst measuring 4.9 cm and is simple in appearance.
Please do follow-up ultrasound in one year.
[ ] Fingerstick blood sugars elevated during admission with
patient requiring insulin sliding scale. She will have
prednisone tapered and stopped on ___. She should have ___
checked as an outpatient after she has been off prednisone for
greater than 90 days. She has history of prediabetes.
[ ] Aspirin was held upon admission given pancytopenia. Consider
restarting once counts recover. | 120 | 420 |
19299113-DS-15 | 23,751,288 | Dear Ms ___,
You presented to ___ with abdominal pain,
somnolence, emesis, and respiratory distress.
You were found to have an infection and myasthenia crisis. You
were treated with plasmapheresis, IVIG, and antibiotics. Your
potassium and magnesium were found to be low. You were seen by
the surgery, interventional radiology, neurology, medicine,
nephrology, and infectious disease specialists.
You received a CT scan which showed a new abscess.
Interventional radiology performed a procedure and you expressed
strong wishes to go home the next day.
We set up ___ services for you after leaving the hospital.
Additionally, you should follow up with your primary care doctor
and your neurologist as an outpatient. We also recommend follow
up with surgery and a gastroenterologist. You will need regular
lab checks after leaving the hospital to monitor your potassium,
magnesium, and other electrolytes as well as your blood count.
We wish you the best,
Your ___ team
Instructions for Drain Care:
You will be going home with your surgical drain. Please look at
the site every day for signs of infection (increased redness or
pain, swelling, odor, yellow or bloody discharge, warm to touch,
fever). Maintain suction of the bulb. Please flush drainage
catheter with 10 cc of sterile saline twice daily. Note color,
consistency, and amount of fluid in the drain. Call the doctor,
___, or ___ nurse if the amount increases
significantly or changes in character. Be sure to empty the
drain as needed and record output. You may shower; wash the area
gently with warm, soapy water. Keep the insertion site clean and
dry otherwise. Avoid swimming, baths, hot tubs; do not submerge
yourself in water. Make sure to keep the drain attached securely
to your body to prevent pulling or dislocation. | TSICU COURSE
=============
She was admitted to the TSICU after being intubated in the ED
for respiratory failure, and was put on vancomycin and Zosyn.
She initially required pressor support which was thought to be
mainly driven by propofol sedation and was quickly weaned as
propofol was weaned as well.
On hospital day 2 she was extubated and was being to room air.
Neurology service was consulted who recommended hydrocortisone
50 mg every 6 hours and started plasma exchange while she was in
the TSICU. CT scan done on ___ showed that the abscess
has now organized more and is smaller in size with less fat
stranding and is now located anterior to the tip of the pigtail
catheter.
From a GI standpoint she was kept n.p.o. due to failing the
bedside speech and swallow which was thought to be in the
setting of myasthenic crisis initially.
Infectious disease service was consulted and recommended
discontinuing vancomycin which was done and continuing Zosyn,
with consideration of long-term ertapenem as outpatient.
On HD5 the patient was hyperventilating in the Am and was
hypercarbic was put on Bipap, neuromuscular service recommended
restarting pyridostigmine and watch for increased airway
secretions. since the patient did not have any surgical issues
and her only remaining problems were neurological issues at that
point the neuro-ICU service was contacted who accepted the
patient.
Neuro ICU course
===========================
She was transferred to neuro ICU team ___ due to electrolyte
abnormalities, anemia, diarrhea and complex care. Electrolytes
were aggressively repleted although she often declined various
doses. Her diarrhea decreased. She received IVIG ___ with plan
for ___nd tolerated this well. For slowly drifting
anemia with Hgb 6.6->6.2 (hemodynamically stable, she received a
unit of pRBC on ___. For her perforated diverticulitis her
antibiotics were changed back from vanc/cefepime to zosyn. Plan
is for 7 day course once drain is pulled. Given stability and
improvement, she was transferred back to the general service
care on ___.
NIMU course
=======================
Ms. ___ is a ___ year old woman with myasthenia ___ (AChR+,
possibly thymoma +, not resected) initially admitted to ICU ___
for myasthenic crisis beginning within hours of discharge for
divericulitis/pelvic abscess drained ___. She received several
sessions of PLEX; however, given c/f abdominal
abscess/infection, she was then switched over to IVIG, of which
she completed a 5 day course (last day ___. Respiratory
parameters were been limited by poor effort with NIF testing
(patient refuses them often), but she was stable clinically with
good strength on neck flexion. She continued on IV zosyn for
continued management of her abdominal infection per ID recs.
Her course was complicated by diarrhea associated with mestinon
(now resolved), leukocytosis, as well as hypokalemia,
hypomagnesemia. Medicine and nephrology were consulted regarding
the electrolyte abnormalities; it was felt that her low
magnesium and diarrhea early on during her hospital stay were
contributing to her hypokalemia. They provided recommendations
regarding electrolyte repletion. Overall, her MG symptoms have
been improving with PLEX and IVIG. She also continued on
prednisone 30mg daily with plan to taper down by 5mg weekly
starting on ___.
- Continue PO potassium chloride replacement 40 mEq daily until
follow-up with her PCP.
- Continue PO magnesium oxide replacement 200mg daily until
follow-up with her PCP.
For the abdominal abscess, surgery, ___, and ID have provided
recommendations. ID recommended to continue Zosyn 4.5g IV Q8H
and once drain is removed, continue Zosyn for another week after
drain removal. ACS recommended repeat CT pelvis with rectal
contrast prior to discharge, which showed new R gluteal abscess.
ACS recommended upsizing of the existing drain and new drain
placement in the new R gluteal intramuscular abscess. Ms. ___
was in agreement with drain upsizing, but did not agree to
placement of a drain in the new abscess. Thus, she underwent ___
procedure for aspiration of the intamuscular abscess and
upsizing of diverticular abscess drain on ___.
The surgical team (attending Dr. ___ agrees with the
plan for her to be discharged on ___, with the drain in place,
continuing antibiotics and with close follow-up in the surgery
clinic.
TRANSITIONAL ISSUES
-------------------
#HypoK, #HypoMag
[]Patient has a primary care appointment on ___
-please check CBC, chem-10 to ensure that Hgb is above 7 and
check electrolyte levels, especially K, Mag. Repletion as
necessary.
___ will check electrolyte and CBC twice/week; results will be
faxed to PCP ___
#Pelvic abscess
#R gluteal abscess
[]follow up with surgery outpatient - Dr. ___ at the ___ Care
Surgery Clinic in ___ weeks. ___ Office Number: ___
___ service set up for zosyn infusion at home
[]continue Zosyn 4.5g IV Q8H and once drain is removed, continue
Zosyn for another week after drain removal
___ will check electrolyte and CBC twice/week; results will be
faxed to PCP office and PCP office has been notified of this
[]follow up with infectious disease outpatient
#Myasthenia ___
[]follow up with outpatient neurology
[]continue Prednisone 30mg daily until ___, then decrease by
5mg per week with plan to remain on Prednisone 10mg daily
ongoing or until follow-up with outpatient neurologist, Dr. ___
___ []25mg prednisone daily
___ []20mg prednisone daily
and so on until back to 10mg daily | 284 | 838 |
15325140-DS-11 | 24,270,552 | Dear Ms ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have a heart attack.
- You had a procedure to assess the arteries around the heart.
There were two blockages found that were stented. You were
started on medications to prevent further blockages in your
heart.
- You were found to have fluid in your lungs after the procedure
and were given medications to help remove the fluid.
- An ultrasound of your heart showed mildly reduced heart
function.
- A physical therapist evaluated you and found that you were
safe to go home independently.
- When your chest pain improved, you were discharged home.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- If you experience severe chest pain, worsening shortness of
breath, or loss of consciousness, please return to the Emergency
Department.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES:
====================
- F/u TTE in 3 months for akinetic apex and concern for thrombus
- please monitor LFTs on atorvastatin 80mg
- Patient would benefit from improved diabetes control. Hb A1c
while inpatient is 8.5%
- Patient's hydralazine and amlodipine were discontinued due to
orthostasis. Please follow-up on antihypertensive regimen as an
outpatient. Ensure medication compliance as patient became
orthostatic when she was given home antihypertensive
medications.
- New medications on discharge: Clopidogrel 75 mg and
atorvastatin 80 mg
- Discharge Cr: 1.1, discharge weight: 133 lb, discharge
diuretic: torsemide 20 mg | 186 | 89 |
10345778-DS-18 | 29,296,823 | -drink plenty of water
-minimize constipation
-no heavy lifting
These steps can help you recover after your procedure.
DO drink plenty of water to flush out the bladder.
DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
Don't take blood-thinning medications until your doctor says
it's OK.
Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is OK unless it transitions from ___,
___ Aid to a very dark, thick or like tomato juice
color
Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a trial of void or void trial).
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 it is available
over-the-counter
AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
No vigorous physical activity or sports for 4 weeks or until
otherwise advised
Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery. | Mr. ___ was admitted to the urology service from the ED and
kept on CBI with hand irrigation as needed to remove clot. His
hematocrit was stable through his admission. By the day of
discharge, his urine had cleared and he passed a void trial. He
was discharged home with instructions to call in or return to
the ED if he was unable to urinate or had further hematuria. | 474 | 70 |
13569498-DS-21 | 23,899,714 | Dear Mr ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came in for fevers
What did you receive in the hospital?
- You were found to have pneumonia
What should you do once you leave the hospital?
- Continue to take the medications we prescribe you
- Follow up with all your doctors ___ as below
- Be sure to have someone help you eat, and follow a careful
puree'd and thickened diet (see diet section)
We wish you the best!
Your ___ Care Team | Mr ___ is a ___ with PMH of Down Syndrome (complicated by
progressive Alzheimer's dementia) and history of recurrent
aspiration PNA, presenting with fever and pulmonary infiltrate
consistent with
recurrent aspiration PNA. The patient completed a 5 day course
of cefepime and
metronidazole with improvement in leukocytosis, fever, and
oxygen requirement. His hospitalization was complicated by
frequent nighttime oxygen desaturations. Goals of care
discussions were initiated with the family, and while it was
ultimately deemed appropriate that the patient be discharged
back to the group home that he is currently living at, hospice
applications were placed for additional support there. | 105 | 98 |
14915593-DS-21 | 24,178,469 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for an infection ___ your knee
which required a surgical procedure to remove the infected
material. The plastic liner ___ your knee was replaced during
the procedure. You were treated with antibiotics and are doing
better, although you will need to continue intravenous
antibiotics as an outpatient to fully treat the infection and
you will need to go to a rehabilitation facility to get your
mobility back. You should follow up with the infectious disease
specialists (see appointment below) and with your original
orthopedic surgeon at ___.
The following medications were ADDED:
CONTINUE Ceftriaxone 2gm intravenously one time daily - course
will be decided by Infectious disease physicians.
TAKE tylenol ___ every 4 hours as needed for pain. Do not
exceed 4gms per day.
TAKE oxycodone 5mg by mouth every 6hours as needed for pain.
CONTINUE lovenox 30mg 1 syringe twice daily, continue for 2
weeks
TAKE Lisinopril 10mg (you used to take 20mg) by mouth daily.
While on all these pain medications you are at risk risk for
constipation. Please take the following medications regularly
to keep your bowel movements soft.
TAKE senna 1 tablet by mouth twice daily.
TAKE docusate sodium 1 tablet twice a day by mouth.
TAKE Miralax 1 packet by mouth daily.
Please continue your other medications as prescribed. No other
changes have been made. | ___ year-old woman with DMII, HTN, HLD, obesity and CKD presented
one week after a mechanical fall with right knee Group G strep
cellulitis, septic joint, and evidence of osteomyelitis of the
surrounding bones, as well as a UTI.
.
# Septic Joint/Osteomyelitis: Joint tap of the right knee showed
impressive septic joint, growing group G strep. Patient was
admitted to the unit after a run of SVT. Orthopedic surgery took
the patient to the OR and performed a right knee washout with
replacement of the plastic liner on ___. A JP drain was
placed for several day which drained serosanginous fluid. Tissue
and bone samples also growing Group G strep, pansensitive.
Patient was inititially started on vancomycin and levofloxacin
___ the ED, but was broadened to Vanc/Zosyn ___ the unit, and then
switched to ceftriaxone once the cultures returned on ___. ESR
(127), CRP (142.8), suggestive of osteomyelitis as well. Bone
sample also growing Group G strep. Midline catheter was placed
(there was difficulty advancing the PICC further). Infectious
disease was consulted and recommended at least 6 weeks of
ceftriaxone and weekly blood monitoring. Patient will have OPAT
monitoring ___ the outpatient setting (___). TTE study was
suboptimal but did not show vegetations on the valves. TEE did
not show any valvular vegetations. JP drain was removed 2 days
prior to discharge to rehab. Joint was bandaged with dry sterile
dressings during admission. Pain was managed initially with
dilaudid and transitioned to oxycodone.
.
#. Point tenderness and erythema over right wrist: Erythema and
tenderness is surrounding a previous IV site, which suggests
previous infilration by the IV. Xray more consistent with
osteoarthritis. Appearance is somewhat suggestive of a
cellulitis, however it has been improving since administration
of ceftriazone. It has also been treated with warm compresses.
.
#. UTI: Patient had a grossly positive UA with WBC greater than
assay and many bacteria. Initial urine culture was mixed flora
and second culture, after antibiotic administration, was
negative. Patient remained asymptomatic. Continued ceftriaxone
should adequately treat the infection.
.
#. Hypoxemia: Upon transfer from the MICU, patient was 5L above
her normal weight with an oxygen requirement. She was lying flat
and breathing comfortably on 2L nasal cannula. Patient was
given lasix 20mg IV and put out 4L of urine. Soon after, patient
was weaned off supplemental oxygen and breathing comfortably on
room air. Echo shows EF>55%.
.
#. SVT: Patient had a single observed run of SVT to 160s ___ the
ED likely secondary to infection. No repeat episode has been
observed. Patient was monitored ___ the MICU and transferred to
the floor, shortly after without any further events. During her
hospitalization, she remained on diltiazem. It was discontinued
several days prior to discharge without any further events.
.
#. DMII: Held oral diabetic medications while inpatient.
Continued home lantus therapy and covered with an ISS. Finger
sticks remained ___ the mid ___ - mid ___.
.
#. HTN: Initially held lisinopril for concern of low blood
pressure and recurrence of SVT, but we were able to restart it
without any issues. Patient was also ___ diltiazem initially on
admission. Just prior to discharge, lisinopril with discontinued
for a rising creatinine (1.2) and K+ (5.2). Blood pressures were
monitored and systolics were below 140.
.
#. HLD: Continued statin therapy.
.
#. CKD: Initially held lisinopril for low blood pressure. It was
restarted prior to discharge, but again discontinued for rising
K+ and Creatinine. Urine Lytes were unrevealing and her
creatinine improved on ___.
. | 230 | 577 |
12936293-DS-4 | 28,277,149 | You were admitted to ___ for evaluation of lower extremity
weakness and spells of altered consciousness; you were evaluated
by neurology and psychiatry, who determined that these spells
are likely non-epileptic in nature.
Activity:
- You should take safety precautions because of these spells.
Use caution when swimming and bathing. You may drown or become
seriously injured if you have a spell while in water.
- Avoid climbing ladders or performing activities involving
heights unattended.
- Take all medications as directed
- Do not drive. You are not allowed to drive by law if you
experience an episode of altered consciousness.
- Please use your wheelchair at all times for mobility.
- Physical therapy will work with you to help you regain your
strength. They will advise you when you may return to using your
cane/walker, and will further advise you on your activity level. | ___ year old female with bilateral lower extremity weakness and
pseudoseizures.
#Bilateral Lower Extremity Weakness and Pseudoseizures
Pt presented to ED with c/o bilateral lower extremity weakness
s/p fall. CT of the head was obtained for question of seizures
and showed no evidence of acute intracranial process. CT
myelogram was ordered due to the patient being status post
spinal cord stimulator placement. The patient initially refused
CT myelogram when she found out it would not be done under
anesthesia. She was admitted to the floor, and CT myelogram was
ordered with anesthesia. On ___, patient had multiple
seizure-like episodes which consisted of thrashing in the bed,
no loss of consciousness, oxygen saturations remain stable and
there was no post-ictal state.
CT myelogram was completed on ___ and showed no evidence of
spinal cord compression.
24 hour video EEG was ordered, which was negative for epileptic
seizures. Neurology was consulted for their recommendations
related to the patient's bilateral lower extremity weakness and
pseudoseizures and recommended a MRI of the brain to rule out
any acute intracranial process. MRI of the brain showed no
evidence of acute intracranial process and a small area in the
right frontal lobe with possible migranous changes. Neurology
work-up was negative and they believe that the patient's
seizure-like episodes are consistent with pseudoseizures.
Neurology recommended outpatient follow-up with the neurologist
at ___ who had seen the patient during her
previous admissions there. Neurology recommends maintaining the
patient's current antiepileptic drug regimen as her medical
history is unclear and we have not yet received the medical
records from ___. The antiepileptic drug regimen
may be addressed and revised as needed during outpatient
follow-up with the Neurologist at ___.
Psychiatry was consulted for recommendations related to
pseudoseizures. Their differential dx includes conversion
disorder (functional neurological symptom
disorder), which may co-exist with primary seizure disorder, and
complex migraines. Per ___, pt continues to have functional
impairments that would benefit from ongoing rehabilitation.
Treatment for conversion disorder includes ___ to address
functional needs and individual psychotherapy. Pt should follow
up outpatient with her psychiatry team in home town of
___.
On ___, the patient was neurologically stable with the
patient actually reporting some subjective improvement in her
symptoms. She was afebrile, tolerating a diet, ambulating with
assistance, voiding without difficulty, and her pain was well
controlled on her home pain medication regimen.
#Disposition
Physical Therapy and Occupational Therapy were consulted for
disposition planning and both recommended discharge to rehab.
Psychiatry recommends treatment for conversion disorder includes
___ to address functional needs and individual psychotherapy.
Her insurance denied both acute rehab and skilled nursing
facility. ___ worked with her during the continued stay, and she
was able to develop enough strength to be able to go home in a
wheelchair, with visiting home ___. Her boyfriend
arrived with the wheelchair, and she was discharged home without
complication. | 140 | 474 |
10233142-DS-7 | 20,640,463 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you had a heart
attack, which happens when the blood supply to your heart gets
blocked
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You underwent a procedure that showed that one of your
arteries that supplies blood to your heart was almost closed
off. We opened it during the procedure with a metal tube called
a stent, which stays in the artery.
- We started you on a lot of medicines to help prevent a heart
attack from happening in the future and prevent your stent from
clotting and giving you another heart attack
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It is very important to take your aspirin and prasugrel every
day.
- These two medicines keep the stent in the artery open and help
reduce your risk of having a future heart attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You are also on other new medications to help your heart,
including metoprolol and lisinopril. These medicines help to
reduce your blood pressure and keep your heart healthier after
the heart attack. Please take these as directed.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | =====================
TRANSITIONAL ISSUES
=====================
[] New NSTEMI discharged on aspirin, prasugrel, atorvastatin,
metoprolol, lisinopril
[] Should be on ASA 81 indefinitely, prasugrel 10 QD for at
least 12 months
[] Uptitrate metoprolol and lisinopril as tolerated
[] Recommend lipid panel in 1 month to assess adequacy of high
intensity statin therapy, consider adding ezetimibe or PCSK-9
inhibitor if with continued dyslipidemia
[] A1c 5.5% on ___
===================== | 291 | 59 |
Subsets and Splits