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16392389-DS-14 | 27,904,442 | Dear ___,
___ was a pleasure taking care of you at the ___
___. During your hospitalization:
-You were found to have a fast heart rate, called atrial
fibrillation
-You also developed chest pressure while you were here and we
checked you for a heart attack which you did not have.
-We treated you with medication through your IV and eventually
transitioned to pills
-We got a stress test of your heart, which did not show any new
damage to your heart.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- You were started on a new medication called digoxin that helps
prevent you from having a fast heart rate.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ================
PATIENT SUMMARY
================
Mrs. ___ is a delightful ___ yo woman with history of afib
on coumadin, CAD
s/p DESx3 in ___, HFpEF, with recent fall with resultant facial
fractures, who
presented with SOB, chest pain, and afib with RVR - initially
admitted to the CCU, however with transfer to the Cardiology
floor s/p Digoxin loading and improved heart rate, with course
complicated by UTI.
#CORONARIES: S/p stent (RCA x1, LADx2 at ___)
#PUMP: EF 35%
#RHYTHM: Af
==============
ACUTE ISSUES
==============
#CAD s/p stent (RCA x1, LADx2 at ___)
#Chest Pain: Not on Plavix, but is on aspirin. Mrs. ___
developed new chest pain during her hospitalization, with new
TWIs found in V4-V6. She was started on a Heparin gtt and
continued for 48 hours. Her Troponins were 0.03 x3. We obtained
a P-MIBI, which showed evidence of moderate fixed septal and
inferolateral wall defects and normal ventricular size and
systolic function. She was continued on ASA 81mg, Atorvastatin
80mg, a reduced dose of lisinopril 2.5mg, and an increased dose
of fractionated Metoprolol as per below.
#HFrEF (LVEF 35%): On furosemide 20 mg daily at home. Throughout
her hospitalization she has not seemed fluid overloaded, and as
such her home Lasix was held. She was started on an increased
dose of fractionated Metoprolol, and she was continued on home
Lisinopril. Of note, she will need a repeat TTE in ___ months
to re-evaluate her reduced LVEF. On discharge, her home
Furosemide was held. Discharge weight 60.69kg
#Atrial fibrillation with RVR: At home, was on propranolol and
diltiazem - both of which were discontinued during this
hospitalization. On admission she was found to have HR to 130s
and 140s. She initially required IV and PO Diltiazem, but then
developed hypotension requiring Levophed while in the CCU (which
was ultimately weaned). Of note, she had a CTA that was negative
for PE. She was loaded with Digoxin, which showed improvement in
her HR. She had Digoxin levels that were initially elevated, and
as such her Digoxin dose was held at times. She was discharged
on a Digoxin dose of 0.0625mg PO daily. She was continued on her
home warfarin and started on fractionated Metoprolol. She was
discharged home with the following medications: digoxin 0.0625mg
PO daily, metoprolol XL 150mg, and warfarin 1mg daily.
#UTI: UA showed large ___, 7 RBC, 12 WBC, few bacteria, and 1 Epi
- consistent with UTI. Mrs. ___ was treated with Augmentin
500mg q8 hours (initially per Plastic Surgery for her facial
contustions), as this provided good coverage. Urine culture
showed no growth. Augmentin continued for 10-day course from
last discharge, finished ___.
#Diarrhea
#Fecal incontinence: Noted upon transfer to the general
cardiology floor. No saddle paresthesias or lower extremity
weakness on exam, thus less likely cord compression. It seemed
most likely related to diarrhea (likely in the setting of
Augmentin) and difficulty ambulating to the restroom in time. We
obtained a C. Difficile test, which was negative. Diarrhea
improved and was resolved on discharge.
#Right eye conjunctivitis
Treated with erythromycin eye drops QID for 1 week ___ to
___. Resolved at discharge
===============
CHRONIC ISSUES
===============
#Facial sutures s/p plastics procedure: Continued Augmentin
500mg q8 hours x10 days from last discharge, finished ___
#GERD: Continued home pantoprazole 40 mg daily
====================
TRANSITIONAL ISSUES
====================
[ ] Stopped home propanolol and diltiazem and started on
metoprolol XL 150mg daily and digoxin 0.0625mg daily. Would
follow-up blood pressure and heart rate on these new medications
and adjust accordingly
[ ] Held home furosemide at discharge and patient euvolemic on
discharge. Would follow-up fluid status and weight as
outpatient. Restart furosemide if she gains ___ pounds above her
dry weight or develops any signs of volume overload.
[ ] Repeat TTE in ___ months to re-evaluate reduced LVEF
[ ] Please schedule appointment with PCP ___
(___) and Cardiologist Dr. ___
___ ___ weeks following discharge from rehab.
[ ] Check INR on ___ and adjust warfarin for INR goal of ___
#CODE STATUS: Full code
#CONTACT:
Name of health care proxy: ___
Relationship: spouse
Phone number: ___
DISCHARGE WEIGHT: 60.69 kg | 149 | 654 |
15986499-DS-13 | 29,100,845 | It was a pleasure taking care of you during your recent
hospitalization. You came in with weakness. We found that there
was evidence on blood tests that you had some injury to your
heart. We started a blood thinning medication to protect your
heart from further damage. After several days we felt that you
were stable and stopped this mediation. However, you developed a
condition called anemia, or low blood count. You felt very weak
and tired and we thought this was due to the anemia. We gave you
a blood transfusion and you felt improved. We think that you may
have a slow bleeding source from somewhere in your
gastrointestinal tract. We started a new medication called
omeprazole to protect your gastrointestinal tract. You should
follow up with a gastroenterologist regarding this concern.
.
We made the following CHANGES to your medications:
STOPPED lasix (furosemide)
STOPPED pravastatin
STARTED atorvastatin (replaces pravastatin)
STARTED colase to prevent constipation
STARTED senna to prevent constipation
STARTED miralax as needed for constipation
STARTED omeprazole
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | REASON FOR HOSPITAL ADMISSION:
___ with PMH HTN/HLD and h/o diastolic CHF last EF 55% ___
presenting with lower extremity weakness x3 days, found to have
elevated cardiac enzymes.
. | 175 | 30 |
13508448-DS-4 | 22,316,403 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
difficulty breathing and were treated for a lung infection as
well as for interstitial lung disease. You completed a course of
antibiotics and will be discharged on a steroid taper. We have
prescribed you home oxygen so that you may return home sooner.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team | Ms. ___ is a ___ YO F with ILD, RA (on prednisone, MTX,
Rituximab), and HF with preserved EF (~60% on ___ TTE) admitted
with dyspnea on exertion and acute hypoxemia.
#Hypoxemia/Dyspnea on exertion with Interstitial Lung Disease
The patient was admitted with acute onset of dyspnea without
evidence of antecedent viral UI, sick contacts or over
aspiration. Labs on admission notable for normal WBC count and
elevated pro BNP with a CXR notable for focal opacity in te
right upper lobe ad diffusely increased interstitial opacities.
Initially treated with furosemide and levofloxacin in the ED
prior to admission to the medicine floor, requiring ___ L of O2.
The patient has a history of early fibrotic lung disease
consistent with RA-ILD followed with PFTS and Chest CT. Both the
pulmonology and rheumatology teams were consulted. The
differential was broad in the setting of underlying ILD and
immunosuppression therapy, and included CHF, CAP, atypical
infections in the setting of immunosuppression, acute
exacerbation of ILD, and drug related pulmonary toxicity. The
patient underwent a high resolution chest CT with diffuse GGO
most consistent with acute exacerbation of ILD vs. atypical
infection. There was likely a contribution from reflux as well
given cough and sputum production in the setting of clear hiatal
hernia, and the patient was treated with BID omeprazole. The
patient completed a 7 day course of levofloxacin for presumed
CAP. Broad infectious workup including serum fungal markers,
urine strep/legionella/histo, viral respirator panel, induced
sputum for Gram stain/cx, funal Gx, AFB x3 and PCP DFA was
negative. Additionally the patient underwent bronchoscopy and
BAL with broad infectious workup which was also negative. Given
the extensive negative infectious workup, the diagnosis was most
likely acute exacerbation of RA-ILD. The patient underwent a
solumedrol pulse of 500 mg IV x 3 days followed by prednisone
taper. Methotrexate was held indefinitely due to possibility of
MTX related lung toxicity. In the setting of high dose
prednisone use, the patient was started on PCP prophylaxis with
___. Patient required home O2 on discharge given ambulatory
saturations <89% on RA.
#Rheumatoid arthritis:
The patient was evaluated by the rheumatology team in house in
the setting of above concern for acute exacerbation of RA-ILD.
She was determined to have decreased ROM and pain on exam
indicating a mildly active flare. The patient was initially
continued on prednisone 10 mg daily and then treated with
solumedrol pulse and high dose prednisone tape as above. Joint
pain improved. As above, MTX was held indefinitely given concern
for MTX related pulmonary toxicity. The patient will follow up
with outpatient rheumatologist after discharge for discussion of
restarting rituximab given negative infectious workup.
=====================
CHRONIC ISSUES
=====================
#Hypothyroidism: Patient was continued on Levothyroxine 150mcg
qD. Of note patient taking 300 mcg Q ___ at home, however tis
was deferred while inpatient in setting of low TSH on admission.
This will be followed as an outpatient by patient's PCP.
#HTN: Patient continued home verapamil 180 q24H.
#GERD: As above, increased omeprazole to BID due to concern for
GERD/aspiration contributing to dyspnea and hypoxemia as above.
#Chronic Diastolic CHF
=====================
TRANSITIONAL ISSUES
=====================
[ ] Patient discharged on prednisone taper as below:
60 mg (___)
50 mg (___)
40 mg (___)
30 mg (___)
20 mg (___)
10 mg ___ - )
[ ] Patient discharged with home O2 given ambulatory saturations
<89% on RA
[ ] Patient continued on levothyroxine 150 mcg daily - admitted
on 150 mcg 6x/week and 300 mcg on ___. TSH 0.26 on admission.
Please follow up outpatient TFTS after discharge.
[ ] Hold methotrexate given possibility of MTX related lung
injury
[ ] Patient started on Bactrim 1 DS three times weekly
[ ] Continue PPI BID
[ ] Monitor BP given high dose steroids at next PCP ___
[ ] Discussion of outpatient rituximab at next rheumatology
appointment | 68 | 618 |
15937283-DS-16 | 27,933,950 | Dear Ms. ___,
It was a pleasure taking care of you while you were a patient at
___. You came to us with
headache, fatigue, and weakness. You were found to have a UTI
for which you were treated with antibiotics. This resulted in
improvement in your symptoms. While you were here you were seen
by Urology. They recommended that you continue to catheterize
yourself a minimum of twice a day. This will help to prevent
UTI. Please be sure to call your primary care physician if you
develop symptoms of UTI such as pain or buring on urination,
urinary frequency, or urinary urgency.
Please take all of your medications as listed below. Do NOT take
citalopram (Celexa) or cyclobenzaprine (Flexeril) while you are
taking linezolid as there is potential for a dangerous
medication interaction. Please be sure to keep all of your
___ appointments. Please discuss ___ these
medications when you see your primary care doctor and after you
are done with the linezolid. | ___ yo F with PMH of renal and pancreas transplant who presents
with fatigue and weakness and was found to have a UTI.
ACTIVE ISSUES
# Fatigue and weakness: These are likely chronic issues that
have worsened in the setting of infection. Also on differential
diagnosis were increasing levels of sedating medications or
tacrolimus toxicity in the setting of her low GFR although these
are unlikely given patient's stable GFR and normal tacrolimus
levels. Hypothyroidism and statin toxicity were also considered
but TSH and CK were normal. Viral screen was also negative
arguing against influenza. Fatigue and weakness improved with
treatment of UTI and patient was feeling energetic and ready to
go home on day of discharge.
# Urinary tract infection: Positive UA. Given first dose of
linezolid and Bactrim in ED. Linezolid started due to recent
history of ___ Enterococcus on urine culture
from ___. Bactrim was subsequently discontinued due to
patient's history of C. diff. Started on ceftriaxone for gram
negative coverage. Given patient's long history of urinary
retention requiring frequent caths and the bladder debris on
renal ultrasound Urology was consulted. They determined that
patient was not complying with recommended cath regimen. They
recommended that she cath herself a minimum of twice per day and
void at least 400 cc with each cath. Urine culture returned as
contaminated on ___. Requested speciation and sensitivities
given the higher likelihood of a polymicrobial infection in a
transplant patient. These studies were pending on discharge.
Switched patient to linezolid and cefpodoxime for outpatient
therapy. Discharged her with a 2 week course of these
antibiotics and with Rx for repeat urine culture in 3 weeks.
CHRONIC ISSUES
# Chronic kidney disease: Patient remained at her stable low GFR
during admission. ___ ultrasound of renal graft.
Increased bicarbonate to 1300 mg TID. Renally dosed all
medications. Scheduled voiding and Urology consult as above.
# Renal and pancreas transplant: Performed in ___. Renal
function was at baseline and amylase and lipase were within
normal limits. Renal ultrasound on ___ was reassuring.
Continued immunosuppressive regimen including prednisone,
tacrolimus, and MMF at home doses.
# Hyperlipidemia: CK within normal limits. Continued
atorvastatin.
# Hypothyroidism: TSH within normal limits. Continued
levothyroxine.
# OSA: Patient uses a special machine at home that delivers PEEP
10 and pressure support that flexes between ___. Per
Respiratory, closest machine we had was BIPAP. Managed with
BiPAP per Respiratory.
# Peripheral neuropathy: Continued gabapentin and Flexeril.
# Depression: Continued citalopram.
TRANSITIONAL ISSUES
- Discharged on 14 day course of linezolid and cefpodoxime
- Now on a higher dose of bicarbonate tabs
- Instructed patient to HOLD Celexa and Flexeril while on
linezolid
- Continue weekly labs faxed to Dr. ___ at ___
- Urine culture 3 weeks after discharge
- ___ with PCP scheduled
- ___ with Transplant Nephrology scheduled
- ___ with Urology scheduled | 163 | 458 |
13697447-DS-18 | 25,214,334 | You were admitted with an asthma exacerbation. We treated you
with prednisone and nebulizers. You should start taking
montelukast on discharge to control your symptoms and follow up
with your primary care doctor, who can do a pulmonary function
test to assess the severity of your asthma. | ___ w likely asthma, HTN p/w subacute asthma exacerbation.
# Hypoxemic respiratory failure, acute
# Asthma exacerbation, acute
# Steroid induced hyperglycemia
# Prediabetes (A1c 6.4)
Given her relatively mild smoking history as well as her mother
having "bronchitis" without a smoking history, this suggests
that
patient actually has asthma rather than COPD. Given the lack of
prominent sputum, that is another reason arguing against the
need
for abx (as well as her QTc prolongation which makes
azithromycin
a less ideal medication anyway). No other risk factors for PE,
and likelihood of sick contacts makes URI induced asthma much
more likely than PE induced asthma. No exam or history evidence
of CHF.
- Weaned O2 for goal sat >92. Satting at 94% on RA on day of
discharge
- prednisone burst 60mg po qd x5d, ___. Had
steroid induced hyperglycemia with this (A1c 6.4)
- s/p 1 dose azithromycin on ___ in ED, but as above, stopping
abx
- standing duonebs, prn albuterol
- Started controller med on discharge - has pre-diabetes so
favor LKA over ICS
- recommend o/p PFTs
# HTN: reports that her PCP was planning on increasing her BP
meds as o/p for HTN anyway, so likely this is chronic HTN in
poor
control
- cont home HCTZ
- added amlodipine
# chronic back pain: NSAIDs are a poor choice in her given her
HTN. She is frustrated by lack of good options
- increased home APAP to 1g TID prn for now
- added lidocaine patch
- may benefit from o/p ___
# QTc prolongation: has at baseline, may be worsened by azithro
dose in ED
- telemetry overnight
- rechecking EKG in AM, stopping tele
# TWFs on EKG
- troponin negative
Outstanding issues
[ ] Started on amlodipine in addition to hydrochlorothiazide for
better control of blood pressure. Some concern for nonadherence
as patient was out of her medicines when she was admitted and
systolics were in the 190s
[ ] Added montelukast to controller medications for possible
asthma. Will need pulmonary function test at outpatient
appointment as well as risk-benefit discussion of inhaled
corticosteroid. This was not provided on discharge due to high
blood sugars in the setting of prednisone use.
[ ] Patient had steroid-induced hyperglycemia. A1c was measured
at 6.4. ___ need further education on management of
prediabetes.
[ ] Complained of shortness of breath when climbing flights of
stairs. Presumption is that this is due to uncontrolled asthma.
If still persists after initiation of controller medications
may want to do further workup for dyspnea.
[ ] Patient has QTC prolongation. Avoid prolonging meds such as
azithromycin
>30 minutes spent on discharge planning including >50% face to
face time | 47 | 416 |
12309980-DS-18 | 25,895,120 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why you were admitted:
- You presented with right-sided chest pain
What we did while you were here:
- Imaging of your lungs showed that the pulmonary embolism in
your lungs on the left had grown a small amount, and that you
have another one on the right, which is new in the last ___ years
but has been there for more than a month
- You were switched from warfarin to lovenox injections
- You talked with our pulmonologist and decided that you would
continue on oxygen at home and not start any new medications for
your pulmonary hypertension. You were ok with getting some
oxygen to keep in your car.
- An echo of your heart showed somewhat worsened pulmonary
hypertension
What you should do once you go home:
- Continue doing lovenox twice daily as instructed while waiting
for your INR to get within goal range. Your new goal range for
now is INR 2.5-3.5
- Please start taking warfarin 7.5 mg daily for now
- You will need to follow-up at your ___ (___
___ Program) in the next ___ days.
You can walk in and do not need an appointment
- Please follow-up with your primary care provider. You should
then get referrals to a pulmonologist and a hematologist
- Please start using the Spiriva inhaler daily as well
We wish you the best.
Sincerely,
Your ___ Care Team | ___ with hx of recurrent DVT/PE on warfarin s/p bilateral
femoral vein ligation, pulmonary HTN, CKD who presented with
pleuritic chest pain and several months of increasing oxygen
requirement with ambulation, admitted due to concern for new
pulmonary embolism, found to have acute on chronic pulmonary
embolism, treated with lovenox. Also found to have worsening
severe pulmonary hypertension, for which he was given O2 for
ambulation. He will continue lovenox while bridging back to
warfarin with new INR goal range 2.5-3.5. | 234 | 82 |
17286918-DS-24 | 27,833,011 | Patient eloped from hospital. By telephone, she was advised to
return to the hospital if she felt unwell or if symptoms
persisted or worsened. | ___ s/p Roux-en-Y in ___ s/p multiple complications, and a
recent c diff infection who presents with nausea, abdominal
pain, and diarrhea.
Pt was admitted overnight ___. On the morning of ___
patient eloped and left the hospital prior to evaluation by the
day team. The day team spoke to her by phone. She reported
leaving due to a personal matter that she needed to attend to.
She was advised to return to the hospital if she felt unwell or
if symptoms persisted or worsened.
# Abdominal pain:
Patient had acute LLQ abdominal pain and no obvious cause on
imaging, ruling out such etiologies as SBO. Exam was also very
benign making a surgical process less likely. Recent c diff
infection; pt reports multiple c diff infections in the past.
States that current sxs started and had not improved since she
was initially diagnosed w/ c diff. This is occuring despite
being treated with Vanco twice, and currently on a taper.
Reports fever but no leukocytosis on labs. Other considerations
for LLQ pain include diverticulitis (negative CT), IBS. Less
likely are referred pain from ulcers, but pt does have a
recently diagnosed anastomotic ulcer - was instructed to stop
NSAIDs and smoking. Stool studies including c diff were sent.
Blood and urine cultures were sent. She was given an IV PPI and
oxycodone for pain control. She did not have known diarrhea
after admission. | 24 | 234 |
16501494-DS-11 | 21,704,549 | Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with cellulitis which is an
infection of your skin. We believe this happened because of the
cut on your leg from your recent fall. Scratching your legs may
have also contributed to your infection. You were evaluated with
a ultrasound of the leg which showed no clots. You were also
evaluated with an xray which did not show any fractures in your
lower leg. You were treated with IV antibiotics for 2 days and
we switched you to antibiotics by mouth after that. After
discharge you should continue to taken amoxicillin and bactrim
through ___. You should try to avoid scratching your skin.
You should continue to put a dressing or an ace bandage on your
right leg to prevent yourself from scratching that area.
We wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old female with a past medical
history of alzheimer's dementia, HTN, eczema, prurigo nodularis
presenting a week after a fall leading to RLE abrasion found to
have cellulitis.
# Cellulitis: The patient presented 1 week following a
mechanical fall with erythema and edema on her right lower
extremity surround an abrasion on her right lateral calf. The
patient was evaluated with a RLE US which was negative for DVT.
She was also evaluated with a RLE xray tib/fib which showed no
fracture. The patient remained afebrile and hemodynamically
stable. It was thought that her recent abrasion predisposed her
to infection in this region. The patient also has a history of
skin conditions (below) which she often scratches which may have
contributed to her risk. The patient was treated with vancomycin
and ceftriaxone which was transitionned to amoxicillin and
tmp/smx to cover strep and MRSA given her risk factors (living
in a dementia unit). The patient should continue these
antibiotics for a total of 10 days (to end on ___. The
patient's leg was wrapped in an ace bandage to prevent her from
scratching the area. The patient should follow up with her PCP
for ___ management.
# Arthlagias: The patient reported pain in her knees and hips.
Per report of her daughter, the patient had recenty been given a
walker and schedued acetaminophen for management of her leg pain
and weakness. The patient was continued on her acetaminophen
TID.
# Pruritus, eczema, prurigo nodularis: The patient has a history
of several skin conditions and she was found to have diffuse
nodules on her upper and lower extremities. The patient had
significant pruritus and, as above, it was thought this may
further predispose her to infection. The patient had been
treated with clobetasol cream in the past with good effect. This
had recently been transitionned to triamcinolone cream due to
problems with insurance coverage. The patient was discharged on
betasone valerate 0.1% cream BID, for equivalent steroid dosing.
The patient should follow up with her PCP for further management
of these medications.
# Dementia: The patient's mental status was thought to be at
baseline. She was continued on donepezil.
# Hyperkalemia, mild elevated in Cr: The patient presented with
elevated potassium to 5.3 and Cr elevated to 1.1 from baseline
0.9-1.0. This was thought to be caused by decreased PO intake
and because of her albuterol being held. The patient did not
have any ECG changes. Her K and Cr were monitored and returned
to baseline.
# COPD: The patient was found to have some wheezing while
hospitalized when her albuterol 2mg PO BID was held due to
difficulty with medication reconciliation. The patient was
treated with an albuterol nebulizer and restarted on her home
medication with improvement in her symptoms. The patient should
f/u with her PCP in the future for further management of this
condition. Can consider albuterol neb treatement in the future
if needed as the patient tolerated this well in the hospital.
# Systolic Murmur: The patient was found to have a systolic
murmur at the RUSB radiating to the LUSB/LLSB and the carotids
bilaterally. This was thought to represent aortic stenosis. No
further imaging was ordered as it was thought that a TTE would
be unlikely to change management. The patient should f/u with
her PCP as needed.
# HLD: Continued atorvastatin
# Hypothyroidism: Continued levothyroxine | 155 | 565 |
13471890-DS-6 | 23,552,904 | You were admitted to the ___ surgery service for treatment of a
small bowel obstruction. This has resolved and you are
tolerating a regular diet.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
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 20
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. | Ms. ___ was admitted to the ___ surgery service for
conservative management of her small bowel obstruction. She was
initially made NPO with IVF; as she had no episodes of emesis an
NGT was not placed. Labs were monitored daily. On HD 2 she began
to pass flatus and was advanced to clears, which she tolerated
without difficulty. She had no further nausea and continued to
pass gas. She was advanced to a regular diet on HD 3 which she
tolerated. She is discharged home on HD 3 in good condition
after successful conservative management of SBO. She is passing
flatus, tolerating a regular diet, voiding and ambulating
normally, with no abdominal pain or nausea. She will follow up
with ACS surgery in clinic in ___ weeks. | 140 | 127 |
12514324-DS-12 | 22,325,391 | Dear ___:
It was a pleasure caring for you during your stay at ___. As
you know, you were admitted due to abdominal pain, and concern
for flare of your Crohn's disease. You were treated with IV
steroids to reduce inflammation, and received medication for
pain management. We consulted the gastroenterologists to assist
in your care. You had a colonoscopy which showed evidence of
colitis, and irritation of your colon. It was felt that your
pain may be due to pain around your rectal stoma. Given that
your pain was better controlled after the IV steroids, we felt
that you were stable to return home. Please follow up with your
primary care doctor as well as your gastroenterologist Dr. ___.
Thank you for allowing us the opportunity to care for you.
Sincerely,
Your ___ Team | ___ is a ___ w/ Crohn's s/p L hemicolectomy and
diverting colostomy ___ and recent C. diff s/p fecal transplant
on ___ who presents with abdominal pain and fevers.
ACUTE ISSUES
#Abdominal pain, presumed Crohn's flare: Patient with marked
colitis on CT and inflammation of rectal stump. Patient was
recently diagnosed with CDiff at ___ and she was on a steroid
taper for a Crohn's flare as well. She was continued on PO
vancomycin and GI was consulted for colonoscopy to further
evaluate colitis. Colonoscopy revealed mucosal ulceration
without evidence of CMV infection in the colon/sigmoid, however
tissue within the rectal stump was not inspected. Given that
the patient's pain was lower in the pelvis than her usual
Crohn's flares, there was concern for PID vs inflammation of the
rectal pouch itself. A pelvic US was considered to evaluate the
adnexa, however radiology felt that the CT abdomen pelvis was
sufficient to evaluate the pelvis. Given her clinical picture,
ovarian torsion was thought to be unlikely, and inflammation of
the rectal stump observed on CT was thought to be the primary
cause of her pain. Cortifoam enemas coupled with antispasmodics
(dicyclomine and hyoscyamine) were attempted and the patient had
significant pain with enemas. After 48 hours, and after
consultation with Dr. ___ primary GI, She was started on
IV methyl prednisolone 20 TID, with improvement in her pain. She
was then transitioned to prednisone 30mg PO daily with
instructions to continue this regimen until her follow-up
appointment with GI (Dr. ___. Per the GI team, PCP prophylaxis
was not needed while taking prednisone. She was discharged with
instructions to take calcium and vitamin D supplements to help
prevent bone demineralization in the setting of steroid
treatment.
- ___ virus negative
#Crohn's Disease
She was continued on her home dose of 20mg prednisone daily.
With continued pain she was transitioned to 20 TID of IV methyl
prednisolone on ___. The patient endorsed improvement in pain
with IV methyl prednisolone, and was transitioned to prednisone
30mg PO daily on day of discharge (___). As above, per GI,
she was instructed to continue taking prednisone 30mg daily
until her follow up appointment with Dr. ___. She was also
instructed to take vitamin D and calcium supplements given her
steroid treatment.
CHRONIC ISSUES
#GERD:
The patient was continued on her home regimen of BID omeprazole
#Asthma-
The patient has known diagnosis of asthma and was continued on
her home Montelukast and prn albuterol and remained clinically
stable.
# Depression
The patient has a history of depression and was continued on her
home Celexa regimen.
Transitional Issues
**Pt will need DEXA scan as out-patient given long term steroids
**Pt was discharged with instructions to start calcium and
vitamin D to prevent bone demineralization in the setting of
steroid treatment. | 132 | 479 |
13855180-DS-20 | 22,341,616 | You were admitted to the hospital with abdominal pain and
nausea. You were evaluated by the Medical, Surgical, and ERCP
teams. You had imaging studies done, including a CT scan, a
HIDA scan and an MRCP (MRI) which did not show any evidence of
bile leak. You still have a fluid collection in your abdomen
which is most likely a resolving blood clot (hematoma). On the
CT scan, it was noted that your previously placed pancreatic
stent had migrated and was now in the small intestine. This
stent should pass on its own through your GI tract.
.
New Medications:
1. Phenergan
.
Please follow-up with your doctors as listed below. You will
see a Gastroenterologist affiliated with your PCP's office. You
will need to have a follow-up x-ray of your abdomen to evaluate
for passage of the stent.
. | ___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___
for gallstone pancreatitis complicated by bile leak s/p ERCP
with stent placement ___ and right abdominal hematoma s/p
percutaneous abdominal drain now with recurrent nausea and
abdominal pain and found to have an extruded biliary stent with
stable ductal dilatation.
.
#Abdominal pain/nausea: initial ddx included extruded biliary
stent vs recurrent bile leak vs possible infected fluid
collection.
--following admission, the patient was made NPO, placed on IVF,
given IV antiemetics and started on IV antibiotics for empiric
cholangitis treatment. The ERCP and Surgical Consult services
were also asked to see the patient. ___ d/w both consult
services, the pt first had a HIDA scan performed to evaluated
for biliary leak, which was negative. She then underwent a MRCP
to further evaluate the fluid collection. Initially the MRI was
read as a possible biloma, so a plan was made to have ___ place a
drain into the collection. However, on further review with
Radiology, it was felt that the collection was most likely a
resolving hematoma. Surgery felt that the hematoma could be
managed conservatively as long as the patient's symptoms
improved. The pt's abdominal pain resolved quickly and her
nausea was well controlled with antiemetics. Her diet was
advanced and her IVF were stopped. Given that there was no
evidence of cholangitis, the patiet had the IV antibiotics
stopped as well. The patient was able to tolerate a full diet
with no pain and nausea. She will be discharged to home with
follow-up with GI as an outpatient. She was discharged with PRN
oral antiemetics. She will need a follow-up KUB in
approximately 2 weeks by GI to confirm passage of the biliary
stent. If it remains in place, she will need a repeat ERCP to
have it removed.
.
#GERD:
--continued on ranitidine. She has not tolerated PPI in the
past.
.
#Post-nasal drip:
--continued on Singulair and PRN fluticasone.
.
. | 142 | 331 |
17142781-DS-14 | 23,801,076 | You were admitted with pyelonephritis -- a urinary infection
that spread to your kidneys. You required IV medications for
several days, and you were initially septic. Fortunately, you
grew a sensitive organism called enterococcus. You will finish a
10 day course of antibiotics (ciprofloxacin). If you ever have
urinary symptoms again, you should immediately go to urgent care
to have your urine tested. Fortunately, you should be able to do
almost any antibiotic (including Bactrim). | Mr. ___ is a ___ year-old man with a history of BPH and reflux
nephropathy who presented with severe sepsis from
pyelonephritis. His urine grew a sensitive enterococcus; blood
cultures were negative. He was treated with IV ceftriaxone, and
received a total of five liters of IV fluids. He continued to
have fevers through HD#2. He was discharged on PO ciprofloxacin
on HD#3 to complete a 7-day course of therapy.
1. Severe sepsis d/t enterococcal pyelonephritis
- ciprofloxacin 500 mg BID x 4 additional days
2. HLD.
- home atorvastatin
3. ADHD. Home Adderal
4. CV Risk. Asa 81 mg.
> 35 minutes spent on discharge activities. | 75 | 101 |
19900867-DS-14 | 25,731,044 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-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 state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
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 <30 DAYS OF REHAB
Treatments Frequency:
Skin staples in place, to be removed at 2-week follow-up | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip 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 left 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. | 556 | 254 |
10613271-DS-21 | 22,255,734 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. You were admitted for
abdominal pain, diarrhea, and blood in your stool. We did a CT
scan of your abdomen, a sigmoidoscopy, and tests for infection.
Based on these tests, and the recommendations of our
gastroenterology doctors, we found that you have moderate to
severe ulcerative colitis. We also did tests that showed that
you do not have a gastrointestinal infection. We gave you
steroids IV then switched you to take steroids as a pill. We
also monitored your symptoms, and had a nutritionist talk with
you about nutritional tips for people with ulcerative colitis.
Please take your medications as instructed, including prednisone
40 mg orally once daily- this will be the dose until you see
your GI doctors on ___. Please also take a calcium and
vitamin D supplement while you are taking prednisone, because
prednisone can lower your calcium levels. Please follow up with
your scheduled primary care and gastroenterology appointments
(see below). Please seek medical attention urgently if you
develop any concerning symptoms, including bloody stool, severe
abdominal pain, or fever.
Sincerely,
Your ___ Care Team | ___ year-old male with no significant past medical history who
presents with abdominal pain, hematochezia, and diarrhea, found
to have moderate to severe ulcerative colitis.
# New-onset, moderate to severe ulcerative colitis:
Patient presented with abdominal pain, hematochezia, and
diarrhea. He was also unable to eat during the day prior to
admission, but began eating on his first day in-hospital.
During this admission, he remained afebrile and without
peritoneal signs on abdominal exam. CT abdomen and pelvis
showed proctocolitis without small bowel involvement.
Sigmoidoscopy showed diffuse colitis involving the rectum with
continuous involvement proximally, consistent with ulcerative
colitis. Sigmoidoscopy biopsy showed moderately active colitis
without granulomas or dysplasia. Infectious work-up was
negative for C. difficile, salmonella, shigella, campylobacter,
vibrio, yersinia, E. Coli O157:H7, and ova and parasites. Given
these findings, he was diagnosed with moderate to severe
ulcerative colitis. He received five days of IV
methylprednisolone, and then was transitioned to oral prednisone
his day of discharge. On discharge, the patient's bloody
diarrhea slowed down, had minimal abdominal pain, and was
tolerating PO intake without difficulty. | 202 | 184 |
16499456-DS-16 | 26,823,631 | You were placed on the neurology service for events concerning
for possible seizure and right leg wekaness. Your evaluation
thus far was normal including the physical exam, the MRI, and
lumbar puncture study. We are not to sure what the etiology of
your presentation was. We will have you follow up as needed. No
further tests are needed now. | Neuro# No further symptoms reported since admit and overnight on
the neurologic unit. She had an MRI which did not demonstrate
any new significant pathology. She also had a lumbar puncture
and the initial CSF results were all within normal limits. Her
examination in the morning was also at baseline without focal
deficit. Her symptoms may have been secondary to a seizure but
this is not entirely clear at this time. No changes to her
medications were made and she was discharged the next day. | 59 | 86 |
16192625-DS-12 | 21,376,989 | Dear Mr. ___,
You were admitted to the Acute Care Surgery service on ___
with an abscess/infection in your large bowel caused by
diverticulitis. You were initially managed with antibiotics and
aspiration of the fluid collection. Your symptoms did not
improved and therefore surgical removal of the affected piece of
your colon was recommended. You tolerated the procedure well.
Post operatively you were given IV fluids until your ostomy
started functioning. Your diet was then progressed to regular
with good tolerability. You were seen by the wound and ostomy
nurse to help learn how to care for your colostomy and for your
VAC dressing on your midline wound. You are now doing better,
pain is controlled, and you are tolerating a regular diet. You
are now ready to be discharged home with visiting nursing
services and 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:
*You had a special dressing applied to your surgical incision
called a wound vac. This dressing will be changed approximately
every 3 days. | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
service on ___ from outside hospital with a CT scan
concerning for perforated sigmoid diverticulitis with a
multiseptated abscess collection. ___ aspiration was preformed.
He was made NPO given IV fluids and IV antibiotics and admitted
to the surgical floor for continued monitoring and management.
On HD4 he was febrile with temperature of 102, white blood cell
count continued to rise to 17.8 - antibiotic therapy was changed
to zosyn. On HD5, due to increasing white blood cell count, the
decision was made to operate. Informed consent was obtained and
on ___ he underwent ___ procedure. He received 6
units of FFP intraoperatively for elevated INR of 2.0. Post
operatively he was exutbated and taken to the PACU in stable
condition then transferred to the surgical floor once recovered.
On POD1 he was hemodynamically stable, afebrile, NPO on IV
fluids and dilaudid PCA for pain control. Wound vac was applied
to midline surgical incision. The patient recovered from his
surgery well. His WBC trended down he had no more fever episodes
and was HD stable. He began to pass gas and than BM per
colostomy and his wound VAC was changed every 3 days. His Jp
drain that was left in his pelvic during surgery was removed on
the day of discharged. the patient was ambulating easily
resumed regular diet and tolerated it well. pathology report
showed Diverticular disease with peridiverticulitis and mural
abscess formation. Six lymph nodes with reactive changes.
The patient received ostomy teaching and was discharged home
with ___ for VAC change and with the following recommendations: | 380 | 275 |
15661132-DS-3 | 23,002,887 | Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted after you fell. You had a cat
scan of your head and x-rays of your shoulders, hips, and knees,
which did not show any fracture or other concerning findings.
.
You were evaluated by physical therapy while here, and they felt
that you were better off by going to rehab first. We have found
you a place at rehab. | ___ year old woman s/p mechanical fall.
. | 72 | 11 |
18303336-DS-21 | 25,491,485 | You were admitted for low blood pressure and bleeding from your
bottom. This was most likely caused by an ulcer in your stomach,
which was seen on EGD (a procedure to look down your throat into
your stomach).
It will be important for you to STOP TAKING PLAVIX AND
INDOMETHACIN!! You should also avoid ALL NSAIDs, like ibuprofen
as these medications put you at a risk of more bleeding.
Please make an appointment with your primary doctor as soon as
possible after discharge, and discuss referral to a
gastroenterologist. You should also make sure to follow-up the
results of the H. pylori test (the bacteria that can lead to
ulcers in the stomach).
Please note the following medication changes:
-Please DO NOT TAKE PLAVIX
-Please DO NOT TAKE INDOMETHACIN or other NSAIDs
-Please START omeprazole to reduce the amount of acid in your
stomach
-Please discuss with the doctor at dialysis whether your blood
pressure is at a safe level after dialysis to start your blood
pressure medications. These are:
--Atenolol
--Amlodipine
--Dyazide.
If safe, you should consider first re-starting atenolol, then
amlodipine. You should also discuss this with your primary
doctor.
- Increase renvela to 800 mg three times a day with meals, as
your phosphate was high during this admission. Please discuss
this dosing with your kidney doctor. | Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant
seizure, gout, who presented from ___ with concern for
UGIB, found to have HCT drop to 22 from baseline ~30.
# Acute Anemia: Initially unstable at OSH, stable at ___,
initially in MICU, rec'd total 3 u pRBC at ___, additional
transfusions at OSH. Most likely secondary to PUD in setting of
NSAID use (was recently prescribed endomethacin), platelet
dysfunction, and use of plavix (was not supposed to be taking
this medication any longer). He underwent EGD which revealed
esophagitis with friability and erythema of the gastric mucosa
with contact bleeding in the gastroesophageal junction as well
as in duodenal bulb and second part of the duodenum. A single
superficial non-bleeding 1.5 cm ulcer was found in the pylorus
extending into the pyloric channel. Also notable was a single 4
mm nodule of benign appearance in the upper third of the
esophagus. The patient was treated initially with IV PPI then
transitioned to Omeprazole 40mg BID. Gastroenterology
recommended outpatient repeat egd in ___ weeks for biopsies of
esophageal nodule, GE junction and evaluation to ensure ulcer
healing. They also requested H pylori serologies to be sent as
an inpatient, and this request was carried out. He was stable,
with brown stool at discharge.
# CAD: The patient has a history of NSTEMI with stent in ___.
Patient was supposed to be off plavix and only on ASA 325mg per
his primary cardiologist, however the patient had been taking
plavix because "I didn't think it would hurt and I had some
extras lying around." He had some ST depressions in the absence
of chest pain, so was ruled out for an MI with serial EKGs and
cardiac enzymes. ASA 325mg was restarted after the patient
stablized and please note he does NOT need plavix at this time.
# CKD: ___ dialysis schedule, continued Renal Caps,
Sensipar 60mg daily, Renagel (Sevelamer).
# HTN: held amlodipine, atenolol, diazide given hypotension,
instructed patient to re-start these medications as tolerated
after dialysis.
# Seizure d/o: continued lamotrigine and levitiracetam.
=== | 212 | 357 |
11922120-DS-38 | 28,467,556 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for high levels of potassium
and kidney injury, which were attributed to a combination of
taking lisinopril and bactrim, as well as low fluid intake. You
were given IV fluids, insulin and sugar, kayexalate, and
lactulose to control the potassium levels. Your kidney function
improved with IV fluids. You were given a new antibiotic regimen
for you to continue to take (Clindamycin and Ciprofloxacin).
Please do not take lisinopril or chlorthalidone until you
follow-up with your primary care physician, who will order a
blood test to determine your current potassium level. You can
continue to take the ciprofloxacin that was prescribed to you,
and you have been given a prescription for the clindamycin.
Please take your antibiotics through ___.
It is important that you take all of your medications as
prescribed, and that you attend all of your follow-up
appointments as scheduled. Please Weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
We wish you the best of health,
Your Care Team at ___ | Mr. ___ is a ___ y/o man with hx of CAD s/p NSTEMI, T1DM
(last A1c 8.5%), dCHF, and multiple prior debridements for
non-healing L foot ulcers recently hospitalized for cellulitis
of right foot, found to have hyperkalemia and ___ on most recent
bloodwork, likely secondary to Bactrim and lisinopril further
complicated by poor PO fluid intake prior to admission.
# HYPERKALEMIA: Patient presented with a serum potassium of 6,
which prompted his admission to the hospital. Hyperkalemia
occurred in the setting of recent uptrend in creatinine on his
prior hospitalization (at that time attributed to prerenal
azotemia) in the setting of recent discharge for foot infection
on Bactrim, flagyl, and ciprofloxacin. Both Bactrim and the
patient's home dose of Lisinopril were thought to worsen the
patient's electrolyte abnormality. Upon further review of OMR,
patient was noted to often have serum potassium levels between
4.5 and 4.7, which could be suggestive of underlying renal
etiology for high normal potassium at baseline. With a minor
renal insult, this potassium level became supratherapeutic.
Hyperkalemia was treated with multiple bouts of D50 + IV Insulin
10 units, with kayexalate, lactulose, and calcium glucose
administered (for concerning T wave peaking noted). Hyperkalemia
improved with improvement in renal function (see below). Patient
was discharged with a stable K of 5.1, and will repeat labs at
the time of his follow-up appointment with primary care on
___.
# ACUTE KIDNEY INJURY (baseline Cr 1.1-1.2): Patient presented
with increased Creatinine, which was noted on his discharge labs
on his prior hospitalization. Uptrend at that time as attributed
to a prerenal etiology, and patient was encouraged to increase
his PO fluid intake. Patient's Lisinopril and Bactrim were held
upon admission in the setting of acute kidney injury and
hyperkalemia. Patient was initially hydrated with IV fluids, and
encouraged to increase his PO fluid intake. Cr peaked at 1.7,
and eventually began to downtrend. Lisinopril was held at the
time of discharge; the patient will repeat a Chem-7 at the time
of his outpatient follow-up appointment, with the decision to
restart Lisinopril to be re-addressed at that time.
# R diabetic foot diabetic ulcer complicated by recent
cellulitis: Patient was recently admitted for cellulitis of his
R foot, and was discharged on Cipro/Flagyl/Bactrim. On current
presentation, Bactrim/Flagyl were discontinued in the setting of
___, and the patient was transitioned to PO
Clindamycin and Ciprofloxacin. Admission foot X-ray remarkable
for retained foreign body (insulin needle); patient was
evaluated by his outpatient podiatrist while in-house, who
recommended no further intervention at this time, as any
procedure to remove the foreign body would likely cause more
discomfort and possible infection risk in comparison to leaving
it in place. The patient will follow-up with podiatry on an
outpatient basis.
# T1DM: Patient with hx of T1DM diagnosed at age ___, presenting
with most recent A1c of 8.5 in ___. He continued his home
insulin regimen while in-house.
# Chronic/compensated diastolic CHF: Patient with hx of dCHF
with most recent EF >55% in ___. Patient was euvolemic on
examination, and was continued on his home medication regimen
(with the exception of lisinopril, which was held in the setting
of ___
CHRONIC/STABLE/RESOLVED PROBLEMS:
# Coronary Artery Disease: Continued home regimen of ASA,
carvedilol, atorva
# Hypertension: Continued home hydralazine, carvedilol, and
chlorthalidone. Lisinopril was held on admission, and was not
restarted at the time of discharge.
# Hyperlipidemia: Continued home atorvastatin.
# Gastroesophageal Reflux Disease: Continued home omeprazole
# Depression: Continued home sertraline.
# Neuropathy: Continued home gabapentin. | 180 | 580 |
16293620-DS-17 | 24,841,345 | Dear Mr. ___,
You were hospitalized due to problems with your speech
(aphasia) 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.
The blood clot causing your stroke was removed during a
thrombectomy procedure.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high cholesterol
- tobacco use
- use of stimulants
We are changing your medications as follows:
- continue aspirin 81mg daily
- continue atorvastatin 40mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | In brief, Mr ___ is a ___ man with h/o tobacco use,
glaucoma who presented as transfer from OSH for Left M1
occlusion. LWK ___ at 0845. He came home from work, took a nap.
Spoke to his brother over the phone after his nap and was
speaking word salad. His wife came home and called EMS. Sent to
OSH where CT head showed L M1 occlusion. Outside the window for
TPA. Transferred to ___ for thrombectomy. NIHSS at ___ 8.
Thrombectomy TICI IIb, admitted to Neuro ICU post angio. Patient
continued with aphasia with word finding difficulties but
occasionally could be fluent. Naming deficit. Patient's speech
improved. Patient has full strength throughout on motor exam.
Patient started on aspirin and atorvastatin. LDL 92. Very poor
vision in R eye but pt says it is chronic. Urine tox positive
for cocaine but patient denies use. Patient counseled on
abstaining from cocaine. Patient was monitored on telemetry;
found to have asymptomatic sinus bradycardia. MRI brain showed
scattered cortical, subcortical and white matter DWI
hyperintensities in the left frontal and parietal lobes are
consistent with acute infarction after incomplete
revascularization of a distal left M1 occlusion, focus of
microhemorrhage in the left parietal lobe. TTE performed,
showing no intracardiac source of thromboembolism. Normal
biventricular cavity sizes, regional/global systolic function.
Mild mitral regurgitation. Normal estimated pulmonary artery
systolic pressure. Remained stable for the remainder of the
admission. Recommendation for outpatient speech therapy. | 298 | 240 |
10313447-DS-21 | 23,980,316 | General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was taken from the ED to the OR for an exploratory
lapartotomy via small Phannensteil incision, evacuation of
hemoperitoneum, right salpingoopherectomy of torsed complex
right ovary and tube. Please see operative report for full
details. From the recovery room, she was transported to ___
___, where her recovery was uncomplicated.
She was discharged home on POD#1 in good condition, ambulating,
voiding, tolerating a full diet and with pain well controlled on
po pain medications. She will follow up at the ___. | 151 | 85 |
16490716-DS-9 | 24,575,997 | Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing in right lower extremity
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing in right lower extremity
- ROMAT
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have open right tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial IMN which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is tdwb in the right 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. | 185 | 236 |
16930664-DS-17 | 22,837,445 | Dear Ms. ___,
You were admitted to the ___ General Surgery Service
for concerns that you had a bleed in your abdomen. At this time
we do not believe this is the case and we are comfortable with
you going home with some in-home services. Please follow up at
your appointments with your primary Physician and your surgeon.
Please resume all regular home medications as no changes were
made to your medications during this admission.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Please follow up
with your primary care Physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you
have increased pain, swelling, redness, or drainage from the
incision
site.
*If you have steri-strips, they will fall off on their own.
Please
remove any remaining strips ___ days after surgery.
Thank you for letting us participate in your care. We wish you
a speedy recovery. | ___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr
___ on ___ presented initially to ___
___ with weakness and decreased appetite since surgery. Her
original CT read at ___ indicated there may be active
extravasation from the gastric artery so she was transferred to
___ for further workup. Here her main complaint was that she
has had trouble caring for herself and she feels "weak." EKG
did not show any acute changes. Labs WNL. Additionally she was
complaining of left shoulder pain so left shoulder x rays were
obtained which did not show acute fracture or dislocation. Upon
further review of her images it does not appear that she has any
active extravasation of any vessels within her abdomen and that
the radiologist may have been seeing staples from her surgery.
She has been completely hemodynamically stable while in house.
She was started on her home medications and a regular diet. She
was seen by social work, case management and Physical therapy
who all agreed she was safe to d/c home with services for home
health and meals on wheels. She agreed with this plan. She
will follow up closely in clinic with her PCP ___ ___ and in
surgery clinic later this week. | 169 | 218 |
15545381-DS-11 | 21,463,547 | Dear Mr. ___,
You were transferred to ___ with a left lung injury after a
motorcycle crash. There was blood trapped in the lining of your
lung, causing part of the lung to collapse. This required a
chest tube be placed to drain the blood and fluid. A repeat CT
scan showed a large retained blood clot. You were taken to the
operating room and underwent a VATS procedure to remove the
retained blood clot. You tolerated this well. Both the chest
tubes have now been removed and your chest X-Rays are stable.
Your oxygen and vital signs are also stable. You are medically
clear to be discharged home to continue your recovery. Please
note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ was admitted to the ICU for close hemodynamic
monitoring. On admission he received 2uPRBCs-however he remained
hemodynamically stable since admission. There was concern if his
chest tube output remained high or if he was requiring
continuous transfusions he would need a thoracotomy. However his
chest tube output remained minimal and his pain was well
controlled while in the ICU. On hospital day two he was then
transferred to the floor
Serial chest x-rays showed minimal improvement in the
hemothorax. A repeat chest CT on HD4 showed a trapped collection
in the left lower lobe. Given the failure to clinically
progress, a discussion was had with the patient and a decision
was made to proceed with a left VATS with washout of the
retained hemothorax. On HD7, the patient was taken to the
operating room and underwent a left VATS washout with chest tube
placement, which went well without complication (reader referred
to the Operative Note for details). After a brief, uneventful
stay in the PACU, the patient arrived on the floor tolerating
sips, on IV fluids, and PCA for pain control. The patient was
hemodynamically stable and had 2 chest tubes in place.
POD2 the chest tubes were placed to water seal. On POD3 the left
anterior chest tube was removed. POD4 a chest CT showed near
complete resolution of the left hemthorax. POD5 the remaining
chest tube was removed.
.
Chronic pain was consulted early on during the admission given
the patient's history of heroin abuse and current use of
suboxone. Pain was well controlled. Postoperatively, diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge on POD5, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, pulling
2500 on the IS, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 336 | 377 |
13492931-DS-21 | 27,912,479 | Dear Ms. ___,
___ were admitted to ___ with low blood pressures. ___
improved with antibiotics and high doses of steroids. We better
controlled your blood sugars with insulin with the help of our
diabetes doctors. ___ left against medical advice while we were
still trying to figure out the cause of your blood pressures. It
was a pleasure caring for ___.
Wishing ___ the best,
Your ___ Team | **LEAVING AMA**
Patient expressed understanding of the risks and consequences of
leaving AMA.
___ female with a history of ESRD s/p remote LRRT c/b
CMV viremia, type II diabetes, and multiple recent
hospitalizations for hypotension re-admitted for fevers and
hypotension presumably secondary to rapid steroid taper and
adrenal crisis in that regard, though suspicious for
undifferentiated systemic illness.
#) Adrenal insufficiency: Initially hypotensive concerning for
septic shock, though rapidly improved with stress-dose steroids
in keeping with secondary adrenal insufficiency in the context
of
chronic exogenous corticosteroids. Definitive prednisone taper
to
be determined with mindfulness of supra-physiologic needs.
Tapered to 15 mg prednisone daily, will need prolonged
outpatient taper and close follow-up.
#) Hospital acquired pneumonia: biapical ground glass opacities
by CT. Initially received empiric vanc/cefepime for said
opacities, which were then transitioned to levofloxacin for 7
day course for treatment of HAP. Smoldering PJP in the context
of elevated LDH and prior positive B-D-glucan is conceivable,
though never hypoxemic. Could alternatively be a manifestation
of pulmonary edema. Evaluated by ___ with plan for bronchoscopy
though patient declined and left AMA. Last day of levofloxacin
___. Repeat B-glucan pending on discharge, please refer to
___ if required.
#) ESRD s/p LRRT: c/b chronic allograft nephropathy secondary to
IFTA of uncertain etiology and CMV viremia, which has since
cleared. Renal function at baseline. Immunosuppression lessened
in the setting of probable pneumonia. Holding home azathioprine.
Continued home cyclosporine, level on d/c: 69. Prednisone as
above. Changed home valganciclovir 450 mg QD to Q48H for
maintenance dosing. CMV-VL negative.
#) Pancytopenia, dual lineage: Presence of macrocytic anemia and
thrombocytopenia since at least ___ concerning for MDS or
plasma cell dyscrasia in the context of abnormal SPEP of
uncertain significance and elevated B2 macroglobulin. No
outpatient hematology oncology follow-up due to frequent
hospitalizations. Evaluated by inpatient heme-onc team with plan
for inpatient bone marrow biopsy though patient decline and left
AMA.
#) Type II diabetes, insulin-dependent: Labile in the
setting of steroids, in the 200s on d/c. Increased home insulin
regimen to NPH 30U QAM and Humalog 7U, 8U, 9U standing with
meals. Arranged ___ f/u on d/c.
#) ___ edema: s/p 40 mg IV lasix while inpatient. Changed home
regimen to 40 mg lasix daily from 20 mg BID, please uptitrate as
tolerated.
TRANSITIONAL ISSUES
===================
- Holding home azathioprine on d/c, restart when able.
- Discharge prednisone dose of 15 mg daily, please taper to
physiologic dose as able.
- Unable to obtain inpatient bronchoscopy and bone marrow biopsy
for further evaluation as patient left AMA. Please arrange to
obtain outpatient.
- Pending rheumatologic w/u and b-glucan on d/c. Please
follow-up.
- Discharge insulin regimen: NPH 30U QAM and Humalog 7U, 8U, 9U
standing with meals
- Changed valganiclovir dose to Q48H for maintenance dosing.
- Please uptitrate lasix as tolerated. Unable to titrate while
inpatient as patient left AMA. Changed dose to 40 mg daily from
20 mg BID.
- Started on Na bicarb while inpatient. Continued on d/c. | 66 | 474 |
10865278-DS-21 | 28,186,950 | 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
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mrs ___ arrived in the ER from rehab after becoming acutely
short of breath, lethargic and developing a rash after receiving
a one time dose of zosyn for fever. She was also mildly
hypotensive and neo was started. She was intubated and sent for
a CTA and head CT to r/o PE. Both were negative for acute
processes. ECHO was unremarkable.
She was admitted to the CVICU, weaned from the vent and
extubated on HD#2. She was pan cultured and continued on Vanco,
Zosyn, and Cipro. ID was consulted and recommended all
antibiotics be discontinued since previous OR cultures were
negative and event was thought to be related to a Zosyn
reaction. She was seen by Plastic Surgery - Dr. ___- and one
of two JP drains was removed. The remaining JP will be removed
at subsequent follow up visit to Dr. ___.
On HD #3 she was transferred to the stepdown unit. Her foley was
removed but was re-inserted after failing to void. She continued
to progress, remained afebrile with normal WBC. She did have
large volumes of loose stool which was negative for c-diff and
O+P. It was noted that due to her very poor appetite she was
only consuming Glucerna whicih caused diarrhea. She was started
on banana flakes with significant improvement. She was noted to
have a Stage II pressure ulcer on coccyx and was seen by the
wound care specialist and regimen of Criticaide and DXeroform
gauze was recommended.
She was discharged on ___ to ___ Rehab with appropriate
follow up appointments. | 132 | 257 |
12069976-DS-4 | 20,839,831 | Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
admitted to the hospital because you fell at your assisted
living facility. Nobody saw you fall, so we don't know exactly
why this happened, but you were dehydrated when you arrived and
your heart rate was fast, so these may be contributing. It is
also likely that your underlying dementia and your balance
problems put you at a higher risk for a fall.
We recommend that your facility takes measures to help prevent
you from falling such as lowering the height of your bed,
putting soft mats on the floor near your bed, and helping you
when you need to walk somewhere.
Because you were in a heart rate called atrial fibrillation, we
discussed starting blood thinners with your health care proxy.
Because of your frequent falls and recent bleeding in your
brain, there is substantial risk with blood thinners, so they
were not started. We did start you on a medication to slow your
heart called metoprolol. Please discuss this with your primary
care doctor. | ___ year old man with advanced dementia, prior TIAs, pulmonary
fibrosis, hyperlipidemia, and BPH who presented ___nd was found to have paroxysmal atrial fibrillation with
RVR in the ED.
# s/p fall: Patient has a history of falls, most recently he was
admitted ___ - ___ for a fall resulting in small
subarachnoid hemorrhages and an ear laceration repaired by
plastics. Given lack of witnesses or history surrounding his
current fall, it is difficult to elucidate the underlying
etiology. Regarding the trauma, his imaging was all unremarkable
(CT head, C-spine, pelvis/hip x-rays). He was noted to be in
afib with RVR in the ED. Volume depletion could have caused him
to be orthostatic or may have prompted his RVR, which may have
contributed to his fall. Stroke or TIA is possible, but he is
demented at his baseline and does not have any new focal
deficits (slight facial droop and left eye ptosis noted on prior
discharge). His orthostatic BPs were positive with SBP dropping
from 150s supine to 120s standing. He was monitored on
telemetry which revealed paroxysmal atrial fibrillation in
addition to his baseline rhythm with what appears to be a first
degree heart block. His mental status returned to baseline prior
to arrival to the floor and he remained alert and oriented to
self only and is interactive and follows commands. He was
maintained on strict fall precautions with low bed height and
bed alarm.
# Atrial fibrillation with RVR: He was noted to be Afib with RVR
to the 130s in the ED which resolved with 2L of IVF. The patient
was likely volume depleted on presentation, which is supported
but slight increase in Cr from 1.0 to 1.2. Patient has CHADS2
score is 4 (hypertension, age, hx of TIA) but is not
anticoagulated given recent subarrachnoid hemorrhages, history
of falls, and dementia patient does not seem to be a good
candidate for anticoaguation at this time. In discussion with
HCP, they are not interested in pursuing anticoagulation. He was
started on low dose metoprolol as this could potentially
decrease his frequency of falls if his atrial fibrillation is
contributing. His underlying rate appears to be a first degree
heart block with intermittently dropped beats. He was continued
on aspirin 81 mg and discharged on new metoprolol succinate 25
mg daily.
# Leukocytosis: WBC count of 11.5 on admission which is stable
from prior admission. He has a left shift with 92% PMNs, but he
remains afebrile without localizing signs or symptoms of
infection. CT chest showed increased tree and ___ opacities and
bronchial wall thickening with bronchiectasis concerning for
small airway infection vs inflammation, however CXR unchanged
and patient without respiratory symptoms. Urine and blood
cultures were pending at the time of discharge without growth to
date. His WBC count fell to 8.9 with fluids indicating that
hemoconcentration was possibly playing a role.
# Hematuria: Patient incontinent of pink tinged urine while on
the floor. This is likely related to foley trauma in the ED.
This should continue to be monitored while he is back at his
assisted living facility and urology follow up can be considered
if this continues and it is within the patient's goals of care.
# Pulmonary fibrosis ___ syndrome): Noted on admission
CXR as stable from prior.
# Hypertension: Recently discontinued lisinopril in an effort to
simplify medications.
# Dementia/ataxia: Alzheimers vs vascular. recent TSH, RPR, B12
returned within normal limits. He was continued on Namenda 10 mg
BID.
# Glaucoma: Continued on timolol and travaprost eye drops BID.
# Chronic constipation: He was continued on colace, senna, and
miralax as needed.
# Depression: Patient's mood was stable. His venlafaxine was
recently discontinued in an effort to simplify his medication
regimen.
# Hyperlipidemia: Recently discontinued simvastatin in an effort
to simplify medication regimen.
# BPH: s/p laser surgery. previously on vesicare however this
worsened his mental status. Not currently on medications.
# Transitional issues:
- Code status: DNR/DNI (confirmed with HCP ___
- Emergency contact: ___ (neice) who is HCP, ___
- Blood and urine cultures pending at the time of discharge.
- Patient was started on metoprolol 25 mg PO daily given
paroxysmal afib.
- Patient was not anticoagulated despite CHADS2 of 4 given
recent subarachnoid hemorrhages and frequent falls.
- Patient's HCP interested in continued discussions regarding
goals of care, specifically having a higher threshold to
hospitalize the patient and possibly considering comfort focused
care. | 185 | 762 |
19342909-DS-7 | 20,785,207 | Please call Dr. ___ office ___ if you
experience:
-Fevers > 101 or chills
-Difficult or painful swallowing.
-Chest or back discomfort.
-Abdominal pain | The patient was admitted to the thoracic surgery service for
evaluation of her regurgitation and shortness of breath, after
having been ruled out for PE and PNA in the emergency
department. She was kept NPO overnight with IV fluids. She had a
swallow study the next morning, which demonstrated contrast
flowing freely through both the anastomosis and also the distal
stomach through the pylorus, with no evidence of obstruction. By
morning, her symptoms had also resolved; she was breathing
comfortably and was tolerating solids and liquids by mouth. She
never showed signs of infection, and she was hemodynamically
stable. She was then discharged home in stable condition, to
continue her protonix and anxiolytic medication, and to follow
up with Dr ___ in clinic in 1 month. | 22 | 129 |
18037456-DS-16 | 29,734,446 | Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted for chest pain and underwent several studies that did
not indicate any serious disease was occuring with your heart or
blood vessels. You were treated with tylenol and are feeling
better.
There were no changes made to your medications. Please continue
to take them as prescribed. | ___ year old woman with H/O breast cancer S/P chemotherapy,
radiation therapy and left breast reconstruction using a right
rectus flap, insomnia, depression, and recent hospital admission
(___) for hyponatremia thought due to Effexor
presenting with chest pain. While awaiting a biomarker series to
exclude acute coronary syndrome, she was transferred to ___
when the ___ CTA was interpreted as possibly suggestive
of a small aortic dissection.
# ? Aortic dissection: CTA at ___ was interpreted
formally as "The assessment of the aorta demonstrates focal
minimal area of calcification in the distal portion of the
aortic arch with associated linear low density opacity most
likely representing part of the plaque but focal minimal area of
dissection cannot be excluded." Patient had limited risk factors
for dissection (no HTN, no reported atherosclerosis), pulses and
BPs were noted to be equal in both arms. She was admitted to the
cardiology floor where blood pressures were monitored and
remained in the 110s-120s systolic. Repeat CTA was done on ___
which showed no evidence of aortic dissection. The imaging
finding on the other CTA was presumably an atherosclerotic
plaque, perhaps slightly ulcerated.
# Chest pain: Patient presented with pain in left chest
reproducible with palpation on exam. Troponins were negative x3
between the outside hospital and labs done in the ___. EKG was
unchanged from prior. She notably has minimal risk factors for
CAD. Echocardiogram in ___ was normal without evidence of
post-chemotherapy LV systolic dysfunction, and she had a stress
test in ___ that was negative. Given the fact her pain was
reproducible by palpation and not provoked by physical activity,
a musculoskeletal cause, such as costochondritis, was deemed
much more likely than ischemia. Patient was given acetaminophen
overnight with good effect. On day of discharge, patient did
recall that she had this problem a few years ago after reading
for a long time and thought it could be due to her body position
while reading. Since she presumably has a pedicled abdominal
flap that was redirected to her left chest as part of her
reconstructive surgery, it is conceivable that when she sits in
certain positions, the circulation to part of her chest wall via
the neurovascular bundle originating in her abdomen might be
compromised. It was recommended to the patient that she be
mindful of ergonomics and change positions often while seating
for long periods of time.
# Insomnia and depression: Recent admission for hyponatremia due
to effexor. Mood reported as stable, currently getting ECT on an
outpatient basis. Continued buproprion.
# Breast cancer: on maintenance hormonal therapy, stable
# Pancreatic hypodensity: CT imaging from OSH incidentally noted
a hypodenisty in pancreatic uncus and recommended ___. Official
interpretation commented that it could also be artifact due to
shadowing. Patient was informed of this result on day of
discharge and recommendation for f/u ___.
TRANSITIONAL ISSUES
1. Patient remained full code
2. PCP can consider ___ for further characterization of
incidental pancreatic finding on CT from ___ | 66 | 493 |
15098642-DS-16 | 28,792,277 | 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 a fall at home.
====================================
What happened at the hospital?
====================================
-The fall was due to general weakness caused by an infection.
You were diagnosed with a bloodstream infection caused by a
urinary tract infection. You were treated with appropriate
antibiotics.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Take your medications every day and as directed by your
doctors
-___ attend all of your doctor appointments, this is
especially important to help with your essential tremor managed
by your PCP.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | TRANSITIONAL ISSUES:
-She will need follow up regarding the carbidopa-levodopa
started as an outpatient for the essential tremor. They may be
causing a feeling of slower mentation that the patient has been
describing.
-She will finish a course of antibiotics (PO cipro) on ___.
-She has a murmur on auscultation. Echo was done, but no report
yet at time of discharge. | 121 | 58 |
10961804-DS-8 | 21,730,193 | You presented to the hospital with arm pain and shortness of
breath. You were treated with IV antibiotics for possible
ongoing urinary tract infection and well as IV diuretics for
fluid overload.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Ms ___ is a very pleasant ___ year old female with hx multiple
falls, CHF w/ preserved EF, and pAFib on ___ who presents
with arm pain and found to be hypoxic.
# Acute on Chronic dCHF: Pt presenting with hypoxia and reports
of DOE and possible PND. Also with ___ edema as well as some
recent weight gain. ECG reassuring, and Tn negative x 2. She was
given IV diuresis on presentation and then transitioned to Lasix
40mg BID which she will continue for 2d after discharge and then
continue 40mg Lasix in AM and 20mg in ___ afterwards. Her weight
prior to discharge was 151.9 lb. Creat rose slightly before
discharge and she declined to have labs repeated on dday of
discharge.
# UTI: Unclear if this is truly an ongoing infection, as she
gave conflicting reports as to whether she was still having
dysuria. Urine cx with mixed flora. Decided to continue CTX for
3 day course for uncomplicated UTI as unclear if pt has a true
infection.
# Paroxysmal atrial fibrillation: Stable, currently rate
controlled. Continued home Rivaroxaban, propranolol, and
amiodarone.
# Hypertension: continued home meds
# HLD: continued statin
# CODE: confirmed full
# CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___ | 45 | 214 |
18730522-DS-11 | 23,064,119 | Dr. ___-
You were hospitalized for septic shock, and found to have a
urinary tract infection. You also needed a breathing tube placed
as you were having trouble breathing. You were given antibiotics
which helped your infection, and you were able to be taken off
the breathing tube.
You had a feeding tube placed to help with your nutrition, and
you should continue to get tube feeds while you are working on
your swallowing. | PATIENT
Mr ___ is an ___ year old man with a history of AF on
warfarin, nephrolithiasis, hypothyroidism, urinary incontinence
and G6PD def admitted to the ICU ___ and with ___ (baseline Cr
1.0), refractory acidemia, hyperkalemia and septic shock.
ACUTE ISSUES
# Septic Shock: Initial presumed source pulmonary vs urinary.
Started on vanco, cefepime, and levofloxacin for broad coverage.
Lactate initially severely elevated, but resolved with volume
resuscitation. Weaned off pressors ___. Small volume ascites
non-tapable. GNRs in urine ultimately speciated two colonies of
E. coli, antibiotics subsequently changed to IV unasyn. MRSA
screen negative. The patient should continue the IV unasyn until
___ to complete a 14d course of antibiotics.
# Hypoxic respiratory failure: Felt multifactorial from volume
resuscitation ISO sepsis, moderate right sided pleural effusion,
and possible aspiration. TTE demonstrated that new global
systolic hypokinesis / LV dilation with EF of ___ and 2+
mitral regurgitation, which was felt to be in the setting of
septic shock and myocardial stunting. Extubated successfully to
facemask on ___ (HD #2) and was weaned to room air.
# ___: Patient developed Non-oliguric ATN, likely secondary to
septic shock. Baseline cr 1.0, with peak value of 2.9. After
resolution of sepsis, patient began to urinate and autodiurese
(post-ATN diuresis). Acidemia and hyperkalemia improved with
concurrent improvement of renal function. Renal was consulted,
but patient did not require RRT at any time this
hospitalization.
# CHF: Patient noted to have elevated BNP at admission, with
hypoxia as noted above. TTE demonstrated that new global
systolic hypokinesis / LV dilation with EF of ___ and 2+
mitral regurgitation. Unclear etiology at this time, unclear if
chronic (from tachymyopathy) or acute (from myocardial
suppression of sepsis). Started on metoprolol and uptitrated for
rate control.
# Severe academia: Pt admitted with pH 7.09, due to severe
lactic acidosis (initial lactate 7.5) and uremia. Patient was
initially treated with bicarb amps and a bicarb drip. With
volume repletion and correction of underlying sepsis, academia
improved. However, he continued to have a non-anion gap
metabolic acidosis (with concurrent respiratory alkalosis) later
during his hospitalization.
# Hyperkalemia: in the setting ___ and ___ academia,
patient's intial potassium (non-hemolyzed) was 7.3. EKG without
concerning changes. Initially temporized with furosemide,
insulin/dextrose, and calcium gluconate. Bicarbonate treatment
for academia also reduced serum levels considerably. After
volume repletion and treatment of sepsis, potassium levels
normalized.
# AFib: Previously on dig, stopped ___ PTA. On warfarin. Tachy in
the setting of sepsis, but rates improved with volume
resuscitation, and later initiation of metoprolol. Once
coagulopathy was reversed, the patient's home warfarin was
restarted.
# Bladder Diverticulum: Likely ___ chronic renal stones.
Outpatient f/u.
TRANSITIONAL ISSUES
[ ] check thigh blood pressure (BP on arms SBP 30mmHg lower than
A line, thigh was congruent)
[ ] TTE in 1 month to follow-up newly reduced EF
[ ] CXR in ___ weeks for evaluation of pleural effusion on R
sided lung mass
[ ] needs ACE inhibitor restarted as an outpatient
[ ] Pt will complete a 14d course of antibiotics for sepsis, end
date of unasyn ___
[] Pt needs urology follow-up as an outpatient for bladder
diverticula | 73 | 513 |
13551674-DS-13 | 24,094,187 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated on your right leg
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
___ 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.
INFECTIOUS DISEASE INSTRUCTIONS:
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: CefePIME 2 g IV Q12H
Start Date: ___ (date of knee washout)
Projected End Date: ___ (6 weeks)
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
ALL OTHER B-LACTAMS (Penicillins, Cephalosporins, Aztreonam):
WEEKLY: CBC with differential, BUN, Cr, ESR/CRP.
FOLLOW UP APPOINTMENTS:
Pending
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE
RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER
THE DATE/TIME OF THIS OPAT INTAKE NOTE.
Physical Therapy:
Right lower extremity: Weight bearing as tolerated
Range of motion as tolerated.
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please change dressing every 2 days OR if the dressing is
saturated.
- No dressing is needed if wound continues to be non-draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a septic right native knee and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right knee irrigation and
debridement, 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
infectious disease team followed her during this admission for
her joint infection. She will be maintained on IV Cefepime 2g
q12h for 6 weeks (end date: ___. She has been scheduled with
follow-up appointments in ___ clinic for monitoring of her native
knee infection. She will receive antibiotics through a PICC line
that was placed during this hospitalization. Please see
infectious disease instructions in the discharge paperwork for
antibiotic and lab testing follow-up, and for where lab results
should be faxed (OPAT note also in OMR). 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
weight bearing 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. | 514 | 345 |
16389873-DS-4 | 25,650,655 | Dear Mr. ___,
You were admitted to the neurology service given concern for
possible stroke. Your MRI did not reveal a stroke, and your
symptoms of falling to the L rapidly improved during admission.
It is most likely that you had an inflammation of the balance
system in your inner ear after a viral illness that is
self-resolving.
You should follow-up with neurology and neurosurgery regarding
your aneurysm. | Mr. ___ was admitted to the neurology service given concern
for possible cerebellar stroke. However, upon repeat exam, it
was thought his presentation was more likely consistent with a
peripheral vestibular dysfunction, possibly post-infectious
given a recent illness.
He had L beat nystagmus on L gaze with falling/swinging to the
left; nystagmus resolved and he was ambulating indepdently with
___. The rapid resolution of symptoms was also more suggestive of
a post-infectious transcient peripheral process.
Of note, his clipped L left paraclinoid ICA aneurysm is 5mm,
from 4mm previously and may represent recanalization as seen on
prior imaging. This should be followed by neurosurgery as an
outpatient. His MRI revealed ___ acute/subacute infarct.
LDL 102 and A1C 5.2%. Patient was continued on atorvastatin 20mg
and started on aspirin 81mg upon admission. ASA 81mg was
discontinued after his MRI revealed ___ infarct, and his
atorvastatin 20mg home dose was continued.
He was monitored on telemetry without abnormality.
He will be discharged to home. | 67 | 163 |
11001738-DS-7 | 26,860,242 | Ms. ___ you had undergone an open small bowel resection for a
small bowel obstruction.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Patient is a ___ year old female with a known history of colon
cancer s/p resectionx2 and HBV who presented to ___ ED on
___ due to abdominal pain and several episodes of emesis.
Abdominal CT was consistent with a small bowel obstruction with
concern for a close-loop obstruction and early ischemia. The
patient was evaluated by the surgical staff expeditiously and
due to her positive exam and concerning radiological findings
that patient was consented and taken to the OR for an
exploratory laparotomy, please view the operative note for
further details. The patient tolerated the procedure well, and
transferred to the floor in stable condition. In the initial
post-op period the patient was managed with NPO/IVF, PCA for
pain control, and serial abd exams. The patient was kept NPO
until return of bowel function, at which point her diet was
sequentially advanced to a regular diet which was well
tolerated. Her pain had been well controlled on a PO regimen,
and the patient ambulated independently, and discharged home on
hospital day 7.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dPCA and then
transitioned to oral oxycodone/tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, the diet was
advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 307 | 369 |
19438264-DS-44 | 23,998,287 | You were admitted to ___ for an infection of your right second
toe. We gave you antibiotics through an IV to help control the
infection.
Please keep the surgical site clean and dry. You may shower 48
hours after your surgery. No tub baths. Please do not rub the
area. | Pt was admitted for R second digit infection. IV antibiotics
(vanc/cipro/flagyl) were started on the night of admission and
pt had non-invasive vascular studies the following morning,
which showed no evidence of large vessel arterial disease in the
legs. Labs were drawn, which were essentially within normal
limits. Foot x-rays were concerning for osteomyelitis in the
distal ___ digit. On ___, pt taken to OR for digit
amputation. Pt tolerated the procedure well and was discharged
on a two-week course of minocycline. | 52 | 82 |
19960203-DS-3 | 23,598,678 | Mr. ___,
you were readmitted from clinic with symptoms of dehydration and
with non working PICC line. In ED your PICC was accessed and you
were started on IV hydration. Gastroenterology team was
consulted for EGD, and ___ team was consulted for PEG tube
exchange to G/J-tube. You were continued on TPN during
admission. On ___ you underwent EGD and PEG tube exchange to
gastrojejunostomy tube. ___ procedure you were started on tube
feeding. When you tolerate TF at goal, TPN was discontinued and
PICC was removed. Unfortunately your J-tube migrated to your
stomach, which required holding tube feeding. Your diet was
advanced to regular and you were able to tolerate small meals.
TF was restarted via J-tube and was well tolerated. During
admission you was found to have blood infection and was treated
with antibiotics. You are now safe to be discharged home with
following instruction.
.
G/J Tube care: Please keep G-tube capped. J-tube with tube
feeding overnight. Flush J-tube with 30 cc of tap water Q6H.
Change dressing daily and prn. Keep tube securely attached to
prevent dislocation. Monitor for signs and symptoms of
infection. | Mr. ___ was sent to the ED from clinic on ___ with
dehydration in the setting of not being able to get his TPN due
to a nonfunctioning PICC line. Upon arrival to our ED his PICC
was able to be accessed and he was given fluids.
Gastroenterology was consulted for EGD and possible GJ tube
exchange. Per GI they would want to wait 6 weeks from PEG tube
placement so EGD was deferred to as an outpatient. ___ was
consulted on ___ for placement of a GJ tube. This was
successfully accomplished on ___ and he was transitioned off
TPN to tube feeds.
After starting tube feeds, he developed an episode of
hypotension and was febrile to 100.2. Broad spectrum antibiotics
including vancomycin, cefepime and flagyl were started. His PICC
line was discontinued. Blood cultures eventually grew sensitive
E. coli. Infectious disease was consulted and recommended a 2
week course of Bactrim from last negative blood cultures. Blood
cultures were with no growth since ___. His vitals
remained stable throughout his remainder hospitalization and he
has been afebrile.
His tube feeds were cycled on ___. Hpwever, the morning of
___, his G tube was unclamped due to nausea and 600cc of
tube feeds had come out of the G tube. A drain study verified
that the J tube had been dislodged and was no in the stomach.
Per interventional radiology, a new site would have to be used.
The patient was given a subsequent trial of PO. He was started
on fulls on ___ and advanced to a soft mechanical diet on
___ with good results. However he was not taking in enough to
nutritionally sustain himself and he eventually tube feeds was
restarted overning to provide 50% daily calories. He continued
to tolerate PO around the feeds.
He was eventually discharged home on ___ with plans for
outpatient follow up. The patient and family verbalized
understanding and were agreeable with the plan moving forward.
All questions were answered to their satisfaction. | 187 | 334 |
11784692-DS-20 | 29,971,581 | Dear Mr. ___,
You were admitted for severe worsening headache. You underwent a
Head CT which was normal as well as an MRI of your brain which
was also normal. We trialed different medications for your
headache including Depakote and Steroids which did not improve
your headache. You were restarted on your home Gabapentin and on
three days of Indomethacin as well as continued on home
Oxycodone for pain. You were also started on Flexeril for muscle
spasms. Given persistent headache, we increased your oxycodone
after discussion with the Pain team here and your Primary Care
Provider, Dr. ___. You also underwent occipital nerve blocks
twice during your hospitalization and preaurical nerve block
once with some relief of symptoms. You also received Toradol and
Magnesium to aid in headache relief. Your headache improved
during your hospital stay.
Please keep your Neurology clinic, Pain center, and Primary Care
provider appointments as listed below. Please also follow-up
with your Psychiatrist following discharge.
If you develop worsening of headache and would like for Dr.
___ to perform another nerve block, please call his
office ___ to schedule.
It was a pleasure taking care of you. | ___ M with history of Pancreatitis, Diabetes, HTN, Depression,
Anxiety, Chronic left hip and back pain, Migraines, who presents
with 6 days of severe headache, initially intermittent and now
constant. Progressed from intermittent burning left sided
headache to constant stabbing and intense right sided headache.
Woke from sleep once.
Differential includes migraine headache given unilateral,
throbbing, with photophobia and nausea. Also prior history of
migraines. However, burning sensation, on right side of face and
eye and jaw, is also suspicious for trigeminal neuralgia. Other
possible headaches include: primary stabbing headache, cluster
headache.
Neuro: Obtained NCHCT and MRI brain, both unremarkable.
Restarted home Gabapentin. Started Indomethacin and initially
Amitrityline, later stopped given psychiatric history. Limited
opioids given on narcotic contract. Pain team consulted and
after discussion with PMD, increased oxycodone dose by 50% for
duration of hospitalization, although this helped with back
pain, not headache. Trialed occipital nerve blocks twice and
preauricular nerve block once given positive trigger points with
some headache relief. Also trialed Toradol, Compazine and
Magnesium per pain team recommendations. Headache improved
throughout hospitalization.
CV: Increased Atenolol to 100mg po daily for BP control given
persistently hypertensive.
Endo: Started ISS for hyperglycemia. To discharge on home
Gemfibrozil and Glipizide. | 188 | 198 |
16837152-DS-12 | 26,790,899 | Dear Mr. ___,
It was our pleasure to care for you at ___.
You were admitted from an outside hospital for a fall and new
fracture in your C5 vertebrea. We found that you had fallen as
a result of not drinking enough fluid to keep your blood
pressure high enough to bring blood to your brain (orthostasis).
We trated you with IV fluids and holding some medications which
will make your blood pressure lower. We also found that you
have atrial fibrillation with rapid ventricular response. We
controlled this with a new medication, metoprolol. You should
talk with your doctor about starting anticoagulation.
We made the following changes to your medications:
Please STOP flomax
Please STOP KCL
Please STOP bumetanide
Please DECREASE simvastatin to 40mg daily
Please START metoprolol succinate 25mg daily
Please START tylenol
Please START a lidocaine patch
Please START tramadol as needed. | ___ dementia, CLL, atrial fibrillation that was transferred from
___ for spine fracture evaluation, admitted for
possible syncope work-up.
#Orthostatic hypotension and syncope. Per report, patient did
not have frank loss of consciousness, although is dry on exam.
Patient does endorse remembering entire event with no associated
symptoms. Of note, he has been on Bumex for at least 8 months
and is dry on exam. Per report, patient has been on tamsulosin
for years (according to his HCP). Cardiac history is
significant for atrial fibrillation, and ? MI based on prior
ECHO. Admission ECG showing ? LAFB, do not appreciate prior
infarct, has negative troponin. Wells score for PE low risk (1.3
%) based on HR > 100 (CLL not under treatment). Labs are
suggestive of hypovolemia (hyaline cast, mild azotemia), and
exam shows notable dehydration. Overall favor that patient fell
from dehydration. Tropoinins negative x2. Right shoulder
without evidence of fracture, with Paget's disease evidence.
Echo without WMAs and preserved EF. We volume resuscitated the
patient and he was able to walk with nursing assistance and
wearing his brace. We held Bumex and Flomax during the
hospitalization.
-Hold Bumex
-Hold Flomax but can restart in rehab when patient taking better
PO's and during the time when the Foley will be taken out.
#C5 non-displaced fractures of bilateral C5 pedicles and lamina
and right sided shoulder pain: Neuro exam non-focal. Etiology
could be from ? Paget's disease based on radiological
examination. Alk phos is normal at 69. Shoulder films negative
although limited. Patient is to continue medium aspen hard
collar at all times for 6 weeks (until early ___. Pain control
with acetaminophen standing 1000mg TID and tramadol 25mg q6h
PRN pain and Lidoderm patch. Spoke with neurosurgery again, no
possibility for taking off collar during day to eat.
-follow-up with Dr. ___ in ___ clinic in ___ervical spine (___)
#Atrial fibrillation CHADS 2 of 2 for age and HTN. Patient had
episode ___, likely secondary to pain versus hypovolemia
versus patient being on metoprolol as an outpatient for rate
control in the past, but having it stopped within the last year.
Patient back in sinus rhythm now. Outside echo reassuring (EF
55%, normal wall motion). Previous EKG is similar. We continued
digoxin .25mg M, W, F and started metoprolol which controlled
the patient when he was taking it. We discharged the patient on
25mg metoprolol succinate daily, which he was taking in the
past. Patient was not on systemic anticoagulation as outpatient
given his previous history of atrial fibrillation, and with his
fracture, we did not start anticoagulation in house. We will
have the patient follow up with cardiology as an outpatient
(patient had never seen) to determine anticoagulation.
-consideration of anticoagulation as an outpatient
#Fevers and positive UA. Patient asymptomatic and growing MRSA
from his urine, possible explanation of fevers, although also
possible is due to questionable aspiration event. Leukocytes
likely secondary to long term Foley. He recently did have
urinary tract infection in setting of urinary retention (E. coli
- resistant to fluoroquinolones). Imaging incidental showing
distended corpora cavernosa. CT Abd/pelvis also made note of
circumferential wall thickening with ? bladder stone. Initial
urine culture positive for ___ staph (likely contaminant).
Foley replaced ___
-Follow up with Dr. ___ urology
#Difficulty swallowing: patient per report able to swallow at
rehab and drink thin liquids without difficulty. In hospital
with ___ J collar on patient has intermittently had difficulty
swallowing. ___, patient failed speech and swallow study.
We discussed possibility of ___ tube with HCP and he stated
that this and a PEG tube would be inconsistent with the
patient's wishes. Will readdress when patient has done swallow
evaluation. Per repeat speech and swallow evaluation, we were
able to advance to nectar thick liquids, soft solids, 1:1
supervision, meds crushed with purees. It is likely patient was
having difficulty due to the collar in place.
#Thrombocytopenia: patient baseline platelet count between
80-200k per outpatient records. Currently within this range.
Etiologies of thrombocytopenia since admission includes
medications, dilutional, primary CLL, platelet clumping.
Digoxin, Simvastatin and Tramadol associated with
thrombocytopenia <1% of cases. Patient was stable at discharge
and within his normal range.
#Normocytic, normochromic Anemia
Etiology may be from underlying CLL among other factors. Recent
Hgb 7.9 on ___. No evidence of warm mediated autoimmune
hemolysis from underlying CLL at this juncture. Possibly anemic
due to volume resuscitation and pain/ catecholamines.
Reticulocyte count 1.5, haptoglobin elevated, LDH, total and
direct bilirubin are normal. Transfused ___ 1 Unit PRBC.
Patient had a stable HCT at discharge, with some fluctuations
from lab variation.
#Leukocytosis/CLL
WBC 59.6 on admission with abnormal differential. In ___, he started going above critical value (WBC ~ mid ___.
Since then, he has had WBC 50-70 (last measured ___. Likely reflective of CLL given smudge cells seen on
smear. We continued outpatient folate.
#BPH: Patient symptomatic with chronic Foley in place which we
did not remove given opioid treatment and holding Flomax for
orthostasis. We continued Proscar and Foley until outpatient
follow up with Dr. ___
#Dementia
Patient AAOx1 on admission. Discussed baseline mental status
with caretaker - does have some element of dementia, uncertain
of baseline mental status. Per HCP, patient at baseline
#Hyperlipidemia: We continued simvastatin; however, dose 40 mg
(instead of 80 mg) given recent FDA warning
#Imaging incidentals
-Partially imaged fluid-filled distended corpora cavernosa of
unclear etiology or significance. Clinical correlation and, if
indicated, correlation with ultrasound recommended.
-Fluid within the esophagus, possibly predisposing to
aspiration.
-will place on aspiration precautions
#Transitional:
-Hold Bumex
-Hold Flomax but can restart in rehab when patient taking better
PO and during the time when the Foley will be taken out.
-Patient is to wear neck brace at all times until neurosurgery
follow up
-follow-up with Dr. ___ in ___ clinic in ___ervical spine (___)
-consideration of anticoagulation as an outpatient for atrial
fibrillation
-Follow up with Dr. ___ urology | 140 | 1,016 |
15296749-DS-8 | 20,538,063 | Continue to follow with hospice for further guidance and
medication adjustment. | Ms. ___ is a ___ woman with history of smoking, COPD,
atrial fibrillation not on anticoagulation, DMII, HTN, HLD,
gastric bypass who presented from rehab to BID-M with shortness
of breath, found to be hypoxic and to have multiple hematologic
abnormalities, transferred to ___ for further management. CTA
was negative for PE, but notable for RLL mass concerning for
malignancy and adjacent pneumonia. Attempts at sputum
culture/cytology were were not successful. Patient completed 5
days of ceftriaxone/azithromycin. Patient underwent a bone
marrow biopsy that revealed evidence of small cell carcinoma.
Bone marrow invasion was complicated by progressive
pancytopenia. Pancytopenia was likely due to infiltrative
malignancy, but cirrhosis and possible ITP may be contributing.
Labs also significant for elevated LDH, MMA, LFTs, INR.
Thrombocytopenia was notably low with minimal response to IVIG
and 2 packs platelets. Thoracic oncology and palliative care
guided goals of care discussion as there were limited treatment
options given her comorbidities and baseline limited functional
status. Ultimately, patient was transitioned to comfort focused
care. Goals are to maintain comfort. Family plans to visit the
patient in ___ weeks.
Patient had intermittent acute toxic-metabolic encephalopathy
complicated by delirium. This may have been exacerbated by
sedative medications. Workup included CT A/P that demonstrated
cirrhotic liver with portal hypertension, splenomegaly,
abdominal varices, and trace ascites. Cirrhosis almost
definitely alcohol related, but patient was also noted to be HCV
positive. Additionally, RUQ US showed Prominence of the
pancreatic duct without focal lesions and in relation to
prominent CHD on recent CT raises the possibility of ampullary
sphincter dysfunction. No further workup was pursued given goals
of care. | 11 | 266 |
12658542-DS-21 | 21,926,879 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had a fall and there was concern that you had an abnormal
heart rhythm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a CAT scan of your head, neck, and chest/abdomen which
showed no fractures or injuries.
- You had EKGs which showed that while your heart rate was slow
while you were here. This was thought to be due to the
metoprolol that you were taking, so we discontinued it. You
should continue to follow up with your PCP about this.
- You urine showed signs of infection, you should continue to
take your home antibiotics for this as discussed with your
infectious disease doctor.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY
=======
Ms. ___ is a ___ year old female with a PMH of DM2, HTN,
HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on
apixaban), and schizophrenia presenting w/ mechanical fall, ED
course complicated by tachycardia which was felt to be a-fib,
but this did not recur during her admission and limited
objective records of the event are preserved. During her
admission she had a 7 second pause while on metoprolol, likely
vagal tone given atrial beat and quick return to NSR without
junctional beats. Metoprolol was discontinued as she had been on
this for hypertension only. She had some left sided abdominal
pain from her fall that was well controlled with ibuprofen.
ACUTE ISSUES
============
# Fall:
Patient fell after tripping over her shower chair in the night
without the lights on, no chest pain, SOB, palpitations, or LOC
with the fall, and no shaking or seizures. Trauma workup in the
ED negative for any fractures or acute processes. Physical
therapy evaluated the patient and deemed her stable for home
discharge without further intervention. Pain control with
ibuprofen and Tylenol (2 GM max daily) as needed.
# Narrow-complex irregular tachycardia, possibly a-fib
# Brief hypotension:
Had an episode of narrow-complex irregular tachycardia while
working with ___ in the ED. No reported history of AFib, and no
recurrence of a-fib during roughly 72 hours of inpatient
telemetry monitoring. Unfortunately, only one EKG was obtained
during her episode in the ED; on review of that EKG, clear
p-waves are present for the first half of the tracing,
suggesting a diagnosis of sinus rhythm with pACs. However, the
second half of the tracing is potentially quite consistent with
a-fib. We were nonetheless reluctant to make the diagnosis based
on only three seconds of objective data.
Will discharge with ziopatch to monitor for atrial fibrillation
vs atrial tachycardia, and possible need for rate control
initiation (possibly restarting metoprolol) and decision on
whether to continue anticoagulation past DVT treatment course
(due to end around ___.
#Pause on tele, likely vagal
Seven second pause while sleeping during her first night in the
hospital. She bradyed down rapidly over maybe 20 seconds, had
one non-conducted p-wave, then sped back up quickly to her usual
rate. She was not otherwise bradycardic and had no other
evidence of heart block. Stopped metoprolol with no further
episodes on telemetry. Plan to discontinue metoprolol on
discharge with outpatient uptitration of her lisinopril as
needed for BP control.
# Recurrent UTIs:
Had UA consistent with infection in the ED, but states that she
doesn't currently have any burning or stinging with urination
that comes with her UTIs. Mental status was at baseline and she
had no fever or systemic signs of sepsis. Urine culture showed
ecoli >100,000, and was fosfomycin sensitive. Did not treat
inpatient but discharged with her suppressive fosfomycin.
# RLE DVT:
Continued home apixaban. Has IVC filter in place from bleeding
with rivaroxaban which should be removed now that she is
tolerating AC without bleeding. Discussed with ___ about removing
it this admission versus scheduling for outpatient, and they
felt that they wouldn't be able to fit her in the inpatient
schedule. Plan to have her follow up with her scheduled visit on
___.
CHRONIC ISSUES
==============
# Recent hospitalization for acute liver failure Due to DILI and
unintentional Tylenol overdose:
LFTs normal this admission
# HTN:
Continued home lisinopril. Stopped metoprolol as above.
# DM2:
Last A1C 5.3%. Held home glipizide, restarted on discharge.
# HLD:
Continued home atorvastatin
# Schizophrenia:
Continued home olanzapine
TRANSITIONAL ISSUES
===================
Discharge Cr: 0.8
Discharge Hgb: 8.3
Discharge INR: 1.4
Discharge LFTs: normal
[ ] Has cardiology follow up with Dr. ___ NP, Ms
___, who should review the ziopatch (and the as of
yet unconfirmed EKG from ___ for Atach vs afib and decide
on rate control and/or extending her anticoagulation to
lifelong.
[ ] ID follow up scheduled for management of recurrent UTIs.
Follow up UTI symptoms. Ensure she is taking her home fosfomycin
treatment on the appropriate schedule. Urine culture this
admission with Ecoli, but fosfomycin sensitive
[ ] Atorvastatin restarted this admission, recheck LFT in ___
months to ensure that they remain stable.
[ ] Follow up blood pressures; stopped metoprolol this admission
due to sinus pause, but discharged on ziopatch as above; may
need uptitration of lisinopril if high BPs.
[ ] Consider discontinuation or reduction of her sulfonylurea.
Her A1c is low enough that she is at risk for harm from
hypoglycemia.
[ ] ___ follow up ___ for IVC filter removal!!
[ ] As per CT C/A/P: Pulmonary nodule in the left lower lobe are
stable from prior. 3 mm right thyroid nodules. No follow-up is
recommended per ACR criteria.
[ ] CT C spine with widening of the right facet joint at C4-C5,
likely degenerative, and multilevel degenerative change
including uncovertebral hypertrophy and facet arthropathy
[ ] Has blister packs with ___ pharmacy which was
updated on discharge to not include metoprolol for the follow up
packs. All changes to her medications should be made through her
existing pharmacy so they can adjust her blister packs.
[ ] Discharging with ___ services to help with medications
#CODE: Full Code
#CONTACT: HCP ___ (friend) ___ | 167 | 839 |
15214482-DS-19 | 23,462,878 | AllCare ___ and Home Solutions have been arranged to provide
tube feeding supplies and assist you with managing the feedings.
Please call Dr. ___ ___ if you have any of
the following: temperature of 101, shaking chills, nausea,
vomiting, abdominal pain, diarrhea, clogging of feeding tube,
continued weight loss
Continue tube feeds as instructed. | Mr. ___ was directly admitted from clinic with systolic
blood pressures in the ___. He was admitted. He had a CT
abdomen/pelvis done which showed loops of small bowel that had
improved, less fluid in the gallbladder fossa, a thick bladder,
and no abscess. He was given Macrobid for treatment of presumed
UTI (5-day course). Blood and urine cultures eventually came
back negative. Blood pressures stabilized, and he actually
became somewhat hypertensive while all of his home blood
pressure medications were being held. He was started on
Metoprolol 12.5 mg BID. That same day, he experienced some
indigestion when drinking Ensure. He subsequently passed a
bedside speech and swallow evaluation, but speech therapy
recommended a video and barium swallow, as he was complaining of
being unable to swallow some solid foods (e.g. ___ toast).
Video swallow was negative for any evidence of aspiration, and
the barium swallow displayed normal esophageal anatomy. GI was
also consulted and recommended an EGD, which he had the
following day. Some erythematous patches were noted in the lower
esophagus, but no biopsies were done, as the patient was
continued on Aspirin and Plavix at the time of the procedure. He
was started on Nystatin swish and swallow empirically for
___ esophagitis, and his PPI dosing was increased to
Pantoprazole 40 mg IV BID in house (transitioned to 40 mg PO BID
on discharge). Due to the patient's poor PO intake, he also had
a post-pyloric Dobhoff tube placed at the time of the EGD. He
was started on tube feeds with Gevity 1.5 at 20 cc/hr, increased
to a goal of 60 cc/hr. Macrobid was d/c'ed on the ___ day of the
course. Patient was monitored in house for 2 more days, and
discharged home with the Dobhoff tube in place and ___ services
secured for help at home with the tube and tube feeds. | 53 | 311 |
17281207-DS-21 | 25,042,687 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. As you know, you came in with back pain. This is
due to an acute pain episode from your sickle cell disease. We
believe your peroid may have been the trigger of this episode.
We treated you with IV fluids and IV pain medications. As you
were feeling better, we will discharge you on a higher dose of
oxycodone (short-acting pain medication) for a few days until
your pain further improves.
We encourage you to talk to your primary care physician and
hematologist about starting birth control as a way to decrease
your acute pain episodes.
We glad you are feeling better and we wish you a happy birthday! | ___ with PMH significant for sickle cell disease presents with
back pain.
# Acute pain episode/Sickle cell disease:
Back pain secondary to sickle cell disease. Trigger for this
pain episode likely multifactorial: menses, dehydration (patient
reports drinking ___ per day instead of the recommended 4L),
and stress. Infection was ruled out as the patient did not have
any infectious symptoms, is up-to-date with vaccinations,
negative CXR, and unremakable UA. The patient was treated with
IV fluids and dilaudid IV PRN. When the pain was adequately
controlled, she was transitioned to oxycodone 10mg. We continued
her home MS ___. We talked briefly about birth control to
decrease the acute pain episodes triggered by menses. We would
recommend the Mirena IUD as it does not have an increase risk of
thrombosis and may decrease the amount of blood loss during
menses. We recommended the patient continue this discussion with
her primary care phyisician and hematologist. | 121 | 152 |
19911351-DS-9 | 26,733,842 | Discharge Instructions
Surgery
· Your dressing came off on the second day after surgery.
· Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
· Do not apply any lotions or creams to the site.
· Please avoid swimming for two weeks after suture removal.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· No contact sports until cleared by your neurosurgeon.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· *** You may take Ibuprofen/ Motrin for pain.
· You may use Acetaminophen(Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
· It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs. | # Hardware failure
Mr. ___ presented to ___ on ___ after c-spine xray on
___ demonstrated hardware loosening. At clinic hardware was
palpable in the cervical spine, no threatened skin, no pain with
palpation. Patient admitted to floor in stable condition, CT and
MRI c/t/L spine were ordered for preoperative planning. Plan for
OR on ___ with Dr. ___ cervical hardware removal
and wound exploration. Patient restarted on tube feeds with oral
supplementation per SNF regimen and nutrition consult. Patient
restarted on home medication, preoperative cxr wnl, patient went
to OR on ___ for planned removal of cervical instrumentation
and wound exploration. During the case, when the patient was
flipped into the prone position he became acutely hypotensive
requiring epinephrine and IVF boluses and to be returned to
___ position. TEE done in OR demonstrated hyperdynamic left
ventricle, concerning for hypertrophic obstructive
cardiomyopathy. Patient was unable to tolerate prone position
and the case was aborted. Distal end of incision was revised
with patient in lateral position in the OR. Please read Dr.
___ report for further details of case. Patient was
brought out to the PACU intubated and was managed by the TSICU
overnight. He was started on IV fluids. He was weaned off
sedation, phenylephrine drip, and extubated. He remained
hemodynamically and neurologically stable so patient was
transferred back to the floor. Patient's surgical dressing was
removed on POD #2 and his surgical incision appeared intact with
sutures in place, no active drainage noted. On POD #3 patients
surgical incision with slight opening at the superior portion of
the incision but no active drainage. Patient remained
neurologically stable.
# Chest pain
Overnight on ___, patient complained of sternal chest pain
which was worse with inspiration. EKG was done, reviewed by the
Medicine team, and felt to be grossly stable from EKGs on prior
admission. Troponins were elevated at 0.04 x4. Chest pain
resolved with pain management. Patient continued to complain of
chest pain on ___ worsening with deep breaths and cough. A
repeat EKG was obtained on ___ which was stable compared to
prior EKGs. Pain was thought to be musculoskeletal in nature s/p
OR positioning. On ___ patient stated that his chest pain has
improved.
#Hypoxia
Overnight on ___ into ___ patient with tachypnea and hypoxia
to the 80's. Patient was placed on supplemental O2 via NC with
some improvement in O2 sat. CXR on ___ revealed low lung
volumes, small bilateral pleural effusions with no
consolidation. Patient also underwent a CTPE which was negative
for an acute PE.
# Dysphagia
Patient presented from SNF with PEG tube on tube feeds.
Nutrition was consulted for recommendations regarding tube
feeds. Post-op, patient was restarted on tube feeds and puree
diet per nutrition recommendations. SLP was consulted who
recommended upgrading diet to soft food, thin liquids, meds
whole or crushed in puree, 1:1 supervision with meals and to
slowly decrease TF after 24 hour supervision of tolerating new
diet.
# Urinary retention
Patient presented from ___ with foley catheter in place. Void
trial was attempted on ___, but patient was unable to void and
coude catheter was replaced. Urology was contacted and it was
recommended that patient follow up 2 weeks from time of
discharge for a void trial. Patient was found to have a UTI on
___ when the urine culture resulted as enterobacter. Patient
was given 1Gm of ceftriaxone on ___ and sent to rehab with
Bactrim BID for a ___nd the nursing facility can
extend course to 14 days if needed.
# Dispo
___ and OT evaluated the patient on ___ and ___ and recommended
discharge to rehab. Patient was discharged back to his ___ on
___. | 296 | 607 |
10731984-DS-4 | 25,707,431 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with fever, rash and joint pain and found to have a disease
called Adult Onset Still's Disease and HLH. You were treated for
this problem with steroids and anakinra. You will ___ with
your doctors in ___ and ___ Care Associate's here at
___ for management of this problem going forward.
Plaese continue your prednisone at 50mg a day until directed to
decrease the dose by your Rheumatology doctor.
Best wishes,
Your ___ Team | This is a ___ no significant PMHx recently seen in ED ___
for c/o fever, who re-presents for fever to 103.1, with multiple
physical complaints, as well as elevated CRP, transaminitis,
elevated ferritin and new leukocytosis.
MICU COURSE
# Septic shock / FUO: Met ___ SIRS criteria at admission and
required pressors briefly until ___. Received about 11L fluids.
Initial differential included infectious, autoimmune,
malignancy. Her hemophagocytic process (elevated LDH, ferritin)
was concerning for hemophagocytic lymphohistiocytosis (HLH).
Patient was seen by ID, heme/onc, and rheumatology. Bone marrow
biopsy was performed, which showed hemophagocytosis.
Presentation was felt to be most likely due to HLH vs macrophage
activation syndrome secondary to Still's disease. CT
neck/abdomen/pelvis was performed given tender lymphadenopathy
and to rule out occult malignancy or abscess. CT showed
nonspecific lymphadenophathy and gallbladder wall edema (likely
secondary to volume overload). Echo for vegetations was
negative. Infectious workup to date has been unrevealing. Beta
glucan was elevated, but was felt to be a false positive given
no clinical signs of fungal infection and improvement on
steroids. Patient was started on broad spectrum antibiotics of
___ per ID recommendations on ___ which was
d/c on ___. Patient was given 1g solumedrol daily for 3
days, followed by 60mg prednisone. She was started on Anakinra
on ___. Meropenem was continued because of immunosuppression on
high dose steroids. Patient was also started on bactrim for PCP
prophylaxis on ___.
# Coagulopathy: Patient presented to ICU with low platelets,
elevated FDP, elevated ___ concerning for DIC. Labs were
trended and patient did not require transfution of FFP or
pRRBCs. Labs improved during MICU course and while on floor.
#Transaminitis / ___: Likely multifactorial, related to
inflammation from underlying process and shock. LFTs were
followed and downtrended appropriately.
# ___: Cr 1.3 in setting of septic shock and volume depletion.
UA with bland sediment. Cr returned to baseline during MICU
course and stayed at normal levels while on floor
# Hypoxia: Patient had new O2 requirement in the setting of
aggressive volume resuscitation. Unlikely to be PNA as she did
not have any previous localizing symptoms except a sore throat.
Was initially started on broad spectrum antibiotics as above,
but O2 requirement decreased as patient self-diuresed and was
weaned to room air on ___.
GENERAL MEDICINE FLOOR COURSE
1. HLH/MACROPHAGE ACTIVATION SYNDROME: As discussed, Ms. ___ was
admitted with fever without localizing signs requiring a MICU
admission for hypotension, pressors and broad spectrum
antibiotics. She also was found to have a transaminitis,
elevated LDH, and rapid ferritin elevation to ___ concerning
for hemophagocytic lymphohistiocytosis with unclear precipitant.
Given the clinical suspicion for HLH, a bone marrow biopsy was
performed. Aspirate smear was reviewed with heme pathology and
was significant for hemophagocytosis, consistent with a
diagnosis of HLH. Given the patient's clinical status with
worsening ferritin and LFTs, prompt steroids were initiated. We
believe that she has a form of HLH known as Macrophage
activation syndrome (MAS) which is associated with juvenile
idiopathic arthritis and other rheumatologic conditions. MAS is
a subset of HLH in which successful therapy of the underlying
condition may produce a good response and allow the patient to
avoid HLH-specific therapy. Therefore, pulse dose steroids as
recommended by rheumatology were continued, to which indefinite
anakinra was added.
2. Fevers/Adult Stills: Ms. ___ had fevers with evanescent rash,
pharyngitis, very high ferritin and questionable LAD that best
fit a diagnosis of Adult Stills Disease. She responded to
Stills treatment including pulse-dose steroids. It is possible
that that was triggered by a viral infection, but if so, that
virus had resolved by the time of her hospitalization.
Infectious work-up did not reveal any infectious causes of the
fevers. A quantiferon gold was indeterminate, EBV serology
consistent with prior infection, CMV with no prior infection and
no evidence of Parvo B19, RSF, Erlichia, Anaplama, Lyme
infection. She was started on Bactrim prophylaxis and high dose
IV steroids were started on ___. On ___ Anakinra ___ was
initiated and she was switched to PO Pred 60mg with a plan to
taper by 5mg weekly.
3. ___: As above, her Cr had initially increased to 1.2, but
then restored to 0.5 with fluids as clinical symptoms improved.
She was mildly dizzy without orthostatic vital signs during the
several days before she was discharged and received small
amounts of fluids with good effect.
4. Hypoxemia: As discussed above, Ms. ___ received large amounts
of IV Fluids so this oxygen requirement was most likely related
to fluid overload. No crackles or decreased breath sounds on
exam, but non-productive cough present. This gradually resolved
on its own and she was without an oxygen requirement and with
good oxygen saturation on discharge.
5. DIC: Her fibrinogen was monitored for possible continued low
grade DIC. These lab values steadily improved and did not
require intervention on the floor.
TRANSITIONAL ISSUES
- Ms. ___ is being discharged on both steroids (Prednisone 50mg
per day X 1 week with a planned 5mg per week taper thereafter)
and self-administered injections of Anakinra
- Ms. ___ will ___ with Rheumatology within 1 week
following her discharge
- Ms. ___ will also ___ with a new Primary Care doctor at
___ for management of her other medical
issues
- Please ___ result of IL-2 receptor test | 88 | 867 |
18855412-DS-10 | 20,558,801 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and found to have a hernia that was
obstructing your intestines. You underwent surgery and had your
hernia repaired. After surgery your diet was gradually advanced
and you were monitored closely. You are now doing better,
tolerating a regular diet, and ready to be discharged to rehab
to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is a ___ yo M with history of non-ischemic
cardiomyopathy, AICD, CKD who presented to the emergency
department on ___ with abdominal pain. He underwent CT scan
that was consistent with an incarcerated umbilical hernia. White
blood cell count normal at 5.7 and lactate normal at 1.9. The
indication and possible complications of this procedure were
explained to him preoperatively and appropriate informed signed
consent was obtained. On ___ the patient underwent small
bowel resection and repair of incarcerated umbilical hernia.
Please see operative report for details.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV Tylenol
and then transitioned to oral Tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Initially post operatively he had increased work of
breathing and a new supplemental oxygen requirement. He was
given diuresis and was able to be weaned off oxygen. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO after surgery. He
was given clears on POD3-4 and on POD5 he had return of bowel
function and therefore was advanced to a regular diet which was
well tolerated. Patient's intake and output were closely
monitored. Foley catheter was removed on POD3 and he was able to
void without difficulty. He was hypernatremic to 151 on POD4
with a resolving acute kidney injury. Nephrology was consulted
and he was given D5W and sodium levels improved. IV fluids were
stopped after 1 day with resolution of hypernatremia. After
stopping fluids, sodium level then increased to 153 on POD8.
Acute kidney injury was judiciously managed given comorbidity of
heart failure with an EF of 15%. His creatinine normalized to
baseline of 1.8 at time of discharge. Given his stable clinical
exam and previous response to fluids, increased oral fluids were
encouraged.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
The patient reported foot pain. Xrays negative for acute injury.
Uric acid level elevated at 13. Recommend increased hydration
and further work up for gout as needed.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged to
rehab to continue his recovery. | 379 | 463 |
11924165-DS-16 | 26,262,386 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
You were here for abdominal pain, and MRI and CT scans show that
you had bile leakage. You underwent a procedure called ERCP and
you received a stent in your bile duct. You will need a Repeat
ERCP in 4 weeks for stent pull and re-evaluation.
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. | Patient presented to the ED with abdominal pain
post-cholecystectomy, and MRI and CT scans were positive for
bile leakage. She underwent ERCP with stent placement in CBD.
Patient then experienced significant improvement in abdominal
pain. Subsequent imaging by ___ showed decrease in size of fluid
collection in the gallbladder fossa with no drainable collection
identified. She received IV-ampicillin sulbactam during her
hospital stay and transition to PO amoxicillan-clavulanic acid
prior to discharge.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid and
then transitioned to oral tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, then post ERCP,
the diet was advanced sequentially to a Regular diet, which was
well tolerated. Patient's intake and output were closely
monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Patient will need a Repeat ERCP with GI in 4 weeks for stent
pull and re-evaluation. She was discharged on 5 day course of
amoxicillan-clavulanic acid and tylenol for pain control. | 730 | 301 |
14454179-DS-18 | 28,081,673 | Dear ___,
___ were admitted to the hospital with a life-threatening bleed
into your left lung. Your INR was >4 so we stopped coumadin. ___
underwent a procedure to localize and cauterize the source of
the bleed: a left bronchial artery. ___ required intubation to
help ___ breathe as the blood in your left lung resolved. ___
had multiple bronchoscopies to remove blood clots and mucous
plugs. ___ were followed closely by rheumatologists who
recommended steroids to dampen any possible lupus vasculitis,
which could have caused the bleed.
___ also developed ventilator-associated pneumonia and were
treated with antibiotics.
Your PCP ___ continue to manage your coumadin. For now,
do not take coumadin. We will recommend restarting coumadin in
approximately 1 week, after IVC filter removal, but the final
decision will be made by Dr. ___ in cooperation with your
hematologist and rheumatologist.
Please see below for a list of ___ signs. Please pay special
attention to any difficulty breathing, chest pain including
discomfort with breathing, leg or calf pain or swelling. Also be
aware of ___ signs for stroke including sudden weakness or
numbness, difficulty speaking, and change in vision.
We recommended ___ rehabilitation because ___ were very
weak after 10 days in bed in the hospital. Physical therapy did
not think ___ were safe to go home. However, ___ refused to go
to rehab.
We made the following changes to your medications:
STOP COUMADIN
STOP LISINOPRIL (RECENTLY DISCONTINUED BY YOUR PCP)
STOP GUAIFENESIN
STOP LOSARTAN, please discuss resuming this medication with your
PCP and ___
START CHLOROSEPTIC SPRAY FOR THROAT DISCOMFORT, EVERY 6 HOURS
AS-NEEDED
START PREDNISONE TAPER, 40 MG ___ THEN 30 MG DAILY UNTIL
___ SEE YOUR RHEUMATOLOGIST, WHO WILL GIVE FURTHER TAPERING
INSTRUCTIONS.
START ATIVAN 0.5 mg UP TO EVERY 8 HOURS FOR ANXIETY OR NAUSEA
FOR 10 DAYS. PLEASE DO NOT DRINK ___ WHILE TAKING
THIS MEDICATION. | ___ with SLE c/b lupus nephritis, w/ESRD on PD & bilateral PE on
chronic coumadin p/w hemoptysis & hypoxic respiratory failure,
found to have L bronchial artery bleed.
# HEMOPTYSIS
On admission pt was HD stable, not hypoxia, and without airway
compromise. She did have significant Hct drop, from 29.6 to 20.8
within 24h of admission. Pt is on chonic coumadin for hx
bilateral PE ___ ago; INR was elevated to 4.4 on admission.
Explanation for acute bleed not entirely clear - initial ddx
included infection (PNA vs abscess) in setting of elevated INR
most likely; diffuse alveolar hemorrhage also possible, &
rheumatology consult also suggested possible pulmonary
vasculitis. No new PE seen on CTA. She initially received
antibiotics for possible pulmonary infection (vanc/levo/flagyl,
subsequently narrowed to levo/flagyl). On HD3, underwent
CT-guided pulmonary angiography for question source of bleed and
possible bleeding into mediastinum. Bleed localized to L
bronchial artery, which was embolized. Solumedrol started for
possible vasculitis. Hct stabilized and uptrended thereafter.
There was discussion of possible pulmonary wedge biopsy for
purpose of solidifying a tissue diagnosis to guide possible
immunosuppression but this was decided against after
risk/benefit analysis. Discharge Hct 35.9. Sent home w/steroid
taper to be further managed in rheumatology follow-up next week.
.
# HYPOXIC RESPIRATORY FAILURE
Pt developed respiratory failure while in the ICU, w/increasing
O2 requirement. CXR showed significant left-sided infiltrate,
most likely from L bronchial arterial bleed (as discussed
above). Pt developed progressive respiratory distress requiring
supplemental O2. She was intubated on HD4 for rigid bronchoscopy
and was difficult to extubate, first because of persistent
L-sided infiltrate (blood) and volume overload (retained >5L
over ___ from PD), then because she developed ventilator
associated pneumonia (VAP). She was already on levo/flagyl at
the time (coverage for possible pulmonary infection as
precipitant for hemoptysis, discussed above);
aztreonam/vancomycin added briefly for VAP coverage. On repeat
bronchoscopy on HD9, large mucous plug removed from LUL
bronchus. Pt's respiratory status improved quickly thereafter,
and she was successfully extubated the following morning. Weaned
to RA within several hours, O2 sat in high ___ for >48h
thereafter.
.
#CHRONIC PE/ANTICOAGULATION
Hx indication for anticoagulation was revisited during this
admission given hemoptysis and supratherapeutic INR on
admission. No acute PE on CTA. Heme was consulted and agreed
w/continuing to hold anticoagulation. IVC filter placed. Review
of OMR records revealed that anticoagulation was started in
___ during hospitalization for lung abscess; large bilateral
PEs were revealed on CTA done for unexplained persistent sinus
tachycardia. She has been on anticoagulation since. OMR also
include diagnosis of antiphospholipid antibody syndrome in
OB/GYN notes (based upon 3 miscarriages and hx CVA age ___ but
rheumatology notes/records show autoantibody panel not c/w this
diagnosis ___ positive 1:320, anti-Ro/La positive, lupus
anticoagulant negative x2, *anticardiolipin negative*.
Rheumatology and hematology were consulted here for assistance
with re-evaluation of pt's indication for chronic
anticoagulation and plan to resume anticoagulation. Repeat
serologies sent - lupus anticoagulation now *positive*,
anticardiolipin again negative, b2glycoprotein Ab pending at
time of discharge. Discharge anticoagulation plan as follows:
- IVC filter to be removed in ~1 week ___ aware, procedure
scheduled for ___
- Resume warfarin after IVC filter removed, with f/u INR checks
at ___ clinic overseen by PCP ___. ___ require
re-hospitalization to restart warfarin, TBD by PCP and heme/pulm
in outpatient follow-up
- PCP, ___ and Pulmonary follow-up appointments arranged
- situation discussed with ___ Dr. ___
will review paper records for any OSH coagulopathy studies sent
prior to initiation of coumadin in ___ and share info w/Dr. ___
.
# SINUS TACHYCARDIA
Pt's HR was 100 on admission and trended 100-140 during her
hospital status. Always sinus tachycardia on EKG and telemetry.
Given hx PE, she had bilateral LENIs and a TTE to evaluate any
right heart strain. Both were wnl. No CTA was obtained because
a) pt had an IVC filter placed on admission so low-likelihood
and b) no anticoagulation would have been restarted as an
inpatient given recent life-threatening bleed.
# Hx ESRD on PD
Renal failure chronic, lupus nephritis. Underwent PD throughout
hospital stay. Initially there was some difficulty evacuating
entire content of PD dwells, and pt became volume overloaded.
Renal consult service followed closely and guided modifications
to PD solution. Pt was euvolemic on PD for 4 days prior to
discharge.
.
# Hx SLE
Diagnosed in ___ and followed by Dr. ___. Complicated by
nephritis, & recurrent pleural effusions, w/additional ocular
and skin manifestations. Plaquenil was continued while pt able
to take POs; held while intubated & restarted thereafter.
Rheumatology consult service followed, suggested possibility
that lupus vasculitis or other vasculitis might have contributed
to her hemoptysis (see above) and recommended initiation of IV
steroids. Steroid taper to be further managed by rheumatologist
in follow-up.
.
# Hx HTN
Recently stopped lisinopril for concern of exacerbation of her
cough. BP meds held on admission given concern for bleeding.
Used PRN IV labetolol to control BPs while intubated. After
extubation, pt's BP ran
.
# Hx MIGRAINE HEADACHES
Takes amitriptyline at home at night. Amitriptyline + PRN
tylenol while here.
.
# Hx GERD
Continued ranitidine. Pt did have some nausea and PO intolerance
but was able to take small-volume POs prior to discharge.
.
TRANSITIONAL ISSUES
1. ANTICOAGULATION | 307 | 856 |
13268892-DS-15 | 28,814,277 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had many episodes of bloody
vomiting
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We gave you fluid through your IV to replenish the fluid you
lost from vomiting and bleeding. This made you feel much better.
- We monitored your lab values to check for ongoing bleed. Your
labs were stable, so we felt your bleed had improved and was
minimal at discharge.
- We recommended performing a study called an EGD, where a scope
is used to look at your stomach. You did not want an EGD while
inpatient. We explained the benefits of this procedure,
including:
- Identifying a source of bleeding
- Identifying ongoing bleed which would require more IV
fluids, possible blood transfusions, and/or ablation with the
scope to stop the bleeding
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications as listed below
- Please schedule follow up with your primary care doctor and
with the gastroenterologists to have your bloody vomiting
evaluated. This is important to make sure you don't have any
more episodes of bleeding.
- If you have any difficulty breathing, lightheadedness,
continued vomiting of blood, please go to the emergency room
urgently.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[] Patient should follow up with GI as an outpatient within 1
week for further evaluation of his hematemesis
[] Patient discharged on 1 month course of omeprazole for acute
GI bleed. Continue or stop as clinically indicated.
[] Discharge hgb 13.3
[] Should have Hgb checked within 1 week of discharge by primary
care physician
[] Patient counseled on alarming symptoms that would prompt
urgent ED evaluation
BRIEF SUMMARY
==============
___ HTN, polysubstance abuse, and left AKA d/t osteo, who
presented with epigastric abdominal pain and vomiting 4 days
prior to admission, which progressed to hematemesis concerning
for upper GIB. Trigger unclear as patient denies EtOH use and
has no lab abnormalities concerning for cirrhosis, no recent
NSAID use, or other historical triggers for GI bleed. He was
fluid resuscitated in the ED with 3L IVF, and had CT A/P which
was unremarkable. Labs notable for mild anemia s/p IVF. He has a
history of GIB d/t gastritis, which was the leading diagnosis.
He received IV pantoprazole BID. He was scheduled for EGD,
however felt better and elected to leave the hospital prior to
further evaluation. As he was hemodynamically stable and with
stable H/H, GI and the medicine team felt outpatient follow-up
was acceptable (though not ideal), however counseled the patient
about the benefits of EGD, particularly around identifying a
source of bleed or identifying ongoing bleed which would require
further fluid resuscitation, possible transfusions, and/or
endoscopic intervention with ablation. He was instructed to
schedule his own follow-up with PCP and GI for further
evaluation of his upper GIB. He was discharged on omeprazole 40
BID. Discharge Hgb 13.3.
ACUTE ISSUES:
=============
#Hematemesis
#Concern for upper GI bleed
#Acute blood loss anemia
Given hematemesis with dark stools, presentation is most
concerning for upper GI bleed. Unclear trigger, as patient
denies EtOH, no NSAIDs, no hx cirrhosis and w/o labs concerning
for cirrhosis. Given his 4 days of vomiting that progressed to
hematemesis, concerning for ___ tear. One prior
admission in ___ for the same issue w/ gastritis on EGD; given
the similarity in presentation, he may have repeat gastritis.
Mild anemia likely secondary to blood loss. Treated with IV BID
pantoprazole while inpatient. He was kept NPO starting ___
midnight and supposed to go for EGD. Patient vehemently declined
EGD as he felt much improved and wanted to leave the hospital.
As he was hemodynamically stable and with stable H/H, GI and the
medicine team felt outpatient follow-up was appropriate, however
counseled the patient about the benefits of EGD, particularly
around identifying a source of bleed or identifying ongoing
bleed which would require further fluid resuscitation, possible
transfusions, and/or endoscopic intervention with ablation. He
is to schedule his own follow-up with PCP and GI for further
evaluation of his upper GIB.
CHRONIC ISSUES:
===============
#HTN
Continued home losartan-HCTZ
#s/p AKA
#Phantom limb pain
Narcotic agreement in place, most recent ___ with PCP ___
___. Continued home pain regimen: Percocet, MS contin,
gabapentin.
Pt seen on the day of discharge ___, hemodynamically
stable, denied any further n/v/hematemesis. He preferred not to
stay in-house for EGD and was intent on leaving under a specific
timeframe, not able to secure him an actual appointment time for
GI clinic but we did provide the number and recommended followup
>30 min spent on d/c activities | 241 | 541 |
14556224-DS-5 | 22,201,327 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you had a seizure at home, and you
were found to be confused and requiring oxygen to maintain
normal oxygen levels.
WHAT WAS DONE WHILE I WAS HERE?
- You were seen by our neurology team, who recommended that you
stay on Keppra 1000 mg twice a day.
- Your labs were monitored closely.
- You had some confusion, which we thought was due to your liver
disease. This improved with you taking lactulose.
- You required some supplemental oxygen briefly, but you no
longer required oxygen on day of discharge.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Please take your medications and keep your appointments.
- It is very important for you to take your lactulose and
rifaximin, as this will prevent you from becoming confused due
to your liver disease.
- We would strongly recommend that you stop drinking.
- If you develop fevers (T > 100.4 F), confusion, belly
swelling, or shortness of breath, please call your doctor or go
to the nearest Emergency Room.
Be well,
Your ___ Care Team | SUMMARY
========
Mr. ___ is a ___ with a history of EtOH use disorder,
alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal
seizures who presented with altered mental status and hypoxia
s/p a presumed seizure. | 190 | 32 |
15041433-DS-21 | 20,984,099 | Dear Mr. ___,
You were admitted to the hospital with an asthma exacerbation.
You were given steroids and nebulizers and your symptoms
improved. Your exacerbation was most likely triggered by a viral
upper respiratory infection.
You will continue to take oral steroids for 3 more days after
you are discharged in order to treat your asthma exacerbation.
You should continue to take your albuterol inhaler as needed.
Please attend your follow up appointment as listed below.
Thank you for choosing ___. It was a pleasure caring for you!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
========================
- None
MICU COURSE
=========================
___ with a history of asthma presenting with an acute asthma
exacerbation likely triggered by a viral upper respiratory
infection.
#Asthma exacerbation: Most likely asthma exacerbation given
history, wheezing on exam and great improvement with
bronchodilator therapy. No history of heart failure, no volume
overload on exam and history inconsistent with CHF. Low concern
for bacterial infection given no fevers, normal CXR, no
leukocytosis. Asthma exacerbation likely triggered by viral URI.
Patient was treated with albuterol nebs Q4h, albuterol nebs Q2h
PRN SOB, ipratropium Q6h, prednisone 40mg PO on discharge with
taper based on symptoms. Flu shot was offered prior to
discharge. The patient's respiration improved with these
interventions and without need of supplemental oxygen.
#Lactic acidosis: No documented hypotensive episodes with very
low concern for end organ and tissue hypoperfusion. Lactic
acidosis likely secondary to beta agonist therapy with stacked
albuterol nebs in the ED. No need to trend lactate. Vital signs
per ICU protocol and can trend lactate if patient develops any
signs of systemic infection or hypotension. Patient did not
develop these signs and no further lactate measurements were
indicated. | 87 | 184 |
11720931-DS-21 | 26,018,558 | Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted out of concern for a pneumonia
What was done for me while I was in the hospital?
- We looked at your lungs with a cat scan, which showed you have
bronchitis
- We looked at your urine under a microscope, and we were
concerned you had a bladder infection
- We started you on antibiotics to treat your infections
What should I do when I leave the hospital?
- Please take your medications as prescribed
- Please keep all of your appointments
- continue your pureed diet with nectar thickened liquids
Sincerely,
Your ___ Care Team | Summary
___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's
disease, DMII, atrial fibrillation on apixaban, and asthma who
presented with dyspnea and a CT scan from an outside facility
suggestive of right lower lobe pneumonitis vs PNA iso probable
aspiration. Read of CT scan here was more concerning for viral
bronchitis. She was also found w/ pyuria. Discharged to complete
a 7 day course of augmentin/azithromycin for CAP/UTI.
Transitional Issues
===================
[] found w/ hypercalcemia (mild) with elevated PTH, normal vit
D.
[] Patient is being followed by neurology and likely does not
have parkinsons disease. She is being weaned off her parkinsons
medications, ensure patient has adequate neurology follow up.
[] Augmentin ___, azithromycin ___
[] Recommend repeating CXR in 6 weeks to eval for resolution of
bronchiolar inflammation, consider CT scan at that time
Acute Issues
============
# Dysphagia, Aspiration Risk
# Aspiration Pneumonia
# Bronchitis, viral
Outside imaging with RLL pneumonitis per report. Patient is at
aspiration risk given CVA history with fluctuating mental
status.
CXR on presentation was without focal consolidation. BNP wnl.
Started on IV unasyn and azithro. CT chest here was concerning
for acute infection, likely viral bronchitis. Given the clinical
setting, w/ neurologic deficits and aspiration risk, we elected
to treat for CAP, unasyn transitioned to Augmentin ___ -
___, and continued azithromycin. Speech and swallow evaluated,
recommended continuing nectar thick liq/pureed solids, no e/o
aspiration at time of d/c.
# UTI: UA w/ positive nitrites, WBCs, urine cx contaminated. As
above, on IV unasyn initially, transitioned to PO augmentin at
time of d/c to treat PNA and UTI concurrently.
# Atrial fibrillation
Continued apixaban, briefly on a heparin gtt while NPO.
# Hypercalcemia
Corrected calcium 11.5 on admission. PTH notably elevated. ___
be
primary parathyroidism +/- some component of bone resorption due
to patient's immobility. Currently asymptomatic w/o GI symptoms,
nephrolithiasis, appears at neurologic baseline. Vitamin D wnl.
CHRONIC ISSUES:
===============
# Tremor
# Concern for ___ Disease
Per last neuro note, was started on amantadine and
carbidopa-levodopa at rehab due to concern for ___
disease. However, per neurology, do not think patient has
underlying parkinsons and think her symptoms are likely related
to stroke. Per family medications have not improved symptoms
much
and neuro is weaning off meds currently. Continued
carbidopa-levodopa ___ 0.5 tab TID, and amantadine 100mg
daily for now, will continue wean w/ neuro as OP.
# DMII
-Discharged on metformin
# History of CVA
- Continued atorvastatin 80 mg PO QHS
# History of GI bleeds (esophagitis and ischemic colitis)
- Continued PPI
# Grave's disease
- Continued methimazole | 129 | 396 |
18622600-DS-33 | 23,804,775 | It was a pleasure to take care of you at the ___!
You came to the hospital yesterday because you had a positive
blood culture. You also had abdominal pain, nausea, and
vomiting. You were treated in the emergency department with
vancomycin, morphine, zofran, and acetaminophen. Your abdominal
pain, nausea, and vomiting were relieved by the time you were
transferred to the internal medicine floor. You received
hemodialysis the following morning. During hemodialysis, you
were given another dose of vancomycin. The blood culture from
___ grew a strain of organism that can be treated in the
outpatient setting (coagulase negative staph). Hopefully, your
line will not need to be changed in order for this strain to be
treated.
We ADDED Vancomycin (dosed at Hemodialysis) to your medication
list
-> you will continue vancomycin for 2 weeks
- if there are questions about the dosing scheme, these can be
directed to Dr. ___ office at ___
Otherwise your medication list is the same as that you had when
you visited your primary care physician ___ ___. | Ms. ___ is a ___ year old woman who came to the ___ because
of a positive blood culture, received hemodialysis, and
receieved antibiotics for line infection.
.
#Bacteremia: A blood culture was performed during a hemodialysis
session on ___ that grew staph epi in ___ bottles of 1 set. She
was then referred to the ED the next day where she received 1g
of Vancomycin; 2 sets of blood cultures were taken. She
remained afebrile. Her WBC was 4.7. She received a second dose
of vancomycin during hemodialysis on ___. Cultures from the ED
on ___ grew staph epi in 1 of 2 sets - ___ bottles. Nephrology
recommended treating through the infection with vancomycin for 2
weeks per HD protocol and this was communicated to her outpt HD
center - ___. Her line was not replaced.
.
#Abdominal Pain, Nausea, and Vomiting: Ms. ___ developed
abdominal pain soon after her hemodialysis session on ___ ended.
This pain was followed by nausea and emesis. She mentioned
that she had eaten at a restaurant at which she formerly
developed a gi illness. She received morphine and ondansetron
while in the emergency department. After she was transferred to
the internal medicine floor, she no longer complained of
abdominal pain, nausea, and vomiting.
.
#Abnormal EKG/CAD: An EKG done on the internal medicine floor
showed inverted T waves in leads I, II, III, and V3-V5 that were
new compared to an EKG from ___. CK-MB and troponins were
sent which were negative for ischemia. Continued her home
medications of Lisinopril 40mg po daily and metoprolol tartrate
100mg po bid.
.
#Chronic Kidney Disease: Ms. ___ has stage V chronic kidney
disease on hemodialysis. She received hemodialysis on ___. She
had an elevated Ca level of 11.2 and an elevated PTH of 3381.
Her PTH in ___ was 2913. Continude her home medications of
Sevelamer 800mg with meals, Nephrocaps 1mg capsule daily, and
Epoetin Alpha.
.
#HIV: Ms. ___ was diagnosed with HIV ___ years ago. She is
followed by the infectious disease specialist, Dr. ___
___. Continued HAART: Atazanavir 300mg po daily, Ritonavir
100mg po BID, Raltegravir 400mg po BID, Emtricitabine 200mg
q96hr (has not yet filled ___ prescription).
.
#Hypertension: Ms. ___ was markedly hypertensive, to a
systolic pressure of 198, while she was in the emergency
department. Despite not having received any anti-hypertensive
medications, her blood pressure fell to 116 upon admission to
the floor. Her systolic pressure then rose to 170 by nighttime.
She received a dose of metoprolol at that time, after which her
blood pressure remained normal throughout the remainder of the
hospitalization.
.
#Transitional issues:
Follow up appointments: She will be following up with her
nephrologist, Dr. ___.
- management of hypertension
- management of hypercalcemia and secondary hyperparathyroidism
Code Status: Full (Confirmed)
Contacts: Son, ___ is healthcare proxy (she does
not have his phone number). Can contact other son, ___,
in case of emergencies, (___). | 177 | 500 |
19349235-DS-11 | 25,359,969 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for evaluation of anemia. You had imaging done that did
not show any signs of bleeding. You had no signs of blood in
your upper or lower gastrointestinal tract. You were found to be
iron deficient and you should start taking iron supplements. You
should also follow up with Dr. ___ Dr. ___ this.
As we discussed while you were here, you may need IV iron to get
your levels back to normal.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please make sure to follow up with your outpatient providers as
listed below.
Please see the attached sheet for your updated medication list.
As you know, iron supplements may cause constipation. Please do
not stop taking them. Instead, add senna to your
___ medications. If you are still constipated,
call Dr. ___ recommend other ___
medications. | ___ with significant cardiac history including PPM placement,
CABG, AVR x2 and CKD p/w worsening ___ edema and increasing
dyspnea on exertion found to have significant hematocrit drop
from 31 to 24 over the past several days.
.
# Anemia - Unclear etiology of acute worsening of anemia but
found to be severely iron deficient, guaiac negative, and
without systemic signs of active bleeding. Imaging was also
reassuring- without occult hematoma. Hematocrit increased almost
appropriately to 2 u PRBCs and remained stable. INR was slightly
supratherapeutic but corrected and remained therapeutic
thereafter. She will need close follow up for management of
anemia, given that she probably has persistent low grade
intravascular hemlysis from her mechanical valve which has been
documented in the past. She was started on iron supplementation
and given instructions to relieve constipation as needed. She
may require outpatient IV iron repletion and should discuss this
with her PCP and nephrologist.
.
.
# Acute on chronic kidney injury: Chronic stage IV CKD followed
by Dr. ___ felt to be from hypertensive disease which
has been well controlled. Acute injury due to hypoperfusion and
resolved ___. Ace inhibitor was held on admission
and restarted upon discharge. Patient was encouraged to drink
water as she had been restricting ALL fluid intake prior to
admission. Follow up with PCP and nephrology as outpatient.
.
.
# CAD and CHB s/p PPM, AVR x2: Stable during this admission.
Continued home clopidogrel and furosemide. Initially held
warfarin for elevated INR and restarted on normal dosing
schedule prior to discharge. Changed ezetimibe and simvastatin
to atovastatin.
.
.
# Gout: Stable and inactive during this admission, held
colchicine during admission for ___ and restarted upon
discharge. Allopurinol continued throughout admission.
.
.
# Leg Swelling: continue home lasix for now and monitor
.
.
Transitional Issues:
- Full code
- ___ with PCP
- ___ with nephrology
- ___ with cardiology and device clinic | 159 | 311 |
17889382-DS-13 | 28,958,709 | You underwent surgery to remove a brain lesion from your
brain.
You underwent a biopsy. A sample of tissue from the lesion in
your brain was sent to pathology for testing. .
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener. | Mr. ___ was admitted to ___ Neurosurgery service on
___ for further work-up of his word-finding difficulties and
new right cerebellar lesion. He was started on Decadron due to
noted vasogenic edema noted on his outside hospital MRI.
The patient was admitted to the inpatient ward for close
neurologic monitoring. Neurology was asked to see the patient
due to his word-finding difficulties.
Mr. ___ was consented for surgical resection of his brain
mass on ___. A chest x-ray and pre-operative labs were
ordered, in addition to a MRI wand study.
On ___, The patient went to the operating room for a R
suboccipital craniotomy for tumor resection by Dr ___. The
procedure was tolerated well. The patient was recovered in the
PACU and stayed there overnight. A post operative head Ct was
performed which was consistent with expected post operative
change.
On ___, The patient was in the PACU in the morning. He was
found to be neurologically intact. The patient denies headache
however stated that he had ___ neck pain. The patient was
started on a low dose of muscle relaxant ROBAXIN. Given the
patients excellent neurological exam, the patient was
transferred to the floor. The patient had his post operative
MRI which was consistent with post op changes, and small foci of
blood and edema. In the morning the patient complained of
objects in his vision field moving downward- this occurred ___
days prior to his surgery but went away, the patient's
peripheral vision was intact and the patient remained
neurologically intact on exam. The patient Foley catheter was
discontinued.
On ___, the patient remained neurologically and hemodynamically
intact. He voided without difficulty. He was mobilizing with
nursing and was evaluated by physical therapy who recommended
outpatient ___. His dressing was removed and his incision was
clean dry and intact with sutures. His pain was well managed on
his current pain regimen.
___: cleared by ___, OT says home with direct supervision for
IADLs, dispo planning, re-eval, home OT and outpatient ___ with
___.
___: neuro intact, no dysmetria. d/c home ___, home OT, outpt
___, dex taper. | 339 | 361 |
10236309-DS-18 | 28,802,658 | Dear Mr. ___,
You came to the hospital because you were not feeling well.
You had a chest x-ray that may have showed pneumonia, though
this was hard to tell because of your plaques.
You finished a course of treatment for pneumonia with
antibiotics and started to feel a lot better.
You also got treatment for COPD exacerbation with steroids,
which really helped you.
When you go home, please work with a physical therapist.
Please talk to your cardiologist and primary care doctor about
the pain and fatigue in your legs because this may require
further testing and treatment.
Your lasix (water pill) amount was decreased. Please weigh
yourself every morning, call MD if weight goes up more than 3
lbs in one day or 5 lbs in one week.
It was a pleasure caring for you and we wish you the best!
Your ___ Care Team | Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular
pacer, COPD on 2L at home, CKD, asbestosis with known pleural
plaques, AAA s/p repair who presented to the ED with a 4 day
history of myalgia, SOB, and cough. | 138 | 43 |
19768422-DS-15 | 23,522,497 | Dear Mr ___,
It was a pleasure being involved in your care at ___
___. ___ were admitted to the hospital due to acute
worsening of your chronic low back pain. An MRI showed that ___
have a herniated disc in your back that is starting to press on
some nerves and causing your symptoms. There was no sign of
infection or masses in the back.
We started ___ on some pain medications to help control your
symptoms. ___ should continue to take ibuprofen and tylenol
scheduled around the clock, with oxycodone available as a
stronger medicine when the pain is bad. Do not drink alcohol,
drive or operate heavy machinery while taking oxycodone.
Avoid doing any lifting or twisting motions that may worsen your
symptoms. Physical therapy will be an important part of your
recovery, so please bring this ___ prescription to your local
physical therapy office to begin sessions. ___ also should make
an appointment with a back surgeon for evaluation for possible
surgery in case your symptoms continue unabated.
Your lisinopril was also increased to 20mg to help better
control your blood pressure. | ___ yo M with h/o hypertension and herniated lumbar disc with
sciatica x 6 months presents with worsening low back pain
radiating down left leg similar to previous sciatica.
# Lumbar radiculopathy: History and exam consistent with
exacerbation of known herniated disc leading to worsening
radicular pain down left leg. No evidence of cord compression
or cauda equina on exam. Xray did not show any bony
deformities. MRI confirmed severe degenerative disc disease with
lumbar disc herniation resulting in multilevel moderate to
severe spinal stenosis and nerve impingement, worst at left L5
(consistent with symptoms). His pain was fairly well-controlled
with standing tylenol and ibuprofen with PRN oxycodone, so he
was discharged on this regimen for pain control. He was
encouraged to continue physical therapy and establish care with
an orthopedic spine specialist for further evaluation and care.
# Hypertension: increased lisinopril to 20mg daily | 196 | 149 |
13040343-DS-15 | 20,456,515 | Dear Mr. ___,
You were hospitalized due to symptoms of right hand numbness,
difficulty speaking, and headache 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.
We incidentally found aneurysms in your MCAs which should be
evaluated by Neurosurgery in outpatient clinic. Please call
tomorrow to make an appointment in their clinic.
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:
History of Radiation and Cancer
High Cholesterol
High Blood pressure
We are changing your medications as follows:
1. START Aspirin 81mg daily
2. START Atorvastatin 10mg at bedtime
3. START Amlodipine 5 mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | He was admitted for dysarthria and Right hand numbness. His MRI
notable for a punctate infarct in L parietal lobe, small vessel
ischemic changes. CTA and US notable for atherosclerosis, <40%
stenosis. His stroke risk factors were evaluated and notable for
history of radiation, A1c (5.3%)/LDL (117)/ Echo: no PFO/ASD,
normal EF. He was started on ASA 81, Atorvastatin and Norvasc
for BP control. Renal following for PD. ___ cleared for home
no services. He was set up with a holter to monitor for pAFIb.
He was discharged home.
Transitional issues:
- ___ of ___ Holter
========================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 117) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (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 | 312 | 323 |
11099330-DS-18 | 20,894,078 | Dear Ms. ___:
You were admitted to ___ after
a fall. The cause of your fall was likely related to not eating
and drinking enough. You were found to have an acute kidney
injury and we gave you fluids to treat this. We also decreased
some of your home medications which are known to cause altered
mental status. You were seen by geriatricians who think your
altered mental status was related to worsening dementia. You
were seen by a geriatrician who recommended starting a new
medicine called citalopram and going down on your home
venlafaxine.
Changes to your medications:
(1) start citalopram 10mg daily
(2) decreased gabapentin to 100mg twice daily
(3) decreased ativan to 0.5mg three times daily
(4) decrease oxycodone to 5mg every 6 hours as needed
(5) decrease venlafaxine to 37.5 mg daily
(6) STOP ambien
You should take all of the rest of your home medications as you
were before.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team | ___ w/ h/o dementia, poorly controlled HTN, on ASA 81 presents
s/p fall in the setting of declining mental status of unknown
etiology with CT showing no acute intracranial hemorrhage but
labs concerning for ___. Cuase of the fall thought to be 2'/2
orthostatic hypotension in the setting of decreased PO intake.
Although her mental status improved with holding of delirium
inducing medications and hydration to treat her pre-renal
azotemia, she was seen by geriatrics who thought her
presentation was most likely related to worsening dementia. | 157 | 86 |
16751019-DS-28 | 29,364,273 | Mr. ___,
It was a pleasure taking care of you at the ___
___ ___. You were admitted to the hospital
because of generalized weakness. It is possible that this was
caused in part by dehydration. You were given some fluids IV and
you improved. You missed a dialysis session on ___ so had
dialysis on ___ in the hospital. Following the dialysis you
were feeling back to baseline. You had another dialysis session
on ___ and were discharged home. Please weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
You were also found to have mildly low thyroid levels. We are
going to check some additional test and your PCP, ___
let you know whether any changes to your thyroid medications are
necessary. | ___ yo M with PMH ESRD on HD, afib on coumadin, HTN, CHF with EF
48% p/w generalized weakness.
ACTIVE ISSUES
# Weakness
Unclear etiology at presentation. One possibility included a UTI
so initially started on antibioitics, however U/A was not
convincing and no leukocytosis so antibiotics were discontinued.
No cardiac symptoms suggesting ACS or focal symptoms to suggest
infection. No neuro findings to suggest CVA or neuropathic. He
had signs of volume depletion so he was given IVF with some
improvement in weakness. Also the possibility that neomycin
bladder dwells could have been causing the weakness so the
volume of neomycin was decreased. At discharge patient felt
back to his baseline strength and was safe for discharge.
# Hyperkalemia
Patient presented with K of 7.1 and EKG showed peaked T waves.
He was given one dose of kayexelate and had two rounds of HD.
On discharge his K normalized and his EKG was at baseline.
# ESRD:
On HD ___, Th, Sa. Missed Th HD so got HD ___ and had a repeat
HD on ___ for ___ schedule. Continued cinacalcet, nephrocaps,
and sevelemer.
CHRONIC ISSUES
# Anemia
This is a chronic, but at presentation he is above baseline and
most likely hemoconcentrated. There was no concern for active
bleeding at this time. His hematocrit was stable throughout the
hospitalization.
# Atrial fibrillation
Continued his home dose of coumadin and metoprolol XL. No
issues during hospitalization and he was discharged
hemodynamically stable.
# Hypertension
Continued home dose of metoprolol.
# CHF
Continued lasix and metoprolol per home regimen.
# Gout
Continue home dose allopurinol.
# Hypothyroidism:
Contine home dose Levothyroxine.
TRANSITIONAL ISSUES
- Please follow-up at your regularly scheduled Dialysis center
- Please follow-up Free T4 and T4
- Follow up blood cultures, urine culture.
- Please follow-up with your primary care physician, ___. | 131 | 313 |
15107347-DS-33 | 21,757,511 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came to the hospital out of concern for
misplacement of your Dobhoff feeding tube. This was found to be
in the correct location.
We made the following changes to your medications:
1. Lubiprostone 24 mcg twice a day
2. Olanzapine 2.5 mg at nighttime
3. Tramadol (Ultram) 50 mg every 6 hours as needed for pain
Please stop the following medications:
1. Bentyl 20mg QID
2. Trazadone 100mg at nighttime
Please continue to take your other medications.
Please follow-up with your providers as listed below. | ___ female with pmhx of anorexia, osteoporosis, chronic anemia
and migraines presenting from ___ with nausea and concern for
migration of Dobhoff.
# r/o Dobhoff migration - Dobhoff has not migrated, it is in
proper place. However a new Dobhoff was placed in the stomach on
___, as ___ (where she is being discharged to) does not
take post-pyloric tubes. This was verified by chest-xray on the
day of discharge.
# Nausea - pt complains of nausea with emesis, and abdominal
pain. Nausea is a chronic problem, perhaps secondary to
gastroparesis from life long anorexia, could also be secondary
to celiac sprue or somatization. She was treated with Zofran and
ativan PRN. We discontinued her bentyl and started amitiza for
possible irritable bowel syndrome and bloating. At the time of
discharge her abdominal pain and nausea was moderately improved.
We increased her ativan from 0.5mg to 1mg TID as needed for
anxiety and nausea.
# Anorexia: The patient had normal electrolytes with exception
of slightly elevated phos. Eating disorder was not initiated as
patient was tolerating tube feeds. She was allowed to order and
eat food for pleasure. Her weight was recorded daily, and at the
time of discharge she weighed 93.2 lbs or 42.3 kg from 41kg on
admission.
# GERD: continued Ranitidine, Maalox.
# CELIAC DISEASE: Maintained gluten-free diet.
# DEPRESSION, ANXIETY: continued Venlafaxine, Abilify,
Clonazepam. She was started on olanzapine 2.5mg QHS on ___,
which she tolerated well. QTc was not elevated. We increased her
ativan from 0.5mg to 1mg TID as needed for anxiety and nausea.
# MIGRAINES: continued sumatriptan and Fiorocet as needed for
headache.
# OSTEOPOROSIS: we continued Calcium, Vitamin D.
# CODE STATUS: Full Code
# EMERGENCY CONTACT: ___, sister ___
___, sister, ___ | 99 | 283 |
17468433-DS-14 | 24,817,629 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for a spinal abscess
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were seen by infectious disease and radiology and it was
determined that your abscess was too small for drainage
- You received IV antibiotics for your infection
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- You decided to leave against medical advice as we have not
placed a PICC or set up home antibiotic infusions with
vancomycin. We will try to schedule this once you leave the
hospital, but this will be difficult and you will likely miss
several doses of your vancomycin. Since you understand the risks
of death, septic shock, recurrent bacteremia, we are discharging
you against medical advice.
- Please come to the emergency room if you develop fevers,
worsening back pain, numbness or weakness, lightheadedness, or
any other symptoms that concern you as it may be a sign that
your infection is back.
*** It is very important that you attend your appointments as
listed below, especially your appointment with infectious
disease. ***
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[] Minocycline dose increased to 100mg q12h, she should continue
on this dose after completing antibiotics for her current
infection
[] Blood cultures from ___ with coag negative Staph
(preliminary), follow up final culture results
[] Discussed with patient risks of leaving the hospital prior to
speciation of cultures and prior to set up of antibiotics for
home infusions. Attempted to coordinate home antibiotics but
were unable to coordinate this on a ___ with her insurance.
She understood the risks (death, septic shock, recurrent
bacteremia) and chose to leave the hospital against medical
advice. She will have an appointment with ID at 10 am on ___
and is agreeable to this and we will email them about the need
to set up PICC placement and home infusions of Vancomycin 1250
mg IV Q 12H pending follow-up with ID regarding course.
[] Held home irbesartan at time of discharge. Follow up BPs and
consider restarting as outpatient.
BRIEF SUMMARY
=============
Ms ___ is a ___ year old woman with history of MRSA
infections (notably left knee PJI, T6-T7 discitis requiring
T4-T9 fusion in ___, hx of L3-L5 fusion laminectomy in ___,
IDDM, HTN, CKD, hypothyroidism who was admitted for evaluation
and treatment of suspected spinal abscess on MRI. This was
evaluated by ID and ___ and determined that it was not accessible
for biopsy or drainage. She was started on IV vancomycin with
final antibiotic course pending blood culture speciation. She
left against medical advice prior to determination of final
antibiotic course.
ACUTE ISSUES
============
#Suspect spinal abscess
#GPCs in blood
#Recurrent discitis
Found to have rim-enhancing fluid collection near L2 on recent
outpatient MRI, along with increasing CRP, concerning for
abscess and potential discitis despite chronic minocycline. ___
BCx from ___ grew coag negative Staph (preliminary). ID was
consulted and recommended IV vancomycin with final antibiotics
pending speciation; however, the patient left against medical
advice prior to determination of final antibiotic course. She
was discharged on her home minocycline 100mg q12h (she had
previously been on 50mg q12h but clarified dose should be 100mg
q12h).
#Left shoulder pain
History of OA of shoulder, s/p cortisone injection ___. She had
pain on moving her L shoulder this admission. She was evaluated
by orthopedics who recommended ___ guided aspiration to rule out
infection (low suspicion), which she declined. Shoulder pain
improved the following day.
#Diabetes, insulin dependent
On Tresiba 46 units in AM at home, treated with insulin glargine
and ISS while inpatient.
___
Baseline renal function with Cr of 1.0, elevated to 1.9 on
admission, suspected pre-renal I/s/o worsening infection and
dehydration. Cr downtrended after IVF and was 0.8 at time of
discharge.
#Hypertension
Held home irbesartan in setting ___ and normotensive at time
of discharge. Initially held furosemide in setting of ___,
restarted after Cr improved.
#Depression
Continued sertraline
#Peripheral vascular disease
Continued rosuvastatin and aspirin
#Chronic pain
On methadone and hydromorphone as an outpatient which were
continued. She reported her home dose of hydromorphone 4mg q4h
prn despite Atrius records stating hydromorphone 2mg q4h prn so
was continued on hydromorphone 4mg q4h prn this admission.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 218 | 558 |
15437107-DS-9 | 22,809,410 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You came to the hospital because you developed
weakness and changes in sensation in your legs. You chose to
leave the hospital against medical advice prior to the
completion of your workup.
We recommend that you return to an emergency room if your
symptoms worsen. Please continue to take your medications as
prescribed and follow-up with your doctors as ___.
We wish you all the best,
Your ___ care team | Mr ___ is a ___ M with a h/o multiple spinal surgeries
following spinal cord accident in early ___, s/p cervical
spine fusion, lumbar spinal fusion, cauda equine syndrome s/p
decompression/fusion (___) with chronic lumbar spinal pain (on
fentanyl and hydrocodone), h/o multiple MRSA infection incl.
bacteremia, chronic diverticulitis, Crohn's and RA (on
immunosuppression), and CVL who p/w acute on chronic back pain
with b/l lateral lower extremity pain, saddle paranesthesias,
inability to void, and bilateral lower extremity weakness
following a minor fall at 14:30 on ___. CT head, abdomen/pelvis,
C-spine were unremarkable. He chose to leave AMA shortly after
his admission prior to completion of Neurologic workup, despite
counseling regarding dangers of leaving. He was offered his home
medications and additional nonnarcotic neuropathic pain
medications in-house. Final radiologic reads of MRI lumbar and
thoracic spine were pending at time of discharge. MRI brain and
C spine were scheduled but not yet performed; ESR and CRP
pending. | 80 | 157 |
12702423-DS-8 | 26,000,954 | Dr. ___,
___ was a pleasure taking care of you at ___. You were
admitted to the hospital due to fevers and hypotension. You
initially went to the ICU and were given IV fluids and IV
antibiotics. Your blood pressure rapidly improved and you
remained afebrile. As the clinical suspicion for recurrent
pneumonia was low, your antibiotics were stopped. You were also
started on steroids for your cancer as well. You also had
abdominal pain during this admission and were started on
long-acting pain medications. You also underwent an EGD which
showed no abnormalities.
CHANGES to your medications:
START prednisone 40mg by mouth daily
START OxyconTIN 10mg by mouth twice daily
START gabapentin 300mg by mouth three times daily
START omeprazole 20mg by mouth daily | ___ M w metastatic RCC (papillary vs clear cell) to lungs & L
pleural effusions s/p multiple chemo regimens (most recently
cycle 10 of bevacizumab + erlotinib on ___, presents after
a recent admission to ___ for PNA, presented with fevers and
hypotension, which was managed with IVFs and antibiotics in the
FICU, but managed with steroids (stopped antibiotics) on the
floor, given that the fever and hypotension were likley related
to his underlying progressing malignancy and adrenal
insuffiency.
# Hypotension: The patient presented with hypotenstion that
resolved with IVF. The hypotension was likely due to
dehydration; the patient reported poor PO intake of fluid for a
few days prior to presenting to the hospital, partly due to
abdominal pain. The patient also reported a fever prior
admission. He was initially started on vanco/zosyn/azithromycin
out of concern for possible sepsis (given patient has recent
pneumonia requiring intubation). These antibiotics were stopped
due to 1)CXR demonstrating radiographic improvement of his
pneumonia, 2) recent completion of adequate antibiotics for that
pneumonia, and 3) rapid improvement of his hypotension and
fever. The patient's hypotension/fever was felt to be related
to underlying RCC and immulogical response by his primary
outpatient oncologist. The patient was started on Prednisone
40mg daily on HD#2, which was continued through discharge. The
patient will continue steroids, until his f/u with his medical
oncologist. The patient remained afebrile and normotensive
while on steroid (and off antibiotics) for the remained of his
hospital stay.
.
# Abdominal Pain: Intermittent sharp epigastric pain may
represent gas or gastritis, as symptoms improved with
simethicone. Given transaminitis, also concern for pain from
capsular swelling or obstruction. Given the persistent pain, GI
was consulted. He was taken for EGD which demonstrated normal
mucosa in the whole stomach (biopsy) and otherwise normal EGD to
third part of the duodenum. A gastric mucosal biopsies was taken
was within normal limits per histopathological examination. He
was continued on his home dose of omeprazole 20 mg daily. He
was also started on gabapentin 300mg TID given that he had
enlarge ___ lymph that could be potentially cause
neuropathic pain. He was started on oxycodone 10mg Extended
Release with oxycodone 5mg for breakthrough pain.
# Transaminitis: Possibly a sign of progressive disease.
However, may also consider iatrogenic, as patient started
erlotinib last week - listed common side effects of
transaminitis and abdominal pain. A RUQ ultrasound was negative.
# Renal Cell CA: metastatic disease. S/P cycle 10 erlotinib and
bevacizumab on ___. He was continued on erlotinib and
axitinib while inpatient. | 126 | 431 |
19763428-DS-9 | 25,223,632 | Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ with back pain and found to have
damage to your heart based on your lab work, despite not having
any chest pain. You underwent testing called a stress test that
showed you would not likely benefit from another cardiac
catheterization.
You also had imaging of your chest and abdomen. This imaging
showed you had nodules in your lungs and kidney as well as a
mass in your chest that may be a cancer. You will have follow-up
with thoracic surgery and may need to have a biopsy. You will
also likely need to have further imaging as an outpatient.
Your main concern was back pain. You had a special study called
a bone scan that showed you had a fracture in one of your
vertebrae. If you have worsening back pain, you may benefit from
wearing a special brace when you walk.
If you have chest pain, worsening back pain, shortness of
breath, or any other concerning symptoms, please let your doctor
know right away.
Again, it was our pleasure participating in your care.
We wish you the very best,
-- Your ___ Medicine Team -- | PRIMARY REASON FOR ADMISSION:
___ year old male with CAD s/p PCI with chronic anginal symptoms,
symptomatic bradycardia s/p PPM, malignant melanoma and other
skin cancers s/p multiple resections and CLL with mid thoracic
back pain, found to have no osseous lesions but with CT scan
revealing new mediastinal mass as well as pulmonary nodules. | 199 | 58 |
15635879-DS-14 | 22,667,602 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain and found to have pancreatitis and a fluid
collection in your pancreas ("pancreatic pseudocyst").
You were seen by GI specialists and surgeons and underwent
additional testing.
You improved and are now able to be discharged home. It will be
important to avoid all alcohol, as this can cause your
pancreatitis to occur again. | This is a ___ year old female with past medical history of
obesity
status post Roux-en-Y gastric bypass, alcohol abuse, admitted
___ with 2 weeks of persistent abdominal pain found to
acute pancreatitis with pancreatic pseudocyst, course
complicated by alcohol withdrawal, treated conservatively with
subsequent improvement, able to tolerate Bariatric 4 diet, being
discharged home
# Generalized Abdominal pain secondary to
# Acute alcohol pancreatitis
# Pancreatic pseudocyst
# Transaminitis
Patient with history of roux-en-y who presented with 2 weeks of
abdominal pain in setting of ongoing heavy alcohol use, found to
have elevated lipase, OSH imaging with suspected pancreatic
psuedocyst. She was seen by pancreas consult and bariatric
surgery consult, was made NPO, started on IV fluids and prn pain
and nausea medications. Given question of abnormal material
seen in gallbladder on CT scan by surgical service, patient
underwent MRCP to rule out biliary stone or anatomic
abnormality. MRCP showed findings consistent with acute
pancreatitis with extensive peripancreatic fluid collections".
No gallstones or CBD stones were seen to suggest gallstone
pancreatitis. She was recommended for ongoing conservative
management. Patient symptoms rapidly improved and she was able
to rapidly advance her diet. She subsequently tolerated a
bariatric 4 diet without issue and demonstrated ability to
maintain her hydration and nutritional status. She was weaned
off pain medications without issue. Patient able to be
discharged home.
# Alcohol abuse complicated by withdrawal
Demonstrated signs of withdrawal on presentation. Initially
reported drinking a small amount each day, but later revealed it
was closer to 5L box of wine over ___ days. Treated for alcohol
withdrawal with valium CIWA. Gave IV thiamin, PO folate,
multivitamin. CIWA subsequently able to be discontinued and
patient remained stable x 1 day. She received counseling from
social work input, was contemplating quitting and was given
potential information re; resources for assistance.
# Peripheral neuropathy
Reported chronic numbness in feet. Given her history, suspected
to be alcohol-related. Would consider additional workup an
management of this. Zinc level pending at discharge.
# Abnormal MRI Liver
MRCP incidentally showed "Severe hepatic steatosis.". Would
consider hepatology referral as outpatient. Counseled on
alcohol cessation as above.
# History of roux-en-y gastric bypass
As surgery was done in ___, patient does not have local
bariatric provider. Patient was recommended to establish with
one. Patient reported that once her ___ gets approved,
she will establish with a bariatric ___ local to her in
___.
# Abnormal CT Abdomen
OSH CT incidentally showed "Nonspecific peritoneal nodularity
along the anterolateral right abdominal wall." ___ radiology
recommended "attention on follow-up." Would consider discussion
re: utility of repeat imaging in the future and/or additional
workup as outpatient.
Transitional issues
- Discharged home
- Recommended to continue Bariatric 4 diet
- Received alcohol cessation counseling
- Patient reports history of B12 deficiency; would consider
outpatient evaluation and therapy for this
- Discharged with ___ application pending--patient plans
to establish with local PCP and ___ in/near
___
> 30 minutes spent on this discharge | 71 | 502 |
17196838-DS-14 | 22,492,516 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You were ___ the hospital for lightheadedness and right
shoulder pain.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- You had an infection ___ your right shoulder joint. You were
started on antibiotics for the infection and had a procedure
done to wash the infected joint out.
- We gave you pain medications to help control your right
shoulder pain.
- We gave you blood and platelet transfusions, because your
blood and platelet counts were low.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call your doctor if weight goes
up more than 3 lbs.
We wish you the ___!
Sincerely,
Your ___ Team | Mr. ___ is a ___ y.o. male with atrial fibrillation (on
Xarelto), osteoarthritis, metastatic Prostate cancer (c/b bone
mets, s/p chemotherapy now on clinical trial
pembrolizumab/radium) who presented to the ED with
lightheadedness and R shoulder pain that was found to be a
septic R. shoulder joint growing MSSA. He is s/p I&D of R.
shoulder joint on ___ and on cefazolin for 6 week course of
therapy. His hospital course was complicated by pancytopenia and
acute on chronic pain requiring titration of his medications.
=====================
ACUTE ISSUES
=====================
#R. septic shoulder joint
Mr. ___ presented with R. shoulder pain and a documented
fever of 101.1F on ___. Orthopedics was consulted and a R.
shoulder CT was obtained. R. shoulder CT was notable for
multiple sclerotic foci involving right distal clavicle, several
vertebral bodies, and second right rib, though was thought not
to be contributing to his R. shoulder pain. It was also notable
for biceps tendon tear, degenerative changes at R. ___ joint,
fluid collection ___ R. subscapularis muscle tracking from joint
space into subscap recess + fluid collection ___ subacromial
subdeltoid bursa. ___ performed an aspiration of this fluid on
___, and the aspirate was found to grow MSSA. He was initially
started on vanc (___) + ceftriaxone (___) and switched
to cefazolin based on sensitivities. He had an I&D of his septic
R. shoulder joint on ___. ID was consulted regarding antibiotic
use and duration, as well as OPAT coordination. Per ID, he
should continue IV cefazolin 2g q8h until ___ for his R. septic
shoulder joint (___). A duplex U/S of his tunneled line
was obtained to rule out possible infected subclavian clot that
may have seeded his R. shoulder joint; however, U/S was largely
negative for DVT. The subclavian could not be fully appreciated
due to overlying dressings from his I&D, however ID did not
recommend repeat U/S.
#MSSA R Shoulder Infection
He presented with several weeks of worsening shoulder pain and
weakness on the right. He underwent CT of the R shulder on ___
which demonstrated an enhancing fluid collection extending into
the subcapsularis muscle tracking from glenohumeral joint space
with large joint effusion. Orthopedic surgery was consulted and
performed R shoulder arthrocentesis on ___ which demonstrated
87,895 WBC (97% polys) and ultimately grew MSSA. He underwent
I&D on ___ with orthopedic surgery. ID was consulted for
antibiotic management and he was transitioned to cefazolin for
planned 6 week course. He had no positive blood cultures. His
course is as follows: Start date: ___. Stop date: ___.
#Right shoulder pain
He denied any history of prior trauma to the shuolder. Due to
severe uncontrolled pain over the admission his pain medications
were uptitrated. Oxycontin was uptitrated from 10mg BID to 20mg
BID. His oxycodone breakthrough pain dose was increased to
___ q4h. Regarding the etiology of his pain, which persisted
even after I&D, orthopedic surgery felt the patient's CT was
also notable for possible adhesive capsulitis vs. rotator cuff
tea vs. biceps tendonitis. Per Ortho, shoulder MRI was not
necessary at the time of his hospitalization and was more
appropriate for outpatient follow-up. He was scheduled for
orthopedics follow up ___ 2 weeks time.
#RUE Edema
This was likely ___ immobility from painful shoulder, as DVT
study was negative at admission and edema improved gradually,
prior to discharge.
#Metastatic Prostate Cancer:
#Pancytopenia
During his hospitalization, he was on a study regimen of radium
+ pembrolizumab and presented with severe
anemia/thrombocytopenia/leukopenia. He continued to be
pancytopenic. PF-4 Ab was obtained, but was negative sp HIT was
ruled out. The differential for this included prolonged
myelosuppresion from radium treatment or progression/bone marrow
infiltration of his malignancy. He was disenrolled from the
clinical trial. He received pRBC and platelet transfusions to
goal of Hgb 7 and platelet 20 prior to discharge. His
anticoagulation was discontinued due to thrombocytopenia. Bone
marrow biopsy was not seen as an urgent procedure that needed to
be performed during this admission, but could be considered as
an outpatient.
#Hyponatremia
He was thought to have chronic hyponatremia. Given that he was
asymptomatic, we monitored his sodium. He continued to be
asymptomatic at discharge.
#Delirium
He reported 2 prior episodes of delirium the week prior to
admission, once at home and once ___ the ED. He became agitated
after starting a trial of high dose prednisone at night to help
with inflammation + appetite/fatigue on ___. This was
discontinued the following day and he was placed on delirium
precautions; he did not have any further episodes of delirium
while hospitalized.
#Fever
He reportedly had a fever of T101.1F while receiving his blood
transfusion on ___. CXR/UA + UCx neg/BCx neg. Transfusion
reaction work-up was neg. He was afebrile since ___. His fever
was thought to have been caused by his septic R. shoulder joint.
#Lightheadedness
He presented with orthostatic symptoms which are likely ___
hypovolemia from diuretics + anemia. He received IVF and pRBC
while hospialized. He appeared euvolemic on exam prior to
discharge. CTH from ___ negative for acute process.
=====================
CHRONIC ISSUES
=====================
# Hypothyroidism
He was continued on his home levothyroxine.
# Lower extremity edema
This was thought to be secondary to his disastolic heart failure
vs. docetaxol, which can cause lower extremity edema. We
initially held his home torsemide at admission, as he complained
of lightheadedness and there was concern for hypovolemia. He was
restarted on his torsemide on ___, but at a lower dose of 20mg
qd (regular home dose is 40mg qd), given his initial complaint
of lightheadedness. He was discharged on this lower dose.
# Peripheral neuropathy
He was continued on his home gabapentin.
# Paroxysmal atrial fibrillatin
He was continued on his home metoprolol 12.5mg bid. His home
rivaroxaban and all other forms of anti-coagulation were held ___
the setting of thrombocytopenia.
# Hyperlipidemia:
He initially presented with a transaminitis and his home statin
was held during this admission. It was restarted on discharge.
=====================
TRANSITIONAL ISSUES
===================== | 131 | 965 |
12407481-DS-18 | 27,271,748 | Dear Ms ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- you had worsening cough and shortness of breath
- imaging of you lungs showed signs of an infection of your
lower airways, likely with bacteria
- you were given medications (antibiotics) to treat the
infection
- your breathing improved during your hospital stay and you were
safe to complete the treatment at home
What should I do after discharge?
- please continue taking the antibiotics as prescribed
- please follow up with you primary care physician as detailed
below
All the best,
Your ___ care team! | ___ female with history of infiltrating ductal breast cancer
___, triple-posotive, s/p mastectomy and reconstructive
surgery, s/p Cytoxan and Adriamycin followed by Taxol and
Herceptin as well as tamoxifen) who presented to the ED on
___ with four weeks of cough found to have multifocal
infectious process.
==============
ACUTE ISSUES:
==============
#ACUTE BACTERIAL BRONCHITIS
The patient presented with cough, dyspnea on exertion,
leukocytosis, tachycardia, fever, consistent with a pulmonary
infection given her CT findings, most likely acute bacterial
bronchitis vs community acquired pneumonia, likely as
complication of a prior viral respiratory infection. There was
no evidence of PE on CTA. No concern for aspiration. The patient
was initially started on ceftriaxone and azithromycin (day 1 =
___ with good response and ambulatory oxygen saturations
between 94 to 97 % on room air. The patient was safe for
discharge with plan to complete her antibiotic treatment course
at home. Prior to discharge, her antibiotics were transitioned
to a po regimen with cefpodoxime and azithromycin. Plan for a
5-day course (Last dose: ___
================
CHRONIC ISSUES:
================
#HISTORY OF BREAST CANCER
Dx ___ with a left breast cancer. Grade 2 infiltrating
ductal cancer, ER/PR positive,HER-2 positive. S/p mastectomy,
Cytoxan and Adriamycin followed by Taxol and Herceptin. S/p ___
years of letrozole. Stable.
#DEPRESSION
Stable. Continued home venlafaxine.
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
Relationship: Husband
Phone number: ___
==================== | 96 | 223 |
14334225-DS-10 | 29,709,912 | Mr. ___,
You were admitted to ___ for pancreatitis and dehydration.
your lab work returned to normal and your symptoms resolved with
hydration with IV fluids.
At this point, it is not clear why you had pancreatitis. I have
made an appointment for you with a new primary care physician to
further investigate this concern.
Please keep the appointments as listed below. | ___ male with epigastric pain, nausea, vomiting found to have
pancreatitis of unclear etiology.
Pancreatitis: Lipase of 400 on admission with nausea at
presentation. He has had 2 other episodes requiring
hospiatlization in the past in ___, which were attributed to
"not moving his bowels right." He had pain with the two prior
episodes, but only nausea with this presentation. His appetite
was down and he hadn't been taking food in ___ days due to the
nausea. He denies heavy alcohol use. He denied drug use aside
from marijuana. He had no stones on RUQ. His triglycerides were
48. He is not on any medications at home. Given this is possibly
his third occurrence of pancreatitis over the last year, an MRCP
would be a reasonable next step in evaluation to further
evaluate his anatomy. His lipase normalized and his symptoms
resolved with hydration. He tolerated advancement in his diet
and was discharged in good condition.
Hyperbilirubinemia: His bili was elevated to 2.4 with most of it
being indirect. Question of possible ___ disease, though
hemolysis (mild anemia) is also possible. It was stable on
discharge and may require work-up as an outpatient.
Atypical cells in differential on admission: Resolved on repeat
in the morning.
Transitional issues:
- Establishment of primary care for further work-up. | 62 | 214 |
11634090-DS-21 | 23,050,826 | Discharge Instructions
Cervical Fracture
Activity
You must wear your hard cervical collar at all times.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | On ___, the patient was evaluated at an OSH after suffering
a fall and striking his head in his apartment. His head CT
showed no acute findings, however, his cervical spine CT
revealed a right lateral mass fracture of C2 and so he was
transported to ___ for neurosurgical evaluation. He was
placed in a Aspen collar and CTA to his neck revealed no
arterial injury. It was deemed that this would be best managed
with conservative measures including Aspen collar, pain control,
and follow up Cervical Spine CT in 6 weeks. He was evaluated by
the Chronic Pain Service who made recommendations for pain
control given methadone use.
On ___ Patient continued to complain of pain. Regimen was
adjusted. ___ consult was ordered. ___ was unable to evaluate the
patient secondary to pain.
On ___ Patient was stable. Awaiting ___ evaluation. He continued
on recommended pain regimen.
On ___, the patient remained stable and his pain was better
controlled.
On ___, the patient remained stable and worked with physical
therapy. His IV dilaudid was discontinued, as he was out of
acute phase of pain.
On ___, the patient remained neurologically and hemodynamically
stable. He appears comfortable in bed, and is able to
participate in the morning neuro-motor exam without being
limited by pain.
On ___, the patient remained both neurologically and
hemodynamically stable. He was able to participate in the
morning neuro-motor exam without being limited by pain, and able
to make great strides with Physical Therapy - and is now able to
be safely discharged home. | 150 | 262 |
19926992-DS-17 | 23,088,200 | Dear Ms. ___,
You were admitted to ___ on ___ for concerns about confusion,
weakness, decreased food intake, and abdominal pain. We ruled
out infection, including pneumonia or urinary tract infection,
electrolyte imbalances, medication-related changes, or possible
bleeding in your head after your fall a few days prior. Your
abdominal discomfort was likely due to constipation, which
resolved. Your kidney function was decreased when you arrived
but has since returned to normal. You have remained confused
since your admission, but we have ruled out important reversible
or life-threatening causes of your mental status changes. It is
possible that given the reported onset of these changes since
your admission for pneumonia at ___, it will take
significant time to return to baseline. We had to hold your
warfarin during the admission, and we will restart it at rehab.
Thank you for allowing us to take part in your care.
___ MDs | This is a ___ year old female with past medical history of
dementia, atrial fibrillation on coumadin, chronic diastolic
heart failure, recent OSH stay for pneumonia, with
post-discharge period complicated by acute metabolic
encephalopathy, admitted ___ and found to have constipation
and ___, volume resuscitated and bowel regimen enhanced,
symptoms resolved, discharged to rehab.
#) Acute Metabolic Encephalopathy - patient with dementia, with
baseline several months prior independent of most ADLs, but over
recent ___ months has had significant decline, presenting with
acute worsening, including agitation and confusion; workup
notable for ___ and constipation (see below); with treatment of
these issues her mental status improved to recent baseline per
family (see below)
#) ___: Cr peaked at 1.9 on admission, secondary to dehydration;
improved with IV hydration, Cr at 1.1 at time of discharge.
ACEi, which was held, was restarted at discharge.
# Constipation - admitted without moving bowels x 1 week; was
passing flatus and no concern for obstruction; CT showed
extensive fecal loading; she received augmented bowel regimen as
well as bisacodyl per rectum followed by manual disimpaction.
Bowel regimen was continued, with regular stooling.
#) ATRIAL FIBRILLATION: CHADS2 = 5. Course was complicated by
INR 4.1, prompting holding of Coumadin on day of discharge.
#) DIASTOLIC CHF: Lasix held in setting of ___ restarted once
patient was taking reliable PO. | 147 | 221 |
12851044-DS-21 | 29,208,303 | Dear Ms ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- you were weak and had difficulty walking
- physical therapy saw you and recommended discharge to rehab
- you were found to have a possible infection in your urine and
were given antibiotics to treat the infection
What should I do after discharge?
- please take all of your medications as prescribed
- please go to all follow up appointments as detailed below
All the best!
Your ___ care team | ___ old woman with a history of ___, reflux
esophagitis, breast cancer, ductal carcinoma in situ and
radiation to the left breast, and venous stasis ulcers, who is
presenting with weakness and falls.
ACTIVE ISSUES
-------------
# Falls
# Weakness:
Likely secondary to progressive deconditioning in the setting
known ___ disease with possible acute exacerbation by
possible UTI as below. Prior falls appear to have been
mechanical in nature without characteristics of syncope. While
she reportedly has had episodes of hypotension in the past,
there was a low suspicion that this was contributing to her
presentation as she denied lightheadedness. In addition, blood
pressures during her hospital stay have been normal to elevated.
Evaluated by neurology. Presentation felt to be inconsistent
with cord compression given normal motor exam. Additionally, the
patient has repeatedly stated that she would not want surgery.
Physical therapy was consulted who recommended discharge to
rehab. Her possible urinary tract infection was treated as
below.
# Possible UTI:
Patient presented with pyuria and mild bacteruria. UTI is
possible as patient did not have pyuria on prior UAs, though
this UA borderline and patient is asymptomatic. Given her
worsening weakness and given the lack of other obvious triggers,
the decision was made to treat with Macrobid ___ BID for a
5-day course (___). Treatment course was completed prior to
discharge
# ___ disease
# Deconditioning
# Home safety:
During PCP visit earlier this year, ___ disease thought
to be relatively well controlled given ability to ambulate with
her walker, and eat and drink without tremor. However, while
there may be a contribution of acute medical issues such as a
possible UTI to her current presentation as above, underlying
___ disease is likely a contributing factor to falls,
weakness, and deconditioning. Given the recurrence of her
symptoms, concern for inability of patient to safely take care
of herself at home. Already has OT, ___, and ___ set up. Plan for
discharge to rehab per ___ as above. Recommend discussing
long-term plan pending development of symptoms at rehab. Home
Sinemet ___ mg 4 times a day was continued. Outpatient follow
up with neurology for later is scheduled.
# L knee abrasions:
Patient had fallen earlier this year on her knee. Abrasions
appear to be healing without signs of infection. Wound care was
consulted.
---------------
CHRONIC ISSUES
---------------
# Hypertension
Normotensive on admission. Continued home lisinopril and
amlodipine. Of note, atenolol had been discontinued prior to
admission though patient and her daughter had been confused
about this. They were counseled. Patient should NOT be restarted
on atenolol.
# Depression
Stable. Continued home citalopram 40mg daily (home dose). Of
note, the maximum recommended dose for this age group is 20mg
dialy given concern for QTc prolongation. EKG was obtained and
QTc found to be 429 ms on admission. Thus, home dose was
continued.
-------------------
TRANSITIONAL ISSUES
-------------------
[] completed 5-day course of Macrobid for UTI
[] continued on citalopram 40mg daily (home dose). QTc 429 ms on
admission and 436ms on discharge. Consider adjusting dose to
maximum recommended dose for her age group (20mg daily)
[] continued on amlodipine 5mg daily as prescribed by her
outpatient providers. However, had not been taking this prior to
admission, likely ___ miscommunication. BP controlled on
amlodipine & lisinopril, so discharged on 5mg qd. Please f/u BP
and adjust amlodipine accordingly
[] Per patient and family, patient had not been receiving daily
Lasix prior to admission (despite outpatient clinic notes
indicating that she was on Lasix 20mg daily). Lasix 20mg PO
daily may be used on a prn basis for volume overload / lower
extremity edema (euvolemic on discharge).
# Emergency contact: ___ (daughter, HCP): ___
# Code: Full (confirmed) | 81 | 596 |
15147932-DS-14 | 21,065,624 | ___ were admitted to the hospital after a perforated colon, for
which ___ underwent numerous operations, including the creation
of a diverting loop ileostomy and abdomen with a VAC. ___ have
recovered from these operations and hospital course well and ___
are now ready to return home. ___ have tolerated a regular diet,
passing gas/stool in your ostomy and your pain is controlled
with pain medications by mouth. ___ may return home to finish
your recovery. ___ will get ___ and physical therapy at home
(set up by the hospital).
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
If ___ have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
In addition, continue eating small, frequent meals throughout
the day to maintain your nutritional status. Your goal caloric
intake is approximately 2800 calories/day, but do not eat so
much that ___ feel nauseated or vomit.
___ have a long vertical incision on your abdomen. The skin is
left open. ___ had a VAC on it while in the hospital. When ___
go home, ___ will go home with wet to dry dressings and the
visiting nurses ___ replace the VAC. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if ___ develop a fever. Please call the office if
___ develop these symptoms or go to the emergency room if the
symptoms are severe. ___ may shower, let the warm water run over
the incision line and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ may gradually increase
your activity as tolerated but clear heavy exercise with Dr.
___.
___ will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication. ___ will also be
prescribed Ativan for your anxiety. Please continue to take it
as needed, but be sure to follow up with your primary care
doctor for further long-term management. In addition, as
discussed, your baseline heart rate since ___ left the ICU was
110-120 beats per minute. We are not concerned about this and
feel that it is your current baseline, but ___ should also
follow up with your primary care physician about this. ___ were
taking lisinopril and hydrochlorothiazide (HCTZ) before ___ came
to the hospital. Please do not ___ these, but ask your
primary care physician when it would be appropriate to ___
them.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck! | In the ER, after the patient's CXR showed free air under the
diaphragm concerning for perforation, he underwent a CT scan
that showed distal colonic perforation proximal to anastomotic
site. He was taken urgently to the operating room, where he
underwent a laparoscopy converted to laparotomy, washout,
drainage of pelvis, diverting loop ileostomy, placement ___
drain on the same day of presentation, ___. He was started on
Zosyn and Vancomycin and iniially did well. His blood cultures
from that time eventually grew Closridium species not C.
perringens or C. septium and Fusobacterium. However, on POD1,
___, he developed hypotension and tachycardia, concerning for
septic shock. Resuscitation was began and he was transferred to
the MICU, where was managed with levophed. Due to feculent drain
outpu, he was taken back to the operating room on the night of
___ for reopening of recent laparotomy, abdominal washout,
mobilization and division of the transverse and descending
colon, colon decompression, and open abdomen. After the
operation, he returned to the ICU and remained intubated/sedated
with pressor requirements. He was also febrile ___ morning and
had increasing pressor requirements. That same day, he again was
taken to the OR for an abdominal exploration and washout.
Subsequently, he had interstitial pulmonary edema and was
iniiated on the ARDSnet ventilation protocol and his respiratory
acidosis impoved. On ___ afternoon, he was transferred to the
SICU and management was continued. On ___, he underwent an
abdominal washout, partial closure colonic mucous fistula,
placement of a drain. On ___ he improved and no longer requied
pressors. Diuresis for significant volume overload was begun
with lasix drip and albumin, to which he responded. The next
day, ___, he went back to the operating room for the final time
and underwent fascial closure of abdominal wall. A VAC was
placed. Tube feeds through an NGT were begun and advanced, goal
of 45 cc/hour. Flagyl was added. Over the next several days, he
could not be weaned from the vent. He was slightly confused, but
following commands. His line was changed and sent for culture.
His culture and blood culures from that time were negative. He
had some agitation and required precedex. On ___, zosyn was
discontinued and cefepime added. On ___, flagyl was
discontinued. On ___, he was extubated successfully, and on
___ he was transferred to the floor. Fluconazole was added. His
Foley and NGT were removed and he tolerated a regular diet. On
___, all IV antibiotics were discontinued and PO fluconazole and
augmentin were started for a goal total of a 7 day course. The
patient was feeling depressed and overwhelmed, as well as
anxious, but not suicidal. Social work was consulted. ___ was
consulted and evaluated and treated him, eventually recommending
home with physical therapy. He was tachycardic consistently
between 110-120 and sometimes as high as 130-140 on a few
occassions, but denied shortness of breath, chest pain, and had
no leg swelling or increased oxygen requirement. He continued to
do well. The drain and central line were removed. Immodium was
started for high ostomy output. The mucous fistula was capped on
___. Overnight ___, he had a brief episode of tachypnea to
40 with no desaturations on room air, and the symptoms
spontaneously resolved. A CXR done then showed only small
atelectasis vs effusion. On ___, he continued to ambulate,
tolerate a regular diet (goal calories 2800 per nurition), and
his ostomy output improved on Immodium. The following day, he
was discharged home with his home VAC placed while in the
hospital, and asked to follow up with colorectal surgery, as
well as his primary care physician to discuss restarting home
antihypertensive medications and management of his anxiety. On
the day of discharge, he was feeling well, without abdominal
pain, tolerating a regular diet, ambulating, with appropriate
ostomy output. | 897 | 634 |
17554010-DS-11 | 21,754,751 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
for shortness of breath. You were treated for shortness of
breath related to tracheobronchomalacia with breathing
treatments.
On discharge, it is important for you to complete the
recommended diagnostic testing and attend your scheduled
outpatient appointments for further treatment and follow up.
Please continue to follow up with your primary care physician,
and specialists upon discharge from the hospital. Please
continue to take your home medications as prescribed.
Please decrease your prednisone (decrease by 10mg every 3 days,
meaning you should take 50mg for three days, then 40mg for three
days, then 30mg for three days, etc.).
Take Care,
Your ___ Team. | Ms. ___ is a ___ woman w/ hypothyroidism, T2DM, and
recent diagnosis of tracheomalacia, who presented with worsening
longstanding shortness of breath, likely multifactorial with a
large component of tracheomalacia.
ACTIVE ISSUES
=============
#) Tracheomalacia:
Pt has a long standing history of shortness of breath and recent
diagnosis of tracheobronchomalacia, who presented with
persistent shortness of breath. During admission patient
remained with good oxygen saturation on room air and in no
respiratory distress. Interventional Pulmonology was consulted
and started workup for tracheomalacia and evaluating for
possible other etiologies that may be contributing to her
shortness of breath. CT trachea and PFTs were performed during
admission (results pending on discharge). Treated with
nebulizers for symptomatic management of her dyspnea and
continued on prednisone and discharged on a prednisone taper. Pt
should have outpatient follow up with Interventional Pulmonology
for further management.
#) Right lower extremity edema:
Pt noted to have lower extremity edema during admission, right
greater than left. Duplex ultrasound did not show any evidence
of DVT. Edema most likely secondary to venous insufficiency. Pt
recommended to elevate legs and use compression stockings.
CHRONIC ISSUES
==============
# hypothyroid s/p thyroid nodule removal: continued home
Levothyroxine
# Diabetes, DM2: not on insulin. ISS while inpatient
# HTN: continued home metoprolol, losartan
# CAD: continued atorvastatin, clopidogrel
TRANSITIONAL ISSUES
===============================
1. Pt should have follow up with Interventional Pulmonology
2. Need to follow up CT trachea and PFTs (results pending on
discharge)
3. Follow up thyroid studies (sent to rule out thyroid disorder
contributing to dyspnea)
4. Consider further outpatient evaluation of additional issues
that may be contributing to her dyspnea as indicated (including
sleep study to evaluate for OSA, TTE, ENT evaluation for VCD, GI
evaluation for GERD)
5. Need to obtain outside medical records from ___ and ___
___ from previous workup done for her
tracheomalacia
6. Pt scheduled for follow up with Dr. ___ endocrinology
for weight loss management, as her weight may be contributing to
her dyspnea.
7. Pt continued on prednisone during admission for treatment of
tracheomalacia. Patient discharged on a prednisone taper
(decrease by 10mg every three days starting with 50mg).
# CODE STATUS: full, presumed
# CONTACT: ___ (HCP, partner, ___, ___
(nephew, ___ | 118 | 348 |
19252503-DS-27 | 29,338,538 | As you know, you were admitted with urinary tract infection and
fever. You were treated with oral antibiotics and intravenous
fluids with good response. You did well on this and had no
subsequent fever.
Please continue to take the antibiotics for the next 5 days.
Please see Dr. ___ in the next ___ weeks. | ASSESSMENT & PLAN: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH
admitted with 2 days of fever, dysuria, frequency and urgency.
# UTI: Mr. ___ was admitted with fever 101, dysuria, urinary
frequency in setting of BPH. U/A had > 182 WBC/hpf, nit neg. He
was found to have WBC 14 but no flank pain to suggest
pyelonephritis. Prostate exam in ED also did not reveal signs
of prostate tenderness to suggest prostatitis.
He was initially treated with IV cipro and then transitioned
quickly to cipro. He tolerated this well with immediate
defervescence and normalization of WBC to 9. Post-void
residuals were checked x3 and revealed no significant retention
of urine - all <100 cc. He was continued on motrin PRN for
pain/musculoskeletal pain. Doxazosin was also continued - given
some history of poor urinary stream, however, finasteride may be
considered as an outpt to help further optimize urinary
clearance.
Mr. ___ Cr rise to 1.6 on HD2 but quickly improved to 1.3
after hydration.
# Elevated TBili: Mr. ___ had an admit Tbili of 2.3 - most of
which were indirect. Follow up Tbili was 1.6. The etiology is
uncertain - ___ possibility and transient sepsis a
possibility although there was no signs of hypotension during
this stay or in the ED.
# CV: h/o HTN, hyperchol, TIA, s/p L CEA, chronic venous
insufficiency. Mr. ___ was continued on ASA, statin,
metoprolol, HCTZ
# OTHER ISSUES AS OUTLINED.
.
#FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: [X]heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: None
#COMMUNICATION: pt and step-daughter ___ ___
#CONSULTS: None
#CODE STATUS: [X]full code []DNR/DNI | 59 | 308 |
19075857-DS-4 | 25,756,727 | Started discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
wbat lle | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip intertrochanteric fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for left short TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
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. | 514 | 258 |
15777308-DS-19 | 29,150,364 | Dear Mr. ___,
You were admitted to ___ with
worsening lower extremity pain and critical limb ischemia due to
a clot in your prior graft site. You underwent thrombectomy or
removal of clot in your prior graft and peroneal angioplasty or
ballooning of one of your arteries. You have now recovered from
surgery and are ready to be discharged.
Please follow the instructions below to continue your recovery:
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
You are being discharged home with visiting nursing and home
physical therapy. If at any point this is too difficult, you
have been accepted at the following facility
___
Please call ___ admission to see if there is still a bed:
___. If one is available they have accepted your
admission. | Mr. ___ is a ___ year old male with ESRD on HD,DM,Hep C,PVD
who is status post a right fem-BKpop bypass and left fem-AKpop
bypass ___ for a right ___ toe non-healing ulcer and
bilateral lower extremity rest pain who presented to ___
___ on ___ with evidence of a
right femoral BK pop bypass occlusion with iliac inflow stenosis
on CTA. He was taken to the OR and underwent a thrombectomy RLE
peroneal angioplasty. For details of the procedure, please see
the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where he remained through the rest of the hospitalization.
Post-operatively, he did well without any groin swelling.
Nephrology and HD were consulted. He returned to the operating
room on POD for an angio. On POD 3 he underwent HD, he was
having pain in his calf and he was noted to have a CK level
elevated to ___. His CK was checked throughout the stay and
remained stable. His calf remained tender, but soft. On POD 4
his pain improved. He worked with physical therapy wand was
ddeemed appropriate for home with services. On POD 6 he was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. On ___ his discharge and need for
follow-up were explained with the use of an interpreter. He
stayed for one additional day for dialysis then was discharged
home with ___ and home Physical Therapy, and was given the
appropriate discharge and follow-up instructions. | 454 | 288 |
11802734-DS-4 | 26,528,782 | 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
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
Physical Therapy:
- WBAT LLE
Treatments Frequency:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get Air Cast Boot wet | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left tibia IMN, 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.
Musculoskeletal: Prior to operation, patient was NWB LLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT LLE. Throughout the hospitalization,
patient worked with physical therapy who determined that
discharge to home was most appropriate.
Neuro: Post-operatively, patient's pain was controlled by IV
pain medication and was subsequently transitioned to oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood for acute
blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 141 | 342 |
14420248-DS-25 | 23,037,173 | Dear Mr. ___,
It was a pleasure taking care of you!
Why you were admitted:
-You were admitted because blood work showed that you were not
receiving sufficient anticoagulation with the dose of warfarin
you were taking.
What we did for you:
- We changed the dose of your warfarin so that you are being
anticoagulated sufficiently.
- You also became short of breath during your hospitalization,
and we determined that this was likely because you had fluid in
your lungs, a pneumonia, and exacerbation of your asthma. We
removed the fluid with hemodialysis, treated your pneumonia with
antibiotics, and treated you with steroids for your asthma. You
improved after receiving these treatments.
What to do when you leave:
- You will need to complete a course of antibiotics
(levofloxacin) for your pneumonia, which is scheduled to end on
___.
- Please take all of your other medications as directed.
- Please also make sure to set up a follow-up appointment with
your primary care physican after your discharge from your
rehabilitation facility. | Mr. ___ is a ___ with a history of HTN, DMII, ESRD on HD
MWF via RUE AV fistula, and asthma, with recent diagnosis of RUE
axillary DVT who presents with subtherapeutic INR, and who was
admitted for an inpatient heparin gtt bridge.
# axillary vein DVT:
# Subtherapeutic INR: Patient has a history of requiring
angioplasty of fistula secondary to stenosis, and has history of
recent axillary vein DVT (___), and therefore required an
admission for IV heparin bridge to warfarin. Prior to admission,
patient was taking warfarin dose 3mg daily. He was maintained on
IV heparin until ___, when his INR had been in goal therapeutic
range ___ for >24hrs. Warfarin dose 3.5mg daily and INR 2.7 at
time of discharge on ___. Patient will be on chronic
anticoagulation given his concurrent history of atrial
fibrillation (see below). Patient was also encouraged to sit up
in cardiac chair and elevate his right upper extremity to reduce
swelling secondary to DVT.
# Hypoxia:
# Hypervolemia:
# HCAP: Patient on RA at home, but escalated to a 4LNC in the
setting of tachypnea and dyspnea. Patient's respiratory status
improved with increasing fluid removal at scheduled HD sessions
on MWF, however the improvement was suboptimal, with patient
endorsing pleuritic chest pain, having productive sputum, and
diffuse wheezes and rhonchi. Patient also developed leukocytosis
and CXR was also concerning for a R basilar opacity. Urine
legionella negative. Sputum cx w/commensal respiratory flora.
Strep pneumo pending at time of discharge. Given concern for
both exacerbation of patient's known reactive airway disease and
pneumonia, patient was treated with 5-day prednisone burst (day
1: ___, 40mgx2days, 20mgx3days, off) and with antibiotics:
initially with vancomycin/cefepime on day 1: ___. MRSA swab
resulted negative on ___ and vancomycin was discontinued.
Patient's leukocytosis improved and he was able to wean off
supplemental oxygen. Cefepime was transitioned to PO
levofloxacin for a planned total 8-day course of antibiotics,
scheduled to end on ___. -continue PO levofloxacin for total
8-day course to end on ___.
# Generalized body aches: Patient has diffuse body aches ___ to
chronic back pain and leg pain, which are typically worse after
post-dialysis. He takes Tylenol ___ TID at home which was
continued in house with good pain control.
CHRONIC ISSUES:
# Atrial fibrillation/Atrial flutter: CHADS2Vasc=3 (CVA, DM).
Patient is on warfarin in the outpatient setting and is
rate-controlled on metoprolol succinate 50mg daily. As above,
patient was admitted with subtherapeutic INR, and was bridged
with IV heparin to warfarin with INR goal ___. IV heparin was
discontinued when INR was therapeutic for >24hrs. At time of
discharge, Warfarin dose was 3.5mg daily and INR was 2.7 on
___.
# End stage renal disease on hemodialysis: Patient has ESRD
secondary to diabetic nephropathy. He received his scheduled MWF
HD sessions while in-house, and as above, increased fluid was
removed as part of treatment for hypervolemia. Patient was
continued on his home cinacalcet, nephrocaps, and vitamin D.
# Asthma: Patient was continued on his home fluticasone INH,
albuterol inh, and albuterol nebs q4h:PRN. As above,
exacerbation of his reactive airway disease likely contributed
to his respiratory distress and patient received 5-day
prednisone burst. He was also started on albuterol:ipratropium
duonebs q6h:prn, with improvement in his wheezing.
----------------- | 171 | 544 |
12669627-DS-18 | 24,014,416 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___.
WHY YOU WERE HERE:
- You came into the hospital because you had left-sided
abdominal pain and some shortness of breath, likely representing
a sickle cell event.
WHAT WE DID FOR YOU:
- We did imaging of your abdomen and found that you had an
enlarged spleen with impaired blood flow likely from sickling of
blood cells. This was most likely causing your abdominal pain.
There was no need for surgery for this.
- You were also seen by the hematology (blood) team.
- We gave you blood transfusions, IV fluid, oxygen and worked on
controlled your pain.
- You were also found on imaging to have imparied blood flow to
your hip joints (called "avascular necrosis of the femoral
head"): we contacted orthopedic surgery, and they decided that
there was no intervention at this point because you had no
symptoms. You have an appointment with them scheduled below.
- Of note, we also found you have gallstones. This can happen in
sickle cell disease. Please talk to your primary care doctor
about this. There is nothing to do for it right now.
WHAT TO DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your doctors as ___ below.
- Please be sure to take the hydroxyurea, as this can help
prevent sickle cell events.
- Please have your labs re-checked next ___ before
you see your primary care doctor, we have given you a lab slip.
- Please make sure you take senna and miralax while you are
taking pain medication, this will prevent constipation!
- We noticed your blood pressures are high. Please have your
primary care doctor check this and discuss if you need further
evaluation or treatment.
- Please do not take oxycodone and drive, and do not take
oxycodone and drink alcohol. Please do not take it with
lorazepam (also called Ativan) as this can cause dangerous
sedation and respiratory depression.
PLEASE CALL OR VISIT YOUR DOCTOR IF YOU DEVELOP:
- Worsening abdominal pain.
- Worsening shortness of breath.
- Fevers, chills, lightheadedness.
- Any symptoms that concern you.
We wish you all the best!
Sincerely,
Your Care Team | Ms. ___ is a ___ year old woman with hemoglobin SC and
hypertension who presented on ___ with 2 days of left upper
quadrant abdominal pain, found to have splenic infarction,
pneumonia vs. acute chest syndrome, and b/l asymptomatic
avascular necrosis of femoral head. She was transfused 3 units
of blood and improved with pain medications, IVF, and
supplemental O2.
#Sickle Cell/Hb C Anemia
#Splenic Infarction
#Pain Crisis
Patient has a history of hemoglobin SC, followed by Dr. ___ in
hematology, and presented with left-sided abdominal pain and
nausea/vomiting, similar to previous splenic pain she had had
before. Three days prior to presentation, she had been seen at
___ for a vaso-occlusive crisis of her left arm and was
given IV narcotics, discharged with oxycodone. The next day, she
developed the LUQ pain and presented to BI on ___. At BI, CT
abd/pelvis revealed an enlarged 16cm spleen with with
heterogeneous enhancement, concerning for splenic infarction.
Surgery was consulted and felt there was no indication for acute
surgical intervention. Patient received 2 units of blood in the
ED on ___ and was given PO dilaudid, IVF, folic acid, and
hydroxyurea. Chronic pain was consulted on ___ and patient was
started on dilaudid PCA and 3 days of toradol. On ___, patient
was transfused another 1 u pRBC and parvovirus studies were sent
for an inappropriate reticulocyte count. When pain was better
controlled, patient was transitioned back to PO dilaudid on
___. She was discharged with a prescription for oxycodone as
she has taken this at home before.
#Acute Chest Syndrome v. Pneumonia
Patient endorsed pain upon breathing and intermittent fevers
upon admission. CXR and CT showed left lower lobe consolidation
concerning for acute chest syndrome v. pneumonia. She was given
supplemental O2 and a five-day course of IV ceftriaxone and PO
azithromycin. On discharge, her breathing was much improved and
was satting high ___ on room air.
#Bilateral Avascular Necrosis of the Femoral Head
Patient notes that she had hip pain a couple of weeks ago, but
on admission did not and was able to bear weight on both legs.
On CT A/P, she was found to have bilateral avascular necrosis of
the femoral head without evidence of collapse. Orthopedic
surgery was contacted, and felt there was no indication for
intervention, as patient was asymptomatic. She has clinic follow
up scheduled.
___
Patient's baseline Cr 0.9, which was elevated to 1.3 on
admission, most likely pre-renal from poor PO intake in setting
of abdominal pain. With IVF, patient's creatinine decreased down
to 0.6.
#Transaminitis
Patient had elevated liver enzymes (peak ALT 106, AST 99), which
was most likely a manifestation of her vaso-occlusive crisis.
She denies a history of substance use and had not started any
new medications, though she notes that she started taking
hydroxyurea the week prior to admission when she started feeling
ill. Patient denied any RUQ pain or tenderness. Labs were
monitored and were downtrending before discharge. There was the
incidental finding of gallstones on CT AP.
#Superficial thrombophlebitis
Patient developed tender, palpable superficial veins in left
forearm and right antecubital fossa where IVs were placed. This
was most likely due to irritation from the IVs, exacerbated by
the SC crisis. There was no erythema or fluctuance, and patient
had good pulses bilaterally. No signs of infection or DVT. Heat
packs were used and the palpable veins subsided, though were not
completely gone by the time of admission.
CHRONIC ISSUES
==============
#Depression/anxiety
Continued home fluoxetine 20mg. Home lorazepam decreased from 1
mg to 0.5 mg i/s/o taking dilaudid while inpatient. She did not
take this while inpatient and says rarely takes it at home.
#Elevated blood pressures
She has a documented history of hypertension, although patient
does not endorse this and she does not take any
anti-hypertensives at home. BPs were often 130s/60s, but did
range as high as 160s/80s. It was difficult to tell if the
spikes were in the setting of pain. Recommend outpatient follow
up.
TRANSITIONAL ISSUES
===================
[ ] Patient discharged with prescription for 5mg oxycodone q4h
and a bowel regimen (Miralax and senna). Please re-assess pain
and adjust medication accordingly.
[ ] Make sure all vaccines for a functionally asplenic patient
are up to date. (Per chart review, patient received PCV13
vaccine on ___, and H. influenza and meningococcal vaccines
in ___
[ ] Follow up on LFTs. If liver enzymes do not improve, consider
further hepatitis workup.
[ ] Follow up on parvovirus PCR and antibodies
[ ] Repeat CXR in 4 weeks to ensure that pneumonia/acute chest
syndrome is resolving (as per Radiology recs)
[ ] Follow-up with hematologist for optimal management of sickle
cell anemia
[ ] Follow-up with orthopedics team to assess severity of
bilateral avascular necrosis of the femoral head
[ ] CT scan showed evidence of gallstones. Patient is currently
asymptomatic.
[ ] Patient's zinc level is 67, the lower limit of normal.
Consider zinc supplementation to possibly decrease sickle cell
crises and infection
[ ] Follow up blood pressure control | 352 | 807 |
16546662-DS-12 | 25,933,674 | Dear Ms. ___,
___ was a pleasure taking care of you at ___
___!
Why was I in the hospital?
- You were admitted to the hospital for severe constipation and
rectal pain.
What was done for me in the hospital?
- We gave you pain medications to help with your rectal pain.
- We gave you medications for your constipation to help you have
bowel movements.
- The palliative care physicians worked with you and your
daughter.
What should I do when I leave the hospital?
- Please take all of your medications as prescribed.
- Please keep all of your doctors ___.
We wish you the best in your recovery!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with a history of atrial
fibrillation on warfarin, cataracts c/b bilateral vision loss,
significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with
recent admission for rectal pain and severe constipation
(discharged on ___, now representing after numerous
telephone calls to outpatient providers with ongoing concerns
for
severe rectal pain/constipation, initially refusing bowel
medications/rectal exam, but eventually achieved resolution of
constipation with oral catharctic agents. Experienced transient
BRBPR, with H&H and hemodynamics remaining stable. These were
thought
to be d/t internal hemmorhoidal bleeding and GI was consulted,
at which
point it was discussed that ___ would be necessary to
make definitive
dx. Colonoscopy was not w/in pts GOC, and BRBPR resolved.
ACTIVE ISSUES
=============
#Rectal Pain and constipation
Ms. ___ was recently hospitalized on ___ for rectal pain
with constipation which was partially alleviated by inpatient
stool regimen. On readmission CT scan showed significant stool
burden with no evidence of obstruction. A rectal exam was
performed in the ED without fissures noted but patient initially
refused all further rectal exams. Per patient and daughter they
attempted 5 doses of lactulose at home without resolution of
pain/constipation. GI has recommended go lytely,
methylnaltrexone, tap water and mineral oil enemas, and manual
disimpaction but patient initially refused all treatment.
Patient eventually consented to attempt recommended GI regimen,
with inability to intake adequate volumes of cathartics.
Experienced small volumes of BRBPR, which on exam thought to be
due to internal hemorrhoids. At this point, GI was re-consulted
and recommended against enemas or manual dis-impaction d/t
pancolonic stool burden and risk of rectal intervention I/s/o
bleeding. It was recommended pt continue oral cathartic agents,
and pt and daughter were told that colonoscopy would be
necessary to accurately dx the source of bleeding. Pt and
daughter declined colonoscopy at this time as it was not within
GOC. Pt experienced BMs with maroon blood on ___, with guiac
positive stool sample. H&H and hemodynamics stable throughout
this time. Pt and daughter again made aware that proper workup
would involve full prep with colonoscopy, and decision was made
that this was not within pts GOC.
For pain she received tramadol and Tylenol. Morphine was given
briefly as a trial to see if pt would be able to tolerate enema
or manual disimpaction, but was discontinued after GI
recommended oral cathartics I/s/o rectal bleeding, as opioid
would worsen constipation.
# Bilateral hydronephrosis
___ had a recently diagnosed UTI and urinary retention
with bladder distention and suprapubic pain on exam. She was
treated with course of ciprofloxacin for her UTI which ended on
___. Her constipation is likely contributing to her urinary
retention and suprpubic pain. We have not done any more
catheters to be consistent with comfort goals discussed during
___ hospitalization.
#A fibrillation on Coumadin
Ms. ___ is on ___ at home but has intermittently refused
doses. She has been taking it fairly consistently during this
hospitalization. She is also currently on 60 mg diltiazem PRN
for Afib with RVR. Will go home on previous Warfarin regimen,
but will need to followup as an outpatient with PCP regarding
the utility of remaining on warfarin given her age and the
risk:benefit profile.
TRANSITIONAL ISSUES
===================
[] Goals of care should be clarified as best as possible.
[] Will need ongoing management of chronic constipation.
Tolerating miralax and senna combination
[]Non-emergent evaluation for causes of iron deficiency
(endoscopy does not seem to be within ___ for patient)
[] f/u to determine whether it is within ___ to continue
warfarin as an outpatient, given the fact that pt regularly
refused it as inpatient and what the risk: benefit profile is at
___
[] we changed her warfarin dosing to 2mg daily per her daily INR
values to treat for a fib but this may need to be discontinued
pending goals of care
[] will INR checked at clinic on ___
[] Palliative care appointment ___ at 11AM; this will
likely be critical in managing stress and discomfort of
comorbidities | 103 | 638 |
14412677-DS-12 | 23,116,609 | Dear Mr. ___,
You were admitted to ___ after
developing fatigue and weakness. You were found to have low
blood counts requiring blood transfusions. In order to determine
the cause of the bleding, you underwent a procedure to look at
the stomach and small intestine. This did not reveal any acute
source of bleeding. This procedure did reveal ulcers in the
esophagus, stomach, and small intestine. Your blood counts
stabilized after receiving the blood transfusions.
Due to these ulcers, you were started on a medication called
pantoprazole. Please continue to take pantoprazole 40 mg by
mouth EVERY 12 HOURS.
As you were noted to have fluid within your abdomen (ascites),
please continue to take ciprofloxacin 500 milligrams by mouth
EVERY DAY with end date ___.
Please assess your stools and look for any dark or tarry stools.
Please avoid alcohol and non-steroidal anti-inflammatories such
as ibuprofen or naproxen.
Since you had an MRI of your liver obtained during this
hospitalization, you do not need the repeat MRI that was
previously scheduled for ___.
It was a pleasure taking care of you during your
hospitalization. We wish you all the best!
Sincerely,
Your ___ Care Team | ___ with a PMH of HBV cirrhosis, history of alcohol abuse, HCC
s/p TACE, and grade 1 varices, presenting with fatigue and
shortness of breath, now with guaiac positive stool and a
substantial Hct drop found to have ulcers within esophagus,
stomach and duodenum.
# Peptic Ulcer Disease: Patient presented to ___ after several
week history of weakness and shortness of breath. On admission
labs were notable for a hemoglobin of 5 and hematocrit of 18.0.
He denied any melena, bright red blood per rectum, or hematesis.
He was admitted to the MICU for close observation given his
history of HBV cirrhosis and grade I varices. Prior to arrival
in the MICU, patient received 2 units of packed red blood cells.
He underwent a paracentesis which did not reveal evidence of
SBP. Abdominal ultrasound was negative for portal venous
thrombus. Given significant drop in hemoglobin/hematocrit
compared to baseline, he underwent a CTA abdomen and pelvis
which showed no definite evidence for active extravasation and
no evidence of retroperitoneal hematoma. Given history of
esophageal varices, he underwent an EGD which revealed 2 cords
of Grade I varices (no evidence of bleeding) as well as multiple
ulcers found within the esophagus, stomach, and duodenum t hat
could contribute to anemia via slow, chronic GI losses. There
was no high risk stigmata that required intervention. H. pylori
serology was negative. H. pylori stool antigen was also negative
(although patient was on pantoprazole at the time). Patient
remained hemodynamically stable with stable H/H. H/H at the time
of discharge was 7.1/23.2. He was discharged on pantoprazole 40
mg PO Q12H. He was continued on his home medication of
sucralfate 1 gram PO QID. Given his history of cirrhosis and
likely GI bleed, he was started on ceftriaxone in the hospital
for SBP prophylaxis with transition to ciprofloxacin 500 mg PO
daily with end date ___ (total course of 7 days).
Of note, the gastric ulcer was not biopsied and will need to be
biopsied given risk of transformation to malignancy.
As part of further anemia workup, reticulocyte count was 2.2.
Haptoglobin was 76.
# Cirrhosis HBV and EtOH: complicated by Grade I varices,
ascites (new onset). No encephlopathy. CHILDS Class B. He was
continued on entacavir. As noted below he was continued on
bumetanide 0.5 mg PO daily but his HCTZ was discontinued prior
to discharge (to decrease risk of becoming hypovolemic on two
diuretics). He was continued on nadolol 40 mg PO daily given
evidence of grade I varices on EGD. He underwent MRI of the
liver with and without contrast given history of ___ s/p TACE
___. MRI revealed no evidence of malignancy. Given evidence
of ascites, a therapeutic paracentesis was planned, however
there was no good pocket to tap based on bedside ultrasound
evaluation.
# Hepatocellular Carcinoma: s/p TACE ___. AFP obtained
during hospitalization was 3.3. He underwent an MRI of the liver
with and without contrast (as he had an MRI Liver scheduled on
___ given his history of HCC). Results showed cirrhosis
with portal hypertension, splenomegaly, and varices with no
evidence of malignancy.
# Grade I Esophageal Varices: 2 cords of Grade I varices noted
on EGD obtained ___. There was no stigmata of recent
bleeding. He was continued on nadolol 40 mg PO daily.
# Hypertension: In the setting of anemia, anti-hypertensives
were discontinued. When H/H improved, he was restarted on
enalparil maleate 10 mg PO BID. Given that he was on both
hydrochorothiazide and bumetanide, decision was made to
discontinue the hydrochlorothiazide to decrease chances of
becoming hypovolemic. He was continued on bumetanide 0.5 mg PO
daily. Discussion regarding outpatient diuretic regimen should
take place at next outpatient appointment. Blood pressure should
also be monitored as patient's HCTZ was discontinued.
# History of Alcohol Abuse: Continued on multivitamin, thiamine
100 mg PO daily.
# Reflux Esophagitis: Discontinued omeprazole 20 mg PO daily and
transitioned to pantoprazole 40 mg PO BID as noted above (given
evidence of ulcers). He was also continued on sucralfate 1 gram
PO QID.
# Sleep Apnea: Continued on CPAP.
# Paroxysmal Atrial Fibrillation: resolved on own in ___. Not
currently on any medications other than nadolol for the
esophageal varices.
# Depression/Anxiety: Lorazepam 1 mg PO qHS insomnia.
# Vitamin B12 Deficiency: cyanocobalamin 1000 mcg PO qday.
TRANSITIONAL ISSUES
===================
-New Medications: Pantoprazole 40 mg PO Q12H, ciprofloxacin 500
mg PO daily with end date ___.
-Please follow up MRI of the liver as this was pending at the
time of discharge.
-Given evidence of gastric ulcer, will need repeat EGD with
biopsy of the gastric ulcer.
-Patient noted to have lip smacking during hospitalization.
Please consider discontinuing prochlorperazine if concern for
tardive dyskinesia.
-Consider repeat H. pylori stool antigen test as patient was on
high dose PPI at time of sample.
-Given evidence of ulcers in esophagus, stomach, and duodenum,
please consider workup for ___ Syndrome.
-Please follow-up CBC within one week as outpatient. H/H at time
of discharge 7.___.2.
-Patient was noted to have eosinophilia during hospitalization.
Please obtain CBC with differential. If eosinophilia is present
please continue workup with Strongyloides testing as patient
recently went to ___.
-Given microcytic anemia, will need colonoscopy.
-Patient was on bumetanide and hydrochlorothiazide prior to
admission. His HCTZ was discontinued and he was continued on
bumetanide to decrease the diuretic regimen he was on.
-Full Code (confirmed) | 190 | 900 |
17231783-DS-14 | 23,812,786 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing of 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 daily for 4 weeks post-operatively to
prevent blood clots.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Per discussion with Dr. ___ may ___ with the
following surgeon in ___:
Dr. ___
Address: ___
Phone: ___
You should ___ in 1 week after discharge.
Physical Therapy:
Patient to remain non-weightbearing to the RLE in short leg
cast. He should use walker provided for BUE assist. Patient
instructed to ___ with Dr. ___) in 1
week following discharge from ___. Should remain ___ until
otherwise directed by Dr. ___.
Treatments Frequency:
Patient in short leg cast. No need for dressing changes. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right distal tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right distal tibia fracture
with Dr. ___ 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.
Despite repeated attempts to convince patient that rehab was the
safest option, patient repeatedly declined rehab placement.
Attempts were made with the ___ team to clear him for home,
but he remained limited in his mobility. On ___, ___
re-established contact with the patient and he was noted to have
improved mobility. However, their final recommendations were for
rehab. Patient again declined this. He was seen at bedside again
with Orthopaedic house staff ___s with Dr. ___.
Patient refused to go to rehab, and preferred to go home. He
also requested ___ with an Orthopaedic Surgeon closer to
home in ___. After discussing with Dr. ___ was
agreed that he should ___ with Dr. ___ on ___
___. As he repeatedly refused rehab despite our
recommendations, we felt the safest option was to provide him
with home ___ and OT (versus letting him leave AMA without
either). This was set-up for him on ___ and he was provided
with a rolling walker.
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 spontaneously. His dressings were changed
and a short leg cast was placed. The patient is
non-weightbeawring in the Right lower extremity with BUE assist,
and will be discharged on Lovenox for DVT prophylaxis. The
patient was instructed to follow up with Dr. ___ in 1
week following discharge. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course. He was given a short course of Oxy/Gabapentin for pain
control, with instructions to wean/discontinue when no longer
needed (in addition to avoiding driving, operating machinery, or
taking with sedatives/hypnotics/alcohol). The patient was also
given written instructions concerning precautionary instructions
and the appropriate ___ care. The patient expressed
readiness for discharge.
Of note, after clearing and setting up patient for home
services, he then stated that he did not want anyone coming to
his home. This was revisited, and patient was told that if he
declined home services he would be leaving ___ medical
advice'. Moreover, we reiterated that he needed home services
___ and OT) for safety reasons. He was eventually discharged
with services as previously set-up, and we are hopeful that he
is cooperative with the visiting therapists. | 357 | 524 |
14850820-DS-17 | 25,259,398 | Discharge Instructions
Dr. ___
___ Angiogram
Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications as
directed.
· It is very important to take the medication your doctor ___
prescribe for you to keep your blood thin and slippery. This
will prevent clots from developing and sticking to the stent.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Care of the Puncture Site
· You will have a small bandage over the site.
· Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
· Keep the site clean with soap and water and dry it carefully.
· You may use a band-aid if you wish.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· The medication may make you bleed or bruise easily.
· Fatigue is very normal.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the puncture
site.
· Fever greater than 101.5 degrees Fahrenheit
· Constipation
· Blood in your stool or urine
· Nausea and/or vomiting
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | Ms. ___ was admitted to neurosurgery service for finding of
incidental finding of anterior communicating artery aneurysm and
Left ICA aneurysm.
#cerebral aneurysms
Patient underwent diagnostic cerebral angiogram on ___
which confirmed aneurysms seen on MRI. No intervention was done
at this time. Groin was angiosealed and she remained on bed rest
for 2 hours. She will follow up outpatient for further
treatment.
At the time of discharge on ___ she was tolerating a regular
diet, ambulating without difficulty, afebrile with stable vital
signs. | 327 | 84 |
16937222-DS-8 | 29,720,351 | Dear Mr. ___,
You were admitted for sudden onset lightheadedness, blurry
vision, and triplicate vision that was concerning for a stroke
in the setting of having a subtherapeutic INR. You had an MRI of
your brain done, and thankfully, it did not show a stroke.
Nevertheless, you likely had a TIA (transient ischemic attack)
given your symptoms and your risk factors.
A TIA is a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot transiently. 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:
Lupus anticoagulant positive
High cholesterol
Sleep apnea
Diabetes
Hypertension
We are changing your medications as follows:
Coumadin 4mg
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ man with HTN, HLD, DM, OSA, and
+lupus anticoagulant antibodies who was admitted ___ with
transient neurologic symptoms including ?diplopia and right
upper extremity ataxia in the setting of being bridged with
lovenox and off coumadin for a planned dermatological procedure.
Imaging shows no infarct, but left vertebral lack of flow and
left subclavian stenosis suggestive of a vertebral steal
syndrome. His history and resolution of deficits suggests either
a TIA (given subtherapeutic lovenox dosing) vs steal phenomenon.
His Cr was elevated on admission to 2.7. Because of this, he was
bridged with a heparin drip until he reached a therapeutic INR
between ___. On discharge, his INR was 2.1. He will need his INR
checked again this week.
As part of his stroke workup, he had a TTE completed, which
showed a ?coarctation of the aorta. Vascular surgery was
consulted and recommended outpatient follow up. It also turns
out that he is only on warfarin and not on Plavix or ASA, though
it is on his medication list. He will need to have this
clarified with vascular surgery. | 281 | 184 |
10343782-DS-30 | 26,606,878 | Dear Ms. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having chills and
back pain
WHAT HAPPENED IN THE HOSPITAL?
- We found that you had an skin infection called cellulitis
- We also found that you had a infection in your urine
- We gave you antibiotics by IV to treat this, and once you got
better we gave you antibiotic by mouth
WHAT SHOULD I DO WHEN I GO HOME?
- Your should continue to take your antibiotics as prescribed
- You should follow up in ___ clinic to help with the
swelling in your leg
We wish you the best!
-Your Care Team at ___ | Ms. ___ is an ___ y/o woman with history of recurrent
urinary tract infections complicated by urosepsis, obstructive
nephrolithiasis, urinary
incontinence, HFpEF, AS, thyroid cancer s/p partial resection,
___ esophagus, chronic back/knee pain, lymphedema who
presented with back pain and chills and was found to have
urinary tract infection and left lower extremity cellulitis.
===============
ACUTE ISSUES:
===============
# Urinary tract infection: Patient presented with chills and was
found to have pansensitive E. coli urinary tract infection.
Imaging was without obstructive nephrolithiasis and showed no
radiographic evidence of pyelonephritis. The patient was
initially given ceftriaxone, and given allergy to Bactrim and
drug-drug interactions with amiodarone, will complete 7-day
treatment course with
cephalexin (Last day: ___.
# Cellulitis: Patient was noted to have left lower extremity
erythema and serous drainage consistent with nonpurulent skin
and soft tissue infection. She was initially given vancomycin
and ceftriaxone and narrowed to cephalexin as above. She was
treated with tramadol for discomfort.
# Lymphedema: Patient has longstanding history of lymphedema
that increased her vulnerability to cellulitis as above. She
will follow up in the lymphedema ___ further management.
===============
CHRONIC ISSUES:
===============
# Chronic back pain
# OA knees: Lidocaine 5% Patch daily. Tramadol as above.
# Atrial fibrillation: Continued amiodarone and rivaroxaban.
# HFpEF: Continued lisinopril, torsemide.
# Aortic stenosis: Stable.
# HTN: Continued lisinopril.
# HLD: Continued rosuvastatin.
# Hypothyroidism ___ hashimoto's, thyroid cancer s/p resection:
Continued levothyroxine.
# Gout: Continued allopurinol.
# GERD c/b ___ esophagus: Continued omeprazole.
# OSA not on CPAP
======================
TRANSITIONAL ISSUES
======================
- Patient to continue cephalexin 500 mg Q6H to complete 7-day
course for E. coli urinary tract infection and cellulitis (Last
day: ___
- Patient provided with tramadol for increased discomfort due to
cellulitis
- Patient will follow up in the ___ clinic
- Communication: ___, friend, ___ | 125 | 290 |
15847566-DS-4 | 29,132,651 | You were admitted to the hospital with pain at the umblicial
site from your prior Total Abdominal Colectomy for Chronic
constipation. You had an MRI for imaging as you are pregnant
which showed a small umbilical incision hernia which will
improve on your own. Your pain is relatively well controlled
with oral pain medication. You will be sent home with a small
amount of oral pain medication. You will likely have pain as you
heal from your surgery and your abdomen expands from the
developing baby. You will be sent home with a small amount of
the pain medication Dilaudid. Please take this exactly as
prescribed. Do not drive a car or drink alcohol while taking
this medication. Please only take this medication as needed, try
tylenol for pain first and then, if you still have pain take the
small dose of dilaudid. The OB team has approved the medication
for a short amount of time only in regaurds to safety in
pregnancy.
Please monitor your bowel function closely. Please continue to
titrate the liquid imodium a you have been at home. Please call
the office if you have more than 1200cc of stool out in 24
hours. If you have any of the following symptoms please call the
office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe. You may shower; pat the incisions
dry with a towel, do not rub. The small incisions may be left
open to the air. If closed with steri-strips (little white
adhesive strips) instead of Dermabond, these will fall off over
time, please do not remove them. Please no baths or swimming for
6 weeks after surgery unless told otherwise by your surgical
team.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck! | ___ was admitted to the inpatient Colorectal Surgery
Service with Umbilical Incision pain. All laboratory values were
stable and she did not have a fever or any other sign of
systemic infection. The high risk OB team was consulted given
that she is approximately 16 weeks pregnant and had been
previously followed by them during her last admission. An MRI of
the abdomen was ordered to evaluate for abscess or hernia. The
read showed a possible small hernia with fat necrosis. This was
reviewed with Dr. ___ this was a nonsurgical issue and
there was no fluid collection under the umbilical incision site.
There were no other significant finding on MRI related to the
surgery, infact, small bowel dilation and post-surgical fluid
was improved. She was monitored closely overnight. She tried a
Lidocaine patch which did not help significantly. PO Dilaudid
did help. All medication choices were discussed with OB. The
following morning she was slightly improved. She had her
baseline nausea, which improves with food and throughout the
day. She is nauseated every morning at home, which seems very
consistent with morning sickness. ___ was very concerned about
her surgical incisions. I examined the incisions and offered
reassurance, she will continue to shower and pat the incision
dry. We went over the MRI symptoms again with her husband
present. She will be seen ___ at ___ and will follow-up
with Dr. ___. It seemed most of the pain was with movement and
she felt as though she had to support her abdomen with her hand.
We tried an abdominal binder for support prior to discharge. She
was discharged home in the care of her husband. The major
aspects of her discharge plan was discussed with OB. She was
sent home with a small prescription for Dilaudid to use if
Tylenol is not covering the pain. We will follow her closely. | 458 | 311 |
11016802-DS-5 | 27,845,466 | You were brought to the hospital on ___ after two unwitnessed
falls from standing height. You suffered a head laceration, left
medial rib fractures of ribs 1 and 2 and a fracture of bilateral
C6 laminae with extension into C6-7 facet and anterolisthesis of
C6 on C7 for which you need to wear a collar for 8 weeks. Please
call Dr. ___ as seen below if having increased neck pain.
Keep the collar on at all times. Be sure to follow up with your
XRAYS that are scheduled for you to have in 2 weeks.
You are now stable and ready to be discharged from the hospital
. Please adhere to the following instructions regarding your
discharge.
Rib Fractures:
* Your injury caused 2 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please follow up with Spine and ACS. Your appointments have
already been scheduled as seen below. | This patient is a ___ year old male smoker with a history of
metastatic throat cancer s/p laryngeal tracheal resection, s/p
removal of L lower jaw, who presented via EMS for evaluation of
AMS s/p fall with positive head strike on ___.
He was evaluated upon arrival. Imaging revealed T1 vertebral
body fracture, and C6 laminar fractures bilaterally for which
the patient was placed into a collar. He was also found to have
left medial rib fracture of ribs 1 and 2.
The patient was seen by ACS and orthopedics as well as physical
therapy. During his stay in the hospital the patient required 1L
FW restriction for low Na. His chem were monitored. He was also
placed on a CIWA scale and was administered a banana bag.
The patient did well throughout his stay in the hospital. Neuro:
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV pain medication and then
transitioned to oral pain medication once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient will be discharged with the c-collar in
place. The patient understands that the collar must stay on for
8 weeks. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 375 | 353 |
12757169-DS-15 | 21,954,602 | Dear Mr. ___,
It was a pleasure taking care of you here at ___. You were
admitted for a left buttock wound that may be developing into a
pressure ulcer. Ultrasound and MRI demonstrated a large phlegmon
in that location. Interventional Radiology was consulted but
reported that there was no fluid collection that they could
drain.
After discussion it was determined that you would go home with
oral antibiotics for 10 days and close follow-up with Acute Care
Surgery clinic this week to re-evaluate the wound. Please follow
the below 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. | ___ with h/o appendectomy for perforated appendicitis
complicated by ARDS, ECMO, and subsequent renal failure and
right hip disarticulation who returns today with left buttock
wound. He has had a pressure sore there for some time and has
daily ___ care and was noted to have increasing redness and
warmth around the area. He denies any fevers, chills, or foul
odor drainage. Soft tissue U/S demonstrated soft tissue
heterogeneity reflective of edema versus phlegmon. MRI
demonstrated phlegmon interdigitating within the left gluteal
muscular fibers spanning an area of 9.1 x 3.3 cm. Interventional
Radiology was consulted and reported that there was no drainable
fluid collection. After discussion with the patient it was
determined that he would go home with PO augmentin x10 days and
close follow-up with Acute Care Surgery clinic this week to
re-evaluate the wound. | 307 | 138 |
15653627-DS-5 | 28,917,505 | ___ were admitted to the hospital after a Laparoscopic
Colectomy for surgical management of your Diverticulitis.
Unfortunately, have this surgery ___ developed a leak at the
anastomosis in the Colon and this required a second surgery and
drain to control the infection as well as a diverting ileostomy.
___ were given antibiotics through your IV and now your will
take antibiotics by mouth until your follow-up appointment with
Dr. ___ will take Cipro and Flagyl. The drain will stay
in place at least until your follow-up with Dr. ___. The
drain is draining a small amount ___ have recovered from this
procedure well and ___ are now ready to return home. Drain
irrigation instructions: Remove bulb drain and flush tube with
20cc sterile normal saline towards patient, then draw 20cc fluid
back into syringe. Replace bulb drain to suction. ___ can shower
with the drain in. Clean around the jp drain site with sterile
normal saline once daily and apply a new gauze dressing and
secure with paper tape. The drain is draining a small amount of
stool from the leak, pus, and small amounts of blood/abdominal
fluid. Please record the output from the drain on the provided
sheet and bring with ___ to your clinic appointment. Please call
our office if ___ have any of the following issues: increased
pain at the drain site, drainage of bright red blood, more than
150cc from the drain in 24 hours, difficulty flushing the drain,
or any concerning symptoms or worries.
___ unfortunately had a kidney injury from dehydration, with ct
contrast dye, and vancomycin. This is returning to normal. ___
must have a creatinine level drawn at your primary care
providers office on ___. They can call our office if the
number has not decreased to under 1.0. At discharge it is 2.6
however, it will still take a number of days to improve. Please
be aware of your urine outout. If ___ feel as though your output
is decreasing, please call the office. Please call if: urine is
dark orangy brown, output is low, burning with urination, or
lower abdominal pain. Do not take Motrin for pain. Hold of
taking lisinopril until clears by primary care provider.
___ have tolerated a regular diet, are passing gas and your pain
is controlled with pain medications by mouth. ___ may return
home to finish your recovery.
Please monitor your bowel function closely. If ___ have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
extended constipation.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc.
Continue to take the medications to control the ostomy output
(imodium/metamucil wafers). The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
Currently your ileostomy is allowing the surgery in your large
intestine to heal, which does take some time. ___ will come back
to the hospital for reversal of this ileostomy when decided by
Dr. ___, Dr. ___ Dr. ___. At your follow-up
appointment in the clinic, we will decide when is the best time
for your second surgery. Until this time there is healthy
intestine that is still functioning as it normally would. This
functioning healthy intestine will continue to produce mucus.
Some of this mucus may leak or ___ may feel as though ___ need
to have a bowel movement - ___ may sit on the toilet and empty
this mucus as though ___ were having a bowel movement, it is not
abnormal to have some leakage of mucus from the rectum, please
place a gauze pad in your underwear if this is happening. If ___
change this pad more than ___ times daily please call the
office.
___ have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. And there is a larger incision near your umbilical
site, the staples were removed from this. These are healing well
however it is important that ___ monitor these areas for signs
and symptoms of infection including: increasing redness of the
incision lines, white/green/yellow/malodorous drainage,
increased pain at the incision, increased warmth of the skin at
the incision, or swelling of the area. Please call the office if
___ develop any of these symptoms or a fever. ___ may go to the
emergency room if your symptoms are severe.
___ may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. Please no baths
or swimming for 6 weeks after surgery unless told otherwise by
your surgical team.
___ will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck! | Mr. ___ was admitted to the inpatient medicine service on
___ for treatment of acute Diverticulitis. Colorectal
surgery was consulted as he was given intravenous antibiotics
and continued to have pain. On ___ the patients abdomen
continued to be tender. On ___ the patient had not had
resolution of pain depsite 48 hours of intravenous antibiotics,
this included changing therapy, the patient was brought to the
OR with Dr. ___. On ___ a Laparoscopic sigmoid
resection was preformed. He did well post-operatively and
recovered in the PACU, he was then transferred to the inpatient
unit. On ___ he was doing well and his laboratory vaules
were stable. The foley catheter was removed. On ___ the
patient was noted to have a small amount of erythema around the
umbilical site.
On ___ the patient had a slightly temperature to 100.3 and
blood and urine cultures were sent which were negative. On
___ he continued to have a low grade temperature to 100.2
with some Dyspnea. A chest Xray was preformed which showed that
the lungs were clear except for some atelectasis. The patient
had multiple small bowel movements. On ___ the patient's
temperature reached ___ F with abdominal tenderness with a white
blood cell count to 14.4. A CT with rectal contrast showed
anastomotic leak and the patient was taken to the operating room
for Laparoscopic washout, placement of drain and diverting
ileostomy. On ___ the patient complained of nausea and
heartburn. EKG and troponins were done given the patients
cardiac history however, were negative. An NGT was placed with
900cc out. On ___ the ngt continued to put out a liter of
outpur. The patient complained on incresed left flank pain
however his cital signes were stable. A urinealysis was again
sent which was negative. The drain was left in place, it was
drainiange brown liquid to serosang. This was likely related to
the previous leak. On ___ the foley catheter wsa removed
and the patient voided without issue. The ileostomy was putting
out liquid stool therefore the nasogastric tube was clamped. On
___ the patient tolerated clear liquids and the intravenous
fluids were dicontinued. He was transiitoned to home medications
and medications by mouth. On ___ the patient complained of
worsened abdominal pain. A CT scan was obtained which showed
Small fluid collection, likely ileus, but no obstruction. On
___ he continued clear liquids. He had elevated ileostomy
output and this was repleted with intravenous fluid boluses. A
PICC line was placed without issue. The ileostomy continued to
have increased output. He was given psyllium and loperamide. On
___ the patient's diet was advanced to regular which was
tolerated well. The patient's pain was stable. On ___ a
vancomycin trough was therapeutic. On ___ Creatinine was
noted to be 3.1, a FeNa was 0.3%, UA: 14WBC, neg Eos. Sediment
pnd. A Renal US was obtained and normal. He was given
intravenous fluids as it was decided he was likely dehydrated
and contrast dye. On ___ intravenous antibiotics were
transitioned to cipro/flagyl by mouth. On ___ the patient's
creatinine was improved to 2.6 and he was discharged home with
the drain in place and this was to stay in place until at least
his follow-up appointment. THe patient was supported by the
nursing staff and seen by social work and the wound ostomy
nursing team while in house. | 1,216 | 565 |
15622314-DS-16 | 22,765,158 | Dear Ms. ___,
You were admitted for abdominal pain and nausea. During your
time here you were given several medications to alleviate your
pain and control the nausea. Your symptoms on presentation were
suggestive of a gastrointestinal disease called GASTROPARESIS
(your stomach and gut moves slower). When we treated you with a
medication that promotes movement of your gut, you felt better
and were able to eat some food and keep it down. We conducted
lab tests to evaluate you for other possible autoimmune diseases
such as Celiac's and we did not find anything irregular. You had
an imaging study (CT Scan of your abdomen and pelvis) that came
back with no abnormalities. You also had an endoscopy which did
not reveal abnormalities.
The GI (stomach and gut) doctors recommended that ___
with them in outpatient clinic. They will determine if a gastric
emptying study or other examination such as colonscopy will be
needed.
Your TSH level was high during admission, so we increased your
Levothyroxine dose to 75mcg. Please ___ with your primary
care physician for continued maintenance of your hypothyroidism.
Please take these NEW medications:
- Reglan 10 mg before every meal and bedtime to help your gut
and stomach move food better to reduce nausea and vomiting.
- Docusate Sodium 100 mg twice a day as needed for constipation.
This medication helps soften your stool.
- Senna 1 tablet twice a day as needed for constipation.
Please CHANGE the dose of the following medications:
- Take 75 mcg of Levothyroxine daily
Please ___ with your gastroenterologist and primary care
physicians with appointments scheduled. | ___ y/o F PMH of ___'s thyroiditis, anxiety, recent
recurrent UTI and Cdiff who presented to the ED with several
months of abdominal pain, nausea and vomiting likely ___
gastroparesis.
.
*** Active Diagnoses ***
.
# Nausea / Vomiting / Abdominal Pain: Likely Gastroparesis:
Likely diagnosis for her abdominal pain given feelings of n/v
almost immediately after eating with significant improvement on
reglan such that pt could tolerate regular PO intake. Could be
due to her bout of C. diff that led to gut distention and
gastroparesis. Additionally, lab evaluation with Celiac panel,
LFTs, CRP, stool studies, H pylori , and lipase were all
unremarkable. CT abd/pelvis also unremarkable. Seen by GI who
performed EGD and EUS that were unremarkable with no further
evidence of gastritis. F/u arranged with GI on outpt basis and
continue Reglan until that time. EKG was performed for baseline
QTc of 440.
.
# Weight loss
Appears most likely from lack of eating from above reason. Per
charts only lost 9 lbs over 6 month period vs pt initial report
of 20+. Will likely improve now that is tolerating regular PO
intake.
.
# Anemia:
Believed to dilutional after given 3L of IVF, stable while here
with iron studies/vitb12/folate all normal. Hct at discharge
35.3.
.
#Hypothyroidism:
TSH found to be elevated at 10 so dosage increased from her
50mcg to 75mcg. Pt setup and instructed to ___ with PCP
for further dose adjustment and re-check of her TSH in ___
weeks.
.
*** Chronic Issues ***
.
# Anxiety:
Stable, on fluoxetine. Pt directed to consider talking with
therapists since the loss of her mother.
.
*** Transitional Issues ***
.
- ___ with GI to evaluate whether further evaluation
needed on outpt basis such as gastric emptying study
.
- Touch base with PCP regarding repeat TSH check given
adjustment of her levothyroxine from 50mcg to 75mcg
.
- Given pt on reglan, consider repeat EKG to evaluate for
prolongation of QTc interval. Normal while checked here.
.
- Discussed pt seeing psych or therapist given difficulties
coping after loss of her mother this past year. | 257 | 331 |
14121516-DS-18 | 28,954,715 | You presented to the emergency department for diffuse weakness,
and a CT of your head was initially concerning for a possible
small stroke. You were admitted to the stroke service and
received a CT-angiogram, and this was not revealing for a new
stroke. Additionally, the final read from the CT you had in the
ED returned as negative for stroke as well. Your blood work was
overall reassuring, and you are already receiving medications to
help prevent future strokes (aspirin and warfarin). Your
weakness is thought to be secondary to your underlying medical
conditions (HES) and perhaps deconditioning or mild dehydration.
We felt your exam improved while in the hospital and you also
reported you felt your weakness was improved. We will discharge
you back to your rehab facility with the same medications you
were on before. | Mr. ___ was admitted to ___ for concern for evolving
stroke on wet read of CT head obtained in ED. The final read of
this CT was normal. He could not tolerate an MRI/MRA, so CTA
was obtained and was also WNL on wet read. (Final read pending).
Just before midnight on ___ he had an episode of mental
status change when he was woken up for neuro check which
resolved in a few minutes after being awake. Because of this,
there was concern for an evolving intracranial process, and a
___ CT scan was performed. The CT scan was negative for any
acute intracranial process. In addition, Mr. ___ had a few
desaturations overnight - he requires CPAP but refused a face
mask. He was given nasal prongs which were thought to be not
helpful as he is a mouth breather while sleeping. It is felt
that this mental status change could be secondary to CO2
retention while sleeping as this resolved within 5 minutes of
awaking.
Mr. ___ continued to have upper extremity weakness and
pain, L>R, throughout his admission. His L lower extremity
weakness improved. His INR was therapeutic at 2.9, so we did not
adjust his coumadin dose.
We also contacted his Heme/Onc team for recommendations about
his pain control medications given his increase in upper
extremity pain. | 142 | 224 |
10956945-DS-4 | 29,866,123 | ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery. | ___ presented to the ___ emergency department on
___ with worsening back and left leg pain. She has recently
undergone an anterior and posterior L4-S1 fusion about 10 days
ago. Lumbar radiographs were reviewed which showed appropriate
alignment of the lumbar spine in both coronal and sagittal
planes. The hardware is in place anteriorly and posteriorly
without evidence of loss of fixation or complication. Venous US
of the left lower extremity was negative for deep venous
thrombosis. Mrs. ___ was admitted to the Ortho Spine service
for pain control and physical therapy evaluation. IV steroids
were continued for 24 hours during the hospital stay. Acute pain
service was consulted and changes were made to patients
medications. An MRI of lumbar spine which revealed a
post-operative seroma without any central canal compromise. ___
was consulted for ambulation and recommended that Mrs. ___
would benefit from an acute rehabilitation facility. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet. | 271 | 177 |
11972365-DS-16 | 24,962,721 | Dear ___,
WHY YOU CAME TO THE HOSPITAL
- You came to ___ as you had chest pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were found to have a heart attack. This was thought to be
largely due to a bad heart valve, in addition to your coronary
artery disease. Your heart valve was replaced.
- Your kidney function worsened, and you were started on
dialysis.
- You were treated for a pneumonia.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- It is important the rehab arrange follow-up with your PCP when
you are discharged
- You need to follow-up with your cardiologist as arranged
- You will start dialysis at ___ dialysis ___ and attend
every ___
- It is important you continue to take all your medications as
prescribed
It was our pleasure taking care of you. We wish you all the
best!
Your ___ Healthcare Team
MEDICATION CHANGES:
[] changed allopurinol to 100mg every other day
[] started carvedilol 12.5mg twice daily
[] started lanthanum 500mg three times daily with meals
[] started sevelamer 800mg three times daily with meals
[] started warfarin 3mg daily; next INR recheck ___
[] stopped aspirin 81mg daily
[] stopped hydralazine 50mg every six hours
[] stopped metoprolol succinate 100mg daily
[] stopped sodium bicarbonate 650mg three times daily | ___ with background history notable for triple-vessel CAD,
status post DES to OM2 on ___, severe AS, Stage V CKD (not
yet on HD), T2DM, EtOH cirrhosis, and L ACA CVA (___) who
initially presented to the ED with chest pain, found to have STE
in aVR with diffuse depressions c/f STEMI. Patient was in shock
in the ED thought to be cardiogenic. He was treated medically
for his MI and received a TAVR during this hospitalization. His
baseline CKD worsened requiring hemodialysis which was started
inpatient.
====================
ACUTE/ACTIVE ISSUES:
====================
# Shock
Hypotensive in ED with lactate elevated to 5.3, status post 1L
IVF with improvement in SBP to 100. Most likely cardiogenic
shock in the setting of possible ischemia vs. worsening AS,
although unclear. Bedside echo without evidence of tamponade.
Low suspicion for PE or tension pneumothorax given stable
respiratory status. His lactate downtrended in ED and
normalized, with stable blood pressures throughout the remainder
of admission.
# Type II NSTEMI
# CAD with known 3VD, s/p DES to OM2
# Severe AS
Patient presented with unstable angina, found to have ECG
changes concerning for global ischemia. Coronary angiogram prior
to this hospitalization on ___ with 3VD and DES to OM2. ECG
changes did not appear consistent with in stent restenosis.
Troponins/CK-MB rose during initial hospitalization, with high
concern for global ischemia in the setting of severe AS, though
patient continued to deny chest pain and repeat ECGs did not
suggest ischemia. Peaked at 4.85, CK-MB peaked at 116. Cardiac
surgery was consulted and echo was performed showing severe
aortic stenosis. Cardiac surgery recommended TAVR as patient was
high risk for SAVR. TAVR was completed one week into
hospitalization after resolution of pneumonia, without
complication. Discussion was had regarding
antiplatelet/anticoagulant therapy going forward, given
requirement for anticoagulation for paroxysmal atrial
fibrillation. Decision was made to continue warfarin and
clopidogrel alone for duration of DAPT (at least three months),
before transitioning to aspirin/warfarin upon completion of
planned DAPT therapy. Goal INR is 2.0-3.0.
# CKD stage 5
Cr 6.2 on presentation, up from 5.6 on ___ post-cath. 7.0 on
___, status post cath with contrast. Discussion was had
regarding further contrast load necessary for TAVR procedure and
possibility of HD requirement, which patient understood and
accepted. Decision was made to initiate HD post TAVR procedure.
Left tunneled line was placed on ___ and HD was initiated on
___. Patient underwent four sessions without issue prior to
discharge. Will start outpatient HD at ___ Dialysis
Center, with a planned ___ schedule at
4PM.
# Aspiration pneumonia
Pneumonia, thought to be secondary to aspiration, was present on
admission treated with five day course of Unasyn.
# Paroxysmal atrial fibrillation
New noted ___, persisted for 12 hours, before spontaneous
conversion to sinus rhythm. Remained in NSR since. CHADS2VASC 6.
Anticoagulation was started with warfarin, with a goal INR of
2.0-3.0, and rate control was maintained with carvedilol 12.5mg
BID.
======================
CHRONIC/STABLE ISSUES:
======================
# HTN
Hydralazine was discontinued in the setting of starting
hemodialysis. Amlodipine 10mg and carvedilol 12.5mg will be
continued on discharge.
# Normocytic anemia
Likely secondary to renal disease with component of iron
deficiency anemia. The patient was transfused twice during the
course of admission (___).
# EtOH cirrhosis
Poorly understood history. Has remote history of ascites, no
known history of hepatic encephalopathy or SBP. Due for variceal
screening. Abdominal US was negative for ascites.
# T2DM
Hypoglycemic to 50's in ED, improved to 70's on re-check. The
patient was on an insulin sliding scale while admitted.
# BPH
Home tamsulosin was initially held but restarted prior to
discharge.
==================== | 202 | 582 |
11415430-DS-11 | 24,927,075 | You were admitted with abdominal pain likely due to a recent
liver biopsy and your underlying pancreatic cancer. You were
also having constipation which has now improved. A port was
placed as previously scheduled. You were also tested for TB
given a concerning finding on your chest CT and started on
treatment for latent TB. | ___ yo gentleman with newly diagnosed pancreatic cancer who
presented with CT finding showing possible reactivated TB during
chemotherapy and with RUQ pain.
Abdominal pain
- Likely related to recent liver biopsy and/or underlying
malignancy. CT done on admission without concerning findings and
hemoglobin remained stable throughout the admission. LFTs were
monitored and stable. He was started and discharged on oxycodone
PRN with good pain control.
Latent TB
- Prior to admission the patient had a chest CT with a cavitary
lesion that was concerning for latent TB and subsequent
reactivation during upcoming chemotherapy. ID was consulted. The
patient was place din a negative pressure room and sputum
studies were done. At the time of discharge returned test were
negative. ID felt it prudent to treat the patient for latent TB
given the cavitary lesion on chest CT so he was started on
isoniazid and pyridoxine. He will follow up with ID as an
outpatient.
Pancreatic Cancer
- A port was placed as previously scheduled during the
admission. He will follow up with his primary oncologist as an
outpatient later this week with plans to start FOLFIRINOX.
Constipation
- The patient was admitted with constipation, likely narcotic
induced and he was started on a bowel regimen with improvement.
He will continue on colace, senna, and miralax. | 55 | 209 |
14293935-DS-2 | 24,090,723 | It was a pleasure to take care of you at ___
___.
You were admitted for a couple of long pauses in your heart rate
and syncope, likely vasovagal in nature. This means that a
trigger, (usually emotional like fear or physical like
straining) causes changes in your vascular system such that your
heart rate and blood pressure drops. We have placed a pacemaker
to keep your heart rate regular, which should help should future
episodes occur.
.
Please decrease aspirin to 81mg daily.
Please take clindamycin 300mg every six hours through ___.
You may also take tylenol ___, ___ every ___ hours as
needed for pain.
.
Please continue taking all of your medications as previously
prescribed and attend your outpatient follow up clinic visits as
detailed below. | ___ y M with past medical history of DM2, CAD s/p PCI + stent
placement, hyperlipidemia, COPD who presented with syncopal
episode and sinus arrest during an elective nuclear stress test
for ongoing DOE (MI equivalent in the past).
. | 124 | 39 |
14924200-DS-32 | 27,995,857 | 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:
- 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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in the left leg
- Range of motion as tolerated in left knee in an unlocked
___ brace
Physical Therapy:
LLE TDWB, ROMAT at knee in unlocked ___
Treatments Frequency:
Dressings may be changed as needed for drainage. No dressings
needed if wounds are clean and dry.
Staples will be removed in Ortho trauma clinic in ___ weeks
during follow up appointment. | ___ year old homeless woman with HCV, CAD s/p NSTEMI,
polysubstance abuse who presents with acute on chronic left knee
pain, found to have a subacute proximal left tibia fracture.
# Left tibia fracture: Patient reports falling 2 weeks ago and
has been having pain in left knee since. She has had multiple
falls over the past yaer. She reports going to a clinic where no
Xrays were taken. She states she was using a wheelchair and has
been walking on the leg, however the pain was very severe. Xray
and CT of LLE show subacute fracture of the proximal left tibia
and fibula with exuberant surrounding periosteal new bone.
Previous Xrays do not show any evidence of deformity in the
tibia apart from severe osteoarthritis. No evidence of bony
lesions.
The patient was taken to the operating room with Orthopaedic
surgery on ___ for a left proximal tibia ___ plate, 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 on the Orthopaedic
surgery service. The patient was initially given IV fluids and
IV pain medications, and progressed to a regular diet and oral
medications. The patient was given perioperative antibiotics.
She was given pharmacologic anticoagulation for her left
popliteal DVT (see below). The patient worked with ___ who
determined that discharge to rehab was appropriate. Due to her
being homeless, she had a prolonged hospital course as most
rehab facilities would not accept her. Staples were removed at 2
weeks as the wound had adequately healed. X-rays of the tibia &
knee demonstrated evidence of callus formation at the fracture
site with good alignment of hardware and tibia. Knee is in
stable varus angulation with severe degenerative changes.
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, wounds were healing well
(staples removed at 2 weeks post-op), and the patient was
voiding/moving bowels spontaneously. The patient is weight
bearing as tolerated in the left lower extremity and will be
discharged with ASA 325 mg po daily x 2 weks for DVT prophylaxis
as she has completed her course of apixaban for her DVT and had
no evidence of DVT on ___ LENIS. 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.
The medicine and psychiatry services were consulted during this
admission for assistance in the management of her medical and
psychiatric comorbidities. Their recommendations are highlighted
below.
# Left popliteal DVT: ___ ___ showed left popliteal DVT.
Started on anticoagulation on ___ with enoxaparin eventually
switched to apixaban 5mg BID given CKD. ___ on ___ with no
evidence of DVT. Completed course of apixaban on the day of
discharge - ___.
# Depression/Mood disorder: Patient expressing depression and no
desire to live. Feels depressed since her son was shot in ___.
Patient was admitted under ___- evaluated by pscyhiatry
and found to have suicial ideation. After surgery, psychiatry
continued to follow, and the patient was no longer suicidal,
stating her SI to be in relation to her knee pain which is now
resolving s/p surgical fixation. Psychiatry cleared the patient
for medical rehab facility.
# HTN: Continued on diltiazem ER 120 mg po daily & amlodipine 10
mg po daily that were started at the last hospitalization.
# Chronic renal failure: Baseline Cr approximately 1.3-1.8.
Increased to 2.0 post-op but normalized to her baseline of 1.3 1
week prior to hospital discharge.
# Normocytic anemia: During hospital stay, the patient's Hct
ranged from 29 - 35. This appears close to her baseline of low
to mid ___ according to lab results in our system dating back to
___. Etioogy of her anemia may be secondary to CKD. There were
no signs of bleeding. It may be worth considering further work
up of her cause of anemia as an outpatient.
# Polysubstance abuse: The patient reports using drugs the day
she arrived to the ED (cocaine and alcohol). Patient has history
of withdrawal seizures from alcohol. CIWA scores <10 since
admission. No evidence of EtOH withdrawal during this
hospitalization.
# Asthma: Patient reports having a history of asthma, last
hospitalization had recommended outpatient PFTs. Patient had
been given ipratropium and albuterol nebs prn. | 198 | 745 |
18195430-DS-16 | 28,875,588 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came because you were having back pain and
nausea and were found to have inflammation of your liver. We did
a lot of blood tests and imaging studies which did not show a
definitive cause of your liver inflammation. We also gave you
medicine to prevent you from withdrawing from alcohol. We think
this may have been a reaction to medication you received during
your last hospitalization called phenobarbital. | ___ h/o HIV (CD4 306 on ___, VL 200K ___ on ART),
adrenal insufficiency on hydrocortisone/midodraine and alcohol
withdrawal c/b hallucinosis in the past with recent admission
for EtOH withdrawl requiring phenobarbital taper in the ICU who
presents with back pain, nausea and vomiting found to have acute
hepatitis of unclear etiology and severe metabolic derangements.
#Acute Hepatitis, possible DRESS: Patient initially presented
with 3 days of nausea and vomiting. Was found to have a
significantly elevated transaminitis with ALT/AST 1017/2650 and
normal bilis consistent with a hepatocellular pattern of injury.
The etiology in a known alcoholic with HIV on ART with
questionable compliance is likely multifactorial. Pt has
steatohepatitis which is seen on U/S and has had previously
tranaminitis (though not as severe), likely from EtOH and ART,
specifically truvada. Given significant elevation there is
concern for viral hepatitis as EtOH alone can not explain this
degree of transaminitis. Patient is HBcAb positive, so is at
risk for reactivation given his steroids for AI and
immunocompromised state. EBV, CMV, HCV and HBV viral loads
undetectable with IgG positivity for EBV and CMV. HCV Ab
negative. Elevated ferritin, though iron is normal ruling out
hemochromatosis. Patient is born in ___, and presents with
eosinophilia which may be concerning for a parasitic infection
though strongyloides Ab negative and stool O&P negative as well.
Patient does not have stigmata of chronic liver disease and his
synthetic function is intact with relatively normal albumin, INR
and plts. He denies any ingestions, other than EtOH, APAP levels
are negative x2 and he denies any new medications, though
darunavir can cause acute hepatitis. Given his alcohol abuse,
there was also concern for ischemic injury if the patient had
been down for a period of time, but his CK was not significantly
elevated to have concern for rhabdo. U/S with Doppler was
negative for thrombotic/obstructive disease. Infiltrative
processes and parenchymal texture would be better characterized
with cross sectional imaging. Autoimmune testing including AMA
and ___ is negative. Ceruloplasmin was wnl. Given patient's
recent admission requiring phenobarbital, in addition to his
elevated eosinophilia and significantly elevated transaminitis,
there is a strong suspicion for DRESS. Patient was given
supportive care and his LFTs quickly downtrended.
#Severe metabolic and electrolyte derangements: Patient
presented with a anion gap of 19 and ethanol level of 296.
Measure sOsm 356 with Osm gap of 4 when corrected for EtOH.
Lactate was only slightly elevated. Patient denied any other
ingestions. Patient had hypokalemia, hypomagnesemia and
hypophosphatemia on presentation. Upon receiving mIVF with ___ NS his hypophosphatemia dramatically decreased along with
his serum sodium. uOsm 333. The patient likely has poor
nutrition with decreased solute intake evidenced by a BUN of 4,
therefore there was concern for refeeding syndrome and beer
potomania physiology to explain his progressive hyponatremia,
though urine electrolytes not entirely c/w this diagnosis,
likely multifactorial with ?component of SIADH. Electrolytes
corrected with repletion and hyponatremia improved with
increased PO intake and fluid restriction. Given concern for
severe nutritional deficiency, thiamine has been replenished in
addition to Ensure supplementation with meals.
#Alcohol abuse/intoxication: patient with multiple admissions
for alcohol use, now presenting with acute intoxication. Has
history of hallucinosis in the past, unclear if DT or seizures.
Scheudled lorazepam was used given his hepatic injury. Patient
did not score on CIWA and was able to be quickly downtitrated.
#Eosinophilia: Patient has new eosinophilia on presentation.
Absolute eosinophilia count 720. Trop negative. Could be ___ AI,
though patient is taking steroids and is hemodynamically stable.
Parastitic disease was also ruled out. Acute onset is likely not
related to malignancy. As above, eosinophilia may be secondary
to DRESS.
# Back Pain: Patient endorses back pain and has focal tenderness
on exam over lower lumbar spine (without paraspinal tenderness).
Lumbar XR shows non-acute fractures. No perineal paresthesia and
rectal tone normal rules out compression/cauda equina syndrome.
Given immunocompromised state, a lumbar spine MRI was obtained
which showed chronic degenerative changes and no fracture,
abscess or neoplasm.
#Adrenal insufficiency: BP suggests that patient is compensated,
but eosinophilia might suggest still adrenal insufficiency.
Steroids were recently uptitrated at last admission from 5 ->
7.5 total daily.
#HIV on ART: last CD4 in the 306 in ___, but with an
active viral load 200K. Repeat CD4 in house was 189, viral load
pending. Patient admits to inconsistent medication use.
Quantiferon gold negative ___. Truvada increases rates of
steatohepatitis and darunavir may cause acute hepatitis per
pharmacy. Will hold ART for now given unsure compliance and
concern for worsening liver dysfunction. Also, patient with need
PJP ppx in the future. No signs of thrush. Therefore, his ART
and prophylaxis may be held for now and restarted after
outpatient follow up.
#Anemia, thrombocytopenia: Likely secondary to alcohol abuse. No
evidence of bleeding. Stable from prior. MCV 85, likely has
multifactorial cause as liver dysnfunction and poor nutrition
should cause a macrocytic anemia.
#Sinus Tachycardia: Rates 100-110s. No chest pain, trop
negative. No dyspnea. Does not appear septic. Patient is not
complaining of pain. Likely due to alcohol withdrawal.
#Suicidal Ideation: Patient verbalized active SI to ED staff.
This is in the setting of acute intoxication. He has repeated
suicidal ideation on the floor and was seen by psychiatry who
placed him on a ___. Patient was started on citalopram.
He was discharged from the medical ward at ___ to the
psychiatry ward at ___.
TRANSITIONAL ISSUES
[]discuss reinitiating ART and starting PJP ppx for CD4 count
189
[]Make hepatology and primary care physician ___
[]Patient discharged on a 1.5 L fluid restriction given
hyponatremia. ___ discontinue if sodium normalizes.
[]On ___, recommend rechecking CBC w/ diff, electrolytes, and
LFT's to trend eosinophilia, sodium, and LFT abnormalities.
[]Consider outpatient orthopedics ___ given spine MRI results. | 84 | 945 |
19546785-DS-13 | 28,063,585 | You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. You then underwent an operation to relieve your bowel
obstruction and it has now resolved. You have tolerated a
regular diet, are passing gas and your pain is controlled with
pain medications by mouth. You may return home to finish your
recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated but clear heavy
exercise should be avoided.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck! | Ms. ___ came to us on ___. She had a CT scan which showed a
closed loop small bowel obstruction. She had an NGT placed, made
NPO and given IV fluids. Thus, she underwent an exploratory
laparotomy with lysis of adhesions on ___. She tolerated the
procedure well and was transferred to the PACU in stable
condition. On ___, her foley was removed and she was voiding
spontaneously. Her NG tube was removed and her diet was advanced
to clears but however, she developed an early postop ileus and
needed to have her NG tube placed back in and diet made NPO. She
was given milk of magnesia and this seemed to help her pass gas
so her diet was then advanced and NG discontinued once again.
Her pain was initially controlled with a dPCA but once she was
tolerating PO, she was switched to oral pain medications. She
passed stool in her ostomy, was tolerating a regular diet and
ambulating so she was deemed fit for discharge home with ___ for
ostomy teaching. | 524 | 176 |
17981697-DS-15 | 24,042,432 | You were admitted to ___ Neurosurgery service for evaluation
of your left hip pain/numbness. You underwent a MRI of your
lumbar spine that showed you have a bulging disc at L4-5, but
that did not explain your left hip symptoms. Neurology was
consulted to further evaluate those symptoms.
You are now being discharged with the following instructions:
You may continue to take your home medications as you were prior
to this hospitalization. | Mrs. ___ was admitted to the Neurosurgery service for
work-up of her right hip, genital pain and paresthesia. She was
initially kept NPO and give IV fluids in case she needed a
surgical procedure. A MRI of the L spine revealed a herniated
disc at L4-5, but no pathology at L1 to explain her symptoms.
Neurology was consulted to assist in working up her
paresthesias/pain. Per their recommendation, a CT of the
abdomen and pelvis was obtained to rule out pathology that could
cause compression of a peripheral nerve. That scan was negative
for any process causing nerve compression.
Mrs. ___ was discharged home on the afternoon of ___. Per
her discharge instructions, she should follow up with Dr. ___
___ Neurosurgery and Dr. ___ Neurology. An EMG was
ordered to further work-up her right-sided paresthesia.
Differential diagnoses, per Neurology, are meralgia paresthetica
or genitofemoral nerve pathology.
The patient was afebrile, hemodynamically and neurologically
intact.
**Attending of record at time of discharge was Dr. ___
___, MD. | 72 | 172 |
Subsets and Splits