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11740165-DS-15 | 27,301,539 | Dear ___ was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
for concern of your biliary drain, and underwent a procedure by
the Interventional Radiology Team to dilate and help this drain
more effectively. While here, we were able to control your pain
with pain relievers, and started you on antibiotics because we
were concerned for a skin infection near your drain entry site.
Please continue to take all of your home medications as
prescribed. Please follow-up with your primary care physician,
and the interventional radiology team as an outpatient.
Take Care,
Your ___ Team. | Ms. ___ is a ___ year old female, with past history of
Roux-en-Y Gastric Bypass ___ ___, Multiple SBOs requiring
cholecystectomy, and ampullary stenosis s/p PTCD with multiple
rounds of dilation recently admitted for abdominal pain and
placement of PCBD conversion of ampullary drain who presents
with progressive abdominal pain, fevers to 101 and purulent
drainage from her cholecystostomy site 3 days after returning
from the hospital.
.
>> ACTIVE ISSUES:
# Possible recurrent biliary obstruction
abdominal wall cellulitis at site of biliary drain
Upon admission, given concern for prior PTBD manipulation,
patient underwent CT Abdomen scan which was remarkable for a
subcapsular fluid collection along the PTBD as it exited the
liver anteriorly, concerning for a biloma but could not exclude
abscess. Patient also was found to have small volume ascites.
Given this, patient underwent immediate uncapping of her PTBD
drain, and then underwent procedure on ___: Exchange of the
exisiting PTBD catheter with a new catheter, and performance of
dilation with cholangioplasty / sphincteroplasty. Patient also
had percutaneous aspiration of perihepatic collection with
minimal fluid aspirated. Cultures returned negative ___ blood.
Patient's abdominal pain improved with tube replacement, and
felt that ampulla had been stenosed, and that repeated dilation
has been only moderately successful. Patient underwent
successful capping trial on ___, and given stability,
patient stable for discharge. Pain regimen was converted from IV
Dilaudid to oxycodone, and was dispensed #30 tablets after
verification with PMP. Furthermore, patient was found to have
redness at drainage site concerning for abdominal wall
cellulitis, and therefore initially treated with broad spectrum
antibiotics, narrowed to TMP-SMX to complete course. Wound care
supplies were given to patient, along with prescriptions for
refills.
.
>> CHRONIC ISSUES:
# Constipation: Given increased narcotic load for abdominal
pain, patient placed on aggressive regimen and had several bowel
movements during hospital stay prior to discharge.
.
# Depression: Patient was continued on home citalopram.
.
# Vasovagal Syncope: Patient was continued on home
fludrocortisone. Patient did not have any hemodynamic
instability during hospital stay.
.
# Chronic Pain / Fibromyalgia: Patient was continued on home
gabapentin.
.
# Papillary Thyroid Cancer s/p Resection: Patient continued on
home levothyroxine supplement.
.
>> TRANSITIONAL ISSUES:
# Cellulitis: Please complete TMP-SMX antibiotic course until
___
# PTBD: Please continue to maintain PTBD drain site, and check
CBC, Chem-7, and LFTs upon discharge follow-up.
# Pain Regimen: Patient was given oxycodone, and bowel regimen
upon discharge for maintenance of pain. PMP checked prior to
prescription.
# Pending Labs: Please f/u blood culture obtained ___ (No
growth upon discharge).
# CODE STATUS: Full
# CONTACT: HCP ___ ___ | 101 | 433 |
14874510-DS-6 | 22,228,689 | Dear Ms. ___,
What brought you to the hospital?
================================
You came to the hospital because of abdominal pain, rash,
fever/chills.
What happened while you were in this hospital?
=============================================
-You were found to have a skin infection on your abdomen
-You receiving imaging of your abdomen and pelvis, which found:
-No evidence of an infected collection or "abscess"
-You were started on antibiotics and the skin infection was
monitored and improved.
-You were discharged on a course of antibiotics.
What should you do when you leave the hospital?
==============================================
-You should take the Cephelaxin 500mg 4x/day (every 6 hours) for
another 6 days, last full day ___. You should take the full
course of antibiotics as prescribed.
-You should carefully clean the skin around the infection,
making sure not to be too rough when cleaning to cause cuts or
abrasions to the skin.
-Please follow up with your ___ clinic provider on ___.
You can walk into the ___ clinic.
-Please bring your discharge paperwork to your follow up visit
with your suboxone provider and your primary care doctor.
-You should have a follow up appointment with your primary care
physician, ___, on ___ at 2:15.
We wish you the best,
Your ___ Care Team | ___ year old female with a history of morbid obesity, superficial
thrombophlebitis (on enoxaparin until stopped ___, LTBI
(completed 9 months of isonizaid), Hep C (neg VL ___,
previous IVDU (last use ___ years ago), PTSD, presenting increased
abdominal redness swelling and warmth found to have erysipelas. | 197 | 47 |
16843758-DS-17 | 27,234,528 | Dear Ms. ___,
You were admitted with bleeding from your pelvic fluid
collection. You had a drain placed under CT guidance and were
started on antibiotics to treat the infected fluid collection.
You are recovering well and 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.
*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 female with a history of perforated
diverticulitis s/p ___ complicated by a pelvic hematoma and
later complicated by ostomy detachment s/p colostomy revision,
who presented to ___ on
___ with concern for rectal bleeding. She was found to
actually have vaginal bleeding with a small defect present at
her vaginal cuff (from her prior hysterectomy), concerning for
drainage from her known pelvic hematoma versus new active
hemorrhage. She was initially tachycardic to the 150s upon
arrival in the ED with SBP in the 130s. Her tachycardia improved
with fluid resuscitation. In this setting, she was admitted to
the trauma ICU for hemodynamic monitoring and serial
hematocrits.
The patient was kept NPO, on IV fluid resuscitation. She was
continued on cipro/flagyl (which she had been taking at home as
directed after hospital discharge). underwent pre-treatment for
a contrast allergy in preparation for a CTA. Imaging
demonstrated a rim-enhancing large pelvic hematoma with no
active extravasation. As such, her vaginal bleeding was presumed
to represent drainage of her old hematoma rather than
active/acute new hemorrhage. She remained hemodynamically stable
with stable hematocrits. She did not require any blood
transfusions after leaving the ED (where she received only 1u
pRBCs due to concern for active bleeding and hemodynamic
instability). On ___, the patient underwent CT guided placement
of ___ transgluteal drain into her pelvic hematoma. Cultures
were sent, and she was found to be growing enterococcus. Her
antibiotics were broadened to vancomycin, cipro, and flagyl
pending sensitivities. On ___, she was started on ___, her
foley was removed, and she was deemed appropriate for transfer
to the surgical floor. Her therapeutic Lovenox and remainder of
home meds were resumed on ___.
On ___ her cultures speciated with enterococcus gallinarum,
which was resistant to vancomycin. Her antibiotic therapy was
advanced to IV Linezolid while cipro/flagyl continued until the
course was completed on ___. Her vac was also changed and her
Coumadin was resumed for hx of afib. On ___ she underwent cat
scan to evaluate for interval change of pelvic collection and CT
showed persistent collection. Her drain was then manipulated by
___ team on ___ and irrigated with TPA. She was re-scanned on ___
and drain found to no longer be in communication with her fluid
collection. On ___ she had ___ drain removed and ___ drain
placed in interventional radiology with good effect. She
tolerated the procedure well. Her wound vac was changed and
antibiotic course was changed from intravenous to oral therapy.
On ___ her antibiotic therapy regimen was completed and on ___
she was cleared for discharge to home at which time she
complained of mild lightheadedness while walking. Orthostatic
blood pressures were then checked. She also reported she
believed she would benefit for home physical therapy in addition
to visiting nurses, and case management was notified and
services arranged.
At the time of discharge, the patient was doing well. She was
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home with
services and received discharge teaching. A follow-up
appointment was made and discharge instructions were reviewed
with reported understanding and agreement. | 267 | 534 |
15608089-DS-5 | 27,610,912 | Dear Ms. ___,
It was a pleasure to take part in your care at ___
___.
You were admitted for right hip pain. An xray revealed that your
hip has avascular necrosis (bone collapse) and you underwent
orthopedic hip surgery.
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:
- Touch down weight bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so 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 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.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Touch down weight bearing right lower extremity
Posterior precautions of right hip
Treatments Frequency:
- 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.
- No dressing is needed if wound continues to be non-draining. | ___ is a ___ year old woman with a PMH notable for Hep
C, HIV on HAART, prior heroin use on methadone therapy, bipolar
disorder, ADHD, HTN, and asthma who presented due to
uncontrolled pain from her recently diagnosed right hip
avascular necrosis.
# Right femoral AVN:
She had been recently diagnosed as an outpatient and requiring
increased support for ambulation and activities of faily living
(using a cane, etc). She lives alone and had reached the point
where she felt her pain and limited mobility were no longer
compatible with living alone in a ___ floor apartment. She was
assessed by ___, who agreed. Ortho was consulted in the ED, who
aspirated the hip and ruled out infection. Her pain was
controlled with her usual methodone, as well as PRN oxycodone.
She went to the orthopedic surgery service with plan for right
total hip arthroplasty.
#HIV: On HAART therapy, which was continued (Truvada, Reyataz,
Norvir). No signs or symptoms of infection. Creatinine was WNL,
no dose adjustments needed.
#Hepatitis C: LFTs were within normal limits. She says she was
told to avoid acetaminophen and declined to take this for pain
control.
#HTN: Continued metoprolol 50mg and HCTZ 25mg.
#HLD: Continued Tricor 145mg daily.
#Methadone maintenance: Her home dose of 170mg daily was
comfirmed by the ED and continued without event in the hospital.
#Bipolar disorder: Continue Depakote 250mg q AM and 500mg q ___.
#Panic disorder: Continued Klonopin 1mg TID.
#ADHD: Held Adderall while inpatient given it is nonformulary
and she did not have her own medications.
# Right hip THA: pain well controlled with PRN oxycodone. She is
touchdown weight bearing on the right lower extremity, with
posterior hip precautions. | 393 | 280 |
19396070-DS-20 | 24,901,979 | Dear Mr. ___,
You were admitted to the hospital because of your heart failure.
Please see below for more information on your hospitalization.
It was a pleasure participating in your care!
We wish you the best!
- Your ___ Healthcare Team
What happened while you were in the hospital?
- You were given medication to help reduce the amount of fluid
in your body to help improve your breathing and leg swelling.
- You were evaluated for a double pacemaker to help both sides
of your heart beat more synchronously. This was done on ___.
You had some bleeding around the device afterwards which was
causing some pain, but the device specialists said this should
improve with time.
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
- Weight yourself daily. On the day of discharge, your weight is
231 pounds. Call your doctor if your weight increases by more
than three pounds. You might need
- Please take your medications as listed in discharge summary
and follow up at the listed appointments. | ___ man with a history of heart failure with newly
reduced ejection fraction (EF 35%), right ventricular dilation
with free wall hypokinesis, moderate tricuspid regurgitation,
permanent atrial fibrillation on rivaroxaban, chronotropic
incompetence while in AF status post single-chamber pacemaker
(___), and DMII presenting with lower extremity edema and
dyspnea consistent with heart failure exacerbation. He was found
to have newly reduced ejection fraction this admission, which
was attributed to dependence on single chamber pacing causing
dyssynchrony. He was taken for biventricular pacemaker placement
on ___. He was restarted on maintenance diuresis and discharged
with plan for close followup.
CORONARIES: recent negative stress test; declined cath in past
PUMP: 35%
RHYTHM: AF, V-paced | 189 | 110 |
16430935-DS-44 | 24,403,660 | Dear Ms. ___,
It was a sincere pleasure taking care of you during your
hospitalization at ___. You
were admitted with swelling of your left leg. We found that the
clot in your leg was likely old or "chronic." After discussions
of the risks and benefits of treatment with you and your family,
it was decided that you would not restart coumadin.
If you are to develop any worsening redness, pain or swelling
in your leg, or shortness of breath/chest pain, you should
report immediately to the emergency department.
PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
RESTARTED ASPIRIN 81 MG DAILY | ___ year old female with dCHF, CKD stage 4, LLE DVT ___
complicated by BRBPR s/p discontinuation of coumadin in ___
who presents with a two day history of left lower extremity
swelling, found to have persistent DVT on ___. | 112 | 40 |
15787487-DS-15 | 23,118,970 | Dear Ms. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having abdominal pain,
nausea, and dark urine. You were found to have an obstruction
of your bile duct. This caused your pancreas to get inflammed.
You were treated with IV fluids and pain control. You underwent
an ERCP to remove some stones, and then you had your gallbladder
removed to ensure the problem wouldn't recur.
You tolerated the procedure well and are now being discharged
home to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | This is a ___ woman with a past medical history
significant for HTN, anxiety, and depression, who is admitted
with cholelithiasis, choledocholithiasis, and gallstone
pancreatitis.
# CHOLELITHIASIS, CHOLEDOCHOLITHIASIS, GALLSTONE PANCREATITIS:
Mrs ___ is a pleasant ___ woman with a history of
hypertension and anxiety who is admitted with pancreatitis in
the setting of choledocholithiais. Patient initially presented
to ___ with abdominal pain and dark urine. At ___,
labs were significant for: ALT: 813 AP: 596 Tbili: 4.61 Alb: 4.3
AST: 514 TProt: 7.2 ___: Lip: 1050. US showed cholelithiasis
without other sonographic evidence of acute cholecystitis as
well as dilated intra and extra hepatic bile ducts. An MRCP
done on ___ confirmed that there were still stones in the CBD
and dilated ducts. The patient went for an MRCP on ___ which
demonstrated CBD stone. The stone was extracted, a
sphincterotomy was performed and she was transferred to surgery
for a cholecystectomy. On ___ the patient underwent a
laparoscopic cholecystectomy. She was taken to the operating
room and underwent a laparoscopic cholecystectomy. Please see
operative report for details of this procedure. She tolerated
the procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. 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. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
# POSITIVE U/A: Patient with positive u/a at ___. She
was asymptomatic and was not treated for UTI. Microbiology
report pending.
# HTN, BENIGN: Patient was continued on atenolol and
lisinopril.
# DEPRESSION: Patient was continued on paroxetine.
On the afternoon of ___, Mrs. ___ was ambulating from the
bathroom to her bed when she became "dizzy" and fell forward on
to her knees. This was witnessed by her roommate. The patient
denied any LOC or head strike. She was assised to bed and
placed in the supine position. Her SBP was approximately 115
and her blood gluocse level was 126. She felt better once she
was settled in bed. She was given a liter of fluid for likely
orthostasis and placed on telemetry to assess for any
dysrhythmias. A complete blood count and basic metabolic panel
was obtained. Results were within normal limits.
On the morning of ___, Mrs. ___ felt much better than the
prior day. She had no further episodes of dizziness on
ambulation. Telemetry showed her in sinus rhythm and no ectopy
was observed. Nursing and the patient's husband ambulated with
the patient during the day and she did well. Mrs. ___ was
tolerating a regular diet and voiding without issue.
On the afternoon of ___, Mrs. ___ was discharged home in
the care of her husband. She was afebrile, hemodynamically
stable and in no acute distress. She was discharged home with
scheduled follow up in ___ clinic. | 775 | 564 |
13024906-DS-6 | 20,540,678 | Dear ___,
___ was a pleasure taking care you during your hospitalization.
You were admitted because you were having lightheadedness and
shortness of breath with activity that we felt was caused by
your aortic stenosis. You were scheduled for a repeat balloon
valvuloplasty in ___ but we decided to do it on this
admission because of your symptoms. The valvuloplasty was
successful but it was complicated by bleeding which caused you
to have low blood pressures and your kidneys to be damaged. Your
blood pressure, blood counts and kidney function had all
improved and were stable by the time your discharge. Your lasix
was stopped. You should followup with your cardiologist.
We wish you the best,
Your ___ team | ___ w/h/o critical aortic stenosis, CAD, CHF, presents from
assisted living facility with symptomatic AS s/p valvuloplasty
___ c/b psuedoaneurysm in R femoral artery.
# Critical Aortic Stenosis: Pt had been scheduled for
valvuloplasty in ___, but was transferred from ___ for
earlier intervention given symptoms. Pt was hemodynamically
stable during pre-hospitalization without CP, SOB. She underwent
a successful valvuloplasty on ___ that was complicated by
formation of right femoral artery pseudoaneursym as well as a
large retroperitoneal bleed. Procedure also complicated by
development ___ likely from hypotension, blood loss anemia
and cholesterol embolization. Deferred TAVR workup (CT
angiogram of the aortic annulus and peripheral vessels) given
patient's wish to limit interventions.
# Right femoral psuedoaneurysm and retroperitoneal hematoma: Was
transfused 3uPRBCs with appropriate bump in Hct and improvement
in blood pressure. Hct nadir 23.5 and systolic blood pressures
as low as 80 (asymptomatic). She was hemodynamically stable and
Hct stable x 48 hours by time of discharge. Surgical
intervention was deferred given patient's desire to avoid
further interventions. Please recheck Hgb, Hct 48 hours after
discharge.
# ___: Acute rise overnight from 1.0 to 1.7. Concerning for
embolism, prerenal ___, or other etiology. FeNA <1% suggestive
of pre-renal etiology. Cr downtrended to 1.2 prior to discharge.
Home ACE-inhibitor was held. Please recheck electrolytes on ___
and consider restarting ACE-inhibitor if Cr has normalized back
to baseline.
#CAD: Continued BB, ASA, Imdur. Will restart Ace-I if needed for
blood pressure control.
#Hyperlipidemia: Continued atorvastatin
#Hypertension: Well controlled during hospitalization. On
metoprolol.
#GERD: Continued omeprazole
#Hypothyroidism: Continued levothyroxine.
# Discontinued lasix, monitor volume status and consider
restarting if clinically indicated (weight gain, worsening ___
edema)
# ACE-inhibitor held during this admission given renal
dysfunction. Recheck electroyltes at follow-up appointment, if
Cr normal then restart ACE-inhibitor (Cr 1.2 on discharge).
# Recheck Hgb/Hct 48 hours after discharge (___) and at
outpatient f/u given recent bleed
# Pt will follow-up with Cardiology (Dr. ___ next month
# Code: DNR/DNI
# Emergency Contact: ___
Phone number: ___
Cell phone: ___ | 119 | 329 |
17954787-DS-14 | 28,497,826 | You were sent from your nursing home with confusion and fever,
due to inadequately treated UTI. You were given IV antibiotics
with good improvement in your symptoms. You will need to
complete a course of IV antibiotics via midline IV. Because
your Coumadin levels were high, your Coumadin was held and you
were given some Vitamin K to reverse the Coumadin. You will
need to resume your Coumadin and have your INR monitored.
.
Please take your medications as listed.
.
Please see your physicians as listed.
. | ___ w/ampullary carcinoma, CVA, afib on coumadin, basal ganglial
hemorrhage, and urinary retention who presents with fevers and
AMS with known ESBL E. coli UTI.
.
#Fever / #Delerium / #UTI:
On presentation, patient had known ESBL E.coli UTI that was
treated as an outpatient with Macrobid. On admission, Head CT
was unremarkable, but UA continued to show evidence of
infection. He initially received broad-spectrum coverage with
IV Zosyn and IV gentamicin, however, once sensitivities of his
ESBL E.coli were reviewed, he was placed on Meropenem. On IV
antibiotics, his mental status cleared quickly and he returned
to his baseline, confirmed by his brother / HCP ___. Repeat
UCx interestingly grew Pseudomonas, but pan-sensitive, so
Meropenem was continued. A midline was placed for access for
prolonged IV antibiotic course. The plan is to treat him with
Ertapenem as an outpatient, to complete a total of a 10 day
course ___ - ___ of appropriate IV antibiotics for his
complicated UTI. However, for his Pseudomonas, he will need
additional PO ciprofloxacin to complete a treatment course. He
could be covered with frequent Zosyn or Meropenem to cover both
organisms, however, his facility cannot due Q6 or Q8 hour dosing
of IV antibiotics. During hospitalization he initially did have
a Foley catheter placed, however, this was discontinued and he
has resumed intermittent straight cath as previous.
.
#Afib:
His appears to have paroxysmal afib, although on day of
discharge, he was in atrial fibrillation with irregularly
irregular rhythmn on physical exam. His HR is well-controlled
with beta-blockade. He p/w supratherapeutic INR to 6, but did
not have any evidence of bleeding. The elevated INR was likely
due to combination of poor PO intake recently as well as oral
antibiotics as an outpatient. Coumadin was initially held and
he was given Vitamin K 5mg x 1 to reverse his INR so a midline
could be safely placed. Given that his CHADS2 score is 2 (as
documented by outpatient Cardiology notes, and presumably his
CVA is not included as it was a hemorrhagic event on Coumadin),
briding therapy was not felt to be indicated. He was given
Coumadin 4mg on ___ with INR of 2.4. INR on day of discharge
was 1.5. He should continued on Coumadin 4mg daily for the next
3 days with repeat INR on ___ with further Coumadin dosing
TBD pending INR results.
.
#Anemia, likely of chronic disease: Patient noted to have lower
than baseline Hct of high 20's vs baseline of low 30's. He did
not have any evidence of active bleeding. Vitamin B12 level was
adequate. Iron panel suggests anemia of chronic disease. This
can be further worked-up as an outpatient.
.
#HTN: Continued home meds of clonidine, metoprolol and
amlodipine. BP in good range.
#GERD: Continued home PPI.
#BPH: Continued home Proscar, Flomax and bethanechol. He had
Foley catheter placed briefly during hospitalization but it has
since been discontinued. He should resume intermittent straight
catheterization 4x daily.
#Hypothyroidism: Continued home Synthroid dose.
#ACCESS: midline
#CODE STATUS: FULL CODE. Confirmed with HCP (Brother ___
___. Previous documentation at nursing home had
documented to attempt resuscitation but do not intubate, however
this is often not possible, so further d/w HCP to clarify was
done.
#CONTACT: HCP, brother ___ ___
. | 87 | 557 |
11351912-DS-19 | 20,199,689 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of your nausea and vomiting, which was secondary to a
recurrent small bowel obstruction. Your symptoms improved after
advancing your diet very slowly and giving fluids through the
IV. It is very important for you to continue advancing your
diet very slowly. It is also very important for you to follow
up with your physicians as scheduled (see below for your
upcoming appointments).
Sincerely,
Your ___ team | BRIEF SUMMARY
=============
___ w/ metastatic rectal CA (s/p rsxn, colostomy, on FOLFIRI
C1D1 ___ w/ lung mets s/p RLL segmentectomy), DM, recent
admission for SBO (s/p lyses of adhesions & partial rsxn c/b
MSSA bacteremia and L5-S1 osteomyelitis), admitted w/ recurrent
partial SBO that was managed conservatively with improvement.
ACTIVE ISSUES
=============
#) PARTIAL SMALL BOWEL OBSTRUCTION
Pt presented with acute onset of abdominal pain, nausea and
vomiting. Imaging was notable for small bowel obstruction with
a transitional point in the right lower quadrant, proximal to
the small bowel anastomosis. Colorectal surgery was consulted
and recommended conservative management and no acute surgical
intervention. Patient was made NPO and given IVF. The
following day, patient began to have output from the colostomy
and was advanced to a clear liquid diet, which he tolerated
well. TPN was continued. Patient discharged on a clear liquid
diet with a plan to advance diet over the next several days.
#) SUSPECTED UPPER GI BLEED
Pt initially with reported coffee ground emesis but had no
further evidence of bleeding during admission and did not
require a transfusion. Managed with IV PPI during admission,
which was discontinued on discharge given low suspicion for GI
bleed.
CHRONIC ISSUES
==============
#) METASTATIC RECTAL CANCER: patient scheduled for follow up
with Dr. ___ further management
#) ANEMIA: remained at baseline and did not require transfusion
#) DIABETES: managed with glargine and insulin sliding scale
while inpatient
#) HYPERLIPIDEMIA: continued home atorvastatin
#) BPH: continued home tamsulosin
TRANSITIONAL ISSUES
=======================================
#) Discharge diet: clear liquids, advance slowly
#) Patient scheduled for follow up with Dr. ___
# Contacts/HCP/Surrogate and Communication: ___
(HCP, mother, ___, cell ___ ___
(alternate, brother, cell ___, home ___
# Code Status/ACP: DNR/DNI | 84 | 277 |
11693648-DS-16 | 25,402,921 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted on ___ with a
2-day history of nausea/vomiting, diffuse abdominal pain and
constipation. In the emergency room, most of your laboratory
work-up was negative except for elevated inflammatory markers.
You also had a CT scan to look at your abdomen and pelvis, which
was concerning for inflammation at the end of your small
intestine as well as a partial obstruction of your small
intestine. You were evaluated by the surgical service, who
thought that there was no surgical concern at that time. On
admission to the medicine floor, you had significant abdominal
pain and was very dehydrated. You were hydrated with intravenous
fluid since drinking made your pain worse. We also started you
on two antibiotics named ciprofloxacin and flagyl to decrease
the inflammation and improve your symptoms. You were also seen
by our gastroenterologists who thought you may be suffering from
inflammatory bowel disease given your history. Your symptoms
continue to improve over 48 hours and by the ___ day of your
stay, you were able to tolerate a regular diet with no abdominal
pain or nausea. Also, your blood culture grew some bateria so we
switched you antibiotic to cover for the microbes. By the time
of discharge, you were able to walk on your own, your pain was
significantly improved, you have transitioned successfully to
oral pain medication and you have been tolerating a regular
diet. We sent some labs as requested by our gastroenterologist
in preparation, should you need any treatment in the future
based on further analysis as outpatient. We strongly suggested
you follow-up with the appointment with the gastroenterologist
and on getting a colonoscopy, which you understand is not only
important for screening for colon cancer but also may help in
making the final diagnosis.
Please take all your medications as prescribed. You will be on a
steroid which you will be taking every morning. You will also be
on oxycodone for pain so avoid driving while on this medication.
PLEASE BE SURE TO HAVE YOUR PPD READ ON ___ BY A
NURSE OR DOCTOR AT YOUR PRIMARY CARE DOCTOR'S OFFICE.
Thank you for choosing the ___. We wish you the very best.
Your ___ Team | ___ with no known PMHx but possibly significant EtOH use p/w
2-day hx n/v/ diffuse abd pain found to have normal creatinine
and lipase, no leukocytosis, LFTs/amylase/lipase normal and CT
abd/pelvis with evidence of terminal ileitis admitted for
further management.
#N/V/diffuse abdominal pain: She presented with a 2-day history
of nausea,vomiting and diffuse abd pain found to have normal
creatinine and lipase, no leukocytosis, LFTs/amylase/lipase
normal, elevated CRP and CT with evidence of terminal ileitis.
She was then admitted to the medicine floor for further
management. Upon arrival on the floor, she was also dry on exam
and was hydrated with IVF bolus and maintenance NS which was
then switched to LR given given continuous nausea and vomiting.
Family history significant for brother with GI problems never
formally diagnosed concerning for inflammatory/ autoimmune
process. Patient has had previous self-limited similar episodes
in past ___ years, possible IBD given history of constipation
with breakthrough diarrhea. Data suporting an inflammatory
process substantial elevation of CRP to 136.7. ESR 16. Physical
exam was pertinent for diffuse abdominal pain but normal bowel
sound and no concern for acute abdomen. Hemeoccult negative in
ED. No hx of colonoscopy. Other etiology include partial SBO in
the setting dilated and fluid-filled with multiple air-fluid
levels supported by her chronic constipation at presentation. We
also considered viral gastroenteritis, but strange to be so
limited to terminal ileum. Given her CT finding and concern for
IBD, she was started on ciprofloxacin and flagyl in the
emergency room which was continued upon admission. She was
switched to Unasyn on ___ when her blood culture grew GPRs but
d/c'ed on ___ w/ low suspicion for bacteremia. She initially
could not tolerate PO due to worsening abdominal pain so she was
maintained NPO and diet was advance when she was clinically
improved. Her pain was well controlled with IV morphine as
needed and her nausea with zofran. Her symptoms significantly
improved by day-4 of stay and she was able to tolerate a regular
diet without pain or nausea. She was transitioned successfully
to PO oxycodone and d/c'ed on it for pain control. We consulted
the GI service who recommended steroid if symptoms do not
resolve and follow-up colonoscopy as outpatient. This will help
to narrow the differential and possibly arrive at a final
diagnosis. At discharge, she was tolerating regular diet without
worsening abdominal pain or nausea, ambulating with benign
abdominal exam. Per GI recommendation, we sent for TPMT enzyme
assay, hep B serology and placed a PPD in preparation should she
need to be started on Azathioprine in the future, pending
further outpatient work-up. She is also to start Entocort 9mg
qAM after discharge. She is set to follow-up with Dr. ___ ___
in 2 weeks and a colonoscopy in 4 weeks. PPD to be read on
___ as an outpatient.
# + blood cx: Blood culture with anaerob GPRx1, thought to be
most likely P. acne. Covered on unasyn starting on ___, but we
feel contaminant, so we d/c'ed uansyn prior to discharge. Final
cultures pending at time of discharge.
#B12 deficiency: B12 level of 234 consistent with mild B12
deficiency. Possible cause include decrease absorption i/s/o
terminal GI disease (most likely) vs decrease intake i/s/o
chronic n/v. Started on PO Cyanocobalamin 2000mcg/day on ___.
# FEN: Pt had low Mg, K, and P which were repleted prn/ regular
diet at discharge
TRANSITIONAL ISSUES
# After discharge, patient second BCx botle grew GNRs. Although
it seems most likely to be a contaminant as it has been 5 days
since culture was sent. Please see WebOMR note on ___ with
details on communication with patient regarding these results
and further management.
#Concern for IBD. No colonoscopy in the past. Pt follow-up with
GI as outpatient as well as a colonoscopy 2 weeks and 4 weeks
from now, respectively
# CODE STATUS: Full (confirmed)
# Emergency Contact: Friend ___ ___ | 381 | 650 |
16807878-DS-5 | 27,563,327 | Dear Ms. ___,
You were admitted to ___ for diverticulitis causing a small
intra-abdominal abscess. You were treated with antibiotics. You
are being discharged on antibiotics to complete a 3-week course.
After that, you will have a repeat CT scan and follow up with
Dr. ___ in clinic. Please read and follow the following
instructions for discharge.
General Discharge Instructions:
-Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Take Augmentin for a total 3-week
antibiotic course (___).
-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 3000 mg in one day.
-Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician. | After undergoing a CT that showed a diverticular abscess, Ms.
___ was admitted to the Colorectal Surgery from the ER for
further management. She was started on IV antibiotics
(ciprofloxacin & Flagyl). By HD2, her LLQ pain had largely
resolved. She was advanced to a regular diet and tolerated it
well. Her antibiotics were transitioned to PO. She was afebrile
and hemodynamically appopriate. She was discharged home on a
3-week course of oral antibiotics (Augmentin), after which she
will have repeat imaging to re-assess her diverticular abscess
and have subsequent follow up with Dr. ___ to discuss surgical
management. | 180 | 100 |
13617481-DS-5 | 25,520,655 | Dear Mr. ___,
You were hospitalized due to symptoms of unsteady walking and
visual changes resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Prior smoking
We are changing your medications as follows:
Take aspirin 81mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ is a ___ old right-handed man with a prior
smoking history and family history of stroke who presented with
sudden onset of lightheadedness and stepwise worsening of
symptoms of blurry vision, double vision, lightheadedness and
headache throughout the day. On initial examination in the ED,
he has a left homonymous hemianopsia, hypometric saccades on
leftward gaze, left appendicular ataxia and inability to walk in
tandem.
CT/CTA shows a right PCA territory stroke with patent posterior
circulation as well as a R ICA which is occluded from the common
carotid to the intracranial portion where it reconstitutes. MRI
revealed right PCA distribution infarcts with evidence of
hemorrhagic transformation. Repeat NCHCT 24 hours after
demonstration of hemorrhagic confirmation showed stability
without increased hemorrhage.
The patient was started on Aspirin 81mg Daily for stroke
prevention. LDL 68. A1C 5.8. TSH normal. Echocardiogram did not
reveal intracardiac thrombus, EF 70%. He was monitored on
telemetry without arrhythmia. He will be discharged to home with
___ of Hearts monitor.
The etiology of his stroke was not clear. He does have complete
occlusion with reconstitution of the R common carotid with no
evidence of dissection (but fat sat sequence not obtained) and
does have extensive collaterals. Though dissection is on the
differential, given his bleed he would not be an immediate
candidate for dual antiplatelet therapy or anticoagulation, so
further imaging was not pursued to classify this during
admission.
It is possible, though rare, that he could have a dissection
near the origin of the common carotid; however, he has no prior
traumatic history to support this. Collagen vascular disease is
another consideration, but he has no hypermobile joints,
hyperextensible skin or valve abnormalities to support this.
Given a stroke of unknown etiology, he will be discharged with a
heart monitor to observe for any evidence of a. fib and undergo
carotid US in ___ weeks as an outpatient. If not revealing, a
TEE may be considered at that time. Additionally, a
hypercoaguable work-up was initiated -- with protein C/S,
antithrombin, beta-2-glycoprotein, cardiolipin ab, and
antiphosphlipid Ab were pending at the time of discharge. He
will have prothrombin and factor V Leiden sequencing tested as
an outpatient. D-dimer pending at the time of discharge which
will be followed, and if significantly elevated a CT Torso will
be pursued to evaluate for malignancy.
He was evaluated by OT who felt his balance was appropriate and
stable for home. However, given his visual field deficit, he
cannot drive.
Of note, his CXR did reveal a lower lung interstitial
abnormality, and a chest CT can be considered as an outpatient
by PCP. He had a low grade fever to Tmax 100.5, with repeat UA
negative, blood culture no growth to date, and CXR negative for
consolidation. | 267 | 460 |
11965254-DS-50 | 27,460,652 | Dear ___,
It was a pleasure taking care of you at ___. You were admitted
because you had worsening abdominal pain for several days
associated with nausea and vomiting, with difficulty being able
to eat food and liquids, and decreased ostomy output. You were
evaluated by the GI and colorectal services. Imaging did not
reveal any perforation (as had occurred in the past), and we
monitored you for any signs of obstruction or blockage. It was
found on the CT image that you had a perirectal abscess, and per
colorectal surgery, interventional radiology aspirated the fluid
(culture pending). After the procedure, you had a fever, and we
gave you IV antibiotics (cefepime and flagyl) to treat for a
suspected infection. However, there was lower suspicion for
infection at this point, and we discontinued the antibiotics.
You will be discharged on your home oxycodone (Immediate
Release) ___ mg PO Q4-6H PRN pain for a total of 21 pills.
Please see your PCP on ___ to obtain refills.
For your midline incision with two areas of yellow drainage:
place wet gauze and let dry, and change dressing daily.
Please follow up with your PCP on ___ at 9:30 AM.
We wish you the best,
Your ___ team | ___ woman with Crohn's disease with recent
hospitalization for SBO with perforation, complicated by
intraabdominal abscesses requiring drainage procedures and
placement of wound VAC and post-operative pulmonary embolism,
who presents with a abdominal pain consistent with acute
pancreatitis, found to have a perirectal abscess s/p aspiration.
In summary, the patient presented with a several-day history of
LUQ worsening pain, nausea/vomiting, and poor PO intake, and
decreased ostomy output. CT abdomen and KUB did not reveal any
perforation. However, CT abdomen/pelvis revealed a perirectal
fluid collection, and per colorectal surgery recommendation, it
was aspirated by ___ (fluid culture pending). The patient was
norovirus and C diff negative. ___ procedure, the patient
spiked a fever to 101.8, which could be due to the abscess site,
and she was placed on IV cefepime and flagyl. There was lower
concern for an infection, and flagyl and cefepime were
discontinued. | 200 | 144 |
13049123-DS-21 | 28,066,500 | Dear Mr. ___,
You came to the hospital because of confusion and worsening
mental status. This is secondary to advanced melanoma. You had a
brain biopsy which revealed the tumor's response to treatment
with surrounding swelling. You were started on steroids to
decrease the swelling in your brain, and on seizure medication
called keppra for possible seizure activity. You will not
continue on your current treatment for the melanoma, but will be
started on a new medication (a BRAF inhibitor). This will arrive
in the mail.
Please follow up with your outpatient oncologists as below
regarding further management of your melanoma.
Thank you for allowing us to take part in your care,
Your ___ team. | Mr ___ is a ___ year old male with metastatic melanoma to the
lungs, brain, and left lower extremity who recently initiated
PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week
of neurologic changes.
# Neurologic decline: His neurologic decline was thought to be
due to increase in metastatic focus in brain with surrounding
edema, and with question of possible underlying seizure
activity. He underwent stereotactic brain biopsy of the lesion,
and pathology showed changes consistent with cerebral edema and
necrosis in response to PD-1, rather than progressive metastatic
disease. He was started on decadron and keppra on admission,
but his mental status continued to be A&O x 2 daily. He
continued to be confused, and confabulated, and was tearful and
emotional at times but unable to verbalize his thoughts clearly.
20-minute EEG showed findings consistent with mild/moderate
encephalopathy with no evidence of ongoing or potential seizure.
His neurologic exam was otherwise nonfocal and he had no other
deficits that were noted during hospital course. He was cleared
for home with home ___.
# Melanoma - Patient was on PD-1 as outpatient, and had recently
completed week 9, dose 5. He had known mets to his lungs, brain
and left leg, but on admission was also found to have new
fungating lesion on his left chest wall, as well as a
subcutaneous pigmented lesion on his left abdomen along with
growth in his brain met. CT torso showed progression of his
disease; decision per outpatient oncology team was to stop PD-1
therapy. He will instead start treatment with a BRAF inhibitor,
which will arrive in the mail.
# Hemochromatosis - Patient has history of hemachromatosis - not
currently being treated.
# Leukocytosis - Noted to have leukocytosis on starting
dexamethasone without fevers, localizing symptoms or signs of
infection. | 112 | 310 |
14523168-DS-10 | 24,832,039 | Dear Mr. ___,
.
You were admitted to the hospital with left sided facial droop
and slurring of your words. A CAT scan of your head was done
which showed that the mass in your head was stable to minimally
larger in size. You also had imaging of your shunt which was in
proper position and not kinked. An EEG was done which showed
that you did NOT have any seizure activity. The cause of your
left facial droop and slurred speech was thought to be secondary
to swelling in your brain. We treated you for this with
steroids. We also started you on Keppra, a medicine to prevent
seizures. Of note, you also had a urinary tract infection which
we treated with antibiotics.
.
We have made the following changes to your medications:
-START Keppra 500mg twice daily
-CHANGE Dexamethasone to 6mg PO bid
-START Cefpodoxime 200mg daily, last day on ___
.
On discharge, please follow up with Dr. ___ Dr. ___
___ Dr. ___ as scheduled below.
.
It was a pleasure taking care of you, we wish you all the best. | Mr ___ is an ___ man with CAD, DM2, sCHF (EF <40%), afib,
and CKD, recently found to have a cerebellar mass (likely
metastatic lung primary), s/p VP shunt placement on ___ and
undergoing WBXRT, who presents today with worsening neurologic
symptoms over the last week.
.
# Progressive neurologic symptoms: Per family, Mr. ___ has
had intermittent facial droop, slurred speech, confusion since
the VP shunt was placed. These progressive symptoms are most
likely secondary to increased edema surrounding the right
cerebellar mass. He was evaluated by neurology in the ___, and
other etiologies such as stroke, seizure, and GBS were thought
to be much less likely. Additionally, shunt series revealed the
VP shunt to be intact. In the ER, he received 6mg IV decadron
and was started on standing dose on the floor. EEG was obtained
which showed diffuse slowing but no epileptiform activity. On
discharge, he will taper to Dexamethasone 6mg PO bid. In the
setting of high dose steroids, he should continue Famotidine for
prophylaxis and blood glucose should be monitored with
fingersticks and insulin sliding scale. He was also started on
Keppra 500mg PO bid for seizure prophylaxis. Whole brain xrt was
continued during the admission. On discharge, Mr. ___ will
f/u with Dr. ___ neuro-oncologist.
.
# UTI: Positive UA in ___, culture with contamination. Given
recent UTI and possible contribution of infection to confusion,
treated with anbitiobics. Will complete 7 day course of
cefpodoxime 200mg PO qd on ___.
.
# DM II: maintained on an unknown dose of 70/30 insulin at home.
Blood sugars likely to elevate in setting of Decadron use.
Patient was on Lantus 10 U qam and humalog ISS in house.
.
# Afib: Not anticoagulated due to recent cranial surgery.
Continued home digoxin, carvedilol.
.
# sCHF: non-ischemic, EF <40%: Continued home digoxin,
carvedilol.
.
# CAD: Continued home statin and carvedilol.
. | 180 | 311 |
15469020-DS-18 | 26,807,614 | Mrs. ___,
___ were admitted to the hospital for treatment of your leukemia
with chemotherapy. ___ developed a blood clot of your right
upper arm, likely due to the IV line that was used to infuse
your medication. This line was removed, and ___ were treated
with a blood thinner until your platelets (the cells that help
your body form clots) dropped to a low level.
.
___ were kept in the hospital until your white blood cells (the
cells that fight infection) recovered from the chemotherapy
treatment.
.
We have made the following changes to your medications:
-START fluconazole (to prevent infection)
-START levofloxacin (to prevent infection)
-START Acyclovir (to prevent infection)
-STOP lisinopril until instructed to do so by your outpatient
doctors. | Summary: Ms. ___ is a ___ yo woman with newly diagnosed AML,
treated with 10d course of decitabine, course c/b PICC DVT and
transaminitis.
.
#New AML: NPM1 mutation postive. Her counts increased
substantially on the day of discharge. Acyclolvir, fluconazole,
levofloxacin were started for prophylaxis.
.
# Transaminitis: Stopped fluconazole, enoxaparin, and
levofloxacin and LFTs improved. However, most likely that
increase was due to the chemotherapy. Levo was restarted, and
LFTs did not increase over several days. Fluconazole was started
just prior to discharge. LFTs should be monitored as an
outpatient.
.
# R upper extremity DVT: Associated with PICC, which was
discontinued on ___, and enoxaparin was stopped on ___ after
the patient became thrombocytopenic.
.
#HYPERTENSION: Held lisinopril
.
# Thigh Plaques: Neutrophilic vasculitis according to derm
biopsy. Likely in setting of losartan. Improved markedly this
admission.
.
==== | 115 | 137 |
19950864-DS-11 | 28,064,275 | Dear Mr. ___,
It was a pleasure caring for you
Why you were admitted?
- You were admitted because there was concern about your safety
at home.
What we did for you?
- Physical therapy evaluated you and recommended that you go to
a rehab facility, but unfortunately due to financial
constraints, this could not be rearranged. It was determined
that it was safest for you to be discharged to your sister's
house.
What you should do when you go home?
- Continue taking all your medications as prescribed and go to
the appointments that we have arranged.
We wish you the best,
Your ___ team | Mr. ___ is an ___ y/o ___ speaking man
presenting after mistakenly going to the hospital for an
unscheduled appointment. TSH within normal limits, RPR with
stable titer in the setting of known latent syphilis. Patient
was found to be B12 deficiency with elevated methylmalonic acid.
Supplementation with vitamin B12 was started. Physical therapy,
occupational therapy evaluated patient and recommended initially
that he be discharged to a rehabilitation facility, subsequently
revised their suggestion to home with ___ supervision. It was
determined that safest discharge would be to with his sister
with services, to which both he and she were agreeable.
#Self care:
Patient lives alone. In light of gait instability observed by ___
and concern by OT that he sometimes forgets to turn off the
stove, ___ supervision was advised. Much has been done in the
past to try to assist the patient. He has frequent follow-up
with his PCP, ___ extensive resources through HCA.
Following extensive discussion with case management, it was
determined that he did not qualify for ___
rehabilitation, and other placement options were financially
prohibitive. Following extensive discussion with his PCP and
case management, it was determined that safest discharge would
be to live with his sister, to which both the patient and his
sister were agreeable. A multidisciplinary family meeting,
including both inpatient and outpatient providers, was held on
the day of discharge, with emphasis to the patient and his
sister on the importance of his new living arrangements for his
optimal safety.
#Confusion/dementia
Patient appears back at baseline. TSH within normal limits. RPR
titer stable; in discussion with his ID provider, Dr. ___,
___ stable titer, recent rule-out for neurosyphilis, and
recent treatment for latent syphilis, no further work-up or
treatment needed at this time. Patient may be b12 deficient as
discussed below.
#B12 deficiency
Patient with low B12 level with elevated methylmalonic acid. ___
be secondary to PPI use and poor absorption. Started B12
supplementation with 1000mcg daily.
#Glaucoma:
Continues to have bilateral eye pain and erythematous sclerae.
Patient has appt with ophthalmologist on ___. Per
ophthalmology, his glaucoma has been difficult to control. His
conjunctival hyperemia is secondary to his eye drops which helps
to control his pressures. Continued home eye drops:
dorzolamide/timolol.
#Sore throat
___ be viral pharyngitis. Centor score of 1, therefore unlikely
strep pharyngitis. Was given lozenges for symptomatic relief.
Patient continued to have persistent sore throat. Swab for strep
pharyngitis pending at discharge and subsequently returned
negative.
#Weight loss: Outpatient PCP performing occult malignancy
work-up. Weight appears back up at 200lb on this admission.
Continue outpatient workup. Patient was seen eating well while
hospitalized. ___ be due to poor access to food.
#Pulmonary Embolism
Continued xarelto for 6 months of treatment (last dose ___.
#History of hepatitis B.
Continued lamivudine.
#Seropositive rheumatoid arthritis.
Continued prednisone 5 mg daily and methotrexate 25 weekly
#COPD
Continued home tiotroprium, and albuterol prn
#Gerd:
Continued omeprazole 20mg BID.
# Chronic Back Pain:
Continued home tramadol
***TRANSITIONAL ISSUES***
- Pt has chronic glaucoma, pain in eye, and conjunctival
hyperemia. Has an appointment with ophthalmologist on ___.
- Patient with B12 deficiency, persistent sore throat, weight
loss, consider workup of possible malignancy, as has been
ongoing in the outpatient setting.
- Consider further work-up of etiology of vitamin B12
deficiency, including IF Ab and EGD.
- Continue to monitor vitamin B12 level and MMA; oral
supplementation was chosen for patient convenience, but may
consider IM injections if deficiency does not improve with oral
supplementation or concern for malabsorption.
New medications: Vitamin B12 1000mcg
# CODE: full
# CONTACT:
Name of health care proxy: ___
___: sister
Phone number: ___ | 103 | 604 |
12785537-DS-4 | 21,969,461 | 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.
- Keep the pin sites on your external fixator clean and dry.
- Keep wound sites wrapped with dry gauze if draining
- No dressing is needed if wound is not draining.
- Keep your leg elevated on 2 pillows as much as possible to
prevent swelling.
ACTIVITY AND WEIGHT BEARING:
- Activity as tolerated
- Left lower extremity: Non weight bearing, elevate on 2 pillows
as much as possible until follow up with surgeon to prevent
swelling. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left comminuted distal tibia/fibula fracture with
intra-articular extension and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for placement of external fixator, 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
patient's home medications were continued throughout this
hospitalization. The orthopaedic team determined that discharge
to home was appropriate with follow up with a surgeon closer to
the patient's home in ___. 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 with ex-fix, and will be discharged on lovenox
for DVT prophylaxis. The patient will follow up with an
orthopaedic surgeon closer to his home in ___. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. | 152 | 254 |
11526668-DS-28 | 26,826,856 | Ms. ___,
Why were you admitted to the hospital?
- you were admitted for worsening shortness of breath and low
oxygen in your blood, especially with walking around.
What was done for you in the hospital?
- we gave you medications to take fluid off of your lungs.
- We changed your medications as your blood pressure was low.
- We decreased your beta blocker to help your heart pump better.
- We increased your home oxygen level to 4L
What should you do when you go home?
- Wear your Oxygen at home all the time.
- Take all your medications as prescribed that are listed on
your medication sheet.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please seek medical attention if you develop any chest pain,
worsening shortness of breath, swelling in your legs or any
other symptoms that concern you
It was a pleasure taking care of you!
Your ___ Team | ___ with known heart failure and AF p/w increasing dyspnea over
___ days, +bibasilar crackles, found to have elevated BNP and
CXR with evidence of fluid overload concerning for HF
exacerbation.
# Acute HFpEF exacerbation (severe pHTN, moderate severe TR):
Patient came in with elevated BNP and e/o pulmonary edema on CXR
and CT chest. Despite this patient weight on admission 71.3 kg
was below her previous dry weight of 74.4kg from ___.
This was after she was diuresed with 120 IV Lasix in the ED with
good output and some resolution of her symptoms. She was given
further IV diuresis with BID bolus of 120-160 IV Lasix without
much change in her weight, but some evidence of being
hypovolemic by labs (bicarb of 30). Ultimately patient was felt
to be euvolemic at discharge and declined further invasive
testing such as a RHC and/or coronary angiography to evaluate
further for etiology of her worsening symptoms. TTE was done as
an inpatient and was largely unchanged. Etiology of exacerbation
determined to be under diuresis taking 40 mg torsemide instead
of 60 mg that was prescribed by Dr. ___ of a desire
to decrease frequency of urination. Will have close follow up in
the CDAC.
# Acute on chronic hypoxemic respiratory failure: likely ___
patients pHTN. Patient O2 rq increased form home 2 L to 4 L at
the hospital with desaturation with exertion even on this. At
home she was intermittently compliant with her O2. O2 titration
study revealed patient needed to be on 4L O2 by NC at home.
# HTN - patient was noted to be hypotensive with ambulation down
to SBP into the 60's. There were concerns about whether patient
was taking her prescribed BP regimen at home given hypotension
observed in the hospital. Medications were significantly
changed: taken off of felodipine was stopped, losartan was
stopped, metoprolol was decreased from 150 mg BID of succinate
to 100 mg daily.
# Afib: DDD pacemaker. Paced rhythm while in house. Metoprolol
decreased as above. Continued on Eliquis. No ASA
# DM2: Given ISS in house
# GERD:
- continued home PPI
# hypothyroidism:
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
- continue home levothyroxine
# depression:
- continue sertraline
# insomnia:
- continue Zolpidem
# OA - continued home tramadol
# OSA - patient refused CPAP while in house.
TRANSITIONAL ISSUES
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
-Interval increase in size of cystic lesion within the
pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be
helpful if desired.
- A 15 x 30 mm left thyroid nodule, for which further evaluation
with
non-emergent thyroid ultrasound is recommended.
- Please monitor patients weight. Call her cardiologist to
change torsemide dose if weight increases by 3 lb or more.
___
- Patient should be on 4 L of O2 at home.
- Patient enrolled in PACT program.
- Discharge Creatinine: 1.6
- Discharge weight: 71.4 kg | 151 | 534 |
15373521-DS-23 | 29,023,448 | Dear Mr. ___,
WHY WAS I IN THE HOSPITAL?
==========================
You were admitted to ___ after you fell and hit your head.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
You had imaging done here which showed you sustained a bleed in
your head, and broke a part of the bone in your spine but this
fracture is stable and will heal on its own. You also sustained
a left acromioclavicular joint (shoulder) separation. The
orthopedic team saw you and recommend conservative management
with a sling.
You were seen by the neurosurgery team for your head bleed and
you do not need any surgical intervention.
You were also noted to have low blood pressures especially when
standing, which can lead to dizziness and cause falls. Your
medications were adjusted to help prevent further falls.
It was recommend that you go to rehab to work on your strength,
but you refused this.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
=============================================
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Please take your blood pressure any time you feel lightheaded or
if you get headaches.
Please wear your abdominal binder and stockings any time you are
out of bed.
Stand up slowly any time you get up. If you feel lightheaded,
sit or lay down immediately.
Please do NOT drive until you are cleared by your doctors.
It was a pleasure caring for you,
Your ___ Team | SUMMARY:
========
Mr. ___ is an ___ year old M w/ hx of CAD s/p multiple PCI
including to LAD with last in ___ after STEMI from in-stent
restenosis, HTN, migraines, and ___ with history of
falls who presented after a fall at home, found to have a
subarachnoid hemorrhage and non-displaced T1 fracture with
vitals notable for significant orthostatic hypotension.
ACTIVE ISSUES:
==============
# Type 3 left AC dislocation
# T1 non-displaced transverse fracture
He was evaluated by the trauma service and images done
demonstrated that he had suffered a subarachnoid hemorrhage,
non-displaced T1 transverse process fracture, and a type 3 left
AC dislocation. He was admitted to ACS/Trauma service for
further treatment of his injuries. The Orthopedic surgery
service was consulted for the left AC joint separation and they
recommend conservative management with a sling, WBAT, and clinic
follow up in ___ weeks. No surgical intervention for patient's
T1 TP fracture, just pain control as needed.
# Subarachnoid hemorrhage
He was assessed by the neurosurgery service regarding his SAH.
They recommended conservative treatment with neurological
checks, keep SBP < 160, and hold patient's home ASA/Plavix for 3
and 7 days respectively. Plavix can be restarted on ___.
# Orthostatic hypotension
# Dysautonomia
# Syncope
# Recurrent falls
# ___ disease:
Since the patient experienced lightheaded prior to his fall, he
was ordered for a syncopal workup with EKG, TTE, and carotid
duplex. He also was checked for orthostatic hypotension, which
was positive. However, due to his extensive cardiac history and
___ disease, he was transferred to the medicine service
for further management of his medical comorbidities. On the
medicine service, all of his home antihypertensives and beta
blockade were held. Unfortunately, he remained orthostatic, so
his case was discussed with his outpatient Neurologist and he
was ultimately changed to Carbidopa-Levodopa (___) 1.5 TAB
PO/NG 5X/DAY, Carbidopa-Levodopa CR (___) 1 TAB PO DAILY at
2300, and ropinirole was decreased to 4 mg BID. He was given an
abdominal binder and TEDS stockings. ___ evaluated him and
recommended discharge to rehab, which he refused and had
capacity to do so. He stated multiple times that he understood
the risks of going home including recurrent falls and head
strikes which could lead to permanent neurologic damage or
death. His family was informed that we unfortunately could not
force him against his will to go to rehab since he had capacity
to refuse. He was discharged home w/ ___. He was instructed on
fall prevention and management of orthostatic hypotension. While
his blood pressures were still orthostatic before discharge, his
symptoms had resolved and he was able to do the stairs multiple
times. He also did not show any signs of overt stiffness from
his ___, although was feeling some of the effects of his
decreases doses of medications. He should have very close follow
up with Neurology and Cardiology. He and his wife were
instructed that he should not drive.
# Chronic HF, borderline EF
# HTN
# Hx of CAD s/p 2 PCI to LAD
EF 45%, worsening from prior. Imaging consistent with LAD +/-
RCA distribution ischemia. Patient was euvolemic on exam. His
home metoprolol and isradipine were all held given severe
orthostasis. He was intermittently hypertensive to the 160s, but
this quickly resolved. Aspirin held for 3 days and Plavix held
for 7 days per NSGY (restart on ___. He remained on his
home atorvastatin. Consider outpatient stress test given
worsening regional wall motion abnormalities
CHRONIC/STABLE ISSUES:
=======================
# Chronic thrombocytopenia
Plts in 130s going back to ___. Stable.
# Depression
Continued home Fluoxetine daily
# Chronic pain
Held home gabapentin given fall
# GERD
Decreased home pantoprazole to daily as no indication for BID | 241 | 599 |
15671382-DS-15 | 20,637,254 | You were admitted with severe abdominal pain. Because of this,
you had an endoscopy (EGD) performed, which showed some redness
(erythema) in the bottom part of your stomach (antrum) and
biopsies were taken. The Gastroenterologists that did this
procedure also recommended an MRI of your abdomen (MRCP) which
showed a dilated common bile duct and some aberrant bile ducts.
These findings are non-specific. The Gastroenterologists will
review this study more closely and contact you with a follow-up
plan. | ___ year old female with history with history gallstone
pancreatitis s/p ccy, and recent admission at ___ for acute
pancreatitis p/w epigastric pain. s/p EGD here showing antral
erythema, bx pending. MRCP ordered (ERCP team following).
.
Abdominal pain
- unclear etiology, pancreatitis seems unlikely given her barely
elevated lipase levels (which are non-specific), the lack of
imaging evidence of pancreatitis, and the very quick resolution
- ddx includes biliary tree problem, versus an antral process,
although this seems unlikely
- ERCP consult followed the patient
- EGD showed antral erythema, biopsies pending
- MCRP showed common bile duct dilation -- could be secondary to
sphincter of Oddi dysfunction
- the patient will follow-up with GI after discharge
.
Renal cyst seen on MRCP
- the patient will follow-up with her PCP about this to
determine if more imaging is needed
.
Asthma
- Continued home albuterol
.
Other
- trazodone PRN insomnia
.
Day of discharge
Interval history: Felt much better today. Hasn't need any pain
medication. Tolerated lunch with some nausea, but would like to
go home. We discussed her plan of care and the importance of
follow-up. She understood, and I answered her questions.
. | 82 | 182 |
16044456-DS-18 | 25,655,898 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
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 ___ 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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever >101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated left lower extremity
Treatments Frequency:
Surgical dressing to remain in place. It may be changed as
needed. | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have left intertrochanteric hip fracture and was admitted to
the orthopaedic surgery service. The patient was taken to the
operating room on ___ for ORIF left intertrochanteric hip
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on 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. | 580 | 256 |
11964069-DS-12 | 21,175,500 | Dear Mr. ___,
___ were admitted to the hospital because of shortness of breath
and increased swelling in your legs. This was thought to be due
to a heart failure exacerbation. Your cardiac ultrasound showed
mildly depressed cardiac function with structural changes due to
underlying coronary artery disease. However, ___ did not have an
acute coronary event or heart attack. ___ were given IV
medications to remove extra fluid and improved after a couple of
days.
Your blood pressure was high. ___ were started on a new
medication: amlodipine. Tomorrow morning, afternoon and night,
please check your blood pressure. If your blood pressure is
above 170, please call your transplant doctor immediately for
further instructions. We will write ___ for a few tabs of
carvedilol for ___ to take only if your doctor instructs ___ to.
___ have symptoms like lightheadedness, chest pain, trouble
breathing, or experience new swelling in your legs, please call
your doctor as well.
___ were evaluated by our ear, nose and throat doctors. ___ will
need to take Augmentin for a total of 3 weeks. Please continue
using the nasal sprays and Netipot.
Your kidney function remained stable, as showed by a renal
ultrasound.
Please follow up with your doctors below as listed.
Sincerely,
Your ___ team | ___ year old male, with past history of ESRD ___ Type I DM, now
s/p kidney/pancreas transplant in ___, with recent admission
for conversion of bladder drain to enteric, presenting with
hypertensive urgency and CHF exacerbation. He was treated with
IV Lasix x2 days and put out well. TTE showed EF 45-50% with
changes consistent with known CAD. Cardiac biomarkers were
negative and BNP was in the 9000s. He remained in normal sinus
rhythm. He had head CT for c/o ongoing sinus issues which showed
changes suggestive of chronic sinusitis. He also was started on
new blood pressure medication of amlodipine.
#CHF exacerbation: Presented with dyspnea, orthopnea and lower
extremity edema. VS notable for BP >200s in ED. Labs notable for
elevated BNP. Echo with EF 45-50%, ECG stable, CXR with no
underlying infection but notable for pulmonary edema, telemetry
with no events. Etiology attributed to uncontrolled
hypertension. Patient was treated with labetolol and IV Lasix
20mg BID and then transitioned to amlodipine and 40mg PO
furosemide. After adding carvedilol, patients blood pressure
dropped to 110s, so it was held. Plan for discharge was
initially for just amlodipine for BP control, but after
discharge, plan was changed to carvedilol BID. Patient was
informed via voicemail and prescribed the medication
electronically. Negative orthostatics and ambulatory saturation
within normal limits.
# Uncontrolled HTN: Admitted with SBP 190-200s, please see above
for more detail. Discharged on amlodipine, carvedilol, 40mg
furosemide.
# Type I DM c/b ESRD s/p Kidney/Pancreas Transplant: Renal
ultrasound stable. Amylase, lipase and blood sugars were
monitored daily and stable.
- continued tacrolimus 3 mg BID with tacro levels
- continued prednisone 5 mg daily
- continued azathioprine 100 mg daily
- continued batrim for PJP prophylaxis.
# Chronic sinusitis: Secondary to NG tube placement in the past,
now with significant pain. CT scan c/w chronic sinusitis. ENT
consulted in patient and recommended nasal spray, fluticasone,
neti pot and Augmentin for three weeks. Plan is to follow up as
outpatient with ENT.
# CAD: Known CAD with prior cardiac catherization in ___ per
reports. No chest pains, palpitations, or ischemic changes seen.
Trops negative, EKG stable, echo stable.
- continued aspirin
# Obstructive Sleep Apnea: With PHTN on echo. Noncompliant with
cpap machine, counseled extensively on risks. Patient f/u with
PCP for further management.
***Transitional issues***
- amlodipine for hypertension. Please check blood pressure
regularly and follow up with providers regarding hypertension.
- no changes to immunosuppression regimen. Tacro trough on day
of discharge 5.0.
- will take Augmentin for 3 weeks (___). Follow up with ENT.
- will be discharged on 40 mg PO Lasix daily. Titrate as needed.
Patient will have labs checked in 3 days to monitor electrolytes
and Cr. Admission Cr .9, discharge Cr 1.1.
- Admit weight 210lb, discharge weight 205.8 lb.
FULL CODE | 210 | 466 |
13352386-DS-22 | 25,557,498 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were admitted to the hospital because your breathing
worsened and you were noted to require more supplemental oxygen.
These symptoms are related to your underlying lung cancer and
COPD. You had a CAT scan of the lungs, which did not show a clot
or an infection. You received your first round of chemotherapy
on ___ and part of this treatment included high dose steroids
which also treated your COPD. In addition, you received routine
nebulizer treatments and an antibiotic azithromycin.
Because of the steroids and your underlying diabetes, you
required insulin shots to control your blood sugar. In the last
few days of your hospital stay, you did not require any insulin.
You should hold off on resuming your glyburide until you see Dr.
___ in a week. However, you should check you blood sugars
every morning and evening, keep a record of them and take with
you to your appointment with Dr. ___. Please call his office
earlier if you have blood sugars >200. You will discharged on
medications for pain and medicines to take as needed for nausea.
Please follow up with all scheduled appointments (see below) and
continue taking all medications as prescribed. If you develop
any of the danger signs listed below, it is important that you
talk with your healthcare providers or go the emergency room
immediately.
We wish you the best.
Sincerely,
Your ___ Team | Ms ___ is a ___ w/ PMHx COPD (on 3L oxygen at home) and newly
diagnosed metastatic lung adenocarcinoma who presents with
worsening dyspnea with CTA negative for PE/PNA, but showing
progression of disease.
#Worsening dyspnea/hypoxia: likely secondary to combination of
progression of disease and underlying COPD. CTA obtained which
did not reveal PNA or PE but demonstrated significant interval
worsening of widespread metastatic disease including innumerable
parenchymal nodules and lymphangitic carcinomatosis. She was
pre-treated with dexamethasone and received carboplatin and
pemetrexid on ___ without issues. Breathing noted to
improve significantly with steroids and duoneb therapy. Oxygen
was downtitrated to 3L NC.
#Metastatic lung adenocarcinoma: Recently diagnosed on
admission ___. Negative for EGFR. As mentioned above,
lymphangitic spread was noted to have worsened over short
interval and thus she was given carboplatin/pemetrexid on ___.
Patient with worsening pain from known bone mets. Fentanyl patch
was added to pain regimen and she was given zoledronic acid on
___. Further chemo as per new oncologist.
#Hyponatremia - Sodium persistently in low 130s on this
admission, requiring no intervention.
# Type II Diabetes: Initially had elevated blood sugars in
setting of high dose steroids managed with SSI. After finishing
steroids, blood sugar consistently < 200 and required no
insulin. Given risk of hypoglycemia, home glyburide held out of
concern for hypoglycemia to restart at PCP ___.
# Hypertension: SBP 150 on arrival. Continued amlodipine 5 mg
daily and lisinopril 10 mg daily. HCTZ 50 mg held.
TRANSITIONAL ISSUES:
- Next chemo to be determined by Dr. ___.
- Patient started on fentanyl patch for pain on this admission.
- Glyburide not restarted due to BS in the 100's with no insulin
requirements by discharge
- Will need ongoing assessment of pulmonary status and titration
of oxygen requirements.
- Code status: DNR/DNI, BiPAP is OK | 243 | 301 |
15741634-DS-15 | 24,343,145 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
Why you were here:
- You had a fall at home and were found to have a fracture of
the head of the L femur (a hip fracture).
What we did while you were here:
- You had surgery on your L femur by the orthopedic surgery
team. They fixed the left femur on ___
- We took a look at the imaging that was done of the abdomen
after the fall, and saw that your pancreatic cancer has
progressed. We spoke with your oncologist, Dr. ___ told
him these results. We had a meeting with you and your wife, and
ultimately decided it would be best for you to return home with
Hospice Services, to manage your symptoms as best we can and to
make sure that you have everything at home that you will need to
be safe and comfortable.
- We gave you the electrolytes to replace the ones that were
low. These included phosphate and magnesium.
- You worked with the physical therapists and they felt that you
would be safe to go home without needing to go to rehab.
What to do when you go home?
For the care of your broken hip:
-Activity: weight-bearing as tolerated on your left leg
-Walk several times per day.
-Avoid lifting weights greater than ___ lbs until you follow-up
with your surgeon.
-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.
OTHER INSTRUCTIONS:
-Please follow up with Dr. ___ on ___ at 2pm.
-You will need to have your electrolytes checked on ___,
___ ___. You may also need some extra fluid
through the IV if you get dehydrated over the weekend or if you
are unable to eat much.
-Please call Dr. ___ or come to the ER if you are
getting dehydrated due to continued vomiting, diarrhea, or other
reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
- Continue taking all your medicines as prescribed below. Dr.
___ decide how long you should stay on the boosted dose
of Prednisone.
Sincerely,
Your ___ Team | ___ year old male, with past history of metastatic pancreatic
cancer (known metastasis to the liver and lung, on palliative
chemotherapy), who presented after a fall at home. He was found
to have a L femoral head fracture, underwent fixation by
orthopedic surgery on ___ and was transferred to the
medicine service for management of subacute generalized
weakness. He was found to have dehydration, severe
hypophosphatemia, as well as progression of pancreatic cancer on
imaging.
.
>> ACTIVE ISSUES:
# Fall/Left Femoral Neck Fracture: Patient fell at home while
getting out of bed, thought to be ___ to generalized weakness
from underlying progressive metastatic pancreatic cancer,
nutritional deficiency, peripheral neuropathy ___ to
chemotherapy, as well as increased dehydration. patient was
found to have a left femoral neck fracture, underwent fixation
by Orthopedic Surgery on ___. On POD#1, patient was then
transferred to the medical service, and continued to have
physical therapy. Given underlying progressive metastatic
disease (see below), further discussions regarding optimizing
post-operative care was discussed with family. Patient continued
to work with physical therapy, ambulate, and continued on DVT
prophylaxis while in house. It was discussed with family to
continue to limit medications and discussed < 5 days further DVT
prophylaxis with anticoagulants as an outpatient for which
family then declined given not within goals of care, and
enrollment into hospice program. Patient was instructed to
continue to work with physical therapy, weight bearing as
tolerated and continue to ambulate maximally given underlying
risks. Hospice services to continue to work with patient, with
daily sterile dressing changes, and follow up within 2 weeks for
orthopedic surgery evaluation.
.
# Severe hypophosphatemia: Patient was noted to have a phosphate
of 1.2, that depleted again rapidly even after IV repletion.
This is likely explained by hypermetabolism from his pancreatic
cancer. He was started on a standing PO phosphate repletion
regimen and was ultimately discharged on phosphate supplement.
He was instructed to follow up closely with his oncologist's
office near home for frequent electrolyte monitoring and IV
repletion as needed.
# Metastatic Pancreatic Cancer (lung, liver), with progression:
Patient has been on palliative chemotherapy with
gemcitabine/abraxane regimen at ___ with Dr.
___. Unfortunately, interval imaging this admission does
suggest disease progression on this regimen. He also had an
elevated bilirubin on admission that downtrended; imaging
demonstrated patency of the CBD stent without need for stent
exchange (this was discussed with Dr. ___, but it was
believed that he likely had a mild obstruction that relieved
without need for antibiotics or intervention. After discussion
with Dr. ___ and with the patient and his wife, it was decided
to enroll the patient in Hospice Services. He will follow up
closely with Dr. ___ on ___ for further discussion of his
treatment goals and plans. He will likely need to come in to the
office for electrolyte checks and repletion and IV fluids on an
as-needed basis.
#Adrenal insufficiency: Patient has chronically been on 20mg
prednisone daily at home for symptom management related to his
cancer. He was noted to be persistently hyponatremic with high
urine sodium during this admission and given recent orthopedic
surgery he was started on stress dose prednisone at 60mg on
___. He was discharged with this dose and asked to follow up
with Dr. ___ on ___. He had no vital sign instability or
other signs of adrenal insufficiency.
# Hyponatremia: Pt with Na in the 120s, which did not improve
with fluid rescusitation. In the context of elevated urine Na of
172, the patient was started on stress dose prednisone (60mg)
for likely adrenal insufficiency as he is chronically on 20mg of
prednisone. His sodium then improved to 133 on the day of
discharge.
# Cervical Spine foraminal narrowing: Imaging indicates
extremely severe foraminal narrowing, pronounced at C5-C7, with
degenerative changes predisposing patient to cord injury in the
setting of minimal trauma. The patient remained asymptomatic
this admission.
# Hyperbilirubinemia: Mildly elevated 1.7 on arrival, which
normalized. Patient with low grade fevers at home and may have
had a transient CBD stent obstruction, but imaging demonstrated
___ stent patency without need for stent exchange. This was
discussed with Dr. ___.
# Thrombocytopenia and anemia: Likely ___ to chemotherapy and
marrow suppression. Remained stable.
#Sinus Tachycardia: Patient was tachycardic from 100s-130s this
admission, which did not correct with hydration. We spoke with
the patient's oncologist office, and the patient appeared to
have been tachycardic on several office visits prior to this
admission. It was believed that this was ___ metastatic
pancreatic cancer.
#?Sinusitis: Imaging concerning for sinusitis, with parnasal
sinus disease. Patient was asymptomatic and fevers resolved
during this admission without antibiotics, so likely not active.
#DVT prophylaxis: At time of discharge patient had 5 days
remaining for total course of DVT prophylaxis with home
injections of lovenox. This was discussed with the family, but
they ultimately decided that was not within their goals of care
and declined.
===================================== | 421 | 818 |
18509741-DS-12 | 20,198,825 | You were admitted to ___ and underwent a revision of your AV
graft on ___, and had a tunneled dialysis line placed on
___. You are now prepared to complete your recovery at home
with the following instructions:
- You may not shower with the dialysis line in place. The
stitches in your wound will remain in place, to be removed at
your follow-up appointment. Do not submerge the right arm, wash
the incision gently and pat dry.
- You may resume your usual diet, following a low potassium, low
sodium, low phosphorous renal diet
- You may resume all your usual home medications, including your
Coumadin at the regular dose. You have also been prescribed a
medication to help with pain control, which you may take once
every 6 hours as needed.
- You should receive dialysis per your usual schedule of ___
and ___, through the tunneled line until your surgeon tells
you that the graft may be used. Please DO NOT allow dialysis to
access your graft until your surgeon has approved it.
- Try to keep arm elevated as much as possible. Sutures will be
removed in follow up with Dr. ___.
- Please call Dr. ___ office at ___ if you
have any of the following: temperature of 101, shaking chills,
Right upper arm appears larger, incision appears red/warm or has
bleeding/drainage, numbness of arm or altered circulation | On ___, she underwent revision and thrombectomy of right
upper extremity arteriovenous graft for bleeding/ulceration of
AVG. Surgeon was Dr. ___. Please refer to operative
note for details. PTFE graft was placed, and some clot was
removed prior to assuring hemostasis, and at the end of the case
there was an excellent thrill.
She did receive two units of FFP to reverse the INR of 2.6
Patient was stable at the end of the case and transferred to
PACU.
Patient had received a dose of Vancomycin, based on the open
area of the graft prior to excision, however during surgical
inspection it was not felt that this was an infection in the
graft and no antibiotics were continued.
Due to the extensive nature of the revision, it was decided the
graft should be rested and healed, and a tunneled line placed
for hemodialysis in the meantime.
Patient receives dialysis two times a week, and there was not an
urgent indication for the line placement. The line was finally
placed on ___. A potassium of 5,5 on POD 1 was controlled
using Lasix and a dose of kayexalate with good results.
Low dose Coumadin was continued as patient has been
anticoagulated for graft patency.
After the line was placed the patient underwent routine
hemodialysis without difficulty.
The revised access has a bruit and thrill, and the suture line
was clean dry and intact upon discharge. | 227 | 227 |
14469264-DS-13 | 28,937,539 | Dear Mr. ___,
You were admitted because your blood pressure was low and you
were confused. Your symptoms improved with intravenous fluids.
You continue to have an infection in your foot. You were not
deemed a surgical candidate given the high risk of the
procedure. You were not able to get antibiotics through the
"PICC" line because you kept pulling out your line. Instead we
are giving you oral antibiotics with the goals of care discussed
with your guardian to not pursue more aggressive care.
We also initiated the process of transferring you to hospice
care. Your infection in your foot is unlikely to improve. This
will serve to focus treatment on measures that will make you
more comfortable.
Please follow up with the Infectious disease clinic for your
antibiotics and the Podiatrists for your foot infection.
Sincerely,
Your ___ Team | ___ man with COPD, orthostatic hypotension, and recent
admission for sepsis likely from osteomyelitis (vs HCAP), who
was referred to the ED on ___ for removal of his PICC line and
found to be hypotensive with AMS likely due to hypovolemia.
Blood pressure improved following fluid administration. Patient
not able to tolerate PICC (pulled out twice), so he was
transition to oral Linezolid for osteomyelitis of R foot.
Patient was transitioned to hospice given patient's age, altered
mental status, impaired functional status and R foot
osteomyelitis without definitive treatment. | 139 | 90 |
15638884-DS-3 | 28,416,092 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came to ___
___ because you are having left shoulder pain. We also did
some blood tests that showed that your heart was under stress.
You underwent a stress test that demonstrated you may have a
narrowing in one of the blood vessels of your heart. You were
started on aspirin and atorvastatin to prevent a blockage from
forming in one of these blood vessels. We will arrange for you
to follow up with a cardiologist as an outpatient to monitor
this.
We think that your left shoulder pain is likely due to your
chronic left shoulder pain.
Your discharge medications and follow-up appointments are
detailed below.
We wish you the best! | ___ with CAD and recent admission at ___ for alcoholic
pancreatitis presents with progressive L shoulder pain and found
to have an elevated troponin concerning for an NSTEMI.
#L Shoulder Pain
#Elevated troponin:
Patient present with acute on chronic L shoulder pain after
recent ICU hospitalization requiring intubation for pancreatitis
and pneumonia. The shoulder pain is likely MSK in etiology as he
said it is an exacerbation of his pre-existing pain. He states
that the pain started to get worse towards the end of his recent
hospitalization due to lying in bed while intubated. He had no
ECG changes though his troponin was noted to be elevated to
0.47. His CK-MB was flat, therefore this likely represents a
resolving Type II NSTEMI from his recent critical illness rather
than a true NSTEMI. He was started on a heparin gtt which was
quickly discontinued and he was begun on aspirin and
atorvastatin. Interestingly, the patient has had a stress test
from ___ which demonstrated an area consistent with a prior MI
without an area of inducible ischemia. This therefore suggests
pre-existing CAD. Reassuringly, a recent TTE performed during
his last hospitalization showed no WMA. Although due to
non-compliance with prior medications, the patient would not be
a good stent candidate so angiography was differed. He underwent
a PMIBI to assess if he had CAD to require ongoing medical
optimization. PMIBI showed Reversible perfusion defects
involving anterior septal wall apical area with associated wall
motion defect He was continued on his home metoprolol and was
initiated on aspirin and atorvastatin. The Cardiovascular
institute was contacted to arrange a follow up appointment with
the patient within the next month.
#History of Pancreatitis: Patient presented to ___ with
alcoholic
pancreatitis after binging on alcohol after his benzos were
d/c'd
by his outside provider. Currently without abdominal pain.
Lipase
wnl.
#History of EtOH Abuse: Prior history of heavy use, quit ___
years
ago, then restarted as above. Last drink was prior to recent CHA
admission. Out of the window for withdrawal.
-started on folate, thiamine, MVI
#Anxiety: Patient appears anxious on exam with tangential
thought
process. Was previously on multiple medications including
buspirone, gabapentin and trazadone, but these were discontinued
during his last hospitalization. Patient was not started on any
new psychiatric medications. Will defer initiation of
anxiolytics/antidepressants to PCP.
#Anemia:
#History of Polycythemia ___:
Prior history of PV thought to be from cigarette smoking due to
negative mutation testing. Previously treated with phlebotomy.
Currently anemia is below baseline, but is stable from recent
hospitalization without evidence of bleeding. No abdominal pain
to suggest hemorrhagic pancreatitis.
#Thrombocytosis: Newly elevated from prior ___ labs in ___.
Was elevated to 400s at CHA, currently 550. Likely reactive due
to stress of recent critical illness. However, given h/o PV, may
suggest underlying marrow disease.
#Exposure to TB: Patient's PCP notified us that he was notified
that the patient was exposed to TB during a recent
hospitalization at ___. We became aware of this
information as the patient was being prepared for discharge. He
was having no symptoms of active TB. Therefore, we will defer TB
testing to his PCP follow up appointment. | 126 | 498 |
16577271-DS-4 | 24,398,272 | 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.
.
Right and left hepatic drains:
*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 ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
What to watch out for when you have a Dobhoff Feeding Tube:
1. Blocked tube: If the tube won't flush, try using 15 mL
carbonated cola or warm water. If it still will not flush, call
your nurse or doctor. Always be sure to flush the tube with at
least 60 mL water after giving medicine or feedings.
2.Vomiting:
*Call doctor if vomiting persists. Vomiting causes the loss of
body fluids, salts and nutrients.
*Give the feeding ___ an upright position.
*Try smaller, more frequent feedings. Be sure the total amount
for the day is the same though.
*Infection may cause vomiting. Clean and rinse equipment well
between feedings.
*Do not let formula ___ the feeding bag hang longer than 6 hours
unrefrigerated. After the formula can is opened, it should be
stored ___ refrigerator until used.
3. Diarrhea:
*This is frequent loose, watery stools.
*Can be caused by: giving too much feeding at once or running it
too quickly, decreased fiber ___ diet, impacted stool or
infection. Some medicines also cause diarrhea.
*Avoid hanging formula for longer than 6 hours.
*Give more water after each feeding to replace water lost ___
diarrhea.
*Call doctor if diarrhea does not stop after ___ days.
4. Dehydration:
*Due to diarrhea, vomiting, fever, sweating. (Loss of water and
fluids)
*Signs include: decreased or concentrated (dark) urine, crying
with no tears, dry skin, fatigue, irritability, dizziness, dry
mouth, weight loss, or headache.
*Give more water after each feeding to replace the water lost.
*Call your doctor.
5. Constipation:
___ be caused by too little fiber ___ diet, not enough water or
side effects of some medicines.
*Take extra fruit juice or water between feedings.
*If constipation becomes chronic, call the doctor.
6. Gas, bloating or cramping: Be sure there is no air ___ the
tubing before attaching the feeding tube.
7.Tube is out of place: If the tube is no longer ___ your
stomach, tape it down and call your doctor or home health nurse.
Do not use the tube. You will need to have a new tube placed. | The patient well know for Dr. ___ was admitted to the
___ Surgical Service for evaluation and treatment of new
subcapsular fluid collection. Patient was admitted ___ the ICU
secondary for hypotension requiring pressors support and sepsis.
She was started on IV Vancomycin and Zosyn empirically.
Patient's INR was 2.3 on admission and she received 3 units of
FFP on HD # 1. She underwent ultrasound-guided drainage of
right upper quadrant subcapsular hepatic collection and fluid
was sent for cultures. On HD 3, patient's Levophed was weaned
off. On HD # 4, patient was transferred on the floor on regular
diet, on IV fluid and antibiotics, with Foley, biliary drain and
2 old JP drains. The patient was hemodynamically stable.
Neuro: The patient received PO Oxycodone with good effect and
adequate pain control.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: The patient was advanced to regular diet, her albumin was
2.0 and NJ tube was placed on HD # 5. Nutrition was called for
consult and tubefeed was started. Calorie count demonstrated
poor oral intake and tubefeed will be continued post discharge.
Patient's bile was refeeded back to the patient via NJ tube from
left sided drain catheter. On HD # 6 patient lost her biliary
drain and ___ was called to replace the drain. ___ requested new
CT and abdominal CT was obtained on HD 7. CT demonstrated
significant interval decrease ___ size of the subcapsular biloma,
with still large residual collection. On HD 8, patient underwent
placement of right and left hepatic drains. Old JPs were removed
on HD 9 as output was low.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient was started on
IV Zosyn/Vanc on admission. Her bile cultures grew Staph aureus
coag positive and Enterococcus. She underwent treatment with IV
Zosyn/Vancomycin for 8 days. Prior discharge patient's
antibiotics were changed to PO Augmentin. She still to have
mildly elevated prior discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a tubefeed
at goal, 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. | 565 | 458 |
18994071-DS-26 | 22,061,509 | Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted to the hospital after a fall, and you were found
to have a fracture of your right hip. The orthopedic surgery
team took you to the OR on ___ and fixed this fracture. You were
also found to have a urinary tract infection treated with
antibiotics.
You should weigh yourself every day, and call your doctor if
your weight goes up by more than 3 pounds. After you leave the
hospital you will need rehabilitation to regain your strength
after the surgery. Your appointments and medications are listed
in your discharge paperwork.
We wish you the best!
-Your ___ Care Team
ORTHOPEDIC POST OPERATVE INSRUCTIONS
======================================
INSTRUCTIONS AFTER ORTHOPEDIC SURGERY:
- You underwent surgical fixation of your right hip fracture
during your hospitalization. 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:
- You are encouraged to bear weight as tolerated on your right
lower extremity.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40 MG 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.
- No dressing is needed if wound continues to be non-draining. | ___ with hx of HTN, DM, HLD, dCHF, Afib not on Warfarin,
Dementia who presents from her nursing home s/p fall found to
have R hip fracture.
#Mechanical fall complicated by comminuted avulsion fracture of
R greater trochanter: The patient presented from nursing
facility after two falls at her rehab facility. CT head negative
for acute intracranial process, CT C Spine negative for acute
fracture or pre-vertebral soft tissue swelling. Right hip XR and
subsequent CT of right lower extremity revealed minimally
displaced comminuted fracture of the right greater trochanter.
Trauma surgery evaluated the patient in the ED and no other
injuries were identified. Orthopedic surgery was consulted who
recommended MRI of the right hip or further evaluation of the
fracture. This revealed a comminuted avulsion fracture of the
right greater trochanter. The patient underwent uncomplicated
intramedullary nailing of the right hip with orthopedics on
___. Post operatively the patient was continued on daily SC
lovenox, and pain was well controlled with oral pain
medications. The patient was tolerating an oral diet well. The
patient as evaluated by ___ who recommended discharge to rehab.
# Leukocytosis:
The patient developed a mild leukocytosis on POD #1. that was
likely a stress reaction. The patient had been previously
treated with IV ceftriaxone for a susceptible E coli UTI. There
were no pulmonary symptoms or CXR evidence of pulmonary
infection. The leukocytosis resolved on POD #2.
#UTI:
Patient presented with + UA and UCx growing E coli, in the
setting of multiple recent falls and leukocytosis. Unclear if
symptomatic on exam though concerning for contribution to fall
and delirium as below. Patient received Ceftriaxone in ED
without reported issue, and daughter unaware of ___ allergy
reported. The patient was successfully treated with ceftriaxone
x 3 days for an uncomplicated UTI.
# Hypoxia:
The patient developed acute hypoxia on ___ with an SpO2 of 80%
of unclear etiology. EKG was non ischemic, and troponins were
negative. There was no evidence of significant volume overload
on exam or CXR. There was no tachycardia to sugest PE, and the
patient had been maintained on DVT prophylaxis. There was no
evidence of focal infiltrate on CXR. This was thought to have
been secondary to microaspiration. This resolved rapidly and did
not recur.
#Delirium:
The patient developed worsening delirium on HD #2 likely
secondary to infection, fracture, and hospital environment
overlying underlying dementia. There was concern that the micro
aspiration event as above may bave been the trigger given the
acute changes. The patient had no further episodes of acute
agitation.
# ___:
The patient developed ___ on HD#3 thought to be pre renal
secondary to her NPO status pre operatively and concuren
diuretic use for CHF. The ___ resolved with IV fluids and
holding home furosemide. | 310 | 457 |
18196421-DS-7 | 28,782,035 | Ms. ___,
It was a pleasure caring for you during your hospital stay. You
were admitted for abdominal pain with concern for cholecystitis
(infection or inflammation of the gallbladder). You had a scan
of your gallbladder which showed that you do not have
cholecystitis. Your abdominal pain improved overnight, and all
of the lab and imaging studies were reassuring. You should
follow up with your Gastroenterologist to discuss having an
outpatient endoscopy to look for problems in the stomach and
first part of the intestines which may be causing your pain. | ___ female with HTN and h/o H.pylori who p/w acute onset of RUQ
pain and nausea/vomiting.
ACTIVE ISSUES
# Abdominal Pain. Unclear etiology; differential included
gallbladder pathology or hepatobiliary pathology given location,
however, LFTs, bili, amylase, electrolytes, WBC all wnl and CT
abd without findings. Had HIDA scan which was negative for
cholecysitis. CXR was normal indicating no possibility of lower
lobe pneumonia causing the pain. Had constipation/gas over last
few days prior to admission. Pain management overnight; patient
felt much improved the following day and nausea resolved. Diet
was advanced and this was tolerated well. Patient has
outpatient colonoscopy scheduled and GI was contacted to
recommend adding endoscopy given h/o gastritis.
CHRONIC ISSUES
# HTN. Normotensive, home HCTZ continued.
TRANSITIONAL ISSUES
-Patient recommended to have EGD in addition to colonoscopy
scheduled for ___. | 94 | 133 |
13230497-DS-19 | 27,815,012 | Dear Ms. ___,
You were seen at ___ for evaluation of your ruptured
appendicitis and abscess. You had this abscess drained by
interventional radiology and they left a drain in place. Drains
were placed in both the right lower part of your abdomen and the
presacral area (pelvis). You were started on IV antibiotics as
well and improved after that.
You will go home with an oral antibiotic. Please take these as
instructed and take them to completion.
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.
JP 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).
*Maintain suction of the bulb.
*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.
*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. | ___ with 2-week history of abdominal pain due to perforated
appendicitis with subsequent abscess formation and significant
leukocytosis (though also component of hemoconcentration) who
presented to ___ on ___. Patient was admitted to ___
surgery service for IV antibiotics (zosyn), IV fluids, pain
control and ___ consult for drainage. CT scan done at this time
showed loculated fluid collection in the pelvis concerning for
large periappendiceal abscess. In particular, 2 large pockets
were present (one within right hemipelvis adjacent to the cecum
and one in the deep pelvis). ___ was consulted on ___ and
patient underwent drainage of fluid collections with subsequent
placement of ___ pigtail ___. Two ___ pigtail
catheters were placed, one in the right lower quadrant and one
placed presacral region. After undergoing ___ drainage, patient
was monitored with serial exams, continued antibiotics and seen
by social work and case management. Her diet was advanced and
drain output decreased. On ___, a repeat CT and drain study
was ordered to assess the patency of drains and remnant fluid.
Interval decrease in size of the fluid collections. The drains
were left in place and the patient was then transitioned to PO
antibiotics (Augmentin) for a 14 day course. The patient
continued to do well and was discharged home with ___ services
and close family supervision on ___ in good condition. | 404 | 222 |
12051380-DS-24 | 27,981,474 | Dear Mr ___,
WHY YOU WERE ADMITTED
- You were having shortness of breath and leg swelling
WHAT WE DID FOR YOU HERE
_ You were found to be volume overloaded, and fluid was removed
from your body with a medication called a diuretic
- Your heart numbers were elevated in the blood suggesting
disease. Coronary angiography showed blockages in many arteries
of the heart
- You were started on new medications for your heart including
metoprolol XL 25mg daily.
WHAT YOU SHOULD DO WHEN YOU LEAVE
- Please take your medication as directed
- Please follow with your primary care doctor and cardiologist
- ___ weight yourself daily and if your weight is up by 3
pounds in one day, please call your primary physician!
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | ___ man with HF recovered EF (EF 40%), LBBB, HTN, HLD
who presents with dyspnea, progressive leg swelling, and weight
gain consistent with acute on chronic heart failure exacerbation
with associated elevated cardiac enzymes. Warm and wet on exam
s/p diuresis. Repeat TTE with preserved EF, now s/p RHC/LHC with
low filling pressures but multivessel disease pending csurg
eval.
# Acute on Chronic Heart Failure Exacerbation
# HFpEF:
Patient with signs of volume overload and elevated proBNP on
admission. Concern for ischemia as provoking factor given
elevated cardiac enzymes, though no acute ischemic changes noted
on EKG and recovered EF on TTE with no FWMA. Cardiac involvement
from his known Inclusion Body Myositis is unlikely. Coronary
angio with multivessel CAD. The patient was diuresed, seemingly
euvolemic on discharge. Cardiac surgery was consulted and did
not feel he was a surgical candidate given his frailty. He was
actively diuresed and then transitioned back to his torsemide 40
mg qd, metop XL 25 mg qd was started, he was continued on his
spironolactone 25 mg BID. Lisinopril was not added due to
orthostatic hypotension.
# NSTEMI:
# Multivessel CAD:
Suspected etiology of CHF exacerbation. Trop and MB rose on
admission and peaked to 1.19. Continued heparin gtt for 48
hours. Coronary angio ___ showed multivessel disease not
amenable to PCI. Cardiac surgery consulted for CABG evaluation
and patient initiated on workup, however, he was ultimately
declined for surgery. Complex PCI is deferred at this time given
his frailty and lack of continued ischemic symptoms and
preserved EF. Discussion will need to be continued with
interventional cardiology as an outpatient. He was started on
atorvastatin 80 mg qd in addition to metoprolol 25 mg XL qd. His
aspirin 81 mg qd was continued.
# Diarrhea:
Multiple loose stools iso neutrophilic predominance and elevated
white count. White count improving and C diff negative. Improved
prior to discharge.
CHRONIC CONDITIONS
=====================
# Normocytic anemia:
Hgb at recent baseline ___. Last colonoscopy ___ with
fragments of adenoma on biopsy, was supposed to have repeat
scope in ___ years. Iron studies unremarkable. Likely anemia of
chronic disease iso myositis. Should have scheduled repeat
outpatient colonoscopy.
# HTN:
Recently amlodipine and metop succ discontinued. Continued
spironolactone and re-added metoprolol. His orthostatic
hypotension prevented starting Lisinopril.
# Inclusion Body Myositis:
Followed at ___. Not on any therapy other than NSAIDs as disease
traditionally poorly responsive to immunosuppresants. No known
history of cardiac involvement. Deferred sending
rheumatologic/inflammatory markers as these are commonly not
elevated in ___. Held NSAIDS during admission and on discharge
given volume overload. Should follow w/ Dr. ___ in
___ clinic. CK was elevated on admission (~200-300),
likely secondary to NSTEMI, started atorvastatin and several
days later CK normalized.
# Depression:
# Insomnia:
Continue home citalopram and zolpidem.
# Gout:
Continued home allopurinol.
TRANSITIONAL ISSUES
==================
-His predicted LOS at rehab will be less than 30 days.
-He will follow-up with his PCP, who is also his cardiologist.
He will also follow-up with his neurologist as an outpatient.
-DISCHARGE WEIGHT: 122 kg
-DIURETIC: Torsemide 40 mg qd (continued home dose)
-NEW MEDICATIONS: Atorvastatin 80 mg qd, metoprolol succinate 25
mg qd
-STOPPED MEDICATIONS: Ibuprofen (please discuss restarting as an
outpatient)
-DISCHARGE CR: 1.1
-DISCHARGE HGB: 11
-Please recheck a chem10 1 week upon discharge to evaluate
electrolytes and kidney function. Consider checking a CK 1 week
after discharge. He was started on a statin with a normal CK
after 4 days of being on a statin.
-Colonoscopy: He had adenoma in the past which was not
completely excised. He will need colonoscopy as an outpatient to
evaluate.
#CODE: full with limited trial
#CONTACT: HCP: ___ (wife) ___ | 129 | 585 |
15324074-DS-9 | 22,455,765 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were transferred to here because you had
difficulty speaking and moving your left side, and you were
found to have right frontal and parietal stroke. In the
hospital, you had episodes of very deep sleeping, so EEG was
done to monitor your brain waves. Because it showed sharp waves,
you were started on a medication called Keppra to help with
that. You DID NOT have a clear seizure.
You were also found to have a urinary tract infection, so you
were started on antibiotics. | TRANSITIONAL ISSUES:
[] Complete course of IV meropenem for urinary tract infection
[] f/u as urology as outpatient for further management of his
recurrent urinary tract infection/BPH
** Stroke Core Measure **
[ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 89) - () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes - () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ left handed man with PMH of HTN, BPH, dementia and recent
hospitalization for MDR UTI who p/w new difficulty speaking and
L sided weakness, found to have posterior right frontal and
parietal infarct. His examination is limited by his inattention
and motor left hemineglect, but shows nonfluent aphasia with
anomia and left/right confusion.
#NEURO: patient with acute posterior right frontal and parietal
infarct, appears embolic given the scattered lesions. He was
started on aspirin 325mg daily. BCx and TTE were done to rule
out endocarditis given recent infection and did not show any
evidence of endocarditis. He passed bedside dysphagia screen and
was started on pureed diet and nectar thick liquid. MRI showed
the right frontal and parietal infact. His hospitalization was
complicated by fluctuating awakefulness during the
hospitalization, and EEG was done which did not show any
seizures but there was one event questionable for seizure. He
was started on Keppra for this event. His labs showed LDL of 89,
so his home simvastatin was continued. His A1C was 6.2% and
patient did not require insulin during this hospitalization. He
was seen by ___ who recommended discharge to rehab.
Patient did have periods of decreased arousal and poor PO
intake, NG tube placement was attempted but patient resisted the
attempts. Spoke with the daughter ___ who stated that
patient frequently refuses medications and food when he is not
feeling well, and that she did not want him to undergo
procedures he did not want such as NG tube placement or PEG
placement.
#CV: no known cardiac history but patient with multiple risk
factors, also with mild troponinemia on admission, which was
likely due to demand ischemia with elevated BP on admission
given low CK and flat MB in setting of kidney disease. His
troponin decreased on its own. His blood pressure was managed
with his home metoprolol after 2 days. He was continued on home
simvastatin for hypercholesterolemia.
#ENDO: His TSH was 1.8 and his A1C was 6.2%
#RENAL: creatinine 1.5 on admission and remained stable
throughout this hospitalization. Unclear baseline, though
reportedly had acute kidney injury in the setting of recent MDR
E coli UTI. His medications were renally dosed.
#ID: recent MDR E Coli UTI per family requiring IV abx at home
(was on imipenem). No WBC or fevers to suggest ongoing
infection. UA without evidence of UTI on admission, but patient
developed malodorous urine and repeat UA showed moderate leuk
esterase and increased WBC. He was started on meropenem and his
UCx showed E Coli that was sensitive to meropenem and
ciprofloxacin. Given his age, IV meropenem was continued. TTE
was also done to rule out endocarditis as the cause of stroke,
and it was negative.
#GI: dysphagia screen was done and patient was cleared for puree
diet and nectar thick liquid. Patient occasionally had poor PO
intake in setting of decreased level of arousal.
#GU: continued on flomax for BPH. Will require outpatient
urology follow up appointment for recurrent urinary tract
infection.
#FEN: heart healthy diet after passing bedside s/s
#PPx: heparin SQ TID, bowel regimen
#CODE: DNR/DNI | 99 | 693 |
13978857-DS-20 | 23,392,518 | Dear ___,
___ were admitted to ___ neurology after ___ presented with
episodes of loss of consciousness concerning for a seizure
resulting in a motor vehicle accident. ___ had CT scans of your
spine that were normal. ___ had a MRI of your brain that was
normal. ___ had a prolonged EEG that was normal. To check for
any cardiac causes for your symptoms ___ had a ECG and
echocardiogram that were both normal. They recommended an
outpatient holter monitor. After ___ are discharged from here
___ should go to the cardiology clinic on Deaconess ___
room 316 to get the holter monitor placed. ___ were seen by the
obgyn doctors who recommended a fetal ultrasound that showed an
intrauterine pregnancy. ___ should follow up with them in their
Family Planning clinic as an outpatient as scheduled below. | # Neuro: Ms. ___ was admitted and had a MRI of the brain that
was normal. She had an EEG that was also normal. She did not
have any further episodes while admitted. She had CT scans of
the spine that were unremarkable. She was given oxycodone for
pain management due to musculoskeletal pain ___ her MVA.
#CV: She had an echocardiogram and a EKG of her heart that were
both unremarkable. due to concern that her symptoms are not
epileptic and may be cardiac in etiology, we have ordered a
holter monitor to be done as an outpatient. She will be
discharged with the instructions to go to cardiology department
to be fitted with the holter.
# OB/GYN: She was seen by obgyn who stated that it was fine to
continue the diazepam. She had a pelvic US that showed an
intrauterine fetus. She stated her desire to terminate the
pregnancy and has an outpatient appointment scheduled with
obgyn. | 139 | 161 |
10395166-DS-20 | 20,689,488 | Dear Ms. ___,
Thank you for choosing to receive your care at ___. You were
admitted for shortness of breath and chest pressure. Given your
history of coronary artery disease and your recent hospital
admission for similar symptoms, we assessed the degree of heart
vessel blockage by coronary angiogram. The cornoary angiogram
did not reveal any blockages in the blood flow. You also
underwent a CT scan of your chest, which did not demonstrate any
clots or damage to the large vessels in your chest. We did an
ultrasound of your heart and the heart valves and pump function
was normal. The ultrasound did show that the left side of your
heart was enlarged but this was unchanged from your previous
ultrasound in ___. We think your pain is likely related to pain
in the muscles and bones in your chest wall affecting your jaw,
versus small vessel disease in your heart which would not cause
significant effects to your heart function.
Moving forward, you should make sure to take the medications as
listed below, and attend the follow up appointments listed
below. If you develop worsening shortness of breath, chest pain,
or other concerning symptom, please talk to your doctor right
away.
Again, it was our pleasure participating in your care here at
___.
We wish you the best,
Your ___ Care Team | ___ with H/O CAD s/p CABG x 3 in ___ (LIMA-LAD, SVG-OM,
SVG-RCA), S/P permanent pacemaker for paroxysmal atrial
fibrillation with sick sinus syndrome in ___, with recent
admission for chest pain with no objective evidence of ischemia
on dipyridamole-MIBI, who presented now with several day history
of jaw and left arm pain (which is her anginal equivalent),
chest pain, and dyspnea.
# Chest pain, CAD s/p CABG: Patient re-presenting with jaw and
left arm pain with chest pressure and shortness of breath, her
known angina equivalent. She had been admitted ___ with
similar presentation, which was thought to be musculoskeletal in
origin. She had a similar presentation during this admission.
Chest pain was not relieved with SL NTG. ECG was benign, and
troponin-T negative X 4. Since she had continued chest pain
despite a recent negative and reassuring pharmacological stress
test, cardiac catheterization was undertaken via the right
femoral artery which showed a normal LVEDP of 10 mm Hg. The LAD
had moderate disease with a patent LIMA. The RCA had moderate
ostial and disease disease. The CX was patent, as was the
SVG-OM. The SVG-RCA was not imaged. There was no evidence of
significant valvular or structural abnormalities by TTE.
Ultrasound technologist was able to reproduce Ms. ___
symptoms with pressure over sternum, directly over surgical
scar. There was no evidence of aortic dissection or pulmonary
embolus on chest CTA. Patient discharged on acetaminophen 1 g
TID for presumed musclosketal pain/costochondritis and diltiazem
30 mg TID for possible coronary microvascular disease. Given
prior CABG, her atorvastatin was increased from 20 mg BID to 40
mg BID. She was continued on home dose of ASA 81 mg daily for
cardiovascular prevention. Patient was not on a beta-blocker
given H/O exacerbation of Raynaud's with beta-blockers.
# Dyspnea - Chronic shortness of breath with acute worsening.
Limited functional capacity due to exertional dyspnea. No clear
cardiac etiology with vasodilator stress test negative for
imaging evidence of ischemia (and no reported bronchospasm).
LVEDP normal at left heart catheterization, and very low
NT-Pro-BNP twice. Pulmonary workup as an outpatient seems
warranted.
# Sick sinus syndrome/paroxysmal atrial fibrillation: s/p PPM.
A-paced with HR of 60. Pacemaker interrogated by EP at prior
admission and rate responsiveness was increased. Dyspnea did not
improve following adjustment of settings, suggesting non-optimal
pacemaker settings are unlikely to be contributing to her
respiratory complaints. CHADS2VASC score 4 suggested she may
benefit from anticoagulation, which she elected to discuss with
her outpatient providers.
# Hyponatremia: Patient intermittently hyponatremic in the past,
baseline Na of 129-135. On presentation had Na of 127, which
improved to 134 on discharge with fluid restriction.
# Chronic abdominal pain/IBS/GERD: Changed home dexilant 60 mg
daily to omeprazole 40 daily due to non-formulary. Continued
hydrocortisone suppository daily PRN.
# Chronic back pain: No pain. Held home cyclobenzaprine PRN.
Continued lidocaine patch BID PRN
# Anxiety: Continued home lorazepam 0.5 mg TID.
# Depression: Continued home Lexapro BID.
# Insomnia: Continued home Ambien 5 mg qHS. | 221 | 489 |
10925445-DS-19 | 26,500,316 | You were admitted to the hospital for worsening abdominal pain
that is likely due to cancer in the liver. To confirm this, you
had a liver biopsy, the results are still pending. In case this
is breast cancer and considering your high risk of a breast
cancer recurrence, tamoxifen was restarted.
Your pain has been controlled with a combination of OxyContin
and hydromorphone (Dilaudid). The OxyContin is long-acting and
should be taking twice a day regardless of the level of your
pain. It will not help taking it for acute/sudden pain. The
hydromorphone (Dilaudid) can be taken in addition to the
OxyContin for acute/sudden pain. For the chronic pain at the
right arm and chest, your gabapentin (Neurontin) dose was
increased. You also have a urinary tract infection and will
need to complete a course of antibiotics at home. CT of your
abdomen shows that you have chronic kidney stones that may be
contributing to the urinary tract infection.
.
MEDICATION CHANGES:
1. OxyContin 20mg 2x a day.
2. Hydromorphone as needed for breakthrough pain.
3. Gabapentin (Neurontin) 600mg 3x a day.
4. Tamoxifen 2x a day.
5. Ciprofloxacin 2x a day. | ___ man with BRCA1 mutation, breast cancer s/p right mastectomy
and axillary lymph node dissection, chemotherapy and radiation,
prostate cancer, melanoma, and LLE DVT s/p warfarin [on
tamoxifen] admitted for abdominal pain and new liver lesions.
.
# Abdominal pain: Likely due to new liver mets. Liver biopsy
done ___ without complication. Started OxyContin, increased
to 20mg BID. Mr. ___ noted improvement in pain with OxyContin
and PRN hydromorphone.
- F/U LIVER BIOPSY, RESULTS PENDING.
.
# Breast cancer: Likely new liver mets. CEA 19, ___ 52.
Mr. ___ admitted to ___ with tamoxifen, but may be
open to trying it again. Liver biopsy done ___, results
pending. Consulted Social Work. Anti-emetics PRN. Restarted
tamoxifen.
.
# Hypotension: Improved with IV fluids. Unclear etiology. Low
AM cortisol, but did not do Cosyntropin stim test as BP improved
with IV fluids.
.
# UTI: TMP-SMX changed to ciprofloxacin due to GI upset. Urine
culture negative.
.
# Right chest pain from radiation changes and peripheral
neuropathy: Titrated up gabapentin to 600mg TID. Continued
temazepam.
.
# Anemia: Secondary to inflammation. Chronic, stable.
.
# Depession: His family believes he is depressed, but Mr. ___
denied this. Consulted Social Work.
.
# GERD: Chronic, stable. Continued PPI and aluminum/mag
hydroxide PRN.
.
# Constipation: Continued bowel regimen.
.
# DVT PPx: Heparin SQ.
.
# FEN: Regular diet. IV fluids.
.
# Precautions: Fall. ___ consulted.
.
# Lines: Peripheral IV.
.
# CODE: FULL. | 192 | 232 |
17885395-DS-7 | 26,329,886 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mr ___ is a ___ male with no significant past
medical history presenting with subacute onset of dyspnea, found
to have evidence of pulmonary edema, with ECHO concerning
for severe mitral regurgitation. He underwent cardiac
catheterization which showed single vessel coronary disease. He
underwent TEE to help evaluate the mitral valve prior to
surgery. He then was transferred to C-Surg for surgical repair.
Mr. ___ was brought to the Operating Room on ___ where
the patient underwent CABG x1 (SVG-PDA), MVR (31mm ___
tissue valve). Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker start was delayed due
to junctional rhythm. Low dose Lopressor was trialed with SB
___ on POD 2, but patient's HR dropped to ___ and he remained in
ICU for Apacing support. Coumadin was started for goal INR ___.
Chest tubes were removed per protocol. POD 3, he developed
rapid atrial fibrillation and was treated with IV/PO Amiodarone
and lopressor. He was gently diuresed toward the preoperative
weight and was transferred to the telemetry floor for further
recovery. He remained in NSR and his pacing wires were removed
on POD 6 (delayed d/t INR 2.1). The patient was evaluated by
the Physical Therapy service for assistance with strength and
mobility. His Lasix was increased for serous sternal drainage,
but the bone and wound itself remained stable. By the time of
discharge on POD 7, he was ambulating with rolling walker, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home with ___ and ___ services in
good condition with appropriate follow up instructions. Patient
had no prior medical doctors and ___ to arrange a formal PCP.
At time of discharge, ___ office is waiting to confirm
follow up visit with Dr. ___ who saw patient at ___
___ preoperatively. Dr. ___ will manage INR
dosing until patient's PCP or ___ follow up can be
confirmed and management transitioned. | 109 | 366 |
18144033-DS-15 | 21,329,664 | Dear Mr. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
- You were admitted for shortness of breath
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You had a CT scan that showed a partial collapse of your right
lung and fluid in your lungs.
- You had an echocardiogram of your heart showing that your
heart was volume overloaded.
- You had dialysis to remove excess fluid from your body and
your NEW DRY WEIGHT IS = 88.8kg.
- You underwent an ablation procedure to treat your abnormal
heart rhythm called "atrial flutter," which corrected to sinus
rhythm.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- It is important that you continue to take your medications as
prescribed.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- You need to follow up with your PCP, cardiologist and
interventional pulmonology according to the appointments below.
We wish you the best in your recovery!
Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ yo M with history of aortic stenosis s/p AVR
(tissue), CAD s/p CABGx2 on ___, DM, ESRD on HD (MWF), HLD,
HTN, who presented with progressively worsening dyspnea for ___
days despite regularly scheduled dialysis sessions found to have
collapsed RLL, bilateral pleural effusions.
ACTIVE ISSUES:
==============
#Dyspnea
#RLL collapse
#Bilateral pleural effusions
#HFpEF
Dypsnea likely multifactorial, likely secondary to volume
overload from HFpEF exacerbation iso elevated BNP, JVP and leg
swelling. Repeat TTE showed normal LV systolic function but RV
pressure/volume overload. Infection unlikely as patient denied
fever, chills, localizing symptoms, and urine/blood cultures
were negative. Also considered bradycardia as trigger, but HRs
have been higher than previous. Dietary indiscretion unlikely as
patient's appetite has decreased. Unlikely due to ischemia given
absence of EKG findings and stable troponin iso ESRD. TEE showed
well seated aortic valve without AR on ___. Notably, has RLL
collapse and bilateral atelectasis, pleural effusions, which
likely contributed to hypoxia. Repeat CXR after dialysis on
___ showed mild improvement in right effusion. IP was
consulted, who recommended aggressive volume removal with
dialysis and no thoracentesis. Patient should follow-up with IP
as outpatient. In coordination with hemodialysis, patient was
dialyzed to a new dry weight of 88.8kg. Patient's dyspnea
improved to where he was ambulating at 96% RA. However, patient
continued to have episodes of air hunger without documented
desaturations while sleeping. Given patient's weight had
improved and patient looked more euvolemic, negative cardiac
work up, negative CTA, these episodes thought to be mainly due
to anxiety. Patient agreed with this assessment and did feel
improvement with Lorazepam 0.5mg QHS PRN in addition to his home
1mg TID (on this for many years). Patient also has a history of
OSA and was on CPAP ___ years ago, however discontinued using
this. Recommended repeat Sleep study and evaluation.
Patient's home torsemide was stopped given minimal urine output
- Nephrology in agreement with this. He was continued on
isosorbide mononitrate and hydralazine was uptitrated for
hypertension to 100mg TID.
#CAD s/p CABG
#Sternotomy wound dehiscence
On exam, appears dry without discharge, but signs of possible
inflammation/infection on CTA. Evaluated by cardiac surgery who
did not believe wound was infected. ESR (55) and CRP initially
elevated, but CRP trended down during admission (27.7 -> 19.9).
Wound care consulted. Patient continued on aspirin, tylenol,
tramadol and oxycodone. Patient's chest pain was tender to
palpation and there were no EKG changes or CKMB elevations (trop
high due to ablation procedure and ESRD), and so thought to be
musculoskeletal in origin.
#Aflutter
#History of AV Block
Patient had advanced AV block with junctional escape in the ___,
immediately followed by 2:1 AV conduction on previous admission.
Has hx of AV Wenckeback and 2:1 AV block. EP consulted then and
decision was potential pacemaker in the future if conduction
abnormalities worsened or symptomatic. HRs have been 50-60s on
admission. Patient denies lightheadedness at rest and no
syncope. EKG on admission showed aflutter with 3:1. EP was
reconsulted and patient underwent TEE and ablation for aflutter
on ___. Findings from the procedure were notable for "high grade
AV block in AVN." Afterwards, his HRs remained in ___
degree AV delay and 2:1 conduction on serial EKGs. He was
heparin bridged and continued on warfarin. Final dose at
discharge was 5mg daily for goal INR ___. Should recheck INR on
___ by ___ and results faxed to PCP, ___.
#Thrombocytopenia
Platelet count trended down from 188 to 110 during admission
possibly in the setting of procedure. 4T score calculated to be
___ (low to moderate risk of HIT). Blood smear showed occasional
schistocytes, though haptoglobin and LDH were unremarkable.
Platelets rebounded without intervention several days prior to
discharge.
#DM
Patient on lantus 55U in morning and novolin sliding scale at
home. He was managed with lantus 35U QAM and HISS while
inpatient. Restarted home insulin on discharge.
#ESRD on hemodialysis
Patient continued on dialysis with aggressive UF to remove fluid
to lower dry weight according to hemodynamics. Continued on
nephrocaps and calcium.
#Anemia
Hgb stable at baseline Hb ___ in recent months. Likely due to
ESRD.
#HTN
Patient was consistently hypertensive during this admission.
Uptitrated hydralazine to 100 mg TID and continued amlodipine 10
mg daily.
#Anxiety
Patient noted to be subjectively short of breath at night,
though no clear oxygen desaturation. Patient reported missing
wife and art at home and stating the hospital was too "sterile."
PCP has been considering increasing Ativan dosing. Continued on
home seroquel and provided Ativan 0.5 mg QHS, in addition to his
home lorazepam 1mg TID. Patient felt improved. PCP was notified
of these changes.
CHRONIC ISSUES:
==============
#HLD
On ___, patient developed whole body myalgias similar to
symptoms he had on simvastatin and pravastatin. CK and LFTs were
normal. Held home rosuvastatin 5 mg qpm. Of note, at this point
patient has been tried on three statins and has not tolerated
these. Started on ezetimibe 10 mg daily.
#GERD
Continued home pantoprazole.
#Hypothyroid
Continued home levothyroxine.
#Depression/Anxiety/Agitation
Continued home quietiapine (dose reduced per patient request),
duloxetine and lorazepam. Added lorazepam 0.5mg QHS:PRN.
#Gout
Continued home allopurinol.
#Back spasms
Continued home baclofen.
#Constipation
Continued home lactulose.
======================= | 158 | 854 |
14785541-DS-20 | 21,210,862 | Dear Ms. ___,
It was a pleasure taking part in your care at ___
___. As you know, you came to the hospital
due to worsening shortness of breath. In the ED, you had a CT
scan that was negative for a blood clot in the lungs, and labs
were reassuring against a problem with the heart muscle (which
were checked due to your chest heaviness). The CT scan did show
bronchitis, a possible infection of the small lung airways, and
severe emphysema. You were admitted for further treatment of an
exacerbation of your emphysema/COPD with prednisone and
nebulizer treatments, and you received antibiotics for
bronchitis. You were also found to have conjunctivitis, and you
were given eye drops. Your breathing improved.
Please see the attached medication list for changes to your home
medication regimen. You will have short courses of azithromycin
and prednisone to finish at home. Other medications include eye
drops and nystatin mouth solution. Also, you have a
prescription for a nicotine patch. We strongly encourage you to
continue avoiding cigarettes, as you have done while
hospitalized. Smoking cessation is an important step toward
improving your health.
Please follow up with Pulmonary Medicine according to the
appointment list below. You should have a repeat chest CT scan
in ___ weeks. | ___ F h/o COPD p/w worsening SOB x 3 wks, now with cough
productive of green sputum and CTA indicating bronchitis and
small airway infection. Ms. ___ was seen in ED and had
CTA chest negative for PE as well as negative troponins in the
setting of chest heaviness. She was admitted due to persistent
SOB and treated with PO prednisone for a COPD exacerbation. She
was also started on a five-day course of azithromycin for
bronchitis/small airway infection.
ACTIVE DIAGNOSES
# Acute bronchitis and small airway infection: Pt endorsed
infectious symptoms including cough productive of green sputum,
sore throat and rhinorrhea. CTA chest in the ED revealed
diffuse bronchial wall thickening compatible with bronchitis and
___ opacities within the right middle lobe, possibly
reflecting early small
airways infection. Differential diagnosis included viral
(coronavirus, adenovirus, rhinorvirus, less likely influenza A
or B given lack of systemic symptoms) versus bacterial
(Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella
pertussis) bronchitis/small airways infection. There was a low
threshold for treatment with antibiotics in the setting of COPD
exacerbation. She was started on azithromycin 500mg PO x 1 and
then 250mg PO x 4 days. (In combination with psychotropic
medications including quetiapine, QTc prolongation was
considered, and QTc was within normal limits at 422 msec.)
Supportive care was provided with acetaminophen PRN and
albuterol/ipratropium nebs.
Sputum was collected in efforts to test for MAC via AFB smear
and culture, but the sample was not processed as expected.
Sputum cytology was negative for malignant cells (although the
yield is low). On CTA chest, there was an opacity in the
periphery of the right middle lobe which was not specifically
commented upon in the radiology report. Repeat CT chest imaging
in ___ weeks is advised. If lungs have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised. Patient was
scheduled for outpatient follow-up with Pulmonary Medicine.
# COPD exacerbation: Pt had decreased aeration in all lung
fields. She reported symptomatic improvement after
administration of steroids in the ED, and PO prednisone was
continued on the floor. She saturated normally on room air and
had non-labored breathing at rest. She passed ambulatory O2
monitoring on hospital day 2 with SpO2>/=92% throughout, but she
was not able to walk far and had purse-lipped breathing with
exertion. She was treated with standing albuterol/ipratropium
nebulizers and continued on fluticasone-salmeterol diskus. By
hospital day 3, there was additional subjective improvement in
SOB. She was discharged with a ten-day prednisone taper and her
usual home COPD medications. ___ was arranged for outpatient
oxygen monitoring, and she should be referred for pulmonary
rehabilitation. She was also scheduled to follow-up with
Pulmonary Medicine as an outpatient. CTA chest showed severe
changes of centrilobular emphysema. She should have repeat
chest CT imaging in ___ weeks after discharge, as described
above.
# Conjunctivitis: Pt developed erythema and soreness of right
eye, which progressed to involve both eyes. Cream-colored
opaque discharge was visualized in the medial canthus of right
eye on admission, and there was yellow crust on both eyelids in
the morning of hospital day 2. Ddx includes viral versus
bacterial or allergic conjunctivitis. Most common causes of
bacterial conjunctivitis include Staphylococcus aureus,
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. She was prescribed erythromycin ophthalmic
ointment to apply to both eyes.
# Smoking cessation: Pt started on a nicotine patch and was
given a prescription for nicotine replacement therapy to
continue as an outpatient. Smoking cessation was encouraged.
CHRONIC DIAGNOSES
# Psych: Pt has h/o depression for which she takes a variety of
other psych meds. Topiramate 350mg daily, quetiapine 200mg PO
BID, bupropion SR 200mg PO q AM, and venlafaxine 75mg PO daily
were continued in order to maintain stable regimen compared to
home. However, this combination of medications increases risk
for serotonin syndrome. Optimization/simplification of
psychiatric medication regimen as an outpatient is advised, in
part to reduce risk of serotonin syndrome.
# Menopause: Pt takes estradiol and progesterone at home for
menopausal symptoms. She had a CTA chest in the ED which was
negative for PE, given her SOB and increased risk for blood clot
while on estradiol. Pt reported feeling like these medications
were not necessary. Estradiol and progesterone were held during
hospitalization so as to minimize risk for PE while monitoring
for improvement in shortness of breath. Duration of treatment
with these medications should be reassessed as an outpatient.
# HLD: Continued home simvastatin.
TRANSITIONAL ISSUES
* Pt will be discharged with home ___ services. Please do oxygen
saturation monitoring as an outpatient and refer to pulmonary
rehab as appropriate.
* Pt should follow-up with Pulmonary Medicine as an outpatient.
Please repeat chest CT in ___ weeks as an outpatient to assess
interval change. If lung findings have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised (see below).
* Sputum was collected to test for AFB smear/culture, but the
specimen did not get processed as expected. If repeat chest CT
is abnormal, consider testing sputum for AFB smear and culture
to assess for MAC pulmonary infection ("___
syndrome").
* Given history of smoking and COPD, family history of lung
cancer, and finding of peripheral opacity in right lung on CTA,
sputum cytology was tested and returned negative for malignant
cells. Please note that sputum cytology has a low yield for
abnormal cells, and further work-up would be necessary to
definitively rule out malignancy if repeat chest CT remains
abnormal after pulmonary/small airway infection clears.
* Also of note, pt is on a variety of psychiatric medications at
home, including bupropion, quetiapine, venlafaxine, and
topiramate. This combination of medications increases risk of
serotonin syndrome. Optimization/simplification of psychiatric
medication regimen as an outpatient is encouraged.
* Please consider whether estradiol and progesterone remain
necessary and, if so, determine their expected duration.
Discontinue when possible so as to avoid risk for blood clot and
other complications. | 223 | 1,007 |
10227155-DS-12 | 25,753,333 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were nauseous and vomiting.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received dialysis
- You were in the Intensive Care Unit for special monitoring and
care of your breathing
- You developed bloody vomit and a scope was placed down through
your mouth which showed bleeding coming from your feeding tube
- You were given medications to help your nausea and to prevent
further bleeding
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.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[ ] Discharge HGB 8.0
[ ] Please complete repeat labs in 1 week by ___ to
follow-up his anemia.
[ ] Patient left AMA before receiving repeat endoscopy to
evaluate suspected ___ tear. Therefore, would greatly
benefit from repeat endoscopy within the next week to ensure
healing. We did not feel comfortable restarted his apixaban
without this re-evaluation. His CHADs2VASc is ___ so we felt it
was reasonable to hold apixaban on discharge, but he will need
to be restarted on this medication when repeat EGD shows
healing.
[ ] Patient likely with ___ tear in setting of
nausea/vomiting due to gastroparesis flare and missed HD
session. Patient should continue PPI as well as prn reglan for
nausea and to help with motility. Patient reports that he has
infrequent gastroparesis flares (yearly) but would benefit from
outpatient gastroparesis management.
BRIEF HOSPITAL COURSE
======================
Mr ___ is a ___ man with history of IDDM, ESRD on
HD (MWF), CAD s/p CABG in ___, Afib w/ RVR history of
gastroparesis on reglan, presented with nausea/vomiting,
initially admitted to ICU in setting of respiratory distress
after missing dialysis, then re-admitted to ICU in setting of
hematemesis found to have possible ___ tear on EGD.
Patient was treated with IV PPI and standing Zofran. Apixaban
was held during this time in setting of bleeding. Course was
also complicated by Afib with RVR resolved with addition of
standing metoprolol. Patient left AMA right as he was been
called for repeat EGD to assess healing of his ___
tear. Patient became belligerent and hostile to medical staff.
He is fully aware that his apixaban is being held until he has a
repeat EGD and therefore has a risk of stroke, and he is willing
to take this risk. Hemoglobin has been stable with no further
bleeding on discharge.
ACUTE ISSUES
===============
#Discharged AMA
Patient left AMA right as he was been called for repeat EGD to
assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Acute upper GI bleed
Patient developed hematemesis after multiple episodes of emesis.
EGD on ___ showed esophagitis and a clot with possible
___ tear. Patient was kept on IV PPI, standing Zofran
until nausea resolved and stable. Apixaban was held in the
setting of active bleeding. Patient has been hemodynamically
stable with stable hemoglobin. No further nausea/vomiting or
melena. Patient left AMA right as he was been called for repeat
EGD to assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Nausea and Vomiting
# Gastroparesis
Patient presented with nausea/vomiting likely in the setting of
known gastroparesis as well as uremia from missed HD session.
Patient was on standing anti-emetics given ___ tear.
Zofran and reglan were made prn. He has been tolerating oral
intake with no N/v. Mild epigastric pain with belching.
# Paroxysmal Afib/flutter
Discharged ___ from ___ on metop, apixaban, amiodarone
but recently switched to carvedilol. His fill history however
does not reflect this, and it appears he has not filled these
meds which his story collaborates. On ___, patient had elevated
HRs in 150s with 2:1 block requiring IV metop with conversion to
NSR. Standing metoprolol tartrate 6.25mg QID was added with
patient continuing in NSR until left AMA. As above, holding
apixaban in setting of bleeding. Unable to get repeat EGD before
left and medical team not comfortable sending him on apixaban
without visualizing his esophagus.
# HTN
Had held home amlodipine, losartan iso GI bleed. Started
metoprolol as above. Restarted home amlodipine as blood
pressures have tolerated.
#Likely OSA
Concern for apneic periods during sleep throughout admission.
Would benefit from outpatient sleep study.
CHRONIC ISSUES
===============
# ESRD
Continued HD per renal
# IDDM
Continued insulin 50 units glargine daily, sliding scale
# HLD
Continued atorvastatin
#CODE STATUS: FULL
>30 min spent on discharge planning including face to face time.
Pt was deemed to have capacity at time of AMA and understood the
risks of leaving prematurely. | 127 | 732 |
10720286-DS-3 | 21,318,735 | Dear ___,
You were admitted to the hospital because you were vomiting
blood.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You received blood transfusions for your bleeding
- You also underwent an endoscopy to identify the source of your
bleeding. You were noted to have dilated blood vessels in your
esophagus (called "varices") which were bleeding.
- These blood vessels can cause very serious bleeding that can
be life-threatening
- You underwent a procedure to stop this bleeding by putting a
band around these bleeding blood vessels
- After the procedure, we monitored your blood counts and you
did not have any repeat bleeding
- Overall you were improved and ready to leave the hospital..
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or your liver will fail and
you will die from this
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY:
========
___ is a ___ with PMH of alcoholic liver
cirrhosis, PHT in the form of EV (on NSBB for primary
prophylaxis), PHG, ascites on diuretics (well controlled),
jaundice, overt obscure GI bleeding and chronic anemia (baseline
___, and ongoing alcohol use who presented with hematemesis
and hemorrhagic shock. She had an EGD ___ showing esophageal
varices and GOV (oozing) s/p banding after which her bleeding
and HgB stabilized, without recurrence of hematemesis or melena.
ACUTE ISSUES:
=============
#UGIB
#Hemorrhagic shock, improving
Ms. ___ initially presented with hematemesis and
hemorrhagic shock (hypotensive to SBP in the ___, lactate 3.0)
to ___. Her initial HgB there was noted to be 7.1
(from baseline ___. She required 2 U pRBCs and 1L IVF with
improvement in hemodynamics, and was started on octreotide gtt,
IV PPI, and IV CTX. She was subsequently transferred to ___
for further management. On arrival, she underwent EGD (___)
showing 4 cords of grade II varices in the distal esophagus, as
well as one cord of varices below the gastroesophageal junction
(most likely representing GOV) which was oozing. Three bands
were applied for hemostasis successfully. Since admission, she
has required an additional 3u pRBCs (last transfusion ___ for
resuscitation, after which her HgB has stabilized without
recurrent hematemesis/melena. She was continued on an octreotide
drip (___), then transitioned to home nadolol on day of
discharge. She finished a course of ceftriaxone for SBP
prophylaxis also on ___, and will continue on daily PPI and
sucralfate on discharge. Discharge HgB 7.7.
# EtOH cirrhosis:
Followed by Dr. ___. MELDNa 19. Decompensated this admission
by variceal bleed s/p banding as above. As of his
hospitalization, the patient was noted to be actively using
alcohol with positive alcohol level. She was seen by social work
and provided relapse prevention resources. She otherwise will
continue on home nadolol for bleeding prophylaxis. Home
diuretics were temporarily held given bleed, but restarted prior
to discharge. She will continue on furosemide
40mg/spironolactone 100mg. She has no history of SBP and
completed 5 day course of CTX for SBP prophylaxis given GIB. She
also has no history of hepatic encephalopathy and no evidence of
encephalopathy this admission. She will follow up with Dr. ___
in liver clinic ___ as scheduled.
# Alcohol use disorder
Serum EtOH 138 on admission. She was continued on thiamine,
folate, multivitamin. Social work was consulted for relapse
prevention, and patient accepted resources for this.
CHRONIC ISSUES
===============
#T2DM
Home metformin 500 BID was held in setting of acute illness.
Hyperglycemia managed with ISS while inpatient. Metformin
restarted on discharge.
#Pruritus
Continued home hydroxyzine 25 TID PRN.
#GERD
Will continue home omeprazole daily.
#Hypothyroidism
Continued home levothyroxine 175mcg daily.
#Depression
Continued home duloxetine 90 daily, home trazodone 150 QHS PRN
for sleep. | 250 | 448 |
12683111-DS-12 | 22,843,326 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for elevated blood sugars >700 and very high blood
pressure at your HD appointment on ___ last week. You were
treated with insulin, fluids and IV blood pressure medicines in
the ICU until your blood sugar and blood pressure stabilized.
You were then transferred to the general medicine floor for
continued monitoring. Your sugars ranged from 400 to 100 on
insulin. Your blood pressure remained stable on your home
dosing of blood pressure medications. You received dialysis on
___ and ___. You should go to your
regular dialysis appointment next ___. Please be sure to
take your insulin and blood pressure medications as prescribed
at home. If you develope headache, shakes, feelings of weakness,
feeling like you are having difficulty staying awake,
palpitations, nausea, vomiting, lightheadedness or fainting
please check your blood sugar quickly. Call your doctor or go to
the emergency room if your blood sugar goes above 300 for more
than 24 hours or below 70 more than twice in a row. You have a
follow up appointment scheduled with your regular nurse
practitioner at the ___ on ___ at
2:00 ___. | ___ yo male with severe type 1 diabetes with multiple
complications, malignant hypertension, and ESRD who presents
from HD center with DKA and hypertensive urgency without
neurologic compromise or obtundation.
# DKA/Type1DM: Multiple prior episodes of DKA (see OMR). Unclear
provocating factor given history of no recent illness, reported
medication adherence, and no CP to suggest MI, though
hypertensive urgency may have been significant stressor. His
glucose management is complicated by ESRD. He had breakfast and
sliding scale 10u Humalog ___ AM per patient. On admission
glucose >700 and anion gap ~34. In the ER he was bolused 2L IVF
and given 8 units bolus insulin, then insulin gtt at 7units/hr.
When he arrived in the MICU his glucose was >700 still. He
received additional IV bolus insulin in the evening of ___ and
rapidly dropped down to 200s during the night, at which point
the insulin gtt was turned down and D5W gtt was started. On ___
he was switched from from an insulin gtt to sliding scale after
his anion gap closed. His sugars remained in the 100-200 range
on ___ and he was tolerating a diet. Long acting glargine was
started at his home dose of 25u qHS and Humalog sliding scale
insulin was continued. Electrolytes were repleted aggresively.
___ was consulted and followed patient throughout his
admission. Blood glucose ranged between 100-400 over the next
several days despite regular monitoring. Sliding scale was
increased with limited effect.
Given multiple complications from T1DM (L eye blindness,
ESRD) he is at risk for signficant morbidity and even death
given dangerous episodes of DKA and now hypoglycemic seizure in
recent history (___). He has follow up with his NP at ___
scheduled for ___.
# Malignant HTN: Developed in ___ around the time of
dialysis initiation. Presents with BPs in 210s systolic on
multiple medications for BP at home. Required IV nitroglycerine
and hydralazine in ICU to obtain good control. On admission to
the floor BP controlled at 110/68 and remained controlled
w/systolic BP <140 throughout remainder of inpatient admission
on home BP medications.
As outpatient BPs noted to be 150-180s on amlodipine,
minoxidil, torsemide, ACEI, and clonidine. These were continued
in house, though lisinopril was held initially given
hyperkalemia, and then restarted ___ after dialysis. His long
term BP goal is <130/80, though this has been very difficult to
achieve despite aggressive BP regimen. Patiet reports
understanding of how and when to take his medications, although
he admits to sometimes forgetting his evening doses. He also
reports that taking the pills on an empty stomach makes him
throw up, and that he has also thrown up a few times recently
because of hypoglycemia. He thinks this may have contributed to
the very high pressures noted on admission.
# Unexplained fevers: Patient became febrile to 101.5 early AM
on ___ and 99.6 on ___. No inciting event for the fever could
be determined. Patient denied nausea, vomiting, abdominal pain,
flank pain, cough, SOB, sinus congestion. He had a negative CXR
and negative blood and PD fluid cultures from ___ and ___.
Repeat blood cultures from both the HD line and peripheral blood
were sent and are pending at the time of discharge. Given that
the patient had no identifying symptoms, antibiotics were not
started. Will follow up with Mr. ___, Dr. ___
nephrologist), and ___ if cultures return positive
as in transitional issues below.
# Elevated trops/EKG changes: TropT to 0.89 on admission and EKG
w/ peaked T waves and possible small ST elevations in V2/V3.
Baseline trop 0.6-0.8, consistent w/ poorly controled htn and
ESRD preventing effective renal clearance. No known hx MI
although past EKG w/changes c/w anteroseptal infarct. Last ECHO
___ showed LVH w/out valvular pathology or focal wall motion
abnormalities. Presentation initially concerning for ACS but
CK-MBs were serially negative and EKG changes resolved to
baseline with nitroglycerin gtt overnight and BP control to
<160.
Trop leak most likely due to hypertensive urgency w/SBP elevated
above 200. Repeat EKG on ___ again consistant with baseline EKG
prior to admission.
# ESRD: TTS. Secondary to diabetic nephropathy. PD catheter
placed ___, but developed a metabolic encephalopathy and was
switched to HD on ___ via tunnelled catheter. Currently
undergoing repeat PD training so he can attempt to swtich back.
Has residual kidney function, on torsemide. Continued
nephrocaps. Low K, low Phos diet. K was repleted gently during
DKA given ESRD. He received HD ___, ___ and ___ without
complications.
# Elevated Transaminases: ALT/AST in ___ on admission.
Negative for HBV and HCV in ___ be related to
hypertensive urgency. Resolved by ___.
# Hx CVA: Discovered ___ in the setting of "altered mental
status" thought most likely due to metabolic encephalopathy in
the setting of failed PD dialysis. MR at the time showed
multiple foci of restricted diffusion identified in the pons,
right occipital lobe, bilateral basal ganglia involving the
internal capsule, genu of the corpus callosum and both centrum
semiovale. CTA of neck showed no carotid atherosclerosis. This
suggests hypertensive infarcts. Long term blood pressure conrol
130/80, but this has been difficult for the patient to achieve
as above. | 206 | 896 |
11437634-DS-19 | 20,803,761 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for
severe shortness of breath/low oxygen level due to a COPD
exacerbation. You were treated with steroids, an antibiotic
(azithromycin), and nebulizers. Please continue the steroid
taper and antibiotic as prescribed. You were also started on
Bactrim, which is an antibiotic to prevent infections while on
steroids. You should continue this until directed otherwise by
your doctor.
Please continue to use your inhalers as prescribed and keep
yourself well-hydrated.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ gentleman with COPD on chronic PO
prednisone, alcohol induced chronic pancreatitis w/ pseudocyst
s/p Whipple, and chronic pain presenting with tachypnea and SOB
admitted to the ICU for COPD exacerbation requiring BiPAP. He
was treated for the following issues during this
hospitalization:
ACTIVE ISSUES
==============
# COPD EXACERBATION:
Patient has known COPD, on chronic prednisone 10 mg daily. He is
not on home O2, but reports that he had been on it many years
ago. He was afebrile without concern for infection per CXR and
was treated with azithromycin, prednisone 40 mg, and standing
nebulizers. He was admitted to ICU given need for BIPAP,
although he was only used it intermittently. He was transferred
to the general medicine floor on HD3, where he was quickly
weaned off of oxygen. Plan was to keep patient for one more day
for frequent nebs/monitoring, but patient was very intent on
leaving. His ambulatory O2 sat and O2 sat on room air were both
>90 prior to discharge, and he was able to ambulate with mild
SOB. As such, he was discharged on a prednisone taper,
nebulizers, and azithromycin. For his cough, he was treated
with guaifenesin-codeine and Tessalon Perles.
# CHEST PAIN:
Patient noted to have chest pain in the ED with prior stress
test in ___ negative for coronary disease. Patient did have
nitro prescribed as medication though unclear indication as he
was without known history of cardiovascular disease documented.
EKG was without changes suggestive of ischemia, trops negative
x3, and normal heart rate raised low suspicion for ACS or PE.
Per patient, this chest pain is a chronic pain and he is managed
on a narcotics contract by his PCP.
# PANCREATIC INSUFFICIENCY:
Patient with known pancreatic insufficiency likely secondary to
Whipple and chronic alcohol use. He is on home creon, which was
continued during this hospital stay.
# CHRONIC ABDOMINAL PAIN:
The patient has had chronic abdominal pain since his Whipple
approximately ___ years ago. As above, he has a narcotics
contract with his PCP, the terms of which were followed during
this hospitalization to manage his symptoms.
INACTIVE ISSUES
===============
# GERD:
Continued omeprazole 40 mg PO DAILY
# Insomnia:
Continued Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
# Appetite stimulant:
Dronabinol 5 mg PO BID
# Depression:
He was continued on his home dose of sertraline this admission. | 96 | 385 |
14910666-DS-9 | 23,036,757 | 1. continue weaning the ventilator as tolerated
2. ambulate daily with assistance
3. staples from back removed, staples from LUQ removed
4. suction as needed/routine tracheostomy care
5. turn/reposition q2 hours when in bed
6. pain control | Ms. ___ was the restrained driver in an ___, and was intubated
at an outside hospital and transferred to ___. After being
examined in the trauma bay, she was admitted to the ICU. | 38 | 33 |
10371476-DS-15 | 25,234,771 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
abdominal pain. We performed blood tests look for dangerous
causes of pain and there were no concerning findings. A CT scan
was done and showed changes consistent with your previous
surgeries, but nothing dangerous.
Given your recent ERCP, it is likely that this is residual pain
from that procedure. Your lipase, a marker for pancreatitis, is
normal.
We have made no changes to your medications. | BRIEF HOSPITAL COURSE + ACTIVE ISSUES
___ year old female with history of multiple abdominal surgeries
and recent ERCP with stent placement, presenting with worsening,
persistent RUQ abdominal pain.
Patient with normal CT scan and reassuring labs. She is
hemodynamically stable and her exam is not concerning for an
acute abdomen. Exam negative for any discomfort. Lipase is
normal. Counseled about gradual relief of pain as pancreatitis
resolves. She was monitored over course of morning and afternoon
of ___ with improving abdominal pain. Was continued on home
medications in-house, and we ensured bowel movement and regular
diet prior to discharge.
INACTIVE ISSUES
# Continued on outpatient psychiatric medications. Medications
reconcilled with pharmacy.
TRANSITIONAL ISSUES
- f/u ERCP in 8 weeks for stent removal | 77 | 123 |
18148913-DS-11 | 20,541,718 | Dear Ms. ___,
It was a pleasure caring for you during your stay. You were
admitted for abdominal distention and a pulled G-tube. During
your admission your abdominal distention improved with a
flexiseal, laxatives, and positioning. In addition, your G-tube
was replaced.
During your admission you had an episode of respiratory
compromise, possibly due to aspiration, for which you were
briefly intubated and in the ICU. You recovered quickly and were
extubated. In addition, you had an exacerbation of your atrial
fibrillation with rapid heart rates. Your heart rate was
controlled with medications and at discharge is within normal
limits. You were started on lovenox for coagulation because your
INR was low. You will go to the nursing home on ___ until
your INR is between ___. Your INR should be monitored at the
nursing home.
You were also treated for a urinary tract infection. You
received a full course of antibiotics for the infection.
In addition, it was noted that you had an increased number of
blasts, or immature white blood cells, in your labs. This
should be monitored as it may represent a disease process or
malignancy. | ___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube,
and atonic colon with several recent admissions for concern of
obstruction who presented from rehab after pulling out G-tube
and with significant abdominal distention. | 193 | 36 |
10122428-DS-24 | 28,752,926 | Dear Ms. ___,
You came to the hospital after the JP drain in your spinal
surgical wound became dislodged. You were evaluated by our
Plastic Surgeons who removed the drain. The Plastic Surgery
team believes that your surgical wound is healing well and not
showing any signs of infection. | SUMMARY:
___ yo F PMHx HFpEF, HTN, T2DM, CKD, prior ischemic CVA,
hypothyroidism, and spinal stenosis s/p L3-4/L4-5
hemilaminectomy/ foraminotomy (___) c/b wound dehiscence and
spinal leak requiring debridement, ___ followed by
lumbar wound debridement and muscle flap closure s/p wound vac
placement with JP in ___, who presents from ___ after
JP drain became dislodged. PRS Surgery consulted. JP drain was
removed. There was no concern for surgical site infection per
PRS. Patient will follow-up with Plastic Surgery as an
outpatient. | 50 | 83 |
15467362-DS-10 | 24,470,818 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever < 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE < 30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Weightbearing as tolerated bilateral lower extremity, range of
motion as tolerated
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the 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. | 627 | 256 |
10729116-DS-10 | 24,481,173 | Dear ___
___ were admitted to the gynecology service at ___ for pain
management and observation of a possible ovarian torsion and
hematosalpinx (blood and fluid in the fallopian tube). We
repeated imaging on the second day of your stay, which
demonstrated that the fluid collection in your fallopian tube
and your abdomen was unchanged since ___ were admitted. Your
blood counts remained stable as well, indicating that ___ were
likely not continuing to bleed into your abdomen or fallopian
tube. Your pain was well controlled on Tylenol and your vital
signs remained stable. The team has determined that ___ are
stable for discharge with close outpatient follow up with your
primary OBGYN for further evaluation and definitive treatment.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where ___ are unable to keep down fluids/food
or your medication | Ms. ___ presented to the ED with abdominal pain since the
afternoon of ___. She had CT scan showing no evidence of
appendicitis but questionable torsion. She then had a PUS which
showed a dilated fallopian tube and complex material with
possible torsion. Pain improved to ___ at time of OB/GYN
consult, without requirement for pain medication. Given imaging
reassuring against torsion, plan made for admission for
observation overnight.
The next morning, labs were stable without concern for infection
or bleeding. She remained stable without further pain medication
requirement overnight, so plan was made for discharge home with
outpatient followup. | 149 | 100 |
14646174-DS-7 | 25,373,333 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were brought to the hospital from your rehab facility
because you were experiencing worsening abdominal pain and
swelling.
WHAT HAPPENED WHILE I WAS HERE?
- You were found to have fluid in your abdomen called ascites,
which was drained multiple times.
- You were found to have a kidney injury for which you received
medicine called midodrine and octreotide.
- You finished your course of treatment for your C. difficile
infection.
WHAT SHOULD I DO WHEN I GET HOME?
- Please take all of your medicines as prescribed.
- Weigh yourself every day and call your liver doctor if your
weight increases by 3 pounds.
- Go to all of your followup appointments.
- Go to ___ next ___ and get a paracentesis.
It was a pleasure caring for you and we wish you the best.
Sincerely,
Your ___ Liver Team | Mr. ___ is a ___ y/o man with a PMH of alcoholic
cirrhosis c/b ascites, esophageal varices (s/p banding
___ HCC (s/p TACE), who presented with abdominal pain,
worsening ascites, ___ consistent with hepatorenal syndrome.
ACTIVE ISSUES
=============
# ACUTE KIDNEY INJURY / Hepatorenal Syndrome:
Creatinine 2.1 on admission from recent discharge Cr 1.1.
Differential included pre-renal in the setting of decreased
intravascular volume given third spacing and poor nutritional
status, as well as poor PO intake, and resumption of diuretics
upon last discharge, ATN (ischemic vs. nephrotoxic), and CIN,
though less likely given lack of recent contrast administration
(though did undergo TACE ___. Patient underwent treatment and
monitoring for hepatorenal syndrome with octreotide and
midodrine, and this diagnosis seemed increasingly likely given
his persistent sodium-avid urine studies and lack of improvement
with daily albumin. Creatinine peaked at 4.5. Nephrology was
consulted for consideration of hemodialysis. There was no urgent
need for HD and question of whether he would tolerate it if
needed given his soft blood pressures. Ultimately he was weaned
off of octreotide. Creatinine overall downtrended and at time of
discharge Cr was 1.8. He was discharged with 15 mg PO TID
midodrine and preferred to not have renal followup. Labs will be
monitored by outpatient hepatologist.
# ALCOHOLIC CIRRHOSIS C/B ASCITES, ESOPHAGEAL VARICES
___ B cirrhosis, with MELD score of 24 on admission.
Complicated by esophageal varices (Banded ___, last EGD
___. Decompensated by mild hyponatremia and worsening
ascites, which were thought related to ischemia post-TACE vs.
progression of HCC. He was continued on Lactulose 30 mL PO TID.
Diuretics were held in setting of acute renal failure.
Management of ascites through therapeutic paracentesis (x3 over
course of hospitalization). Patient will have outpatient
paracentesis after discharge starting ___.
#Goals of care
Discussion held with treatment team, palliative care, patient
and wife regarding goals of care on ___. Patient prioritizes
independence, increased quality of life, and spending time at
home with family. Discussion was held about options of
tubefeeding, hemodialysis and pleurx catheter placement and that
some options may not be best aligned with his goals. Will plan
to continue ongoing discussion outpatient. Patient elected for
DNR/DNI on ___. He has palliative care followup scheduled
outpatient.
#Megaloblastic anemia
#Pancytopenia
#Acute blood loss anemia
Patient with anemia likely multifactorial due to chronic
megaloblatic anemia likely nutritional, with concern for
concurrent acute blood loss anemia in setting of acute Hgb/Hct
drop and CT imaging suggestive of bleed likely ___ paracentesis
on ___. He received 2u pRBCs and Hgb remained stable. Discharge
Hb 10.3.
# Neuropathy
Etiology of paresthesias in distal fingers and toes is unclear,
possibly related to alcohol use. Gabapentin was initially held
given concern for worsening of tremors, however patient felt
that the neuropathy was his most debilitating symptom. Restarted
gabapentin renally dosed, 300 mg BID with some improvement.
Please monitor renal function outpatient and titrate
accordingly.
#QT Prolongation
Patient alarming on tele for a few beats of Vtach/Vfib. Patient
was asymptomatic. EKG showed QT prolonged at 534. Patient was on
standing Zofran, prn Compazine, quetiapine qhs, mirtazapine qhs,
all of which were discontinued.
# ABDOMINAL PAIN:
# NAUSEA:
On admission had acute on chronic abdominal pain, accompanied by
ongoing nausea. Diagnostic paracentesis was not concerning for
SBP. Pain likely multifactorial from large volume ascites and
capsular distension from cirrhosis/HCC. Pain was adequately
managed with PRN Tylenol. Fentanyl patch and Tramadol had been
started in rehab, were discontinued on discharge as they were
not needed.
# TREMOR AND HALLUCINATIONS
The patient developed a new intention tremor and visual
hallucinations during his recent admission. This was thought to
be adverse effect of one of his pain medications (top contenders
were felt to be oxycodone and gabapentin). Neurology saw him on
last admission and agreed with this assessment. Unfortunately,
the tremors have persisted. CT head without contrast showed no
e/o acute intracranial process and gabapentin was restarted
without exacerbation of these symptoms.
CHRONIC ISSUES
==============
# HEPATOCELLULAR CARCINOMA
The patient was diagnosed with hepatocellular carcinoma in
___. Enlargement of previously identified liver lesion
(2.1cm->2.3cm) seen during ___ admission with multiple new
lesions (4 total). He underwent TACE on ___ and will followup
outpatient with hepatology.
# HCV
The patient had a weakly positive (less than 1.50E+01 IU/mL) HCV
viral load in ___, but the patient's last negative HCV antibody
was in ___. HCV antibody and viral load were repeated during
___ admission and both were negative.
# MODERATE MALNUTRITION
Patient presents with moderate malnutrition in the setting of
chronic alcoholic cirrhosis. He continued MVI, Thiamine. Started
megestrol for poor appetite with some improvement.
# DEPRESSION:
Sertraline 50 mg daily was held on discharge on ___ for
unclear reason. Patient was not receiving at rehab. Can consider
restarting.
# GERD:
Decreased omeprazole to 20 mg daily.
# C. DIFF COLITIS:
Diagnosed during ___ admission. The patient received a
course of Flagyl started ___, ultimately a 2 week course from
end date of ceftriaxone (course: ___. Repeat C diff
stool study negative on ___.
CORE MEASURES
=============
# CODE: DNR/DNI
# CONTACT: ___, wife, ___
TRANSITIONAL ISSUES
==================
[ ] Restarted gabapentin renally dosed, 300 mg BID (decreased
from 300 TID). Please monitor renal function outpatient and
titrate accordingly.
[ ] Discharged with 15 mg Midodrine TID.
[ ] Decreased omeprazole to 20 mg daily.
[ ] Started megestrol for poor appetite.
[ ] Held spironolactone on discharge due to worsening renal
function and managing volume with paracentesis.
[ ] DNR form signed upon discharge. Consider filling out MOLST
form at outpatient followup as goals of care are further
elucidated.
[ ] Discharged with ___. | 148 | 900 |
13810570-DS-10 | 27,866,117 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
- You had two episodes of falling and losing (or near-losing)
consciousness.
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- We looked at your brain and the blood vessels of your head and
neck using a CT scan. We did not find any problems with your
brain or blood vessels.
- We watched the electrical activity of your heart overnight.
You did not have any bad heart rhythms.
- We looked at the strength and structure of your heart using an
echocardiogram. This is roughly unchanged from the last time
you had an echocardiogram with Atrius.
WHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL?
- Please follow up with your primary care doctor and
cardiologist as scheduled.
- Please ask about your referral for a longer "event monitor" to
look at the electrical activity of your heart over a month. We
have placed an order through ___, but you may need other
information from your ___ team.
We wish you the best,
Your ___ Care Team | This patient is a ___ year old female with a past medical history
of a central line associated aortic valve endocarditis (with a
porcine aortic valve replacement complicated by a
___ CVA with left sided deficits), MI (on aspirin),
and gastric lap banding (___) who presents with two
episodes of recent falls.
ACTIVE ISSUES
# Falls/Syncope:
Pt with two syncope-like episodes. One episode occurred a week
prior to arrival (without prodrome and true loss of
consciousness); the second episode seemed to be more vertiginous
in nature, with room-spinning dizziness and weakness that
resolved upon sitting down. Given patient's complicated cardiac
history, she was evaluated for ischemic/arrhythmic etiology of
her falls. Troponins were negative x2, an EKG showed a right
bundle branch block and T wave inversions (stable compared to
previous EKGs). An Echocardiogram was done, without new drop in
EF/wall motion abnormalities/valvular defects since the earlier
study from ___. Overnight telemetry did not show any
arrhythmias. CT head and CTA that did not reveal any acute
processes or issues with cranial perfusion. Possible
contributors to Pt's syncopal/near-syncopal episodes include
transient cardiac arrhythmia (not observed on 24hrs of
telemetry), poor PO intake (Pt hydrating well but not eating
much). She was discharged home with an order placed for an
event monitor (no monitors available at ___ at time of
discharge), and encouraged to follow up with her PCP and primary
cardiologist.
# Elevated blood pressures without diagnosis of hypertension:
Pt with SBP's into the 170-180's while in the ED. These
resolved spontaneously to SBP < 140 on arrival to the floor.
Not started on antihypertensives given no clear diagnosis prior
to arrival.
- f/u pressures in office.
# Incidental pulmonary nodules and
# Pulmonary micronodules:
5mm and 3mm RUL nodules noted incidentally on wet read of CTA
head/neck; also with calcified mediastinal lymph node and
interstitial/perifissural micronodules in the apices, possibly
consistent with sarcoidosis. Per ___ Society Guidelines,
no follow-up recommended in a low-risk patient with low-risk
history. Given the possible consistency with sarcoidosis,
further evaluation with repeat chest CT - or rheumatology
referral - could be considered.
- Consider rheumatology evaluation as outpatient
- Follow up on final read of CTA head/neck
# Incidental thyroid nodule:
Also noted on wet read CTA head/neck. 5mm L thyroid nodule,
which by ___ recommendations does not require follow-up unless
there is additional clinical concern.
- Follow up final read of CTA head/neck.
# Incidental 1-2 mm L paraclinoid internal carotid
artery/aneurysm:
Noted on wet read CTA head/neck.
- Follow up final read CTA head/neck. | 186 | 424 |
14775170-DS-8 | 22,580,636 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because you had damage to your
kidneys. We gave you IV fluids and encouraged you to eat and
drink and your kidney function improved. It is very important
that you continue to drink plenty of water to prevent
dehydration. We also treated you with antibiotics for a urinary
tract infection. You will need to see your doctor within one
week to recheck your electrolytes (including kidney function).
We made the following changes to your medications:
Restart:
1. Metformin 1000mg twice per day
Stop:
1. glyburide since your blood sugar level was very low
2. duloxetine, please discuss restarting this medication with
your mental health provider if it is still needed.
3. oxycodone | ___ with DM, HTN, Depression, ___ Tylenol overdose presents
from ___ with oliguria and ___. | 123 | 18 |
16972806-DS-15 | 24,613,318 | Mr. ___,
You were admitted to ___
because you had confusion and a headache.
WHILE YOU WERE HERE:
- We did some labs on your spinal fluid and found that you do
not have meningitis
- We found that you have pneumonia and we treated this with
antibiotics
WHEN YOU GO HOME:
- Please continue all medications as directed
- Please follow-up with the doctors listed below
- ___ any shortness of breath, confusion, or worsening headache,
please call your doctor or return to the emergency department
immediately
We wish you the best,
Your ___ Care Team | ___ year old gentleman with a history of HTN, DM, lumbar
microdisectomy s/p spinal stimulator, and chronic pain on
narcotics contract who presented with fevers, headaches, and
confusion. Found to have CAP and treated with 5 days of
CTX/Azithromycin. Discharged in stable condition.
# Concern for Meningitis:
The patient presented after leaving AMA from OSH with concern
for meningitis due to headaches, fever, and confusion. He had
been empirically started on Vancomycin, CTX, and acyclovir and
these were continued. His symptoms resolved with the exception
of mild residual headache. He underwent delayed LP which showed
unremarkable cellular composition of CSF. HSV PCR was negative.
Antibiotics were stopped with the exception of CAP treatment
(see below). CSF and blood cultures were pending on discharge
and should be followed-up in the outpatient setting.
# Community Acquired Pneumonia:
Patient presented with fevers and productive cough. He was found
to have a right middle lobe consolidation consistent with CAP.
Treated with 5 days of CTX and Azithromycin (ENDED ___.
Symptoms improved on discharge.
# Transaminitis:
Patient found to have mild to moderate hepatocellular
transaminitis. RUQ US revealed steatosis. This should be further
followed-up in clinic. Consider HCV screening if not already
performed. Recommend repeat LFTs.
# Chronic Pain: Continued home regimen: Quetiapine Fumarate 50
mg PO QAM and 100 mg PO QHS, Pregabalin 300 mg pO TID, Baclofen
10 mg PO TID PRN pain, Lidocaine patch. Narcan script provided.
# Hypertension: Continued home Trandolapril 2 mg PO BID
# Diabetes Mellitus: Patient maintained on inuslin sliding scale
during hospitalization. Discharged on home regimen.
# Gout: Continued home Allopurinol ___ mg PO QDaily
# Insomnia: Continued home Mirtazapine 45 mg PO QHS and
Trazadone 100 mg PO QHS
TRANSITIONAL ISSUES:
- CSF and blood cultures were pending on discharge and should be
followed-up in the outpatient setting.
- Treated with 5 days of CTX and Azithromycin (ENDED ___
for CAP
- Transaminitis should be further followed-up in clinic.
Consider HCV screening if not already performed.
- Recommend repeat LFTs.
- Recommend continued downtitration of opioid regimen as
possible in the outpatient setting
- Patient prescribed naloxone in case of opioid overdose
- Patient on multiple seratonergic medications, please reassess
- Would recommend verification of allopurinol dosage which is
above usual dose
# CODE: Full (confirmed)
# CONTACT: ___ (___) | 87 | 369 |
19866759-DS-12 | 24,554,565 | Dear ___,
It was a pleasure taking care of you. You were admitted here
because you had a blood clot in right leg. You were treated with
subcutaneous lovenox injections for the blood clot. You need to
continue this treatment for three months at least.
Please follow up with your other appointments as outpatient.
Sincerely,
___ MD | ___ is a ___ y F with Malignant peripheral nerve sheath
tumor,
metastatic to the lung despite Pazopanib treatment.
Pt has developmental disability , obesity and T2DM. She
recently had a flight to ___ and despite being active found
herself having leg swelling bilaterally.
US ___ showed R posterior tibial clot. Since it was
symptomatic for pt, decision was made to start pt on Lovenox
1mg\kg bid. Pt tolerated this without complicatinos and was
discharged in a stable condition | 56 | 79 |
11196338-DS-21 | 23,754,977 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital with
nausea and vomiting. This was likely due to chemotherapy and
improved.
There was concern that your feeding tube was misplaced so this
was replaced.
You also had a drainage of your ascites (abdominal fluid). There
was concern for infection of the fluid for which you received
antibiotics and will finish at home.
Your tube feeds were modified to help you tolerated them better
at home so as to improve your nutrition. You will start by
running the tube feeds over 16 hours. You should follow-up with
your outpatient Nutrition team. While on this schedule of tube
feeds, you can take your Zenpep (pancreatic enzyme replacement)
at bedtime and in the morning.
Please continue your prior home medications.
Please follow-up with your Oncologist.
All the best,
Your ___ Team | Mr. ___ is a ___ male with a history of
diarrhea-predominant IBS, oropharyngeal dysphagia (c/b
aspiration now s/p G-Tube for nutrition), metastatic pancreatic
cancer (c/b malignant ascites) on protocol ___ who presents
with
nausea/vomiting and recurrent ascites.
# Nausea/Vomiting: Given temporal association to chemotherapy,
this is most likely chemotherapy induced nausea/vomiting, which
was insufficiently treated with PO medications at home.
Alternatively, may be due to mass effect of increased abdominal
fluid collection pushing on stomach. As well could be related to
bolus tube feeds. Obstruction unlikely as CT negative for it.
Much improved now and no further nausea or vomiting. Now
tolerating feeds with standing metoclopramide as needed.
# Diarrhea: Patient with increased diarrhea. Was briefly
constipated on admission but returned to diarrhea after
bisacodyl PR x1. Does have history of diarrhea predominant IBS
but large volume liquid diarrhea with nocturnal component is
suggestive of other etiology. He takes pancreatic enzyme
supplementation at appropriate dose (3 caps w/meals, 1 cap with
snack) so unlikely. At risk for SIBO or bile acid malabsorption.
Per patient, can handle at home with loperamide.
# Malignant Ascites:
# Bacterial Peritonitis: Patient s/p paracentesis on ___ with
PMN count 5,702. Possibly reactive from malignancy, procedures,
G-tube, but PMN count much higher than prior paras. ___ be
secondary from pulled back G-tube. Received CTX, remained
afebrile and stable, discharged on ciprofloxacin to complete 7
days.
# Cough: Patient with increased cough which is unlikely due to
PNA as CXR negative, but could be ___ increased aspiration of
oropharyngeal contents, post-nasal drip, viral process,
increased pleural effusion. Respiratory viral culture negative.
# Oropharyngeal Dysphagia with Aspiration:
# Severe Protein-Calorie Malnutrition: Patient is s/p G-tube and
typically receives Jevity 1.5 (7 cartons daily over 5 feedings)
with reglan to minimize vomiting, and loperamide to minimize
diarrhea. CT in ED had question of malposition of G-Tube but
contrast study showed appropriate filling of contrast in stomach
suggesting was in position however it needs upsizing and there
is still a question of proper location so patient underwent
replacement on ___. Patient was seen by nutrition and had
repeat video swallow which showed continued aspiration and
continued to
recommend NPO as diet. Switched =tube feeds to Jevity 1.5,
cycling over 16
hours which he tolerated.
# Metastatic Pancreatic Cancer: Metastatic to liver and omentum.
He is on clinical trial Protocol ___. Discussed with his
oncologist Dr. ___. Continued enoxaparin 80mg daily (study
drug)
# Anemia: Downtrending likely from IVF/albumin. Also due to bone
marrow suppression from chemotherapy and malignancy. He received
1 unit PRBC on ___.
==================== | 142 | 414 |
17921262-DS-24 | 29,271,452 | Mr. ___,
.
You were admitted to the hospital for back pain, eye pain, and a
decrease in your blood counts after being hit by the blunt end
of a pistol. We performed an MRI of your back that shows no
damage to your spinal cord. You were also seen by ophthalmology
who found no damage to your eye. Your eyelid will remain
swollen for the next several days. We suspect that you lost
blood in your stool. However, you would not allow us to follow
your blood counts, or test your stool for blood.
.
You were discharged to home.
.
Medications changed this admission:
STOP seroquel
STOP celexa
START ibuprofen every 6 hours as needed for pain | ___ year old man with antisocial personality disorder admitted
for left eye pain and back pain s/p trauma with blunt object,
found to have diminished lower extremity sensation and
significant hematocrit drop from baseline.
.
# Normocytic anemia: The patient was admitted with a 10 point
hematocrit drop from baseline of 36-38 to 27.1. On admission,
he endorsed 4 episodes of maroon stool prior to admission.
Guaiac in the ED was negative. The patient had several
documented bowel movements during admission, but refused to save
stools to visualize or guaiac. He denied hematemesis or coffee
ground emesis. No evidence of RP bleed on CT. No evidence of
hemolysis on laboratory testing. On day 2 of admission, the
patient began refusing labs, so hematocrit could no longer be
followed. The patient was continued on folate, as he likely has
folate deficiency from chronic alcohol abuse (despite lack of
macrocytosis).
.
# Back pain/Inability to walk: On admission, the patient
endorsed acute inability to walk following trauma to lower back.
He described associated symptoms of decreased lower extremity
sensation bilaterally and urinary retention. He refused to
participate in lower extremity motor exam. He underwent
lumbosacral spine x-ray that was without evidence of fracture.
Given associated symptoms, the patient underwent lumbar spine
MRI that showed chronic degenerative disease (unchanged from
___ with mild chronic multilevel foraminal narrowing, but no
evidence of cord compression. The patient was continued on
tizanidine, acetaminophen, ibuprofen, and a lidocaine patch for
pain. He was not provided narcotics per psychiatry
recommendations. With stable MRI findings, the patient was
discharged to home. On discharge, he was able to stand, dress
himself, and ambulate with a cane. He was recommended to
continue ibuprofen for pain.
.
# Eye trauma: Patient with trauma to right eye from blunt end
of pistol. Right eyelid swollen closed. Appearance unchanged
over the course of admission. The patient was seen by
ophthalmology, who determined that there was no direct trauma to
the eye. He was found to have cotton wool spots from chronic
disease.
.
# Threatening behavior: On admission, the patient endorsed
intent to "kill the people out to get him" when he is
discharged. However, he did not specifically name anyone. He
also endorsed hearing voices, but was unable to report the
gender of the voices or what they were telling him. He demanded
Seroquel and Celexa throughout admission, stating that these
were chronic medications. However, he did not have a primary
provider and had only filled one prescription for short supply
written by the emergency department in the last year. The
patient was seen by psychiatry, who determined the patient has
antisocial personality disorder, and is without indication for
acute psychiatric admission or psychiatric medications. On the
day of discharge, the patient required security supervision, as
he was threatening staff. He was escorted from the building by
security at discharge.
.
# Polysubstance abuse: The patient reported cocaine and
marijuana use prior to admission. He also endorsed drinking a
pint of vodka a day. CIWA scale discontinued on second day of
admission, as patient consistently did not score. He was
continued on thiamine, folate, and B12 throughout admission.
.
# ___: On admission, creatinine elevated to 1.4 from baseline
of 1.1. ___ likely prerenal in the setting of blood loss, as it
resolved with IF fluids in the emergency department. | 123 | 605 |
13498038-DS-2 | 24,215,117 | Dear ___,
___ was a pleasure taking part in your care during your
hospitalization at ___. You were admitted with abdominal pain,
and underwent testing to investigate the cause. CT scan did NOT
show appendicitis, bowel obstruction, or kidney stones, and
ultrasound of the abdomen did NOT show gallstones. With
ibuprofen and your usual home medications your symptoms improved
and you were able to be discharged home. It is important that
you follow up with your PCP as directed below to discuss your
symptoms. | Ms. ___ is a ___ with history trichotillomania, OCD and
chronic abdominal bloating who presented with right-sided
abdominal pain distinct from bloating pains of unclear etiology.
# ABDOMINAL PAIN: Patient with long hx of bloating, but
describes current pain as very different. Pancreatitis,
nephrolithiasis, obstruction, UTI, appendicitis ruled out with
imaging and labs, no ovarian mass on CT or torsion or gallstones
on abdominal-pelvic US. No CMT on pelvic exam and denies recent
sexual activity (husband passed in ___. Functional (gas,
constipation, pre-menstrual cramps) remain on differential as
well as endometriosis. Hx of trichotillomania raises concern for
bezoar/obstruction, but patient passing stool and flatus, no SBO
noted on CT, not distended. Pain was well controlled with
ibuprofen at time of discharge
-Patient instructed to follow with PCP ___ 1 week of
discharge.
# ENLARGED APPENDIX: CT abdomen showed an enlarged appendix with
no signs of inflammation. Patient had no pain over Mc___'s
site, no fevers or leukocytosis. Surgery evaluated the imaging
and did not feel findings were consistent with acute
appendicitis. Most likely normal variant. Patient aware.
# VAGINAL DISCHARGE: likely physiologic.
- GC/Chlamydia PCR were pending at time of discharge | 83 | 191 |
14845506-DS-10 | 29,109,455 | Dear Ms. ___,
You were admitted to ___ because you
were still losing weight while at ___ Eating Disorder Unit
and the physicians there found your low heart rate to be
concerning.
You were put on an eating disorder protocol responded well
gaining weight appropriately. Your electrolytes and lab values
remained stable throughout your stay. You are now healthy enough
to restart treatment at ___ and have been accepted there.
It was a pleasure taking care of you!
Sincerely,
Your ___ Healthcare Team | Ms. ___ was admitted for continued weight loss and concern
for bradycardia at ___ Inpatient Eating disorder unit. She
arrived in stable condition, and has remained stable throughout
her admission. She was on the ___ eating disorder protocol and
did not fail any meals. She has gained about 4 lbs during
admission.
# Malnutrition secondary to anorexia nervosa
Ms. ___ was admitted on the eating disorder protocol which
is a multi-team protocol involving nutritionists, physicians,
social workers, psychiatrists, and nursing staff. Though she has
frequently complained about the restrictions and demands of the
protocol, she ultimately cooperated eating all meals in 30
minutes and being observed for one hour following. She has been
given a regimen of supplementation with nutriphos, a
multivitamin with minerals, thiamine, and folate. Basic
electrolytes have been evaluated daily and remained within
normal limits throughout her stay. She has gained weight during
her stay from 67% to 70% of ideal.
Behaviorally, she has been found in the kitchen on several
occasions after being told she could not be there. She attempted
and may have succeed in making caffeinated beverages and
sneaking sugar packets to her room to induce purging. Of note,
despite continuous complaints of hard small stools, no bowel
movements have been observed by nursing staff. Patient continued
to report constipation but none documented, frequently asked for
laxatives. With history of abuse none were given, especially
since she did report some BMs.
#Bradycardia: Initially transferred with concerns about extent
of bradycardia. At baseline, patient has sinus bradycardia at
rest. She was monitored on tele with rates as low as high ___
while sleeping, however during the day rates were ___ at
rest and rose appropriately with exercise. She had no
symptomatic bradycardia.
# Depression
Currently reports depressive symptoms that are likely
multifactorial from malnutrition and possible true depression.
She wants inpatient psychiatry at this time. She endorses
passive suicidal ideation and reports "holding back desires to
harm herself. During her stay she has been started on zyprexa
2.5mg TID with meals in addition to her normal 5mg qhs. QTC ___
was 382. She was not found to need a ___ or to need a 1:1
sitter.
Chronic Problems
================
# Anxiety
- clonazepam PRN
# Insomnia
- Diphenhydramine PRN
# Hypothyroidism
- continue levothyroxine 25mcg daily
# Anemia and leukopenia
Likely secondary to malnutrition, chronic and stable. HGB 10.4
on admission and 10.9 on ___. Leukopenia resolved prior to
discharge at 4.3 on ___
TRANSITIONAL ISSUES
===================
[] Despite gaining weight, she is still severely malnourished.
Additional inpatient treatment is needed with careful monitoring
of her diet and meals as she returns to a healthy weight.
[] She has made repeated attempts to obtain sugar or other
laxative substances. She still needs to be closely monitored at
all times.
[] She continues to endorse significant depressive symptoms
including thoughts of self harm. These might improve with
increased weight, however she has needed and will continue to
need close psychiatric care for both her eating disorder and
depression.
[] She has recently been started on zyprexa 2.5mg TID with meals
in addition to her long standing 5mg QHS. She may additional
dose adjustments. | 78 | 506 |
15362660-DS-18 | 29,635,468 | Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had fever, new rash, and found to also have low blood
counts.
====================================
What happened at the hospital?
====================================
-You were found to have an abscess in the right arm that was
infected and likely causing your fevers. It was incised and
drained which allowed your new antibiotics to work.
-Your low blood counts were likely due to bone marrow
suppression from the Bactrim antibiotic you were taking prior to
this hospital stay. Your bone marrow should continue to recover
on its own. You did require a unit of blood transfusion due to a
very low blood count.
==================================================
What needs to happen when you leave the hospital?
==================================================
-WHEN TAKING DOXYCYCLINE: Administer with meals to decrease GI
upset. Administer capsules and tablets with at least 8 ounces
(240 mL) of water and have patient sit up for at least 30
minutes after taking to reduce the risk of esophageal irritation
and ulceration.
Use skin protection and avoid prolonged exposure to sunlight and
ultraviolet light.
Last day to take doxycycline is on ___.
Avoid Bactrim antibiotic in the future.
-For the right arm wound, cover with gauze and wrap in Kerlix.
Change dressing once daily until your appointment with Dr.
___. Do not remove the iodoform packing.
-Take your medications every day and have your CBC (blood count)
laboratory levels checked as directed by your doctors. ___
should be drawn on ___, with results being forwarded to Dr.
___.
-Please attend all of your doctor appointments and arrange for
them as below.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | ___ year old lady with history of crohn's disease on adalimumab
who was admitted with pancytopenia and fevers and rash in
context
of travel to ___ and use of Bactrim for 10 days
prior to admission.
#Soft tissue infection/cellulitis/right antecubital fossa arm
abscess
-Underwent bedside biopsy by dermatology which produced 20 cc
purulence
on drainage. Biopsy prelim shows CoNS and no fungus seen or AFB
at time of discharge.
-initially on IV vancomycin, then transitioned to PO
doxycycline on ___ for 10 day course. This was recommended by
ID consult.
-patient will follow up with dermatology on ___ as scheduled.
#Pancytopenia
-Not suspecting tickborne illness. Anaplasma PCR negative.
Parvovirus IgG positive but IgM negative. Parasite smears
negative. Lyme serology negative.
-Heme onc consult suspect thus far that the cytopenias are
largely due to Bactrim bone marrow suppression She did require
1uPRBC on ___. Subsequent daily H/H demonstrates stability in
counts.
-Patient will have repeat CBC drawn a week from discharge for
follow up with her hematologist, Dr. ___.
#Crohn's disease
-Holding off on adalimumab due to
acute infection and neutropenia. Will remain on home
dose of prednisone on discharge.
-She will need to follow up with her primary GI, Dr. ___, on
discharge, to determine future re-introduction of humira as
outpatient.
Ms. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was 35
minutes. | 282 | 212 |
17493598-DS-12 | 28,243,706 | Dear Mr. ___,
You were admitted to the ___
after you had right-sided weakness which was due to a bleed, or
hemorrhage, in a small part of your brain. This was probably
caused by your blood pressure being uncontrolled while you were
on a blood thinning medication. Your symptoms had dramatically
improved by the time you were discharged. We worked closely with
our nephrology team to come up with a good plan to manage your
blood pressure without it going too high or too low. After you
leave the hospital, it is very important to continue to monitor
your blood pressure closely and to work with your primary care
doctor to manage your medications.
Because you have hypertension, high cholesterol, and a-fib, you
are risk to have more strokes in the future. We adjusted your
medications as below to minimize the risk of this happening.
You are being discharged on a new blood pressure medication,
Amlodipine, which you should take every day. You should wait
until after dialysis ___ hours) to take it on the days you have
dialysis.
We are also restarting your Coumadin, a blood thinning
medication to help prevent future strokes. You should continue
to take your anti-cholesterol medication, atorvastatin, every
day.
Finally, you were diagnosed with a urinary tract infection prior
to discharge and were prescribed an antibiotic, Bactrim, which
you should take for a total of 7 days (starting ___.
You should take it after dialysis on the days when you have
dialysis.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ yo man with hx multiple vascular risk factors
including afib on Coumadin who presents from ___ with
RLE weakness, found to have L putamen IPH. His exam is notable
for asterixis, inattention, frontal release signs, mild anomia,
R facial droop and mild weakness of the RLE. NCHCT notable for
severe global atrophy, chronic R inferior division R MCA
infarct, vascular calcifications and small (0.6 cc) acute L
putamen IPH. Etiology likely hypertensive given SBP to 200s on
presentation to OSH.
MRI confirmed acute hemorrhage of the L putamen. His symptoms of
weakness resolved completely by the time of discharge. In
consultation with our nephrology colleagues, we controlled his
BP initially on labetolol and transitioned him to once daily
amlodipine prior to discharge. Given his multiple risk factors
for having another stroke (HTN with cerebrovascular disease on
imaging), A-fib, and diabetes, we restarted his Coumadin prior
to discharge with an Aspirin bridge. He was also diagnosed with
a UTI and was discharged to complete a 7-day course of oral
Bactrim.
Transitional issues:
- BP control: He is being discharged on Amlodipine 5mg PO daily.
He should wait until several (___) hours after dialysis to take
his amlodipine on HD days, and ideally try to take as close to
the same time every day as possible. Monitor carefully for
post-dialysis hypotension as this was an issue previously, and
he may require further adjustments of his regimen.
- Anti-coagulation: He is being discharged on Coumadin 2.5mg PO
daily, with an INR goal of ___. This is half his usual dose of
5mg PO daily while he is on Bactrim for his UTI. His Coumadin
will need to be increased again after this course is completed.
He is also taking Aspirin 81mg daily while restarting Coumadin.
This should be discontinued once his Coumadin is therapeutic.
- UTI: He is being discharged on a 7-day course of PO Bactrim
DS, beginning ___, to finish on ___.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
35 minutes were spent on discharge. | 382 | 432 |
17969380-DS-11 | 25,392,274 | Dear Mr. ___,
You were admitted to ___ due to an infection in your
bloodstream; you received intravenous antibiotics. Your blood
was checked daily until it was clear of the infection. You
underwent a number of laboratory and imaging studies to
determine the source of infection, which were unrevealing. Due
to the severity of the infection, a PICC line was placed; you
will continue on intravenous ceftriaxone 2gm daily through
___ (a 4-week course); the Infectious Disease doctors at
___ then determine whether you need a longer
course of antibiotics or if you can stop at that time.
In addition, during your stay, your immunosuppression was
monitored closely. You should continue taking tacrolimus 1.5mg
twice daily, Cellcept 500mg twice daily, and prednisone 5mg
daily. Because you had a decrease in your white blood cell count
during your stay, your Bactrim was stopped; you should take
Dapsone 1500mg daily for prevention of infection while on
chronic steroids. Please follow up with your Transplant doctor
to monitor these medications.
Thank you for letting us be a part of your care!
Your ___ Kidney Team | ___ PMHx PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate
cancer, HTN/HLD, presenting with sepsis and GNB bacteremia
thought to be ___ infected intraabdominal cyst vs UTI.
# Severe Sepsis: following transfer from OSH, blood cultures at
OSH were notable for ___ bottles with (+) GNR. Initial concern
was for urinary source, given patient's recent admission for E.
coli UTI and bacteremia and concern for increased urinary
frequency. However urinalysis was unrevealing for infection,
given only 1WBC, negative nitrites, and trace leukocytes.
Infectious work-up was initiated, including blood, urine, stool,
and viral studies. He was initially hemodynamically unstable and
received a x1 dose of amikacin and aggressive IVF resuscitation.
With continued IVF, his blood pressure stabilized. Due to
ongoing fevers, he was transitioned from Zosyn to cefepime.
Blood cultures were repeated with fevers and were (+) for GNRs
x3 days, urine culture was negative. Due to persistence of
bacteremia and concern for poor source control, Infectious
Disease was consulted. In the setting of PKD, a MRI abdomen was
performed to assess for infected cysts which was unrevealing.
Due to patient's headaches, an MRI brain was performed which was
negative for intracranial process. An echo was obtained which
showed no vegetation. Following speciation of blood cultures and
improved stability of the patient, he was transitioned from
cefepime to CTX. Blood cultures after ___ were notable for no
growth. A PICC was placed to allow for completion a x4 week
course of antibiotics.
# ___ on CKD in the setting of PKD s/p LRRT (___): Cr 2.5 on
arrival, baseline creatinine 1.5 - 2.1. In addition, patient was
noted to have low urine output. A renal transplant ultrasound
was obtained which was normal. He received aggressive IVF
resuscitation and his MMF was held in the setting of sepsis. His
urine was spun and was notable for mild ATN. CMV was checked and
no viral load was detected. Urine BK was negative. He was
continued on tacrolimus and prednisone for immunosuppression.
Due to leukopenia (discussed below) his Bactrim ppx was held and
he was transitioned to dapsone. His creatinine was trended and
continued to improve; discharged with creatinine of 1.5. His MMF
was restarted day prior to discharge at a dose of 500mg BID;
outpatient provider should ___ as appropriate.
# Leukopenia/Neutropenia: during admission, patient was noted to
be neutropenic. Concern for marrow suppression in the setting of
persistent bacteremia vs EtOH use given patient reported daily
EtOH use vs splenic sequestration given splenomegaly on
exam/imaging vs medication-induced. His home bactrim was held
and he was transitioned to atovaquone for PCP ___. Heme-Onc was
consulted who recommended treatment with G-CSF, with resultant
resolution of his neutropenia. Of note, patient's imaging was
concerning for new splenomegaly; he should be monitored closely
and repeat imaging considered.
# HTN: on admission, his home anti-hypertensives were in setting
of sepsis. They were restarted in the hospital after his sepsis
resolved.
# HLD: he was continued on his home ezetimibe/simvastatin.
# Question of pre-diabetes: he was monitored on the insulin
sliding scale while in house and did not require insulin.
# GERD: he was continued on his home omeprazole
# Gout: his home colchicine was originally held in the setting
of ___ this was restarted prior to discharge
Transitional Issues:
[] D1 of clear blood cultures ___ plan for 4 week course of
CTX 2gm IV q24hr (last day ___
[] Given neutropenia, Bactrim was stopped and patient was
started on Dapsone 1500mg qd for PJP ppx
[] Tacrolimus trough was elevated on admission; discharged on
dose of 1.5mg BID. Plan to recheck level on ___
[] MMF was held on admission ___ sepsis; restarted at dose of
500mg BID, please ___ to home dose if needed (750mg BID)
[] Cinalcet was held ___ hypocalcemia during admission; please
continue to monitor
[] Physical exam and abd MRI notable for splenomegaly (measured
at 16.6 cm, no focal lesions) with previous obtained imaging
reports without mention of splenomegaly, please continue to
monitor
Code: FULL
Contact: ___ | 178 | 662 |
19905556-DS-7 | 26,911,900 | Dear Ms. ___,
It was a pleasure taking care of you at the ___. You were
admitted for treatment of cellulitis. You were treated with
antibiotics and with elevation of your right leg to help drain
the infected fluids. We also had our wound care nurses place ___
dressing over the blisters. The cellulitis improved so we felt
you were ready to continue treatment from home.
However, the cellulitis infection is not yet cured, please
continue to take the antibiotic called Clindamycin until
___. We also will have a visiting nurse assist with
changing your leg dressing.
We'd also like you to follow-up with your PCP.
Sincerely,
-- Your ___ Care Team | Ms. ___ is a ___ with T2DM, COPD, and prior cellulitis who
presents with RLE lesions most consistent with cellulitis ___
venous stasis dermatitis. | 107 | 24 |
12050233-DS-8 | 27,519,848 | You were admitted with symptomatic anemia and chronic kidney
disease. You were given 2 units of red blood cells with
improvement in your kidneys. You were found to be severely iron
deficient. You were started on ferrous gluconate (you did not
tolerate ferrous sulfate in the past). Do not discontinue this
medication unless you discuss with PCP.
You were found to have decreased kidney function. You will need
to see the kidney doctor as an outpatient for further assessment
and management. | ___ with hx of chronic anemia (Hct 30) who p/w several months of
feeling dizzy and tachycardic as well as new onset CP, now with
acute on chronic anemia and chronic renal failure.
# Iron deficiency anemia, beta thalassemia, menorrhagia: This is
consistent with severe iron deficient anemia. Her CKD may also
contribute. She was treated with 2u PRBC with improvement of her
tachycardia, chest pain and shortness of breath. She continued
to feel palpitations. She was started on ferrous gluconate TID
(has not tolerated ferrous sulfate in the past due to pruritis).
She did not have any side effects. She was treated with colace
and senna as well. She will need to follow up with her PCP to
get repeat lab draws. She will follow up with nephrology where
she may require epo injections.
# Chronic kidney disease stage IV: Based on GFR she is nearly
stage V. Nephrology was consulted and think this is chronic
renal failure. She has protein in her urine but was not started
on an ACE inhibitor due to dizziness. She should be started on
one in the near future if she tolerates. She will follow up with
nephrology. This appointment will be scheduled by the nephrology
department with an interpreter and she will be contacted about
the appointment.
# Palpitations: Likely due to PVCs as seen on EKG. No evidence
of arrhythmia. Possibly exacerbated by anemia. She will need
further monitoring as an outpatient.
# Menorrhagia: She should receive further evaluation as an
outpatient to determine if further management is necessary.
Of note, she was warned not to take any more ___ herbs.
TRANSITIONAL ISSUES
- f/u pcp for labs and symptoms evaluation
- f/u nephrology for evaluation and treatment of CKD
- consider ACEi and epo (epo after iron repletion) | 80 | 291 |
13569498-DS-18 | 23,630,943 | Mr. ___,
You were admitted to the hospital for pneumona. You were
started on antibiotics for the infection which improved your
symptoms. You were given IV fluids and oxygen to help you
breathe. We were able to ween you off of oxygen.
We are sending you home on antibiotics for an additional 5 days.
-Levofloxacin 750 mg Daily for 5 more days. | ___ Male with down's syndrome with pneumonia.
# Cough: Likely PNA given CXR findings. Patient also hypoxic at
triage, but appears comfortable with normal O2 sat currently on
RA. Lactate mildly elevated at 3.3, decreased to 1.4 the
following morning after fluids. Given 750 Levo in the ED, and
continued daily on the floor. Will send home with 5 days of
levo. Repeat chest xray showed resolving opacities. Pt sent
home afebrile with O2 sats >90 on RA. Has appt for PCP follow
up.
# Incontinence: Not normally incontinent of urine. Likely due to
coughing fit and acute illness. UA was negative.
# Down syndrome: Will continue home meds for now including bowel
reg and Paxil.
# FEN: 500cc bolus, replete electrolytes, regular diet
# Prophylaxis: boots, bowel regimen
# Access: peripherals
# Code: Full (confirmed)
# Communication: Patient's Sister (HCP) | 64 | 153 |
13209155-DS-13 | 27,277,736 | You were admitted to the medical service with concerns for a
COPD exacerbation. Your oxygen levels were checked and remained
normal. You had no evidence of pneumonia or COPD exacerbation.
You should continue to use your inhalers and quit smoking. You
had an X-ray of your right arm which is known to be broken. You
should remain non-weight bearing and start OT and pendulum
swings. You will need to follow up with ortho-trauma as an
outpatient.
You were also seen by psychiatry for psychosis. You were started
on abilify and got an injection. However, you should continue
taking the abilify pills for 2 weeks until the injection kicks
in. | This is a ___ with history of psychiatric disease who presented
with disorganized thinking. She was seen by psychiatry who
recommended inpatient psychiatric admission. She was
subsequently admitted to medicine for management of COPD
exacerbation.
#Chronic COPD without exacerbation
The patient was noted to have wheezing in the emergency
department and was treated for a COPD exacerbation with
Solumedrol and Azithromycin. Her lung exam was without wheezing
on admission to the medical floor, she was able to speak in full
sentences, she was afebrile and not short of breath on
ambulation making both COPD and Pneumonia unlikely. The patient
was monitored for a number of days in the ___ medical
setting on her home inhalers with good control of her
respiratory symptoms. Smoking cessation was advised.
#Schizoaffective disorder with decompensation.
The patient presented with delusions and disorganization after
her medications were stolen. She was seen by psychiatry who
placed a ___ and recommended inpatient admission. The
patient was intermittently agitated, requiring IM Haldol 5mg
IM/Ativan 2mg IV/Cogentin 1mg and a security sitter. She
continued to be agitated requiring a security sitter and doses
of the above medications. Attempts were made to place her in an
inpatient psych facility but no beds were available for several
days. She was continually evaluated by psych daily until it was
felt that she was no longer a harm to herself or others and
close to her baseline on ___. Her home abilify was
increased from 15 to 20 mg and she received an injection of
long-acting abilify prior to discharge. Arrangements with the
SW at ___ to assist pt in finding psychiatrist locally.
#Right humerus fracture
Missed outpatient follow up. Discussed with orthopedics who
reviewed X-ray. Patient can begin ROM. She should remain
non-weight bearing but can begin pendulum swings and follow up
in clinic after discharge. pain was managed with ibuprofen,
acetaminophen and oxycodone. | 110 | 313 |
18404315-DS-24 | 28,059,743 | Dear Ms. ___,
You were admitted with abdominal pain and vomiting due to viral
gastroenteritis. Your imaging tests were reassuring and you
were able to take in oral intake.
Please call your PCP tomorrow to schedule a follow up visit in
the next ___ days, as this appointment could not be made prior
to your discharge. Please discuss a referral to
gastroenterology for your chronic radiation enteritis.
It was a pleasure caring for you.
Your ___ Care Team | ___ y/o F with hx of radiation enteritis presenting with acute
onset nausea, vomiting, and crampy abdominal pain. Reports BRBPR
which she has had in the past. CT scan shows radiation enteritis
without obstruction. Believed to have viral gastroenteritis on
top of chronic radiation enteritis.
On day of admission pt complained of ___ chest pain, sharp,
pleuritic, reproducible, non-radiating with no
SOB/diaphoresis/palpitations. EKG similar to previous. Later
that day pt had episode of hypotension to 72 systolic,
asymptomatic, that prompted 2L fluid bolus, trops x 2
(negative), stat H/H (decrease from previous hemoconcentration
but recheck stable), and CXR (normal). This episode was
attributed to hypotension. Pt had not received any IVF since
admission so maintenance fluids were continued and blood
pressure responded appropriately.
On last day of admission patient complained of the medical team
not giving her meds as prescribed (her reported 300 mg colace
BID was changed to 200 mg BID and her home 0.3 mg clonidine TID
was held after hypotensive episode- pt was normotensive at the
time). Pt had taken home clonazepam and clonidine in the ED when
first admitted and was asking nursing for opiates for a headache
despite being on methadone. Her neuro exam was non-focal. Pt
eventually left AMA, despite counseling from medicine team, but
beforehand was informed to make f/u appointment with PCP and
discuss GI f/u. | 79 | 224 |
16498795-DS-22 | 21,569,743 | Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
*Continue to follow with ___ clinic as scheduled to monitor
your INR level. Call Dr. ___ with any question
regarding Coumadin. | The patient with history of cystic duct stump leak and biloma
s/p percutaneous drainage was admitted to the General Surgical
Service with increased abdominal pain and fever. The patient
completed the course with Cipro/Flagyl at home. On admission,
the patient underwent abdominal CT, which demonstrated interval
decrease in size of the fluid collection within the gallbladder
and new undrainable right hepatic lobe fluid collection. The
patient was started on IV Unasyn, IV fluids and his Coumadin was
held. The patient was hemodynamically stable.
On HD # 2, patient was afebrile with stable vital signs, his
abdominal pain resolved. On HD # 3, patient was advanced to
regular diet with good tolerance, IV fluid were discontinued and
antibiotics were changed to PO Augmentin. Patient's percutaneous
drain was removed and he was restarted on home dose of Coumadin.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 171 | 245 |
13557341-DS-14 | 28,389,767 | 1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for 6 months per Dr. ___ and while
taking narcotics. Driving will be discussed at follow up
appointment with Dr. ___.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
7) Per Dr. ___ can not return to working in the warehouse
for 3 months.
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ year old male past medical history only significant for
hyperlipidemia who was admitted on ___ following ventricular
fibrillation arrest.
Given the lenght of his inpatient stay, his preoperative course
will be divided into systems.
# VF arrest: Patient had a witnessed VF arrest while at a gas
station that happened to have an ambulance there at the same
time. CPR was started immediately. On presentation to ___,
cardiac cath was performed demonstrating severe RCA and LAD
disease and moderate LCX disease with normal flow. None of the
lesions were intervened upon. TTE was performed which
demonstrated mild symmetric left ventricular hypertrophy with
mild left ventricular cavity dilation and severely depressed
biventricular systolic function (LVEF ___ with 2+ mitral
regurgitation. LV thrombus was unable to be ruled out, and
patient was started on heparin. Pt's Vfib was thought most
likely to be due to global ischemia in the setting of three
vessel disease. Non-ischemic causes such as electrolyte
abnormality, a hereditary channelopathy or old MI scar
initiating a focus of arrhythmia were also considered in the
differential. Post cardiac catheterization, patient was cooled
per cooling protocol and rewarmed. On being rewarmed, patient
was found to be neurologically intact, and was extubated.
Repeat TTE demonstrated severe global left ventricular
hypokinesis (LVEF = ___ with relatively better wall motion
in the basal inferolateral wall. No masses or thrombi are seen
in the left ventricle. Pt was also noted to have possibly
worsened mitral regurgitation. While in the CCU, patient was
loaded with amiodarone given his vfib arrest of unclear
etiology, and continued on amiodarone PO. He was also treated
with aspirin 325 mg daily, metoprolol tartrate 25 mg q6 hours,
and captopril 3.125 mg q8 hours. Heparin gtt was started due to
concern for possible LV thrombus on initial TTE. On transfer to
the floor, pt's captopril was discontinued and lisinopril 5 mg
daily was started. In addition, metoprolol was titrated to
metoprolol XL 125 mg daily. Atorvastatin was started at 10 mg
daily given pt's known history of myalgias with other statins.
Lisinopril was changed to Losartan 25 mg daily after pt
developed a cough. On the floor, pt underwent a thallium
viability study which showed extensive myocardial viability in
all coronary artery territories. In addition, TTE ___
demonstrated continued LV dysfuncttion with LVEF = 20% and
improved MR from previous study. It was determined that pt would
undergo CABG with cardiac surgery. As part of pre-op work up,
pt underwent extraction of 3 teeth (19, 29, 30) with extensive
decay.
# CAD: As discussed above, cath on arrival showed severe RCA and
LAD disease with normal flow. No PCI were performed, and
further interventions held off while undergoing cooling. Seen
by cardiac surgery and underwent CABG x4 with Dr. ___ on
___. Atorvastatin was initially held during the cooling and
low dose atorvastatin at 10 mg daily was started once patient
was transferred to the floor. Aspirin was started while
hospitalized.
# Heart Failure: Initial TTE post-arrest demonstrated severe
systolic diyfunction with and EF ___ and 2+ mitral
regurgitation. Repeat echo demonstrated severe global left
ventricular hypokinesis (LVEF = ___ with relatively better
wall motion in the basal inferolateral wall. No masses or
thrombi are seen in the left ventricle. Pt was also noted to
have possibly worsened mitral regurgitation. Pt was started on
an ACEi and metoprolol as described above, and lasix 40 mg
daily. Lasix was changed to 20 mg daily, and the ACEi was
changed to losartan after pt developed a cough. Post-CABG, he
was followed by Dr. ___ recommended that he be discharged
home with Life Vest for 3 months.
# Superficial thrombophlebitis: On the floor, pt developed a
superficial thrombophlebitis of his right forearm. Pt was
already anticoagulated with heparin as described above, and warm
compresses combined with elevation were instituted which were
effective. | 136 | 681 |
19364967-DS-3 | 27,494,410 | Dear Mr. ___,
It was a pleasure caring for you here at ___. You came to the
hospital because of arm and leg pains and nodules on your skin.
We had the rheumatologists, infectious disease doctors as ___
as the dermatologists see you while you were here.
For your pain we gave you ibuprofen, oxycontin and oxycodone.
To avoid stomach irritation, please take zantac (ranitidine) or
pepcid (famotidine) while you are on ibuprofen.
Also while here you were found to be anemic. You had no blood in
your stool, and it seems that the inflammation may be causing
your blood counts to be low. With improvement of the
inflammation, we expect the anemia to improve.
Please follow up with your primary care doctor and
rheumatologist. Your primary care doctor ___ coordinate the
appointment with your rheumatologist.
There are still several tests pending and your PCP ___ be
informed of the results. The rheumatologists who saw you here
will communicate with your rheumatologist to update her on your
hospital course. After we confirm you do not have TB you will
likely be started on prednisone. Expect a call from the
rheumatologists tomorrow. | ___ with 6 wks of myalgias/arthralgias, 15 lb weight loss, and
tender subcutaneous nodules on all extremities has started
workup for rheum vs ID vaculitis vs erythema nodosum was
admitted for pain control and further workup.
.
#fever/arthralgias/subcutaneous nodules, likely c/w NODULAR
VASCULITIS: Pt had already undergone extensive outpt w/u, with
skin biopsy most c/w nodular vasculitis with plan to initiate
systemic steroids. However, due to severe pain, pt presented to
the hospital for pain control. Rheum, ID and Derm Consults were
involved in his care. The following workup has been done: Smear
negative for parasites, Lyme antibody negative, Erhlichia
IgG/IgM negative, CMV neg, Anaplasma IgG/IgM negative, Quant
gold neg, Blood culture negative x 2, Hep panel neg, HCV neg,
HIV neg, ASO neg. ___ neg, ANCA neg, normal SPEP, normal
Complement levels, antiphospholipid Ab neg, cryoglobulin neg.
Further infectious w/u at ___ was done to r/o fungal
infection, which was negative. He had one positive blood
culture from ___ which grew GRAM POSITIVE COCCI IN CLUSTERS,
however, another set from the same day was negative for growth,
and he had 4 more additional sets of blood cultures, so the
positive blood culture was felt to represent contaminant. He
had a TTE that did not show evidence of vegetations / infective
endocarditis.
He underwent repeat skin biopsy at ___, with dermatopathology
result showed: lots of hemorrhage, c/w acute and chronic
inflammation, but otherwise non-diagnostic. HIs outpt path
slides were obtained and were reviewed by ___ Pathology, and
based on their review, the findings are c/w nodular vasculitis.
Pending return of Quantaferon gold, if TB is ruled out,
Rheumatology Consult plans to coordinate with his outpt
Rheumatologist and recommend the initiation of systemic steroids
for treatment of nodular vasculitis.
.
#Sinus tachycardia: HR iniitally in the 120s and before d/c in
the low 100s. Tachycardia felt to likely be related to pain and
improved with pain control.
.
#Microcytic anemia: Ht ___ MVC 78 then after IVF was
___ anemia with iron low at 25, TIBC 286 ferritin
312. Haptoglobin and LDH both WNL, not suggestive of hemolysis.
Guaiac negative. On d/c Ht was 27..
.
#Elevated LFTs: ALT 124, AST 58 Alk P ___, then started trending
down and on day before d/c AST 39 ALT 87 Alk P ___. Per pt he
has frequently had elevated LFTs whenever he is sick even in
college. It is possible that either infections of systemic
inflammation could explain this. RUQ u/s was unremarkable. Hep
C serology was negative. Hep B serologies were c/w prior
immunization.
.
.
TRANSITIONAL ISSUES
[]per rheum, they will discuss w/ outpatient rheum the plan to
be started on prednisone assuming quant gold neg | 189 | 465 |
14769071-DS-17 | 29,415,334 | Ms. ___,
You were admitted to ___
because you were having severe joint pain.
WHILE YOU WERE HERE:
- We found out that you had an infection in your joints called
gonorrhea
- We washed out your joints with surgery and gave you
antibiotics
- You had some kidney injury while you were here that is
recovering now
WHEN YOU GO HOME:
- Please continue all medications as directed
- Please follow-up with the doctors listed below
- ___ monitor for the "alarm symptoms" listed below; if you
experience any of these symptoms please call your doctor or
return to the emergency room immediately
We wish you the best,
Your ___ Care Team | ___ with history of HIV, bilateral carpal tunnel syndrome, and
OA of knee who presents with oligoarthritis. She was found to
have septic arthritis due to gonorrhea and treated with surgical
washouts and doxycycline. Hospital course complicated by acute
renal failure of unclear etiology which improved prior to
discharge. Also found to have vaginal bleeding.
#Gonococcal Arthritis:
The patient presented with fever and severe joint pain. She had
tap of R knee prior to ED presentation which showed ___ WBC.
Tap of left wrist with ___ WBC, which was thought to be
concerning for septic arthritis. She was continued on
Vancomycin/CTX. The patient went for surgical washout of left
elbow, left wrist, and right knee with purulent fluid in the OR.
Her clinic knee culture subsequently grew rare staph which was
thought to be contaminant. Urine gonorrhea came back positive
which was likely cause of septic arthritis. The patient was
continued on CTX for gonococcal arthritis, which was
subsequently narrowed to doxycycline due to concern for AIN (see
below). The patient should continue a 2 week course of
doxycycline (___). She received one-time dose of 1g
azithromycin. Joint fluid cultures were pending at discharge and
should be followed-up in the clinic. She should follow-up with
___ clinic, orthopedic surgery, and hand surgery after discharge.
She was discharged on Tylenol for pain. Her partner was notified
with intent to seek partner treatment with his provider.
#Acute renal failure:
The patient's course was complicated by acute renal failure,
with creatinine peaking at 5.6 from baseline ~0.6. Unclear
etiology of this ___ but creatinine trended towards normal prior
to discharge. It should be noted that WBC casts were seen in the
urine, so the patient's CTX was changed to doxycycline due to
concern for AIN. This may have contributed to the cause.
Discharge Cr 2.0. Recommend repeat Cr and BMP in clinic.
Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
#Vaginal Bleeding:
The patient was found to have slowly downtrending Hb in the
setting of vaginal bleeding between periods. She remained
hemodynamically stable. She received 2U of pRBCs during
hospitalization for Hb 7.1 with slow downtrend. Her Hb was
subsequently stable and her bleeding stopped. UHCG negative. She
should follow-up in clinic with OB/GYN for further workup and
consideration of ultrasound and endometrial biopsy. She should
also have repeat CBC in clinic.
#HIV: Continued abacavir 600, lamivudine (dose adjusted for
renal dysfunction to 150 daily), and etravirine 400. CD4: 787.
HIV VL: NOT DETECTABLE.
#GERD: Continued ranitidine
#History of sleeve gastrectomy: Vit D, MV, B12
TRANSITIONAL ISSUES:
- Continue a 2 week course of doxycycline (___).
- She received one-time dose of 1g azithromycin.
- Joint fluid cultures were pending at discharge and should be
followed-up in the clinic.
- She should follow-up with ___ clinic, orthopedic surgery, and
hand surgery after discharge.
- She was discharged on Tylenol for pain and miralax for
constipation.
- Her partner was notified with intent to seek partner treatment
with his provider.
- Recommend repeat Cr and BMP in clinic. WHEN CREATININE RETURNS
TO NORMAL WILL NEED DOSES OF RANITIDINE AND LAMIVUDINE INCREASED
TO HOME-DOSE.
- Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
- She should follow-up with OB/GYN for continued workup of
vaginal bleeding between periods.
- Recommend repeat CBC in clinic for slow vaginal bleeding.
- Discharged with limited PO Zofran for nausea likely due to
doxycycline
# DISCHARGE CR: 2.0
# CODE: Full (confirmed)
# CONTACT: ___: ___ Daughter (*please note patient
does not want updates to go to anyone else besides her daughter) | 106 | 602 |
10009049-DS-16 | 22,995,465 | Dear Mr ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted after you were diagnosed with pneumonia. We
started you on antibiotics and you improved. You also had issues
with moving your bowels which resolved with conervative
measures. Please continue a full liquid diet at home (soups,
jello, shakes) and advance to regular diet slowly as tolerated.
___ MDs | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ year old male with
no significant medical history presenting as transfer from OSH
with c/o cough, n/d/diarrhea, and chest pain found to have fever
and hypoxia. On further work-up, pt. was found to have a
multifocal pneumonia. Culture data was unrevealing. Pt. was
placed on antibiotics and continued to improve. His O2
requirement resolved and he was discharged with close follow-up.
ACTIVE ISSUES
=============
# Sepsis and Community Acquired Pneumonia: Mr. ___
presented with tachycardia, temp to 104, and multifocal
opacities seen on CXR. He was started on ceftriaxone and
levofloxacin in accordance to ___ guidelines for community
acquired pneumonia. Respiratory viral panel negative,
legionella negative, strep pneumo antigen negative, and cultures
were unrevealing. Pt. grew GPCs in clusters in blood ___
bottles) which raised concern for possible MRSA bacteremia from
MRSA pneumonia. Pt. has negative MRSA swab and without known
MRSA risk factors. TTE was negative for evidence of
endocarditis and surveillance blood cultures were negative.
Oxygen requirement had resolved by day 2 of admission and he was
transferred to the floor. He was transitioned to levofloxacin
to complete his course of antibiotics.
# Chest Pain: Pt. complained of left sided sharp chest pain
made worse with coughing and deep breathing. Most likely
pleuritic chest pain from underlying inflammatory pleuritis from
pneumonia. Cardiac enzymes neg x2 making cardiac ischemia less
likely. No ischemic changes or other notable changes seen on
ECG. TTE done on ___ and was grossly normal with LVEF 60-65%.
# Abdominal Distension: Initially, pt. presented with diarrhea,
CDiff negative. Continued to complain of abdominal distension.
KUB showed multiple air filled loops of bowel without air fluid
levels consistent with possible ileus. Pt. continued to
complain of minimal flatus, abdominal distension made worse with
consuming POs, and minimal BMs. Slowly, he began to tolerate PO
intake. At time of discharge, pt. was tolerating full liquids
without issue. He was encouraged to advance his diet as
tolerated.
# Anemia: Patient with downtrending Hct throughout this
admission. Initial and repeat DIC labs returned negative. Most
likely etiology ___ bone marrow suppression due to acute illness
with possible suppression ___ medication effect. No signs of
active bleeding.
# ___: Pt. with evidence ___ on admission. Likely pre-renal
etiology in the setting of pneumonia and sepsis. With IVF, pt's
creatinine returned to baseline and ___ resolved.
CHRONIC ISSUES
==============
# BPH: Stable. Continued on flomax
TRANSITIONAL ISSUES
===================
# Antibiotics: Pt. should continue levofloxacin for an
additional 4 days to complete a 10 day course. | 65 | 446 |
16660031-DS-9 | 21,402,730 | Dear Ms. ___,
You were admitted to the hospital because your sugars were very
elevated. We think that you likely have diabetes. We wanted to
treat you with insulin while we were awaiting some more lab
work, but you decided to leave the hospital against medical
advice. You understand the risks of leaving the hospital
without further treating your elevated blood sugars.
It will be VERY important for you to follow up with your primary
care doctor this week. We are giving you a prescription for
metformin, a medication that can help lower your sugars. Please
start taking this medication to help control your sugars and
follow up with your primary care doctor.
PATIENT LEFT AMA. She did not wait for her paperwork, but was
given a prescription for Metformin and instructed to follow up
with her PCP. | # Hyperglycemia - appeared HHS > DKA and was treated with SC
insulin and 4L of IV fluids to good effect in ED and
normalization of her serum osms. Her K and Phos were repleted.
A search for infectious causes of her presentation including UA
and CXR was unrevealing and the patient was afebrile. On
admission the patient was refusing further insulin. She
repeatedly stated she wished to manage her blood sugars with
diet and oral medications. She understood that this was a
dangerous therapy for her acute condition and that there were
risks including death. She was started on metformin 500 BID and
her sugars on the floor ranged between 300 to 400. She left
against medical advice with a prescription for oral metformin
and stated that she would follow up with her PCP. She
understood the risks of leaving and that she may have to return
in an ambulance or die as a result. An A1c was pending at
discharge.
# thick vaginal discharge - treated empirically with one dose of
fluconazole
# HTN - continued home amlodipine and atenolol
# HL - held simvastatin due to increased risk of rhabdo with
fluc
# Chronic pain - continued gabapentin, oxycodone, oxycontin.
Doses and refills confirmed with ___.
# Vertigo - continued home meclizine
# GERD - continued home omeprazole | 140 | 232 |
19370314-DS-21 | 29,662,120 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were having worse shortness of breath than usual, as well
as leg swelling.
What did you receive in the hospital?
- You were treated for a COPD exacerbation with steroids and
antibiotics.
- You received a water pill to help remove fluid from your
lungs.
- We performed an ultrasound of your heart which did not show
obvious signs of heart failure.
- We performed a CAT scan of your chest which did not show blood
clots.
- You were evaluated by our physical therapy team, who diagnosed
you with BPPV, which can be easily treated as an outpatient.
- Your oxygen level improved and you were ready to leave the
hospital.
What should you do once you leave the hospital?
- Try as hard as you can to stop smoking, as this will help
improve your shortness of breath.
- Take your medications as prescribed.
- Attend your follow up appointments as scheduled.
We wish you all the best!
- Your ___ Care Team | ___ woman w hx COPD (last PFTs "normal" per ___ pulm note
___, ongoing smoker, presented w acute on chronic SOB and DOE,
symptoms and findings concerning for both COPD exacerbation as
well as potential congestive heart failure. | 173 | 39 |
13731663-DS-4 | 21,120,411 | Dear Mr. ___,
You were hospitalized due to the sudden onset of a right facial
droop, headache, and chest pain. You had a CT and MRI of your
brain which showed that you did not have a stroke. The symptoms
you experienced were most likely due to a complex migraine,
which is a type of headache. You have an appointment with
Neurology to follow up.
We are not making any changes to your regular medications.
Please continue to take your regular medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization.
-The ___ Neurology Team | Mr. ___ is a ___ year old male with multiple cerebrovascular
risk factors including hypertension, hyperlipidemia, diabetes,
obesity and smoking presenting with multiple episodes of right
facial droop and dysarthria concerning for TIA v. new ischemia
v. migraine. On initial examination, the patient demonstrated
right facial droop with good activation. Otherwise his
sensorimotor examination was unremarkable. He was admitted to
rule out stroke, rule out MI, and to asses for stroke risk
factors.
# NEURO: In the Emergency department, a CT/CTA Head/Neck showed
no thrombosis, aneurysm or dissection within the principal
arteries of the head and neck, but did show atherosclerosis.
MRI showed "No intracranial hemorrhage or acute infarct.
Numerous foci of patchy and confluent FLAIR hyperintensity in
the white matter, nonspecific but consistent with severe chronic
small vessel ischemic disease". Mr. ___ stroke risk factors
were assesed with fasting lipid panel and HbA1c (see labs
section for details). During his hospitalization, home
pravastatin 10mg daily was increased to atorvastatin 40mg daily
and home aspirin was increased from 81mg daily to 325mg daily.
At discharge, both medications were returned to ___
medications and doses. Mr. ___ was seen by physical therapy
and speech pathology. He was assesed to be back at his baseline
with resolution of the facial droop and no residual symptoms.
He was determined to have a complex migraine as the cause of his
symptoms.
# ___: EKG and troponin-T x1 normal. Echo: "Mild symmetric left
ventricular hypertrophy with a normal LVEF and biatrial
enlargement. Mildly dilated ascending aorta. No ASD/PFO
demonstrasted on saline contrast injection." He was monitored on
telemetry and no concerning findings were recorded. His home
dose of atenolol was halved from 100mg to 50mg daily to allow
his blood pressure to autoregulate. His more norvasc was held
during his hospitalization. Both medications were returned to
home doses at discharge.
# PULM: Chest radiograph from the emergency department revealed
possible pneumonia vs COPD flare. Mr. ___ was started on
azithromycin 250mg for a five day course. He was also provided
with his home dose of atrovent and albuterol.
# ENDO: HbA1c result was pending at the time of discharge.
Blood sugars were monitored with finger sticks QID and Insulin
sliding scale with a goal of normoglycemia.
# Toxic/Metabolic: Slight transaminitis (ALT 66, AST 63),
consistent with HCV history.
# ID: UA negative for UTI. Chest radiograph concerning for PNA
and patient was started on azithromycin x 5day . | 109 | 417 |
11577761-DS-9 | 20,793,231 | Dear Mr. ___,
.
It was a pleasure taking care of you at ___. You were admitted
due to having sleep disturbances and a concern for a change in
your behavior. After initial evaluation in the ED there was
concern that you might have had a stroke, and therfore you were
admitted to the Neurology Service. An initial scan of your head
was performed (CT Scan) and was reassuring. Afterwards you had
another more detailed scan (MRI) to evaluate for stroke and it
demonstrated no evidence of stroke, bleeding, masses or other
clearly contributory changes. There were no obvious vessel
abnormalities. In addition, several investigatory studies were
done to evaluate for other causes of cognitive change; there
were no signs of significant infectious or toxic-metabolic
disturbances. It is thought that your thinking and behavior
changed in the setting of increased use of pain medication and
sleep aids. We stopped these agents (oxycodone, ambien,
benadryl) at the time of admission, with excellent improvement
in your thinking. (The abnormalities noted at the admission
exam completely resolved as well.) We recommend you refrain
from taking these medications in the future; please use tylenol
(eg 650 mg every four hours as needed for pain).
.
We made the following changes to your medications:
- discontinue ambien
- discontinue benadryl
- discontinue oxycodone
.
Please start thiamine, folate, and a multivitamin.
.
As you were discharged on the weekend, we were unable to
schedule follow up appointments for you. Please coordinate an
appointment with Dr. ___ (___). | Mr. ___ is a ___ year-old right/left-handed man with a past
medical history including Afib/WPW on A/C, HTN, CHF,
cirrhosis/EtOH, 2wks ago wide exision of sarcoma resection bed
(RLE) with multiple recent psychoactive and sedating medications
(Ambien, Oxycodone, Benadryl) who presented to the ___ with
behavioral issues and sleep disturbances. He was admitted to
the stroke service from ___ to ___.
.
On initial evaluation his neurologic examination was not
remarkable for any gross
sensory or motor deficits. Likewise, there are no speech or
language or visual deficits by history or on exam. HOWEVER, the
exam did reveal a few unexpected findings -- First, was a subtle
sensory loss in the LEFT arm (patchy pinprickassymetry); Second,
there may be a subtle LEFT neglect (line bisection neglected on
the left side; VF testing intermittently abnormal on the left);
Third, he had a constructional/visual-spatial deficit manifest
as inability to copy a cube. These subtle deficits all localize
to a potential Right-parietal (cortical) deficit; the lack of
motor findings implied that any such lesion avoids the frontal
(precentral) motor cortex. Of note patient had several risk
factors for stroke
(primarily afib, but also HTN, age, positive smoking history).
.
A CT of the head showed no evidence of hemorrhage, masses, or
obvious signs of ischemia. There did not appear to be evidence
of stenosis, dissection, or aneurysm on angiography. As the
patient's symptoms were considered concerning for stroke, an MRI
of the brain was performed. The study revealed no signs of
acute ischmic stroke.
.
The patient most likely had an issue with polypharmacy which
accounted for his presentation. We recommended to stop taking
oxycodone, ambine, benadryll.
For his atrial fibrillation, the patient continued his home
medications and anticoagulation without any issues. He was
monitored on continuous telemetry without any significant
events.
. | 248 | 294 |
16896516-DS-17 | 29,158,016 | 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 4 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Partial weight bearing in the LLE.
- Remain in air cast boot until post op visit. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tibial shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibia IM nail insertion, 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 PWB 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. | 164 | 239 |
15415643-DS-18 | 25,940,647 | Mr. ___ it was a pleasure taking care of you during your
stay at ___. You were admitted for an infection of your
urinary tract. You were by the infectious disease specialist and
treated with antibiotics. You will need to complete your
antibiotic course at home. | ASSESSMENT AND PLAN:
___ with history of BPH, HLD, dementia (alert and oriented x 1
at baseline), BPH with urinary retention and recurrent urinary
tract infections, who presents with confusion and abdominal pain
with positive urinalysis all consistent with recurrent sepsis
from UTI including MDR GNR (susceptible to penems) similar to
two recent hospitalizations.
# Sepsis, severe, without shock:
# Bacterial Urinary tract infection:
# Acute Renal Failure
Profound leukocytosis with neutrophilia and bands, with fever to
101, hypotension and elevated lactate, acute renal failure and
source clearly UTI. Patient has history of multi-drug resistant
urinary tract infections, last two cultures only overlap with
Meropenem sensitivity. Patient has underlying BPH and retention
which is likely contributing to increased risk of recurrent
UTI's. He initially received Cefepime in ED, however, his most
recent urine culture was resistant to Cefepime. ARF and lactic
acidosis both related to hypovolumia and sepsis most likely. He
was evaluated by ID who knew him well. They agreed with
Meropenem. His urine culture grew MDR Klebseilla sensitive to
penems. In house, he was treated with Meropenem. He had a
midline placed. He received and test dose of Ertapenem and
tolerated this well. He will complete a 7 day course of
Ertapenem (starting: ___. Per ID, reasonable to continue
fosfomycin 4g PO q10d. Unfortunately, given his BPH as noted
below, these UTIs will likely recur. The family is aware of
this.
# Acute Metabolic Encephalopathy:
# Dementia:
Patient has baseline dementia and is alert and oriented x 1, can
ambulate with aid of walker and can use a cup to drink but needs
assist to eat, can communicate and answer questions generally.
Presents altered, non-responsive to questions, unable to follow
commands consistent with. Encephalopathy was most likely
toxic-metabolic related to sepsis. CT head negative for acute
intracranial process. His mental status improved by to baseline
upon treatment.
# BPH/Urinary Retention:
Chronic history with prior admission requiring foley catheters,
difficult placements and urology following. No foley placed
during this admission. However, BPH is likely the underlying
trigger for his recurrent UTI. He was continued on Tamsulosin
and Finasteride.
# Sigmoid Distention: Concern for Ogilve
This is a chronic problem with several prior CT Torso performed
in the ED showing similar findings of "persistent dilation of
the sigmoid colon without bowel
obstruction." This CT is showing more dilatation than the prior
CT and again concern for ___ syndrome. His
abdominal exam, however, is completely benign, soft, non-tender,
no peritoneal signs and he had a large BM last evening. Given
increased dilation and notable leukocytosis, ACS was consulted
to opine on possibility of toxic megacolon. However, his C. diff
was negative and ACS thought this was acute worsening of
___ and no further intervention was needed. His exam
remained benign and he continued to pass gas and have bowel
movements.
# Elevated Troponin:
Likely demand related in setting of sepsis. During prior
admissions for similar symptoms he developed ST Depressions in
V4-5 on admission EKG with a similar Trop elevation of 0.05 with
MB 3. Not a candidate for cath or anticoagulation anyway, highly
unlikely to be acute plaque rupture
# Hypokalemia: had mild hypokalemia during his stay, which
corrected with oral repletion and had resolved as of discharge.
Should have a repeat BMP early next week to follow up on this | 46 | 548 |
16581909-DS-21 | 20,940,064 | Dear Ms. ___,
You came to our hospital because of diarrhea and concern that
you might have Crohn's disease. At our hospital we determined
that this was an inflammatory bowel disease, possibly Crohn's
disease. You had an MRI of your small intestine, an EGD and a
colonoscopy, and were treated with steroids. Your pain and
diarrhea improved with steroids. Please continue taking oral
steroids and follow up with GI.
We wish you all the best!
-Your ___ Care Team | Ms. ___ is a ___ woman with h/o recently diagnosed Crohn's
disease who presents after leaving ___ AMA
for further evaluation and treatment of lower abdominal pain and
diarrhea.
# Abdominal pain, diarrhea:
# Severe malnutrition:
Possibly IBD however per GI, pathology results atypical for
Crohn's disease. Patient also with significant other IBD-related
symptoms such as oral ulcers, lower extremity arthritis, and
skin manifestations which could be consistent with Behcet's
disease though she does not meet clinical criteria for
diagnosis. Her stool studies were largely unrevealing and
serologies for parasites were pending at time of discharge. Her
symptoms improved and CRP downtrended to 6 after IV
methylprednisolone x 4 days (___). She was
tolerating a low-residue diet by day prior to discharge. She was
transitioned to PO prednisone 40mg daily on ___ with plan
for prolonged steroid course and ___. She was started on
calcium/vitamin D supplementation, a PPI, and Bactrim for PCP
___.
TRANSITIONAL ISSUES
====================================
-Patient had PPD placement and quantiferon in house which were
negative
-Patient was discharged on prednisone ___ with calcium/vitamin
D, PPI, and Bactrim for PCP prophylaxis
___: 40mg x1 week, 30mg x1 week, 20mg x1 week, 10mg x1 week,
5mg x1 week, then stop.
-Patient was started on escitalopram for anxiety, which was
exacerbated by steroids. She was also given a small amount of
lorazepam in case of panic attacks, which she has had in the
past prior to this hospitalization.
-Patient to continue low residue diet
-Patient to F/U with GI at ___
-Patient will require outpatient hepatitis B vaccine
-Patient reports she was previously misdiagnosed with Celiac
disease; please discuss at GI followup whether she can resume
gluten in her diet
-Entamoeba histolytica, Yersinia enterocolitica, Schistosoma,
and Strongyloides antibodies were pending at the time of
discharge
-Final HSV culture from swabs of oral ulcers were pending at
time of discharge (prelim negative) | 76 | 299 |
18254039-DS-11 | 23,412,780 | Dear Ms. ___,
It was a pleasure to take care of you during this
hospitalization. You were admitted to ___
___ for abdominal discomfort and a dry cough. A
chest X-ray was done that revealed a possible pneumonia, and you
were given one dose of intravenous antibiotics followed by
antibiotics by mouth. A stool sample was sent and revealed
growth of a bacteria called C. difficile for which you were
started on an antibiotic by mouth. You did not have any fevers,
abdominal pain, or shortness of breath while you were in the
hospital. You are now safe to go home to complete your oral
antibiotics.
The following medications were ADDED:
- Please take Levofloxacin 750mg by mouth daily for 6 days
- Metronidazole 500mg by mouth three times daily for 14 days
Please hold your stool softeners until your diarrhea and
infection resolve.
Please take your medications as directed and attending your
follow-up appointments as scheduled below. | ___ F with hx of HTN, spinal stenosis, vertigo, and anxiety who
presents for nausea, abdominal pain, and dry cough found to have
new opacity concerning for community acquired pneumonia and to
be Cdiff positive.
# Community acquired pnumonia: The patient was found to have a
new R upper lobe opacity compared to a CXR from 2 days prior,
with concerns of possible pneumonia. Clinically, this could be
consistent with her general malaise, low-grade fevers, and
abdominal discomfort. She was administered one dose of IV
ceftriaxone and azithromycin, and switched to PO Levofloxacin on
second day of admission. Throughout this hospitalization, she
remained afebrile without shortness of breath and oxygenating
well on room air. She was discharged with plans to complete a 7
day course of antibiotics.
# Clostridium Difficile: The patient had an episode of soft
stool at home prior to admission, which she brought into the
hospital and was sent for stool studies (C. diff, culture, O&P).
Her C. diff ___ came back positive though the patient
remained afebrile, without abdominal pain/discomfort, and a
normal white blood cell count. Her bowel movements were
infrequent. She was started on PO Flagyl with plans to complete
a 14 day course.
# Hypertension: The patient was maintained on her home dose of
Losartan 100mg PO QD, and her blood pressures remained
well-controlled in 130-140s throughout the hospitalization. | 157 | 230 |
18952261-DS-30 | 23,026,565 | Dear Ms. ___,
You were admitted with fevers, nausea, vomiting. You came to the
ICU for a fast heart rate. You quickly improved with treatment
for nausea and IV fluids. We found no evidence of an infection.
We believe your symptoms are related to your chemotherapy
regimen. After speaking to your oncologists we are holding this
for now. You should follow up with your oncology team next week
to discuss the next steps. | ___ with PMH of relapsed Hodgkin's lymphoma who is one day s/p
Bendamustine and Brentuximab who presents with fevers, nausea,
vomiting, rash concerning for acute infection vs. drug side
effect.
#Drug Reaction: Patient presented with fever, tachycardia,
tachypnea, with an elevated lactate, which in setting of
infection would be consistent with severe sepsis. She had some
nasal congestion and infected contacts so may have had a viral
illness. She had no evidence of pneumonia or UTI and no other
localizing symptoms. Flu negative. Port appeared uninfected. The
rash and her symptoms resolved quickly however after hydration
and sympotmatic management of sympotms, making this more likely
to be drug side effect, likely from bendamustine. She had no
respiratory compromise or drop in pressure to suggest an
anaphylactic reaction. CTA showed no evidence of PE.
#Respiratory alkalosis - Secondary to tachypnea likely from
reaction to medication
#Elevated lactate - Unlikely from hypoperfusion. Lactic acidosis
is known to occur in lymphoma from anaerobic metabolism.
#Nausea/vomiting -symptomatic control with Zofran, ativan
#Hodgkin's lymphoma - Recurrence now s/p C2 of bendamustine and
brentuximab prior to BEAM auto SCT. She may be able to get
bendamustine again in the future with more
premedication since no anaphylaxis was noted.
Transitional
===========
-follow up with oncology, they will contact you about an
appointment | 73 | 209 |
18992584-DS-19 | 27,974,968 | Mr ___:
It was a pleasure caring for you at ___. You were admitted
with dizziness. You were seen by neurologists and given IV
fluids. Your symptoms improved and your blood pressure
improved. The neurologists recommended following up with them
in clinic for additional testing--they will be in touch
regarding scheduling a time.
During your hospital stay you were were confused. You were seen
by psychiatry who felt that this was a reaction to too much
stress and not enough sleep. They recommended increasing the
dose of your Cymbalta and considering using melatonin to help
with your sleep. It is really important that you find health
ways to manage your stress--please consider seeing a therapist
to discuss this.
You are now ready to leave the hospital. | This is a ___ year old male with past medical history of venous
insufficiency, recent workup for bilateral lower extremity pain
thought to relate to potential peripheral neuropathy of unknown
etiology, admitted ___ w orthostatic hypotension,
resolving with IV fluids, course complicated by episode of
delirium though to have been precipitated by recent increased
stress and decreased sleep, subsequently ambulating safely, able
to be discharged home with PCP and neurology ___.
# Orthostatic Hypotension / Neuropathy / Lower Extremity Pain -
as documented in prior discharge summary and neurology notes,
patient with peripheral neuropathy of unclear etiology; he
presented with episode of orthostatic hypotension and reported
recent syncopal episode; suspected etiology of syncope was
orthostatic hypotension; he received IV fluids with subsequent
normal orthostatic vital signs. He subsequently revealed
increased stress at home related to marital discord and that he
had only been sleeping < 2 hours per night as a result. He
continued to report ongoing pain and tingling in his lower
extremities, unchanged from his recent admission. He was seen
by the neurology service who recommended outpatient ___
for additional workup and repeat EMG. Stress and lack of sleep
were felt to be a major driver regarding his ongoing symptoms,
and recent reported decreased PO intake (likely the etiology of
his hypovolemia / episode of orthostatic hypotension). At time
of discharge he was able to safely ambulate in the hall today
without issue. Continued home gabapentin, prn Tylenol,
methocarbamol. Trialed on lidocaine cream.
# Delirium - On evaluation by social work and neurology patient
appeared to be responding to internal stimuli and making bizarre
and disorganized statements
clearly awake. Given concern for a primary psychiatric process,
he was seen by psychiatry who felt he had acute encephalopathy
as a result of intense stress and sleep deprivation with
underlying major depressive disorder and anxiety disorder. Case
discussed with neurology who did not believe this was related to
a primary neurologic issue. Psychiatry recommended increasing
duloxetine dose to 90mg daily.
# GERD - continued ranitidine
Transitional Issues
- Discharged home with prescription for increased dose of
duloxetine and trial of lidocaine cream. | 133 | 360 |
14474676-DS-11 | 20,750,461 | * You were admitted to the hospital for evaluation of your right
pleural effusion and eventually required lung surgery to drain
the fluid and help to reexpand your lung. You are recovering
well and are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry. The chest tube sutures
will be removed at your appointment with Dr. ___ week.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you. | ___ hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of
right renal artery c/b by RP bleed (embolized ___ @___)
presented to ___ for right flank and abd pain. She
was found to have recurrent RP bleed w/o active bleeding on
___ imaging and right pleural effusion. She was dyspneic and
underwent initial pig tail catheter placement.
Acute issues
#RP Bleed, Right Pleural Effusion: Course began with initial
admission to ___ for balloon angioplasty of right renal
artery stenosis ___ fibromuscular dysplasia. Course complicated
by RP bleed from wire injury(pt reported) then s/p emobolization
___. Presented to ___ ED and eventually transferred to
___ given recurrent bleed w/o active extravasation. No ___
intervention at this time. However, given effusion, she
underwent pigtail catheter placement but her right lung did not
fully reexpand and she was taken to the Operating Room on
___ where she underwent a right VATS decortication. She
tolerated the procedure well and returned to the PACU in stable
condition. She maintained stable hemodynamics and her pain was
controlled with a Dilaudid PCA. Her chest tubes remained on
suction for 48 hours and her chest xray showed almost full
reexpansion of the right lung. Her oxygen saturation on room air
was 97% and her port sites were healing well. Following removal
of her tunes on ___ her post pull chest xray revealed
almost full expansion of the right lung except for a tiny
basilar space. She was converted to oral Oxycodone and Tylenol
and had adequate pain control. Her chest tube sutures remain in
place and will be removed at her post op visit next week and she
was reminded to continue to use her incentive spirometer.
Chronic issues
#Hx IVDU/Substance Abuse Disorder: Per patient at bedside stated
no IVDU for 6 months, however told thoracics fellow most recent
use was 3 months. Patient finished 7 day course of oxycontin and
oxycodone recently and denies any current use. Hep C positive.
HIV negative, RPR negative.
#Hypertension: Secondary to fibromuscular dysplasia
- HydrALAZINE 100 mg PO TID
- Carvedilol 25 mg PO BID
- amLODIPine 10 mg PO DAILY
#Polycystic Kidney Disease: Pt w/known PCKD. Patient has not had
imaging of head to look for berry/sacular aneurysms. No current
headaches or visual symptoms.
- obtain pcp ___ records
- will need MR-A head/neck.
#Insomnia, Anxiety
- TraZODone 50 mg PO QHS:PRN insomnia
- ClonazePAM 0.5 mg PO BID
#Iron Def Anemia
-Ferrous Sulfate 325 mg PO DAILY
TRANSITIONAL ISSUES
=================
- will need MR-A head/neck to look for brain aneurysm given
polycystic kidney disease
Ms. ___ was discharged to home on ___ and will follow
up with Dr. ___ week in the Thoracic Clinic. | 284 | 471 |
17239322-DS-18 | 22,415,651 | Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
with a small bowel obstruction. You were taken to the operating
room for an exploratory laparotomy with extensive lysis of
adhesions and a connection made between your intestines to
bypass the obstructed area. After surgery you continued to show
signs of infection and a CT scan showed an acute infection in
your gallbladder. You were too sick to undergo a second
operation at this time and therefore you were given IV
antibiotics and had a drain places to remove the infected fluid.
You were also found to have infection in your urine and stool
for which you were treated with appropriate antibitoics based on
the cultures.
While in the hospital you developed fluid in your lung for which
you had a pigtail drain placed to help improve your breathing.
Once the fluid was removed, the drain was taken out and your
lungs remained inflated.
Your existing percutaneous nephrostomy tube accidently became
dislodged and was replaced by the interventional radiologists on
___.
The lower portion of your surgical wound was opened to allow
extra fluid to drain and prevent infection. You should continue
to pack this wound with dry kerlex to allow it to heal from the
inside.
Due to your extended stay in the hospital, you became
deconditioned. The physical therapy team worked with you and
recommended discharge to an acute rehab to continue your
recovery.
You are now doing better, tolerating a regular diet, breathing
comfortably on room air, and your infections are improving with
antibiotic treatment.
You are now ready to be discharged to rehab with 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. | ___ year old female s/p anterior pelvic exenteration, ileal
ureteral conduit
for poorly differentiated carcinoma of unknown primary on
___. This was complicated by a right ureteral obstruction
resulting in a right PCN. The patient underwent salvage
radiation and subsequent small bowel obstructions requiring
exploratory laparotomy, and recent c. diff infection. She
presented to the hospital on ___ with nausea, vomiting and
abdominal pain. On cat scan imaging she was reported to have a
closed loop bowel obstruction. The Acute care surgery service
was consulted.
Based on the cat scan findings, the patient was taken to the
operating room where she underwent an exploratory laparotomy,
LOA, and entero-enterotomy. For details regarding this
procedure, please refer to the operative report. The patient was
taken to the intensive care unit after the procedure. She
remained intubated. She was noted to have labile pressures
requiring levophed and intravenous fluids. She was started on
flagyl for the reported c.diff.
On ___ she was extubated and resumed home Advair to augment her
pulmonary status. The fentanyl drip was weaned to intermittent
doses of intravenous Dilaudid and the levophed was weaned off.
She reported right upper quadrant pain and right flank pain.
The patient continued with serial abdominal examinations and the
white blood cell count was monitored. To assist with pain
management, the patient resumed her home fentanyl patch. The
Acute pain service was consulted for consideration of an
epidural catheter. Because of her mental status and elevated
INR of 1.6, the pain service were reluctant to place an epidural
catheter and she continued on oral and intravenous home pain
regimen.
After return of bowel function, the ___ tube was
removed and she was advanced to clear liquids. Her vital signs
were stable and she was transferred to the surgical floor.
Over the next two days, her respiratory status declined in the
context of her difficult to control post-operative pain. She was
transferred back to the intensive care unit secondary to
increased O2 requirement. Radiographic imaging of her chest
showed bilateral pleural effusions and a pigtail catheter was
placed in her right chest. On ___, the patient's hematocrit
drifted down and she was transfused 2 units PRBCs, with an
appropriate response. She continued to report abdominal pain.
Cat scan imaging was negative for a post-operative abnormality
but it did show a distended gallbladder. A percutaneous
cholecystostomy tube was placed on ___ to treat presumed
acalculus cholecystitis. The patient's LFT were monitored. The
patient was started on a course of meropenum and cefepime.
On ___, while attempting to remove the right sided pigtail
catheter, the patient's percutaneous nephrostomy tube was
removed. On ___, the patient was taken to ___ for replacement
of the nephrostomy tube. The chest tube remained in place, and
was placed on water-seal. Her antibiotics were narrowed to cipro
for pseudomonas UTI, and tube feedings were restarted, and her
central line access was removed. The patient was again
transferred to the surgical floor for continue management.
The right sided chest tube was placed on water-seal and removed
on ___.
The patient was reported to have purulent material draining from
her abdominal wound and the lower wound staples were removed.
The wound was lightly packed with a dry dressing. The white
blood cell count was monitored. At this time, the patient was
noted have a swelling of the left upper extremity and a
ultrasound was done. No DVT was reported.
The nutritional status of the patient continued to be
sub-optimal. She was evaluated by Speech and Swallow and cleared
for a soft diet. Her oral intake was poor and a PICC line was
placed for TPN. Despite her limited intake, she developed
abdominal distention and vomiting. She was reported to have an
ileus on imaging and was started on a bowel regimen. A
___ tube was placed for bowel decompression and she
was made NPO. After return of bowel function, the ___
tube was removed and the patient's diet was slowly advanced.
Because of caloric depletion, TPN continued along with calorie
counts.
On ___ she had a temperature of ___ F, tachycardic to
130's, and hypotensive with a systolic BP 60's and therefore
transferred to the intensive care unit. PICC line was removed in
setting of sepsis and therefor TPN was discontinued. Patient was
found to have bacteremia with gram negative rods and a e. coli
infection in percutaneous nephrostomy. She was treated initially
with cefepime and flagyl. Once cultures sensitivities were
obtained, she was transitioned to ceftriaxone and a midline was
placed. On ___ she was hemodynamically stable and transferred
back to the surgical floor.
Infectious disease recommended 2 weeks of antibiotic treatment
for bacteremia and an additional week of oral vancomycin for
chronic clostridium difficile infection.
At this point in hospitalization, her remaining issue was
nutritional intake. She was given Dronabinol to stimulate
appetite and family was encourage to bring foods of from. The
patient appetite and caloric intake improved with these
interventions.
In preparation for discharge, the patient was evaluated by
physical therapy who recommended discharge to rehab.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
making adequate urine, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Rehab stay anticipated <30 days. | 564 | 914 |
17294505-DS-13 | 23,598,058 | Dear Mr. ___,
You were hospitalized with blood in your urine after an
outpatient cystoscopy. Due to retained blood clots, you
developed a urinary tract infection and sepsis, for which you
required treatment in the ICU. You improved with antibiotics and
had no further evidence of bleeding after removal of your foley
catheter.
You will need to complete a course of antibiotics through ___ and follow up with your outpatient urologist.
Please continue to take your medications as prescribed.
With very best wishes for a speedy recovery,
___ medicine | ___ man with history of CAD s/p CABG, ischemic
cardiomyopathy (LVEF 25%), VT s/p ICD, atrial fibrillation on
warfarin, prostate cancer s/p brachytherapy, CML on nilotinib
who presented with gross hematuria after routine outpatient
cystoscopy s/p traumatic foley placement with retained urethral
foreign body s/p extraction and CBI initiation, with course c/b
shock, suspected septic due to UTI, and atrial fibrillation with
RVR, called out of FICU ___, s/p successful voiding trial with
improvement in hematuria treated with IV Vanc/Cefepime from
___ transitioned to Ceftriaxone until discharge and
continued on Cefpodoxime to complete course of antibiotics
ending on ___. He will follow-up with urology for outpatient
evaluation and continue on Coumadin for atrial fibrillation.
# Shock, presumed septic, now resolved, due to
# Urinary tract infection:
Developed shock in setting of gross hematuria, traumatic foley
placement, and retained urethral foreign body s/p extraction.
Suspect urinary source with UCx growing pan-S E.coli. CXR
without pneumonia, and blood cultures without growth to date.
Likely some component from baseline systolic heart failure, but
no compelling evidence for cardiogenic shock. Briefly required
phenylephrine in the FICU via RIJ, weaned off with IVFs. He was
treated broadly with Vancomycin/Cefepime initially (___),
transitioned CTX based on culture results with plan to complete
course of antibiotics until ___, continued on Ceftriaxone
IV while hospitalized and transitioned to Cefpodoxime on
discharge.
# Gross hematuria:
# Prostate cancer s/p brachytherapy:
P/w gross hematuria after routine outpatient cystoscopy.
Underwent traumatic Foley placement in the ED c/b retained
catheter and clots (extracted by urology) and development of
UTI/sepsis as above. Two way coude was placed with initiation of
CBI, with improvement in hematuria. Underwent a successful
voiding trial on ___. Monitored in house until INR therapeutic
on coumadin with no further episodes of frank hematuria with
clots. He will f/u with outpatient urology (scheduled for ___.
# Anemia:
Chronic anemia likely multifactorial due to CKD, AoCD,
nilotinib. Acute component secondary to gross hematuria in
setting of anticoagulation. Transfused 1 unit pBRC on ___ and
Hb subsequently stable. Hgb 8.8 on discharge.
# Thrombocytopenia:
Chronic, stable, suspect secondary to nilotinib, continued this
admission. Plt wnl on d/c.
# Transaminitis/hyperbilirubinemia:
Developed mild transaminitis and hyperbilirubinemia on ___,
likely secondary to shock, which downtrended with management as
above.
# Atrial fibrillation:
CHADs2vasc = 4. Developed RVR in setting of suspected septic
shock as above, improved with treatment of infection. Warfarin
initially held for hematuria (did not require reversal), resumed
at home dosing on ___ without bridging. Home metoprolol and
digoxin were continued.
INR 1.8 on discharge on the 1 mg of warfarin 4 times a week, and
2 mg the other three days. Will need INR check ___.
# Ischemic cardiomyopathy (LVEF 25%):
# VT S/p ICD:
As above, developed shock that was presumed septic in setting of
UTI, without evidence of frank cardiogenic shock. Home torsemide
and ACE were initially held in setting of volume resuscitation
and subsequently resumed. Home metoprolol was continued.
Torsemide was restarted and on discharge, ACE was resumed on
discharge. He will f/u with his outpatient cardiologist, Dr.
___. Dry weight on discharge 70.67 kg (155.8 lb)
# CAD s/p anterior MI s/p CABG:
# NSTEMI, type II:
Patient with elevated troponin on admission in setting of CKD.
Suspect mild demand in setting of sepsis and atrial fibrillation
as above. Downtrended. Home statin was continued. Of note,
patient is not on an ASA in setting of warfarin use. Deferred
consideration of ASA to outpatient cardiologist Dr. ___.
# Chronic kidney disease stage III:
Recent baseline around 1.8-2.2, now stable at baseline. Renal
ultrasound on ___ without hydronephrosis. Home calcitriol and
vitamin D were continued. Cr 1.8 on discharge.
- continue calcitriol and vitamin D
# Hypertension:
As above, initially required pressor for shock, weaned off with
fluids and treatment of infection. Home metoprolol was continued
and home torsemide subsequently resumed.
# Hyperlipidemia:
Continued home statin.
# CML:
Continued home nilotinib. F/u with Dr. ___ on ___
# Gout:
Continued home allopurinol, renally dosed. | 85 | 648 |
17294389-DS-24 | 29,387,258 | Dear Ms. ___,
.
It was a pleasure taking care of you at ___
___ in ___. You were admitted with abdominal pain
after having had a splenic artery embolization at a hospital in
___. While you were admitted, we obtained another cat scan of
your abdomen which showed a collection of blood around the
spleen which is stable, and no active bleeding. The surgeons
evaluated you but do not feel that there is any surgical
intervention needed.
.
Please make the following changes to your medications:
1. start tylenol ___ every 8 hours as needed for pain (do not
exceed a total of 2 grams per day)
2. start oxycodone ___ every 6 hours as needed for pain
3. start senna and polyethylene glycol to prevent constipation
while you are taking the oxycodone
4. continue the ciprofloxacin and flagyl through ___ in
order to complete a total of 28 days of the antibiotics | Assessment/Plan: ___ ___ witness with PMHx s/p HCV
cirrhosis completed full treatment, in Afib now presenting with
abd s/p splenic embolisation
#Abdominal Pain - Pt recently sustained a traumatic splenic
laceration in early ___ s/p mechanical fall in trying
to catch a bus. She was unaware of the laceration until she
became lightheaded and passed out a few weeks later. She was
brought to an OSH in ___ where she was found to be anemic and
the splenic lacerations were identified on CT. She underwent
splenic embolization at OSH on ___. Of note, she did
not receive any blood products, because she is a ___
witness. Even though she was anemic s/p bleed from splenic lac
at ___, when she was admitted to ___ her HCTs were stable at
38.4. Per pt, decision was made to undergo splenic embolization
over surgery bc of her religous reasons for not getting blood.
Pain was controlled with acetaminophen 650mg Q8h standing and
oxycodone 5mg PO q6h prn pain. Repeat CT was performed to assess
for evidence of phlegmon that could rupture and leading to
bleeding. CT results revealed a stable hematoma around the
spleen. Transplant surgery was consulted in the event there were
findings requiring repeat intervention. Pt was hemodynamically
stable throughout stay, with pain control improving. Pt was
discharged with close follow-up with her PCP and hematologist.
To prevent constipation with pain medications, pt was discharged
on an aggressive bowel regimen.
# Splenic artery embolization: Pt was continued on
flagyl/ciprofloxacin which was started at OSH for a total course
of 28d to prevent splenic abscess. Patient should also be
assessed for vaccinations against encapsulated organisms once
she is a spleniC (e.g. pneumovax, HIB vaccination, and N.
meningitides vaccine).
#S/P multiple Falls - First fall sounds like it was
purelymechanical as she denies chest pain, sob, palpitations,
lightheadedness. The subsequent falls were likely ___ to anemia
and lightheadedness. While at ___ her hct has been stable. ___
worked with her to ensure that she was steady on her feet.
#Elevated alk pos: Alk phos was marginally elevated at 108,
which was trending down from a month prior. It was likely
elevated for multiple reasons including her recent splenic
embolization and HCV cirrhosis.
# HEP C cirrhosis - Pt completed her therapy for HCV and her
most recent viral load undetectable. While she was hospitalized,
we limited acetaminophen for pain control to <2g/day. Pt had
grade 4 cirrhosis by biopsy from ___. She completed a total
of 48 weeks of treatment which included telepavir completed on
___, interferon, and ribavarin. Per prior notes, most recent
HCV viral load in ___ was undetectable.
# Afib: currently irregularly irregular. CHADS risk score = 0,
thus does not need anticoagulation and not symptomatic per
patient
# Hypothyroidism - stable and continued on home levothyroxine
per endocrinology note from labs on ___. | 146 | 470 |
12281410-DS-7 | 23,066,287 | Dear Mr. ___,
You were admitted to ___ for
evaluation of a fall and left-sided weakness. Imaging of your
brain with CT and MRI showed that your weakness was due to a
bleed on the right side of your brain. It is likely that your
bleeding was due to high blood pressure, for which your blood
pressure medications were adjusted during your stay.
As a result of your brain bleed, you also had difficulty
swallowing safely. A tube was temporarily placed in your stomach
to assist with feeding and administration of medications.
During your stay, you also had a urinary tract infection treated
with antibiotics.
Please follow up with your primary care provider within one week
of discharge from your acute rehabilitation facility. Please
also follow up with Neurology at the appointment listed below.
It was pleasure taking care of you at ___.
Sincerely,
___ Neurology | ___ man with history notable for HTN, prior hypertensive
infarct, and CLL s/p ___ transferred from OSH after
presenting with left-sided weakness, found to have right basal
ganglia IPH on CT. Follow-up MRI did not demonstrate
microhemorrhages suggestive of underlying CAA as etiology of
hemorrhage, raising suspicion for hypertension (particularly in
light of persistent hypertension noted during the admission)
rather than trauma as the proximal cause of the IPH. Note was
made on MRI, however, of several small foci of contrast
enhancement within the basal ganglia and medial temporal lobe
portions of the hematoma potentially concerning for an
associated mass, for which repeat MRI with and without contrast
is recommended for further evaluation.
Subsequent course complicated by dysphagia s/p uncomplicated PEG
placement as well as E. faecalis UTI treated with a seven-day
course of ampicillin. HTN managed with captopril (transitioned
to lisinopril prior to discharge) as well as home metoprolol and
spironolactone. Chronic thrombocytopenia again noted during the
admission, with subcutaneous heparin held for platelet levels <
50,000.
TRANSITIONAL ISSUES
1. Ongoing blood pressure monitoring and titration of
antihypertensives.
2. Follow up MRI brain with and without contrast as above within
the next three months.
3. Ongoing speech therapy and assessment of swallow function.
4. Periodic monitoring of platelet counts.
5. Optional follow-up chest CT in 12 months for incidental
pulmonary nodule noted on CTA.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (X) Yes - () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (X) Yes - () No | 140 | 319 |
11057357-DS-24 | 29,004,374 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You presented to us with worsening shortness of
breath. You were found to be volume overloaded as well as COPD
exacerbation. You were treated with nebulizer treatment and
steroids in addition to more aggressive diuresis. Your symptoms
improved and you were able to be discharged.
Please take all your medications as instructed. Please attend
all your follow up appointments. Weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
All the best,
your ___ team | ___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents
with shortness of breath x several days consistent with COPD
___ CHF exacerbation.
#COPD Exacerbation: Precipitating factor unclear but most likely
cardiac given report of palpitation by pt and crackles on exam.
Infectious cause less likely as no systemic systems such as
fever, cold symptoms, or CXR findings. Pt was treated with
prednisone 40mg x5 days, last dose ___, in addition to nebulizer
treatments. Advair and tiotropium were added to her home
regimen.
#Palpitations: Pt reported palpitations x1 month, raising
concern for ICD malfunction. She has been self dosing carvedilol
for such symptoms. EP was consulted for device interrogation.
Her Device battery is at RRT (recommended replacement time).
However, pt expressed reluctance in replacing the battery. She
has an appointment with Dr. ___ on ___ and this will be
discussed further during that visit.
#Systolic (EF 15%) and Diastolic CHF ___ CRT: Pt presented with
worsening dyspnea and dry cough. She has been self dosing
torsemide at home. She reports non-compliance with her diet and
Na use x1 month. Exam was notable for crackles in the lungs but
no JVD or peripheral edema. Diuresis regimen included additional
torsemide doses (___), lasix 60mg IV, and metolazone 2.5mg.
-Continue home beta blocker, digoxin
- torsemide dose may be adjusted as appropriate in discretion of
PCP ___ cardiologist | 90 | 241 |
18153015-DS-24 | 28,396,226 | -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--which is attached to a string and
may be visible at your urethra.
-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.
-You will be given a course of antibiotics as prophylaxis to
reduce your risk of infection while ureteral stent is in place
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up or you have
been otherwise explicitly advised.
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-NAPROXEN 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.
-NAPROXEN should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-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 until the stent has
been removed. Light household activity and work may be
performed. | Ms. ___ was admitted to Urology service after ED observation
and in anticipation of going to the OR for surgical intervention
for her uteral stone. She was taken from the ED to the
preoperative holding area and subsequently to the cystoscopy
suite after consent obtained with ___ interpreter. No
concerning intraoperative events occurred; please see dictated
operative note for details.
The patient received perioperative antibiotic prophylaxis. The
patient was transferred to the floor from the PACU in stable
condition. On POD0, pain was well controlled post-operatively
and she was provided with pneumoboots and incentive spirometry
for prophylaxis and home medications were resumed. On POD1, the
patient ambulated, basic metabolic panel and complete blood
count were checked and heart healthy diet was advanced as
tolerated. The remainder of the hospital course was relatively
unremarkable. The patient was discharged in stable condition,
eating well, ambulating independently, voiding without
difficulty, and
with pain control on oral analgesics. The patient was given
explicit instructions to follow-up in clinic in approximately
one week for ureteral stent removal. Urine cultures at time of
discharge were negative but with mixed flora suggestive of
contamination. | 473 | 187 |
13976907-DS-43 | 26,047,210 | Dear Ms. ___,
You were recently admitted because you were experiencing chest
pressure and were unable to complete a stress test in the
emergency department because of an abnormal heart rhythm and
symptoms. You had a different type of stress test in the
hospital which was normal. You stayed for a few days afterward
in order to have your Coumadin restarted safely. You were
started on a new medicine called amiodarone.
You are now ready to continue your recovery at home.
Your medications were changed to help control your heart rhythm
a bit better.
====================
MEDICATION CHANGES
====================
-STOPPED flecainide
-STARTED amiodarone 200mg BID to control your atrial
fibrillation
-DECREASED aspirin to 81mg daily to decrease the chance of
stomach bleeding
You will need to wear a heart monitor for 30 days to better
diagnose your heart rhythms.
We wish you a speedy recovery,
Your ___ Cardiology Team | ___ with CAD, HFpEF, pAF on Coumadin for anti-cardiolipin (INR
goal 2.5-3.5), MR ___ porcine valve replacement ___, known
multifocal lung adenocarcinoma, seizure disorder, gout who
presents with chest pressure/dyspnea at rest and aborted stress
test due to atrial irritability and dyspnea. She underwent
persantine MIBI test inpatient which showed no perfusion
defects.
While awaiting P-MIBI she was maintained on heparin gtt given
anti-phospholipid syndrome and prior stroke. After perfusion
study complete and determined no plan for cardiac
catheterization she was restarted on coumadin. She was kept
inpatient while her Coumadin was restarted on heparin bridge
given her anticardiolipid syndrome with prior TIA. She was not a
candidate for lovenox bridge given her renal function. She is
being discharged on a dose of 7.5mg daily with plan for INR
check ___
Electrophysiology saw her regarding her paroxysmal atrial
fibrillation and her antiarrhythmic plan. Flecainide carries a
mortality risk in patients with CAD and therefore she was
transitioned to amiodarone. Her baseline TSH/FT4 were normal
(4.9/1.1). LFTs normal.
She is being discharged with ___ of hearts monitor for
further characterization of her paroxysmal afib versus other
arrhythmias.
# Orthostatic hypotension
- positive orthostats; pt states this is chronic
- consider this problem prior to starting nitrates
- fall precautions
# Hyperlipidemia- She was continued on rosuvastatin 40mg qHS
# Gout- She was continued on allopurinol ___ daily
# Seizures- she was continued on home Keppra 750mg BID
# Anti-cardiolipin antibody
-INR goal 2.5-3.5 with Coumadin as per above
-bridge heparin gtt as per above
# Lung adenocarcinoma
-stable, undergoing outpatient 6 month surveillance
======================
TRANSITIONAL ISSUES
======================
-STOPPED flecainide
-STARTED amiodarone 200mg BID
-DECREASED aspirin to 81mg daily (to reduce risk of bleeding)
-NEEDS TO F/U with primary care doctor and cardiology as
scheduled
-DISCHARGED WITH ___ cardiac monitoring for 30 days
-discharge weight: 62kgs
-full code
-HCP: ___ (husband) ___ | 137 | 287 |
18541624-DS-24 | 23,120,423 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted to the hospital with chest pain and
shortness of breath. Imaging studies showed growth of the cancer
in your lungs and the area around your heart. The cancer is
causing your pain and trouble breathing, and is compressing your
airways and some of the blood vessels around your heart. You
recently got chemotherapy, which may help with your symptoms,
but your disease is not curable. You told us that your goal is
to go home and spend time with your family, and we are sending
you home with hospice services. | Mr. ___ is a ___ yo M with newly diagnosed neuroendocrine
tumor of the lung which is metastatic to brain and skin who
presented with chest pain and was found to have progression of
his cancer encasing the pulm artery, pulm veins, SVC, and left
atrium.
# Chest pain and SOB: These symptoms are likely from the
progression of his lung cancer which is very aggressive and
invasive to the medastinal structures including bronchi and
vasculature. Per oncology, increased symptoms may also be
secondary to inflammation from recent initiation of
chemotherapy. CTA was negative for PE and there is no clinical
evidence of pneumonia. Negative troponins and pattern on EKG
more consistent with diffuse myocarditis or pericarditis from
the tumor invasion rather than a vascular territory. Outpatient
oncologist (Drs ___ documented very clear
discussion with the patient and family that his cancer was
aggressive and life expectancy was on the order of weeks on
___. Per radiation oncology, no benefit to chest or whole
brain XRT at this time. Palliative care was consulted. Morphine
dosing increased to help with pain and dyspnea. Per discussions
with the patient and his family, code status was changed to
DNR/DNI and decision made to send him home with hospice.
# Hyponatremia: Na 128-130 during hospitalization, did not
improve with IV fluids. Urine electrolytes suggestive of SIADH
with urine Na 199, urine osmolality 645, likely secondary to his
malignancy.
# Chronic pain: from prior falls and accident. Used morphine ___
at home. The patient was transitioned to home with hospice.
# H/o depression and EtOH use: social work and pall care
involved.
# Code status: DNR/DNI, home with hospice
# HCP: daughter, ___ ___ cell, ___
Transitional issues
- blood cultures pending at time of DC, no growth to date | 108 | 294 |
12460244-DS-18 | 21,627,054 | You were admitted to the hospital with shortness of breath. You
were found to have the flu (influenza). This infection likely
also triggered a COPD / emphysema flare. Because of the
difficulty in breathing, you were briefly admitted to the ICU
for special breathing equipment. You will need to complete a
course of antibiotics for flu. You are also on a short
prednisone burst for mild COPD / emphysema flare.
.
Please take your medications as listed.
.
Please follow-up with your physicians as listed.
. | ___ yo F with history of COPD and reactive airway disease
(asthma), hypertension who presented with impending hypercarbic
respiratory failure attributed to influenza infection causing an
asthma vs. COPD exacerbation.
.
#) Influenza, COPD/asthma exacerbation: Patient presented in
moderate respiratory distress with accessory muscle use and poor
air entry on exam. She required non-invasive positive pressure
ventilation initially but weaned to supplemental oxygen over the
course of her ICU stay. The trigger for this exacerbation was
most certainly influenza A (she had no been vaccinated this
year) and she was started on oseltamavir on admission (___) for
a planned 10-day course given her severe presentation. She also
received standing nebulizer treatments, corticosteroids and
azithromycin for a component of COPD and asthma exacerbation.
Given her youth, relatively low pack-year for smoking, we
obtained an alpha-1 antitrypsin level, which was reassuring. Her
PFTs in ___ documented an obstrutive ventilatory deficit with
severe asthma. She remained dyspnea with exertion following
transfer to the floor, but overall was much improved. She was
weaned off supplemental O2 successfully. She requested a
nebulizer machine, which we were able to obtain. She will
complete a short steroid taper on discharge.
.
#) Elevated hematocrit: Hematocrit 54.8 on admission. As high as
45% back in ___. Polycythemia ___ should be considered in
women with this hematocrit, though secondary polycythemia is
also a possibility given her pulmonary disease. However, her
lack of oxygenation issues supports a primary cause. Epo level
was low. LFTs were reassuring. She should be referred to
Hematology for further work-up.
.
#) HTN: Held her home carvedilol initially given her
bronchospastic airway disease and risk of beta-blocker induced
bronchospasm. Resumed her amlodipine for BP control once she
clinically stabilized. Carvedilol is being re-started on
discharge.
. | 88 | 295 |
16529785-DS-12 | 26,649,985 | Dear Ms ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain and dizziness.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a cardiac catheterization to look for any disease in
your heart vessels. You had no disease in the arteries that feed
your heart.
- You were given some fluids through the IV.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Your primary care doctor ___ adjust your blood pressure
medications in the outpatient setting.
- Seek medical attention if you have new or concerning symptoms
or you develop any new chest pain, swelling in your legs,
abdominal distention, or shortness of breath at night.
We wish you the best!
Your ___ Care Team | ___ with ___ stress with inducible inferior/posterior
ischemia concerning for RCA stenosis, treated with medical
management, hypothyroidism, and bipolar disorder presenting with
chest tightness and dizziness, s/p cardiac cath ___
showing no CAD.
CORONARIES: No angiographically apparent coronary artery disease
PUMP: EF >55%
RHYTHM: NSR
=============
ACTIVE ISSUES:
=============
#Chest tightness
Presented with chest tightness that occurred at rest. Troponins
negative. ECG with normal sinus rhythm, global t wave
flattening, no ST elevations or depression. Given full dose
aspirin. Taken to cath lab and found to have no CAD. On
discharge, stopped patient's imdur, SL nitro and aspirin. Chest
tightness had resolved at time of discharge. Likely MSK in
origin.
#Lightheadedness, dizziness
Likely ___ to hypovolemia. On day of discharge, given 500cc IV
fluid bolus.
===============
CHRONIC ISSUES:
===============
#HYPERTENSION
Patient was taking imdur, metoprolol, and amlodipine at home
prior to admission. Discontinued imdur on discharge. Per chart
review, it looks like outpatient cardiologist had stopped
patient's amlodipine ___ concern for lower extremity swelling.
She indicates she continued to take it. On exam in the hospital,
she has no lower extremity swelling. Will discharge her out on
amlodipine 2.5mg daily which can be discontinued in outpatient
setting if she develops any lower extremity swelling or her
blood pressures normalize. BPs 100s/60s on discharge.
#BACK PAIN
- Treated with lidocaine patch and tylenol
#HYPOTHYROIDISM
- Continued levothyroxine
#BIPOLAR DISORDER
- Continued divalproex, quetiapine
#DEPRESSION
- Continued citalopram
#OSTEOPENIA
- Next alendronate dose due ___, Continued vitamin D | 154 | 229 |
15602488-DS-18 | 20,265,966 | Ms. ___,
It was a pleasure to meet and care for you during your
hospitalization at ___. You
were admitted with chest pain and shortness of breath. Lab
tests showed evidence of a heart attack. Because of your risk
of previous coronary artery disease, you had a catheterization
which showed a large obstruction in one of the major heart
vessels. A stent was placed.
You should continue ticagrelor (a blood thinner) for the next 1
week (end date ___. Once you finish your ticagrelor,
please start plavix immediately on ___. You must continue
this for at least 4 additional weeks. Please discuss with your
cardiologist exactly how long you should be on plavix. You much
continue to take aspirin forever.
We wish you a speedy recovery.
All the best,
Your ___ Care Team | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ with hx CAD
(single vessel coronary artery disease, LAD w/ 40% stenosis
after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in
___ (first PCI with BMS to D1 complicated by acute closure
requiring 2 additional BMS stents), HTN, hx. of GI bleeding who
presents following acute onset CP and SOB found to have
hypertensive urgency and NSTEMI. Pt. had coronary angiography
which revealed 90% lesion in mid LAD, s/p placement 1 BMS. Pt.
tolerated the procedure well. She had notable bruit at femoral
access site. Preliminary read of ultrasound revealed no evidence
of AV fistula, pseudo aneurysm or other complication. She was
chest pain free at time of discharge.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with acute onset CP and SOB found to be
with significantly elevated blood pressures. Cardiac enzymes
sent which revealed troponin elevation. Given pt's known
coronary artery disease, pt. was taken for coronary angiography
where she was found to have a 90% lesion in mid LAD. One BMS
was placed across this lesion. Pt. was loaded with ticagrelor
and told to continue ticagrelor for a limited 7 day course given
her previous history of GI bleed. Pt. was then told to
transition to plavix for approximately ___ weeks given placement
of BMS. She was also initiated on crestor 5mg daily.
# Hypertensive Urgency: Pt's elevated blood pressures were self
limited and improved without medication. Given her significant
history of anti-hypertensive intolerance and allergy, initiation
of BP meds were deferred at this time. This was communicated to
pt's outpatient cardiologist. Outpatient regimen will be
considered if BPs remain elevated.
CHRONIC ISSUES
================
# GERD: Pt. was started on ranitidine for GI protection in
setting of ongoing aspirin, anti-plt therapy, and her hx. of GI
bleed.
# Mild obstructive sleep apnea (dx/ by sleep study ___: Pt.
diagnosed with OSA on ___ sleep study. Pt should be seen as
outpatient for possible CPAP.
# Hypothyroid: No current therapy. Continue monitoring as an
outpatient.
# Pernicious anemia: Continue on vitamin B12 supplementation
TRANSITIONAL ISSUES
======================
# Ticagrelor and Plavix: Pt. should continue with ticagrelor
through ___. Following termination of ticagrelor, pt. should
start on plavix on ___. This should continue for at least 4
weeks. Total duration to be discussed with ___. cardiologist
Dr ___
# Pt. started on crestor 5mg daily on this admission (unable to
tolerate higher doses)
# Pt. scheduled to have TTE as an outpatient per Dr. ___
# Began ranitidine for GI protection in setting of ongoing
anti-plt therapy and previous GI bleed
# CODE: Full, confirmed
# CONTACT: Carmalina (daughter, HCP, ___ | 136 | 444 |
19665025-DS-7 | 22,751,409 | Ms. ___:
It was a pleasure to take care of you. You were admitted to
___ because of belly and back pain likely to be due to a flare
of pancreatitis. We treated you with intravenous fluids and pain
medications. As you are tolerating oral intake, we are able to
discharge you today.
Please follow up with your doctors as below.
Please review your medication list closely. | Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain and recurrent pancreatitis.
.
# Acute on Chronic Pancreatitis: Patient with recurrent flare
of her pancreatitis over the last 2 days. Her last flare
requiring hospitalization was ___. There continues to
be no clear etiology of her symptoms. She last had her MRCP 4
months ago and given her acute symptoms, and is not due for
repeat MRCP so we did not perform. Patient maintained on pain
control, IVF, and NPO status initially with gradual advancing of
diet. Patient did well and was discharged home with plan to
follow up in primary care.
.
# Chronic Splenic Vein Thrombosis: Patient with known chronic
splenic vein thrombosis. Likely secondary to recurrent
inflammation from pancreatitis flares. Monitored patient for
signs/symptoms of bleeding from gastric varices.
.
# Diabetes: Held metformin while in house given poor PO intake
and risk for ___ and possible need for further contrast studies.
Maintained on ISS. Discharged back on home metformin.
.
# Yeast infection: Patient noted to have UA with 12 WBC but
asymptomatic. Thereafter on history/physical noted to have
signs/symptoms of vulvovaginal candidiasis. It is likely this
may have contributed to WBC in urine. Treated patient with
fluconazole IV (given NPO status).
. | 64 | 225 |
19514951-DS-19 | 27,842,085 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for abdominal
pain, nausea and diarrhea. You underwent several diagnostic
imaging procedures, none of which pointed to any obvious cause
for your symptoms. You may have had a viral illness that led to
your symptoms. Chronic marijuana use can also lead to a vomiting
syndrome similar to yours; we would recommend decreasing or
stopping your use of marijuana.
You were treated with anti-nausea medications and pain
medications, and your symptoms improved. By discharge you were
able to eat comfortably and were having normal bowel movements.
You were sent home to follow up with your PCP and
gastroenterologist for further evaluation and treatment.
We wish you the very best in your recovery!
-___ medical team at ___ | ___ year old gentleman with PMH of DMII, NAFLD, anxiety, CAD
s/p MI, and HIV on HAART admitted with acute onset vomiting and
right sided abdominal pain. for one day. His LFTs and lipase
were initially normal on admission, but his LFTs gradually
uptrended on subsequent days. Abdominal imaging including CT,
RUQ U/S and MRCP were unrevealing. Viral hepatitis serologies
were negative this admission. Tox screen was also negative this
admission. He has no history of sick contacts or abnormal food
intake, though he was born in ___ and travels back to see
family on occasion. His HIV is well controlled with a CD4 count
of 1100 in ___. An opportunistic infection was felt to be
less likely due to his robust CD4 count. Of note, he is
followed by GI for NAFLD, chronic abdominal pain/nausea, and a
history of pancreatitis. An EGD in ___ showed gastritis with
normal biopsies.
Symptoms resolved with supportive care including IVF,
anti-emetics, and pain control. HIs LFTs also downtrended
without intervention. Acute complaints were felt to likely be
due to viral gastroenteritis with associated liver inflammation
as no other source of hepatobiliary pathology was identified.
Chronic symptoms may be related to post-cholecystectomy
syndrome, an IBS varient, hyperemesis variant, or possibly
gastroparesis. Pt. was advised to follow-up with his outpatient
gastroenterologist for continued management of chronic symptoms.
Throughout the admission, pt. was continued on his home HAART,
divalproex, anti-anxiety, and anti-hypertensive medications. | 135 | 252 |
12852481-DS-10 | 24,176,077 | Dear Mr. ___,
It was a pleasure taking care of you.
Why you were admitted,
- You were admitted because you had persistent sore throats and
were found to have a condition called aplastic anemia.
What we did for you,
- We started you on immunosuppressive therapy with ATG and
cyclosporine to treat your aplastic anemia
- We gave you antibiotics for the infection of your tonsils,
which resolved
What you should do when you go home,
- Please take all your medications as prescribed and go to the
appointments that we have arranged | ___ with history of polysubstance abuse (reportedly clean for ___
years), presented with with pharyngitis, pancytopenia found to
have newly diagnosed severe aplastic anemia. Also noted to have
IgA deficiency. He started immunosuppressive therapy with AtG
(___) and cyclosporine (___). His tonsillitis was treated
with cefepime (___) and clinda (___) until clinical
improvement and counts recovered with ANC>500. Course
complicated by methylprednisolone induced hyperglycemia, of
which ___ was consulted for management, which resolved after
cessation of steroids. Donor search was initiated for possible
bone marrow transplant in the future if patient relapses.
#Aplastic Anemia
BMBx confirming severe aplastic anemia. Vital studies negative.
Suspect immune related. Patient was started on ATG/cyclosporine
(D1: ___ and cyclosporine (___) with goal cyclosporine
level 200-250. Patient tolerated ATG without major
complications, although did experience some transaminitis (see
below). Patient was also treated with course of
methylprednisolone (Day 5: ___ to Day 14: ___. He was started
on acyclovir for prophylaxis. Voriconazole was started for
fungal prophylaxis, but was held in the setting of transaminitis
(see below). Patient's course was complicated by
thrombocytopenia, and he required platelet transfusions, which
he will likely need to continue in the outpatient setting.
Patient was discharged on cyclosporine, prednisone 3 week taper
(to end on ___, and acyclovir, with plan to restart
fluconazole as outpatient.
#Tonsillitis/Neutropenic fever
Patient with neutropenia, sore throat, and swollen exudative
tonsils. No abscess on CT of neck. Patient was treated with
Cefepime (___), Clinda (___), s/p Vancomycin
(___). Antibiotics were discontinued with evidence of
clinical improvement and when counts recovered with ANC>500.
#IgA Deficiency
Likely congenital as pt reports having frequent sinopulmonary
infections as a child. CT torso negative for lymphadenopathy,
but has mild splenomegaly of 14.4cm. Anti-IgA pending at time of
discharge.
#Steroid induced hyperglycemia
Patient with elevated FSBG in setting of methylprednisolone.
___ was consulted for further management. Hyperglycemia was
very mild and controlled with sliding scale insulin that
eventually resolved after cessation of steroids.
#Transaminitis:
Likely in the setting of voriconazole, ATG, and atovaquone, with
ALT peaking in 200s and AST in the 200s. Voriconazole and
atovaquone were discontinued, and following conclusion of ATG
therapy, ALT/AST downtrended. ALT/AST ___ on ___ at time of
discharge on ___.
#Polysubstance abuse: Reports clean from IVDU for several years.
Denies known EtOH withdrawal but has history of heavy drinking.
Also with tobacco abuse. Tox screen negative on admission.
Patient was agreeable to a sober pain management plan. Offered
patient nicotine patch/lozenge, although pt declined.
TRANSITIONAL ISSUES
========================
- Please consider starting fluconazole ppx for patient upon
discharge in the setting of his immunosuppression with recent
ATG therapy as well as ongoing cyclosporine and prednisone
therapy. Pt had been on voriconazole, but this was held in the
setting of transient transaminitis that was likely ___ to
combination of ATG therapy, voriconazole, and atovaquone.
- Patient received pentamidine for PCP ___ (Day 1:
___, in the setting of transaminitis as discussed above. His
next dose will be due on ___.
- Patient was started on cyclosporine as inpatient as discussed
above, with goal range 200-250. On day of discharge, ___,
cyclosporine level 389, and dose was decreased from 550mg daily
to 500mg daily. Please recheck cyclosporine level at outpatient
appointment on ___.
- Patient required intermittent platelet transfusions during
hospital course, and will likely need regular transfusions as an
outpatient.
- Patient was started on three week prednisone taper following
conclusion of methylprednisolone therapy, to end on ___.
- Patient has anti-IgA antibody pending at time of discharge. | 88 | 576 |
18786508-DS-40 | 21,294,681 | Dear Mr. ___,
You were admitted because you were having fevers at home. We
performed studies to determine the cause of your fevers. All of
the studies you have received in the hospital, including a CT
scan of your chest and abdomen, has not revealed a source for
your fevers. Fortunately, you only had a mild temperature when
you came in, and did not have any fevers during your stay. We
are very reassured by this. At this time we feel that you are
safe for discharge home. It is very important for you to follow
up with the appointments listed below.
It was a pleasure to be a part of your care!
Your ___ treatment team | Mr. ___ is a ___ year old male with history of cryptogenic
cirrhosis s/p liver transplant, cholangitis, CKD, and recurrent
mild febrile illnesses, who presents with fevers.
# Fevers: Patient with fever to 101.2 at home. On the night of
admission his Tmax was 99.6. He did not have a recurrence of his
fevers for the rest of his hospital stay. Workup with RUQ US,
blood and urine cultures was unrevealing. CMV viral load pending
on discharge. CT scan did not reveal evidence of abscess or
PTLD. However, the radiographic possibility of cholangitis was
raised. Clinically, there was low suspicion for cholangitis with
normal LFTs, no leukocytosis, no fevers, and negative cultures.
He had mild diffuse abdominal pain, which patient stated was his
baseline. He is scheduled for close follow up in the liver
clinic for further monitoring.
# Liver transplant: S/p transplant in ___ for cryptogenic
cirrhosis. RUQ u/s on admission in the ED unremarkable. LFTs
were within normal limits during his hospital stay without
evidence of graft dysfunction. He was continued on home
Cellcept, sirolimus, ursodiol, and Bactrim. Sirolimus levels WNL
on admission, but pending on discharge.
# CKD: Thought to be ___ prior cyclosporine toxicity. Creatinine
at baseline during his stay.
# Holosystolic murmur: Consistent w/ mitral regurgitation. No
previous documentation of murmur and last TTE w/o significant
valvular disease. Unlikely to be related to current
presentation. Blood cultures negative. Consider outpatient TTE
to evaluate etiology of murmur.
# Abdominal bruit: Heard diffusely throughout abdomen. No
palpable/pulsatile mass. CT scan notable for normal caliber of
abdominal aorta. | 114 | 268 |
14630468-DS-22 | 23,224,727 | you were hospitalized from some bleeding at your trach site from
too much deep suctioning. you should cough up phlegm instead of
having deep suctioning | ASSESSMENT AND PLAN: ___ w/chronic trach ___ laryngeal cancer
s/p exploration and tracheal tube change on ___ by ENT presents
from nursing facility with trauma from too much deep suctioning
at ___ causing mild tracheitis
Tracheitis: likely due to repetitive suctioning and recent
procedure. Resolved. ENT advised no use of antibiotics and
avoidance of frequent deep suctioning, use of cough training and
pulmonary toliet. Patient only had one episode of low grade
fever in the ED and did not receive antibiotics once she was
admitted to the floor. She remained on her usual cough meds and
humidified trach mask to keep secretions wet to be able to cough
up. She should f/u with ENT, Dr. ___ in 4 weeks.
Schizophrenia/Anxiety: cont home meds
CAD: cont home meds
neurogenic bladder: maintain foley, UA negative, culture urine
grew 10k proteus, not treated
FEN: tube feeds
I communicated discharge plans on ___ Dr. ___ ___ | 26 | 153 |
Subsets and Splits