note_id
stringlengths 13
15
| hadm_id
int64 20M
30M
| discharge_instructions
stringlengths 42
33.4k
| brief_hospital_course
stringlengths 45
22.6k
| discharge_instructions_word_count
int64 10
4.86k
| brief_hospital_course_word_count
int64 10
3.44k
|
|---|---|---|---|---|---|
16559830-DS-2 | 21,981,326 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fall at your nursing home and unfortunately broke
your right hip.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent a successful hip surgery with the orthopedic
surgeons.
- You were noted to be quite confused and so were transferred to
the general medicine service for ongoing treatment.
- You were treated for a urinary tract infection and started on
thyroid medication.
- You continued to have confusion and so had an MRI of your
brain which showed ####
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Surgical 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 right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take SQH BID 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 | ___ PMHx recurrent severe depression who came to the hospital
after a fall at her nursing home, found to have a R
intertrochanteric hip fracture. She underwent repair with
Orthopedic Surgery on ___. Hospital course was complicated
by encephalopathy (hyper/hypo active delirium), hypoxia, ___ and
Klebsiella UTI. She improved and was discharged to rehab near
her mental status baseline.
Of note, she had a markedly elevated LDH and a leukocytosis that
was of unclear etiology. She also had uterine thickening and an
exophytic uterine mass (possibly fibroid) that warrants follow
up as an outpatient (PCP and ___ were made aware).
TRANSITIONAL ISSUES
===================
[] Patient will require heparin ppx through ___ per
orthopedic surgery recs (4wks)
[] Patient will require orthopedics follow-up 2wks after
discharge with ___, NP
[ ]Staples to be removed at follow-up appointment in 2 weeks
[] Patient was started on levothyroxine 50mcg qDay. Repeat TFTs
in ___
[] Patient will require repeat thyroid US as an outpatient to
evaluate L thyroid mass
[] Should consider nonemergent pelvic US vs. MRI to evaluate
incidental endometrial thickness measuring up to 14mm
(endometrial carcinoma cannot be excluded)
[] ECG was notable for inferior Q-waves, patient should have
HbA1C/lipids evaluated, consider initiation of ASA/statin
[ ] Repeat CBC and LDH 1 week after discharge and send result to
PCP. Discharge WBC 16.9, discharge LDH 500.
[ ] Ibuprofen and lansoprazole should be stopped on ___. | 670 | 228 |
14880390-DS-4 | 26,260,022 | You underwent a right inguinal hernia repair. Please follow
activity restrictions, take pain meds only as needed and to no
greater degree than as prescribed, and follow up in ___ clinic
as directed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than 15 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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 then that is okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Continue your deep breathing exercises.
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mr. ___ was admitted to the ___ service with HPI as stated
above. A CT scan demonstrated a small fat-containing right
inguinal hernia with no evidence of bowel loops within it as
well as evidence of previous abdominal surgery. He was taken to
the operating room for a right inguinal hernia repair which went
without complication. The patient was extubated and went to the
PACU and then to the floor in stable condition.
Pain was well-controlled on an appropriate regimen of pain
medicines and the patient remained afebrile in the postoperative
period. He tolerated an advanced diet without nausea or
vomiting. He was discharged to home on ___ with
appropriate prescriptions and instructions to follow up in ___
weeks in ___ clinic as well as what signs and symptoms of which
to be vigilant. He expressed appropriate understanding of all
instructions and was discharged to home in good condition. | 774 | 158 |
17809030-DS-18 | 22,901,561 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You were having abdominal pain and bloody diarrhea
What happened while you were here:
- You were found to have an infection called c.diff, which
causes diarrhea
- A scope of your bowel showed that inflammation, consistent
with a flare of your ulcerative colitis
- You were treated with intravenous steroids and antibiotics and
your symptoms improved
What you should do once you return home:
- Continue taking your medications as prescribed
- You should taking oral vancomycin for two weeks (end date
___
- Continue taking prednisone 40mg through ___ 30mg through
___, 20mg through ___, 10mg through ___.
Sincerely,
Your ___ Care Team | ___ with a history of pan-ulcerative colitis on balsalazide,
IBS, and bipolar disorder, who presented with BRBPR and diarrhea
x1 month found to have C diff infection and ulcerative colitis
flare, treated with PO Vancomycin and steroids.
# Ulcerative colitis
Patient with h/o UC, presented with bloody diarrhea and
abdominal pain, consistent with UC flare. This was likely
exacerbated by or triggered by C diff infection. Patient
evaluated by GI with flex sig on ___ which showed diffuse
erythema, edema and friability of the mucosa, pathology
consistent with ulcerative colitis. Stool studies as above
notable for C diff infection, remaining stool studies pending at
the time of discharge. She was started on IV methylprednisone
and transitioned to oral prednisone after ~48 hours. CRP
initially elevated to 72.2, peaked at 96, and improved to 55 at
the time of discharge. Patient also with marked improvement in
symptoms following treatment with steroids/vanc. Patient
declined DVT ppx during admission despite understanding of risks
and benefits - that she is particularly high risk for DVT given
h/o UC. Patient discharged on PO prednisone taper (40 mg x 10
days, then 30 mg x 10 days, then 20 mg x 10 days, then 10 mg x
10 days). She was given a prescription for omeprazole
(prescribed previously by outpatient providers) given prednisone
taper. Home balsalazide held during admission per GI, restarted
at discharge.
# C diff infection:
Found to be C diff positive on admission, likely community
acquired. Treated with PO vancomycin 125mg q6hrs, ___, which
she will continue for 14d course through ___.
# Bipolar Disorder:
Continued home dextroamphetamine-amphetamine, divalproex, and
mirtazapine
TRANSITIONAL ISSUES:
====================
[ ] Patient discharged on PO prednisone 40 mg x 10 days, then 30
mg x 10 days, then 20 mg x 10 days, then 10 mg x 10 days.
[ ] Continue PO Vancomycin 125mg q6hrs through ___.
[ ] Provided Rx for omeprazole, previously prescribed by
outpatient providers but patient unable to fill. F/U with
outpatient providers, including PCP and GI, to determine
requisite course.
[ ] Stool Cx pending at discharge. F/U with outpatient providers
for these results.
[ ] F/U pending pathology, CMV staining. F/U with GI for these
results. | 116 | 362 |
15275684-DS-23 | 29,066,185 | Dear Ms. ___,
You were recently admitted to ___
___.
Why I was here?
- You were brought in with chest pain and found to have a heart
attack.
What happened while I was here?
- You underwent a cardiac catheterization and had the blockage
in your heart vessel opened.
- You were started on medications to help treat your heart
disease and prevent blood clots.
- You were seen by the physical therapists, who recommended
rehab.
What I should do when I go home?
- Continue to take all of your medications as directed.
- Follow up with your primary care doctor and the cardiologist.
- Follow up with the ___ clinic for management of your
Coumadin dosage.
Thank you for allowing us to care for you,
Your ___ Care Team | Ms. ___ is an ___ year old woman with T2DM (on insulin), HTN,
HLD, newly diagnosed AF (not on anticoagulation), who presented
from ___ (assisted living facility) with 2 hours
of chest pressure, EMS EKG with ST elevations in precordial
leads and associated ST depressions in inferior leads, urgently
taken to cath lab, now s/p 2 DES to LAD.
#STEMI:
#CAD:
#LV apical aneurysm:
Patient without prior history of CAD. Presented with chest pain,
found in EMS EKG to have ST elevations in precordial leads and
associated ST depressions in inferior leads, and urgently taken
to cath lab. On cardiac angiography, found to have 3 vessel
disease with 2 DES to LAD. Given heparin bolus and loaded with
cangrelor. She was started on ASA 81mg daily and metoprolol
12.5mg q6h. Her pravastatin was changed to atorvastatin 80mg
daily. She then underwent TTE which showed reduced EF 35%,
severe apical hypokinesis with focal akinesis, and LV apical
aneurysm. She was started on coumadin for LV thrombus ppx. Given
need for anticoagulation for apical aneurysm, patient's
antiplatelet agent was switched from ticagrelor to clopidogrel.
During ___, she was noted to be bradycardic to the ___ and
her metoprolol was decreased to 12.5mg BID. She was then
transitioned to metoprolol succinate 25mg daily. When her
creatinine recovered, she was started on lisinopril 5mg daily
and her amlodipine was discontinued.
#Acute ischemic cardiomyopathy with reduced EF:
As above, patient's post-MI TTE with new reduced EF 35%, severe
apical hypokinesis with focal akinesis, and LV apical aneurysm.
As above, she was started on metoprolol and high-dose statin.
She was also started on anticoagulation with Coumadin.
Lisinopril 2.5mg daily was started, but discontinued after 1
dose due to post-cath ___. She was started on lisinopril 5mg
daily once her post-cath ___ improved. She had minimal ectopy on
telemetry and therefore did not receive a lifevest. Plan for
repeat TTE in 8 weeks to reassess LVEF.
#Atrial fibrillation:
Newly diagnosed during admission in ___. Rate controlled with
diltiazem ER 120mg. Not placed on anticoagulation at that time
despite CHADS-Vasc score 5 due to concern for age and fall risk.
Her diltiazem was d/c'd post-MI and she was started on
metoprolol (as above). She was also started on Coumadin for LV
apical aneurysm.
___:
Patient with increase in creatinine from baseline 1.0 to 1.3
after catheterization. Initially had been started on lisinopril,
which was d/c'd after bump in creatinine. When her creatinine
improved, she was started on lisinopril 5mg daily.
#Depression
#Anxiety:
Patient with noted anxiety during admission. Her outpatient
psychiatrist recommended discontinuing fluoxetine and starting
duloxetine 30mg daily instead.
TRANSITIONAL ISSUES:
=====================
#Medication changes:
- stopped diltiazem
- started metoprolol succinate 25mg daily
- stopped pravastatin
- started atorvastatin 80mg qPM
- started aspirin 81mg daily
- started clopidogrel 75mg daily
- started warfarin 2.5mg daily (to be adjusted per
___ clinic)
- started lisinopril 5mg daily
- stopped amlodipine
- stopped fluoxetine
- started duloxetine 30mg daily
[] post-STEMI TTE with newly reduced EF 35%. Not given LifeVest
as she had very minimal ectopy on telemetry. Please obtain TTE
in 8 weeks (___) to check for recovery of LVEF. If
continues to be depressed, consider ICD placement.
[] Patient with episodes of bradycardia to ___ with ___.
Metoprolol decreased from 12.5mg q6 to 12.5mg q8. She was then
transitioned to metoprolol succinate 25mg daily. Please continue
to monitor HR and adjust metoprolol dosage as clinically
indicated.
[] Patient started on Coumadin, ASA, and Plavix for LV apical
aneurysm s/p PCI for STEMI. Please monitor for bleeding.
[] Check Chem 7 on ___ to check creatinine and
lytes while on lisinopril.
[] Check INR on ___ and adjust warfarin dose as
needed.
[] Consider starting spironolactone as outpatient given low EF
and insulin-dependent diabetes.
# CODE: Full (confirmed)
# CONTACT: HCP: daughter ___ ___ | 133 | 622 |
14779211-DS-8 | 25,527,137 | Dear Mr. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in with your PCP ___ ___ weeks after
discharge.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr. ___ was evaluated by the Acute Care Surgery team in the ED
on ___ as described in the HPI. Admission CT abdomen/pelvis
and RUQ ultrasound both demonstrated acute calculous
cholecystitis. He was admitted on ___ under the Acute Care
Surgery service for management of his acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy on HD 1. Please see operative report for details
of this procedure. He tolerated the procedure well and was
extubated upon completion. Of note, he voided prior to his
surgery, but when a Foley catheter was placed for the procedure,
he had a post-void residual of greater than 400 CC. He was
subsequently taken to the PACU for recovery.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor tolerating a clear liquid diet, on IV fluids, and
with scheduled acetaminophen/toradol and PRN oxycodone for pain
control. He was hemodynamically stable. His vital signs were
routinely monitored and he remained afebrile and hemodynamically
stable. Post-operative labs were notable for elevated lactate to
4.0, which was attributably to likely dehydration. He was
initially given IV fluids postoperatively, as well as a 1000 CC
fluid bolus with improvement in his lactate to 1.0. His
maintenance IV fluids were discontinued when he was tolerating
PO intake. His diet was advanced during the afternoon of POD 0
from clear liquids to regular, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. Given his high post-void
residual in the OR, we sent a UA, which was unremarkable.
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. His pain level was routinely assessed and
well controlled at discharge with an oral regimen as needed.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. He was voiding appropriately, and on questioning
reported urinary frequency prior to this hospitalization. He was
instructed to mention this to his PCP at follow up for further
work up and possible intervention. 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. He was instructed to follow
up with his PCP in ___ in ___ weeks. If necessary, his PCP
may refer his to Urology or General Surgery as needed. | 731 | 438 |
12705112-DS-6 | 23,877,597 | Dear Mr. ___,
You were admitted for episodes concerning for seizures, which
was likely from your previous stroke. In addition, you were
found to have an abnormal heart rhythm, called atrial
fibrillation. In the course of working this up, you were found
to have a small clot in the heart, as well as heart failure. You
were seen by cardiology, who recommended several important
medication changes.
START apixaban 5mg twice daily
START levetiracetam 750mg twice daily
START furosemide 40mg twice daily
You will need to follow up with your cardiologist, as well as
cardiology at ___, for additional follow up imaging and
procedures.
Please weigh yourself daily and if you gain 3 or more pounds in
1 day, please call your cardiologist.
Sincerely,
___ Neurology | ___ y/o male with a past medical history of stroke in ___,
aortic regurg s/p bioprosthetic valve replacement ___, HFpEF,
found seizing in parked car with preceding erratic driving,
presented with slight hypothermia (95 degrees at OSH), intubated
on arrival to outside hospital. Transferred to ___ for cvEEG,
which was negative for seizure. Course complicated by tenuous
respiratory status ___ COPD, aspiration PNA), and paroxysmal
atrial fibrillation with RVR.
#Seizure
#Altered Mental Status
At OSH, received a total of 6 mg of lorazepam, 2L normal saline,
1 g of Keppra, and started on a propofol drip. By report, he may
have received a dose of phenytoin at OSH, not clearly
documented, though phenytoin level on arrival to ___ was 18.7.
Unclear trigger for seizure. Meningitis was considered so
empiric coverage with vancomycin, ampicillin, acyclovir was
initiated, though was discontinued after he rapidly improved on
arrival to ___. LP therefore deferred. Continuous EEG showed
diffuse background slowing and disorganization, no seizures or
epileptiform discharges. Initiated keppra 750 mg BID, which he
tolerated well.
#Acute respiratory insufficiency
#Aspiration PNA
#COPD exacerbation
#Pleural effusions:
Intubated as above for airway protection in setting of concern
for seizure. Extubated ___ with continued respiratory distress
(wheezing, accessory muscle use, shortness of breath). Etiology
likely multifactorial due to pleural effusions (including fluid
collection above hemithorax- nonsurgical, aspiration PNA, and
reactive airway disease (h/o smoking). CTA negative for PE. He
was diuresed with Lasix, as high as 40mg IV, with modest
benefit. Respiratory status improved with initiation of high
dose IV steroids x5 days (___) and unasyn x7 days
(___) for COPD/aspiration pneumonia.
#Paroxysmal atrial fibrillation with RVR:
Placed on dilt gtt initially, which was weaned with uptitration
of home metoprolol with good effect. However, despite high doses
of Metoprolol, heart rate remained elevated to the 130s. He was
therefore given a bolus + 48 hour infusion of Amiodarone, with
some improvement in his heart rate. Switched home rivaroxaban to
apixaban per discussion with outpatient cardiologist to reduce
bleeding risk. On the floor, cardiology consulted for additional
recs, recommended TEE and potential cardioversion. On TEE,
however, patient found to have a left atrial thrombus, so
cardioversion was aborted. Plan for 4 weeks of uninterrupted
anticoagulation, followed by cardioversion. This was
communicated with his outpatient cardiologist Dr. ___.
#Heart failure
Diuresed with 40mg IV BID to good effect, discharge dry weight
was 52.4kg. Discharge diuretic dose will be 40mg PO BID.
#ETOH use disorder:
Per wife, he does not drink, though records from the outside
hospital indicate 3 or more alcoholic beverages per night. He
was given a phenobarb load x1 on admission. Initiated thiamine,
folic acid repletion.
#History of stroke:
Transitioned to apixaban as above. Continued home atorvastatin.
#Thrombocytopenia:
Likely due to splenic sequestration in setting of chronic ETOH
use.
#HTN:
Held home lisinopril.
#History of aortic valve replacement:
TTE with well seated and normally functioning valve. | 117 | 460 |
19277667-DS-15 | 27,615,867 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
had headaches, difficulty walking, and severe confusion. You
had a brain MRI that showed signs of toxoplasmosis (brain
infection because of your AIDS). You were started medication to
treat the infection and your neurological status improved. You
were evaluated by Physical Therapy who felt you were safe at
home and a repeat MRI showed that your brain infection was
getting much better. Best of luck to you in your future health.
Do not take methamphetamines or other illegal drugs or use
injection drugs. Please take all medications reliably and as
directed (including your antiretrovirals and your toxoplasmosis
treatment), followup with all providers as scheduled (or call
ahead of time to reschedule), and call a doctor if you have any
questions or concerns. You have been given a cab voucher to get
to ___ to pick up your pills.
Sincerely,
Your ___ Care Team | ___, a ___ yo M PMHx AIDS (only known OI PCP ___ ___
and did not complete tx, recently started on HAART, most recent
CD4 39 on ___ ___, actively smoking crystal
meth, syphilis, and who left AMA on ___ after an admission
for headache and represented to the ___ ED on ___ with
headache and AMS. He is now s/p intubation for MRI showing
multiple ring enhancing lesions concerning for toxo vs. CNS
lymphoma, and 6d MICU stay c/b SIADH and agitation, during which
he was transitioned to empiric treatment for toxo. LP was not
performed initially due to concern of cerebral edema with high
risk of herniation. He self-extubated in MICU and was
transferred to floor for continued treatment. He continued to
improve (and therefore did not require lumbar puncture or brain
biopsy), his mental status returned to baseline, his ataxia
resolved, ___ cleared patient to go home, his lung lesions noted
previously resolved.
# Central Nervous System Toxoplasmosis (presumed): Patient with
history of HIV/AIDS presented with ___ days of headache, ___
days of ataxia, and 1 day of delirium and CT-Head showing
multiple hypodensities in bilateral basal ganglia, thalami, left
temporal lobe, and cerebellum. Initial differential included
drug intoxication (positive amphetamines but wouldn't explain
ataxia), toxic-metabolic disease (Na 128 but otherwise normal),
cryptococcal disease (negative serum antigen), toxoplasmosis,
meningitis (HSV, TB), neurosyphilis, PML, CNS fungal disease,
septic emboli, CNS ___, PRES (by imaging, no significant
hypertension or relevant drug exposures), vasculitis, and
HIV-associated encephalitis (possibly superimposed on
HIV-associated neurocognitive dysfunction/atrophy). Neurology
Consult wanted MRI Brain but did not want lumbar puncture due to
concern of posterior fossa edema and thus increased risk of
herniation. Infectious Disease Consult wanted cryptococcal
antigen and initially wanted many CSF labs (also started
initially on vancomycin/ceftriaxone/ampicillin/acyclovir at
meningitic dosing). Patient initially had poor
concentration/judgement but this worsened to disorientation and
severe agitated delirium requiring 4-point restraints (patient
still managed to slip out, jump out of bed, and immediately
strike head against wall). Team attempted twice to obtain MRI
on main hospital floor (once within hours of arrival without
sedation which failed, a second time shortly before ICU transfer
with 4mg of lorazepam also failed). Due to need for MRI Brain
to determine clinical course, continued worsening of patient's
encephalopathy, and by Neurology/ID recommendation, patient was
transferred to MICU for MRI, Bronchoscopy, and potentially LP
and Brain Biopsy. MRI Brain showed multiple ring and solid
enhancing lesions in basal ganglia and
supratentorial/infratentorial white matter most concerning for
toxoplasmosis, CNS lymphoma, and less likely
fungal/bacterial/metastatic disease. Given concerns regarding
herniation from LP and invasiveness of brain biopsy (as well as
known Toxoplasmosis IgG), patient was started on empiric course
of pyrimethamine/sulfadiazine/leucovorin starting ___ along with
a single day of dexamethasone and levetiracetam for seizure
prophylaxis. Patient had history of sulfonamide allergy and so
underwent desensitization (without incident). Neurosurgery was
consulted for possibility of brain biopsy. After patient
self-extubated in ICU and was stable, he was transferred back to
the hospital floor. Due to overall stability and dramatic
improvement in focal neurological deficits by ___, patient did
not receive LP or brain biopsy (improvement at that time no
longer felt to be dexamethasone-related). His regimen was
subsequently changed to TMP-SMZ 2tabs BID on ___ with continued
improvement (total 6 week course, improved compliance). His
ataxia resolved completely (with mild residual upper extremity
dysmetria), his confusion cleared completely, and ___ cleared
patient to go home. HCP noted that patient had repeated
exposures to an outdoor cat and cleaned after the cat despite
being repeatedly warn by doctors and family not to. Repeat MRI
on ___ demonstrated dramatic improvement in the CNS lesions and
patient was discharged (taxi'd to ___ to receive
prepackaged TMP-SMZ and levetiracetam).
# Delirium/Agitation: Noted on admission, likely secondary to
CNS Toxoplasmosis versus contributions from amphetamine usage
versus possibly bipolar syndrome. Made admission MRI Brain
impossible without intubation/sedation. In ICU, patient
self-D/Cd central line, endotracheal tube, and innumerable
peripheral IVs. Currently somnolent with antipsychotics and
tolerating PO. Then Code Purpled on ___ in early morning
wanting to leave AMA but was redirected without force and with
quetiapine/lorazepam. Of note, last hospitalization at ___
ended with AMA discharge. On 5:00 on ___, Code Purple was
called since patient was bored and wanted to go home; received
25mg PO Quetiapine. At 6:30 again Code Purpled. Nightfloat
attempted to redirect but patient went out of room into hallway,
was unable to state consequences of leaving, and received
lorazepam 1mg, and was peacefully brought back to his room. At
8:00, he Code Purpled a ___ time, made it to the ___ elevator,
assaulted the PGY2, and had to be escorted back to room by
security. Later in the day he was less agitated with sister/HCP
present. Quetiapine was replaced with olazapine due to concern
of effect on ART. Late ___, he Code Purpled for a ___ time
but was easily redirected back into his room; given lorazepam
1mg PO x1. His quetiapine was changed to olanzapine due to
concern of ART interaction. His QTc was in low 400s and so
daily EKG monitoring was stopped due to stability. As of
___, he demonstrated some impulsivity but understood the
consequences of leaving and was fully oriented. Physical
Therapy consult felt that the patient had no acute ___ needs.
Since ___, patient was calm and no attempted to leave AMA.
Speech and Swallow recommended aspiration diet but liberalized
over the course of his hospital stay. for the remainder of his
inpatient stay, he was stable on olanzapine 5mg and trazodone
50mg. He was oriented and was able to understand the nature of
his condition and treatments and consequences of noncompliance
and was discharged to home without any psychiatric medication.
# SIADH / Hyponatremia: Noted to have Na 120s on admission with
Urine Na 100s that worsened with IV normal saline in ED. Likely
in setting of active CNS process, though lung process is also
possible given recent chest findings. Na has since returned to
140+, from 128 on admission, with hypertonic saline. ___ have
been a component of hypovolemia (since patient was not eating in
final days prior to hospitalization) and SIADH may improve with
improvement in brain lesions. Down to low 130s on ___ and
beyond despite fluid restriction but patient overall
asymptomatic.
# HIV/AIDS: Patient with a long history of HIV/AIDS (unclear if
acquired from MSM or IVDU) for as well as thrush and PCP ___
(did not complete treatment) recently started on ART ___,
not previously did to concerns of noncompliance) On ___, his
CD4 count was 39 and his viral load was ~250,000. On a visit on
___, his VL was 984 (notions of medication noncompliance but
VL would suggest otherwise). His outpatient regimen of
Emtricitabine-Tenofovir 200-300mg PO Daily, Ritonavir 100mg PO
Daily, Darunivir 800mg PO Daily,
Azithromycin/Atovaquone/Nystatin was continued as inpatient
aside from atovaquone (replaced with toxoplasmosis treatment).
Of note, patient did not receive TMP-SMZ due to recorded
sulfonamide allergy (no issues with desensitization during ICU
stay) which may have resulted in poor coverage of toxoplasmosis.
# Leukopenia: Patient with HIV/AIDS with previously normal WBC
noted to be leukopenic on ___ having recently been started on
Toxoplasmosis treatment. No neutropenia on ___ and WBC normal
on ___ and beyond.
# History of Crystal Meth Use and IVDU: Patient had allegedly
stopped IVDU 6 months prior to presentation and crystal
methaphetamine several days prior to presentation (positive
urine toxicology). After the acute phase of his
hospitalization, patient was noted to be somewhat somnolent
possibly secondary to methamphetamine withdrawal. Patient was
counseled to abstain from recreational drug use.
# Right Upper Lobe Cavitary Lesion and Ground Glass Opacities:
Lung findings (6mm cavitary lesion) noted on prior imaging with
patient no-showing numerous outpatient bronchoscopies. Overall
unclear etiology given lack of fever/chills/cough, positive IGRA
but negative AFBx3 in ___. Bronchoscopy with bronchoalveolar
lavage on ___ (while intubated in ICU) by Interventional
Pulmonology grew late CMV Early Antigen Positive and later
pansensitive Staphylococcus aureus but Infectious Disease was
not concerned given lack of CXR findings and change in symptoms.
Patient was initially on Contact/Airborne precautions but these
were discontinued once patient was in ICU. Repeat CT-Chest on
___ showed interval resolution of all lung pathology.
Differential on discharge includes viral pneumonia versus
incidentally treated PCP ___ (with evidence on BAL) versus
unclear etiology.
# ___: Most likely pre-renal or contrast-induced, given contrast
for CT angiography on ___ oliguria during MICU stay. Cr has
since returned to baseline. Nephrology was consulted in ICU for
assistance with ___ and SIADH but signed off in ICU given
normalization of renal function. | 170 | 1,482 |
14222873-DS-20 | 21,842,851 | Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted because your kidney function was abnormal. This
was likely due to damage to your kidneys from intermittently
having low blood pressure. Your kidney function slowly
recovered and will hopefully continue to improve. You were
given medications to remove fluid from your legs. After your
leg swelling resolves and your leg ulcers heal, the orthopedic
surgeons will replace your knee. Your blood pressure became
high, so you were started on a new medication to help with this.
It is very important that you continue to take your medications
as prescribed and keep your follow-up appointments.
We wish you good health!
Sincerely,
Your ___ Team | Mr. ___ is a ___ gentleman with HCV cirrhosis ___ years
s/p OLD and h/o DVT and PE (on Coumadin) who was transferred
from an OSH with chest pain, which resolved on admission, but
found to have supratherapeutic INR and ___.
# Acute on chronic kidney disease: Cr up to 2.2 on admission
from baseline of 1.4-1.5. Cr rose to 2.7 after albumin/IVF
boluses. Muddy brown casts were seen on urine sediment. Per
renal, multiple hypotensive episodes and bradycardia likely
resulted in ATN. Patient's creatinine slowly improved after
starting diuretics. Cr on discharge was 2.1. Kidney function
is expected to recover with time.
# Anasarca: Patient was grossly anasarcic after being volume
resuscitated with albumin for hypotension. TTE was largely
unchanged. Patient was diuresed with 40-80 mg IV Lasix/day and
his edema improved. He was discharged on torsemide 40 mg po
daily.
# Hepatitis C cirrhosis s/p OLT: Transplanted in ___, on
cyclosporine 75 mg q12h. MMF was stopped in clinic in
___ and LFTs remained normal. HCV VL 342,000 IU/mL on
___. Last biopsy was performed at previous admission
revealed Grade ___ inflammation, no acute cellular rejection, no
steatosis or ballooning, and stage ___ fibrosis. Atovaquone
was continued for prophylaxis. Cyclosporine was decreased to 50
mg q12h and levels were monitored.
# Supratherapeutic INR: Patient's Coumadin was held on
admission for supratherapeutic INR. He received vitamin K for
INR 5.2 and INR then became subtherapeutic. Warfarin was
restarted with a heparin gtt until INR became therapeutic. INR
became supratherapeutic again and Coumadin dose was adjusted.
INR on discharge was 3.6. He was discharged on Coumadin 1 mg
daily.
# Hypertension: Patient was initially hypotensive and losartan
and diuretics were held. He received an albumin bolus with
improvement in his blood pressure. He then became hypertensive
during the latter part of his hospitalization (SBP up to
170/180s). Losartan continued to be held given ___. Patient
was started on amlodipine 5 mg daily, which can be uptitrated as
needed.
# Prior left knee infection s/p hardware removal in ___:
Patient has chronic pain related to his previous knee
infection/hardware removal. He also has shallow venous stasis
ulcers on bilateral lower extremities. Patient's orthopedic
surgeon plans to replace his knee hardware once his ulcers have
healed and his leg swelling has resolved. Patient's pain was
well-controlled on home Oxycontin and po Dilaudid. He became
confused after receiving IV Dilaudid, so this was avoided.
# Catheter-associated UTI: Initial urine culture was negative.
Repeat urine culture after catheter was placed grew >100,000
Klebsiella sensitive to ceftriaxone. Foley was exchanged and
patient completed a 7 day course of ceftriaxone. Foley was
removed prior to discharge.
# Chest Pain: Patient had chest pain at OSH, which resolved on
admission here. No ischemic changes on EKG and three sets of
cardiac enzymes were negative. Considered PE, especially given
h/o prior PE, but patient had been therapeutic on Coumadin. CTA
was deferred given ___.
# Atrial fibrillation/pauses: Not on agents for rate or rhythm
control. During last admission (___), patient was
bradycardic at night with ___ second pauses seen on telemetry.
Patient continued to have pauses with HR ___, though rates
improved to ___ without intervention. It is unclear if these
pauses are contributing to hypotensive episodes. Patient is
followed by Dr. ___ have further outpatient EP
evaluation if warranted.
# Hyponatremia: Na persistently low (as low as 130s), which is
chronic per review of prior discharge summaries. Hyponatremia
neither responded to nor worsened with albumin or diuretics. | 122 | 624 |
15751585-DS-9 | 29,061,217 | Mr. ___,
You were hospitalized for a right leg deep vein thrombosis
(blood clot). You were started on warfarin and your INR level
(that we monitor to make sure that your blood is adequately
thinned by the warfarin) is being monitored. You are also
getting another blood thinner called Lovenox injections twice
daily that will be stopped once your INR level is at a
therapeutic level. Your INR will still be checked at rehab.
You may still have some pain and discomfort in your right leg as
the clot heals. You will also be seeing the hematologist in
clinic in several weeks in follow up. | Mr. ___ is a ___ male with history of unprovoked left
carotid dissection, left MCA stroke with hemicraniectomy and
bilateral pulmonary emboli in ___, residual right sided
weakness and aphasia, and right hip fracture in ___ who
presented with 5 days of increased RLE weakness and was found to
have extensive right leg DVT. He had been on warfarin from ___
until ___ for prior stroke and immobility, then was stopped
by hematology. He was on prophylactic Lovenox when he was
discharged in ___ after his hip fracture, which was
discontinued when he left rehab in late ___.
Ultrasound on ___ showed "1. Occlusive deep venous thrombosis
of the right common femoral, femoral, popliteal, gastrocnemius,
posterior tibial, and peroneal veins, extending down to at least
the level of the ankle. 2. No deep venous thrombosis of the left
lower extremity." He was started on a heparin drip and then
transitioned to Lovenox 1 mg/kg BID. He was started on warfarin
5mg QHS on ___. He had mild RLE pain. His INR was 2.4 on
___, the day of discharge.
Hematology was consulted and recommended having 2 therapeutic
INR values 24 hours apart before discontinuing Lovenox. He will
need at least 3 months of therapeutic anticoagulation.
When he was admitted he also had a non-contrast CT head that
showed no acute intracranial findings and stable chronic
infarcts. Neurology was consulted and will arrange outpatient
follow-up. He had no new neurologic changes on exam.
He also had frequent headaches that he described as unilateral
and associated with lacrimation and rhinorrhea, lasting minutes
to hours. He felt these were like cluster headaches he had in
the past. He has not had success with finding pain relief
previously, but he and his wife wanted to try increasing the
nortriptyline, as they felt this had partially helpful in the
past. This was increased to 150mg QHS.
He was evaluated by ___ and OT, who both recommended rehab. He
was discharged to ___ on ___.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes. | 108 | 369 |
12565064-DS-21 | 20,145,835 | It was a pleasure taking care of you here at ___
___. You were re-admitted to our hospital
for management and care of your periheral arterial disease.
Unfortunately imaging showed your previous right lower extremity
SFA stents were no longer patent, causing your pain at rest. You
were placed on heparin drip to help perfuse your lower
extremity, and scheduled for surgery.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily, and your home
ticagrelor as you previously took it
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 | Mr. ___ was admitted to the Vascualar Surgery service with
HPI as stated above. including recent placement of 2 left SFA
stents and peroneal angioplasty. He underwent duplex which
noted no flow through the distal stent.
He went back to the OR on ___ for occluded right distal
superficial
femoral artery stent and underwent Right lower extremity
imaging, AngioJet thrombectomy, stenting of distal SFA, and
balloon angioplasty of proximal superficial femoral artery
stent; for full details please see the dictated operative
report.
He tolerated the procedure well and went to the PACU and then to
the floor on good condition. He was maintained on a heparin
drip as well as his home aspirin and ticagrelor overnight, and
his activity and diet were advanced on POD#1. He was normalized
on his home meds and the heparin drip was discontinued; he
voided without catheter.
On the afternoon of POD#1 that patient was felt to be
progressing well and appropriate for discharge. He will
continue his home anticoagulation and resume all other home meds
upon discharge. He is discharged to home on the afternoon of
POD#1, ___, in good condition and with appropriate
instructions, information, and plans to follow up. | 314 | 206 |
10354217-DS-13 | 24,115,619 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ with
shortness of breath due to your aortic valve replacement not
working. This caused fluid to build up in your lungs. We used a
water pill to remove this fluid, but you will require a aortic
valve replacement to prevent this in the future. You will meet
with cardiac surgeons on ___.
For your heart failure and fluid. You should weigh yourself
EVERY morning after going to the bathroom and before
eating/drinking. If this weight decreases or increases by more
then 2lbs, please call your doctor. You were started on a new
dose of Furosemide (Lasix) with a goal of keeping your weight
the same as currently. Your weight on discharge is 185.5lbs,
make sure to weigh yourself on your scale in case this differs. | ___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
and ascites, HTN, HLD and AS s/p bioprosthetic AVR in ___
(previous TTE ___, mean AV gradient 24) presenting with CHF
___ aortic stenosis.
.
Active Problems:
# Decompensated aortic stenosis with acute CHF: Pt s/p AVR in
___ for AS with bioprosthetic valve and has had good functional
capacity. Orthopnea, cardiomegaly, hypoxia and pulmonary edema
in the setting of progressive decline in functional capacity and
elevated BNP is consistent with acute decompensated CHF. TTE
showed normal EF with concern for increased gradient in aortic
valve, concerning for symptomatic AS with TEE confirming
non-working AVR. She denies CP or syncope. She was seen by
cardiology who recommended cardiac surgery eval for redo AVR.
Patient currently at or near dry weight. Functional capacity
increased from walking 10ft on presentation to 5 laps around the
nursing station on d/c. Low Na diet. Switched to PO Lasix 120mg
with strict instructions for patient to weight herself every
morning as critical AS is pre-load dependent and do not want to
dry her out too much. Patient will return to AS clinic on ___.
Hepatology deemed her low risk for surgery.
# EtOH Cirrhosis: Due to longstanding EtOH use. Currently well
compensated. ___ Class A. MELD 7. RUQ showed mass
suspicious for HCC, AFP 2.6. MRI read did not pick up any mass
and after speaking to radiologist confirmed that sometimes there
can be a "fake out" with U/s. Did recommend f/u ultrasound in 3
months. Continued home Spironolactone, Nadolol. EGD without any
significant changes from previous.
Chronic Problems:
# GERD: Patient reports heart burn for 2-days that lasts about
30min. Had not mentioned this previously because didn't think a
big deal. Not worse with exercising. Pt on Pantoprazole at home
for GERD. Likely non-cardiac. EKG no acute changes. Encourage
sitting upright after meals. Continue Protonix
.
# Anxiety: Continue home Alprazolam | 143 | 325 |
13111369-DS-19 | 27,951,807 | Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
shortness of breath and were found to have fluid in your lungs
at ___.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Chest tubes were placed to drain the fluid from your lungs.
After your breathing improved, the chest tubes were removed.
- You received diuretic medications to help remove more fluid.
- You were more sleepy so tests were performed to make sure that
you do not have an infection or bleed in the brain. These tests
were negative.
- You preferred to return home rather than be evaluated for
rehab, you were felt to have capacity to make this decision
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Dr. ___ be the new Oncologist taking care of your
AML.
We wish you all the best!
Sincerely,
Your ___ Care Team | PATIENT SUMMARY
=================
Ms. ___ is a ___ year-old woman with AML (now in
ongoing Complete Response following Decitabine/Venetoclax x 3
cycles), who was admitted on ___ with recurrent pleural
effusions secondary to acute on chronic Congestive Heart Failure
exacerbation (resolved following bilateral chest tubes), Acute
Kidney Injury (Cr improved to 1.3 on discharge, peak 2.0), and
failure to thrive.
TRANSITIONAL ISSUES
===================
[] Please refer patient to establish Primary Care and Cardiology
(any provider) follow up at ___ as she wishes to receive
all her care there
[] Metformin was held given labile renal function, consider
restarting if patient improves and PO tolerance is improved
[] Home olanzapine was also held given lethargy during
admission, can restart PRN
[] f/u Cr and diuretic dosing within the next 2 weeks: pt has a
history of nephrotic syndrome, with significant variability in
the serum creatinine over the past several months from
0.9-2.4mg/dL.
[] f/u dyspnea and pulmonary exam: pt may need titration of home
diuretic and hypertension medications to prevent reaccumulation
of pleural effusions.
[] f/u BP, medication adherence: pt with labile BPs, can have
SBPs up to 180s when refusing PO amlodipine and metoprolol.
ACUTE ISSUES
==============
# Bilateral pleural effusions
# Dyspnea
Presented from home with recurrent bilateral pleural effusions
and dyspnea x3-4 days. Labs consistent with transudative pleural
effusion, most likely ___ acute on chronic CHF. S/p bilateral
chest tube placement by IP on ___ with resolution of dyspnea,
removed ___. Diuresis held intermittently in setting of ___, as
below. Discharged on torsemide 20mg PO QD per nephrology
recommendations to help prevent reaccumulation of pleural
effusions.
# Acute on Chronic HFmrEF
Presented with elevated BNP, b/l pleural effusions, ___,
elevated JVD, consistent with acute heart failure. Dyspnea
improved after chest tube placement. No clear precipitant of her
CHF though her home medications did not previously include a
daily diuretic. EKG w/o acute ischemic changes and she denied
chest pain so less likely ACS. ___ TTE without significant
change from prior. She has a history of nephrotic syndrome for
which she required on the last admission 80-160mg IV Lasix
boluses. S/p IV diuresis, appeared euvolemic at time of
discharge. Continued home metoprolol.
# Failure to thrive
# Malnutrition
# Lethargy
Pt noted to have 40 pound weight loss on admission (~120lb)
compared to last documented weight 1 month prior (~160lb). Bed
weight accuracy limited and possible contribution of weight from
edema during last admission, however pt likely has lost
significant weight related to insufficient PO. Very poor PO
intake during this admission. Diet liberalized and supplements
provided per Nutrition. Pt was also noted to be often somnolent,
although arousable. ___ be related to generalized weakness and
failure to thrive. NCHCT negative for intracranial bleed. Per
discussion with social work, patient, and family, patient tends
to do much better when at home where she has an extensive
support network and home services.
# AML
Diagnosed during last admission, now in ongoing Complete
Response following Decitabine/Venetoclax x 3 cycles. Continued
home acyclovir. Per discussion with Dr. ___ on ___, pt will
follow up with Dr. ___ in ___ for further AML care.
# ___
# Nephrotic syndrome
Pt has a history of nephrotic syndrome, Cr bumped 1.5 to 2.0 on
___, likely ___ IV Lasix. Diuresis was held and ___ resolved.
Renal spun urine, no casts, many calcium phosphate crystals
including triple phosphate. Discharge Cr 1.3.
# Leukocytosis
# P. acnes in pleural fluid
WBC 9.2 -> 19.6 on ___ with left shift (86% PMNs), downtrended
to normal without antibiotic treatment. Flu negative in the ED.
CXR without evidence of consolidation. Pt endorsed cough and
transient sore throat, no abd pain or diarrhea, dysuria. BCx,
UCx neg. Reassuringly she remained afebrile and HDS. ___
anaerobic pleural fluid with P. acnes, likely contaminant. BCx
were negative throughout admission.
# HTN
Per chart review, during her last admission SBPs often up to
180s, home losartan 25mg QD was changed to amlodipine 10mg QD
due to labile renal function. On amlodipine 10mg QD she had SBPs
130s-160s, regimen not uptitrated further because of labile SBPs
sometimes dipping to ___. Continued home amlodipine and
metoprolol, in addition to PO hydralazine 25mg q6h prn for
SBP>160. Pt often refusing PO medications.
CHRONIC ISSUES
==============
# Delirium
Patient has a history of hypoactive delirium inpatient.
Continued delirium precautions during this admission.
Discontinued home olanzapine given occasional lethargy.
# Stage II Pressure ulcers
Pt noted to have two stage 2 pressure injuries on admission.
Continued wound care with mepilexes.
# CAD: cont metoprlol
# T2DM: held home metformin, discontinued ISS as has not been
requiring insulin
# DL: not on statin
# GERD: cont famotidine, protonix
# OA: cont lidocaine patch
CORE MEASURES
=============
#CODE: full code, presumed
#CONTACT: Name of health care proxy: ___
___: Daughter
Phone number: ___ | 178 | 763 |
15157919-DS-18 | 23,778,674 | Dear Ms. ___,
You were admitted to the hospital out of concern that you were
not acting yourself. We did not find any signs of infection or
heart attack, or any other medical issues that might have caused
your confusion.
.
We made the following changes to your home medications:
INCREASE amlodipine to 10 mg daily
START metoprolol 12.5 mg twice daily
START diclofenac gel to painful arthritic joints | ___ year old woman with history of dementia, hypertension who
presents to the hospital with with an acute encephalopathy which
spontaneously resolved.
.
# Acute encephalopathy (toxic-metabolic) - During this
admission, there was no clear predisposing etiology for her
change in mental status. Per history there was a
supraventricular tachycardia during her acute event, however we
have no ECG record of this. During this admission, she underwent
an EEG that showed no evidence of seizures. Her bloodwork was
unremarkable and did not reveal any metabolic derangement. An
infectious workup including chest Xray and urinalysis were
unremarkable; blood and urine cultures had not growth, but were
still pending at the time of discharge. A CT head was also
unremarkable and the patient had no significant focal findings
on neurologic exam to support a stroke. She was monitored on
telemetry and ruled out for an ischemic cardiac event with 2
sets of negative cardiac enzymes. She did have a slightly
elevated lactate on admission, which resolved with
administration of IVF, suggesting the patient may have been
dehydrated. In the emergency room she received ativan and
zyprexa for agitation and was sleepy overnight. In the morning,
she appeared to have returned to her baseline mental status; she
was oriented and cooperative and requested to return home to her
nursing home.
.
# Tachycardia - The patient had an EKG showing normal sinus
rhythm on admission. She was monitored on telemetry and had
several episodes of non-sustained sinus tachycardia, which were
asymptomatic.
.
# Hypertension - The patient was significantly hypertensive
during this admission. Her amlodipine was increased to 10mg
daily, and she was started on metoprolol 12.5 mg twice daily.
.
# Glaucoma - continued home meds.
. | 66 | 302 |
10578209-DS-21 | 21,443,552 | Ms. ___,
You were admitted with weakness and shortness of breath found to
have low blood counts (anemia) and received a blood transfusion
with improvement in your symptoms. You were also found to have
pneumonia treated with antibiotics.
Please continue to follow up with your oncology team.
It was a pleasure taking care of you.
-Your ___ team | ___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion and weakness found to have
anemia and pneumonia.
1. Acute on chronic normocytic anemia and thrombocytopenia
-s/p chemotherapy ___ with subsequent nadir as likely cause
of anemia. She essentially has pancytopenia with
thrombocytopenia and a relative leukopenia (drop in WBC from
30.8 ___ s/p Neulasta to 7.8 today). Transfused 1Unit PRBC ___
with improvement in hemoglobin to 7.4 to 7.6. Fecal occult
testing was negative. She noted improvement of her SOB even
prior to transfusion and felt better and requested to be
discharged home for further management as an outpatient
2. Community Acquired Pneumonia
-Potential small airway infection noted on CT. She has been
afebrile this admission. Was treated with a 5 day course of
levofloxacin that will continue through ___.
3. DOE and weakness
-Likely in setting of symptomatic anemia although potentially
mulficatorial in setting of pneumonia and poor PO intake. No PE
on CTA chest. She reported improvement in her SOB and symptoms
even prior to transfusion.
CHRONIC MEDICAL PROBLEMS
1. Metastatic pancreatitic cancer: Most recent treatment ___
with FOLFOX w/ Neulasta support. Continue oxycodone and
pancreatic supplementation.
2. Nausea/vomiting: Seems to be a side effect of chemotherapy on
antiemetics not currently an issue.
3. GERD: continue omeprazole
4. Opioid-induced constipation: continue bowel regimen
5. Hypophosphatemia: replete and monitor
>30 minutes spent on discharge | 57 | 229 |
11742862-DS-10 | 25,752,942 | Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take pain medications as prescribed for any post
procedure pain or discomfort; no not operate a vehicle nor any
other machinery while under the influence of narcotic medicine
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.
Take antibiotics as directed. You will be on two antibiotics,
Ceftriaxone and Metronidazole, delivered intravenously via your
PICC line and orally, respectively. Per the recommendation of
the Infectious Diseases service, you will likely be on these
antibiotics for at least 6 weeks. You also have follow up with
the infectious diseases doctors ___ below) in about 1.5 weeks.
You will follow up with Vascular Surgery clinic on ___ call
the office sooner for any questions or concerns. | Hospital course prior to Vascular Surgery involvement:
___ y/o F with PMH of of AAA s/p repair x 2 (___) c/b
aortic graft infection on chronic suppressive antibiotics and
diverticulosis who presented with GI bleeding.
ACTIVE ISSUES
# Bleeding per rectum: Source localized to duodenum, which
could represent ulcer or vascular lesion within the GI tract.
Also, there was high concern by Surgery for the possibility of
aorto-enteric fistula given h/o AAA s/p repair with aortic graft
infection. There was no bleeding GI lesion evident on recent
endoscopy ___. Colonoscopy on ___ showed internal
hemorrhoids, a polyp in the ascending colon, and no evidence of
recent or current bleeding. Push enteroscopy on ___ showed a
___ tear with no bleeding in the gastroesophageal
junction. She was transferred to the medical ICU for
hematochezia and presyncopal symptoms on ___ as per HPI. Urgent
CTA abd/pelvis was negative for extravasation of blood. She
underwent capsule endoscopy. A trauma line was placed in the
RIJ. She became hypotensive in the afternoon to SBP ___ and
received 1L LR. Tagged RBC was positive for blood in the ___
portion of the duodenum. Hct dropped from 30 to 21. She received
3U pRBC, ___, and calcium repletion overnight for Hct down to
21. She had multiple episodes of hematochezia overnight and
remained hemodynamically stable. Hct responded well to three
units pRBCs which suggested that bleeding had at least
temporarily stopped. GI anticipated repeat endoscopy in the
morning to look at duodenum more closely, but per Surg it would
not change their management due to strong concern for fistula.
She was transferred to the ___ to be under the
management of Vascular Surgery.
CHRONIC ISSUES
# Aortic graft infection: The patient is on chronic antibiotics
since ___. As cefixime is non-formulary, antibiotic was
chanaged to cefpodoxime 400 mg PO QD at time of admission.
# GERD: Continued home omeprazole.
# Anxiety: She was continued on home citalopram and lorazepam.
She was written for IV lorazepam on ___ due to escalating
anxiety due to medical problems and NPO status.
TRANSITIONAL ISSUES
#CTA revealed small renal neoplasm and pancreatic cyst which
need MRI evaluation.
#F/u capsule endoscopy results.
Hospital course after time of initialy Vascular Surgery
involvement:
Ms. ___ was admitted to the Vascular Surgery service with
HPI as stated above and went to the OR emergently for the
above-listed procedure. During the procedure, she required 7
units of PRBCs and 4 units of FFP. Post-operatively her crit
was found to be 38.9; she had a brief episode of hypotension to
the ___ post-op but recovered and repeat crit was found to be
36.
Overnight into POD#1 she had three bloody maroon bowel movements
and persistent melena. Her hematocrits, measured serially,
drifted to 33, but she remained stable and was transferred to
the VICU the following day. There, repeat crits were stable in
the low ___, and it was decided to advance her diet. The
following day, POD#3, she was considered safe to bear weight and
got up with physical therapy; she became briefly orthostatic to
the ___ but was entirely asymptomatic and recovered. PO intake
was encouraged and she got up again later and did well.
Also on POD#3, ID was consulted and recommended not less than 6
weeks of PO metronidazole and IV ceftriaxone. These were
initiated in the inpatient setting. The patient received a
left-sided PICC line to continue receiving IV antibiotics in the
outpatient setting. On the same day, her foley came out and she
voided.
She tolerated a regular diet and her pain was well controlled on
POD#4, she ambulated well with minimal assistance, and she was
determined to be safe for discharge to home with services. She
will continue to receive daily ceftriaxone infusion through her
PICC. She will take daily aspirin for anticoagulation and oral
metronidazole for infection prophylaxis. She has follow-up
arranged with ID and with vascular surgery. She is discharged
to home on POD#4 with all appropriate information, warnings,
prescriptions, and follow-up. | 414 | 685 |
17793913-DS-2 | 20,131,280 | Dear Ms. ___,
You were admitted to the hospital because your doctor ___.
___ was concerned for your abdominal swelling, right lower
leg swelling, abdominal pain, jaundice and your overall health
status.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were briefly in the medical intensive care unit due to low
blood pressures. This resolved without the need for an extended
course of antibiotics. You were not found to have any evidence
of infection.
- 6 L of fluid was removed from the abdomen on ___. You were
then restarted on your ___ medications to help continue to
remove fluid from your abdomen.
- Your laboratory results were followed closely during your
hospital stay. It was decided that you did not need steroids to
help with inflammation around your liver, though this was
discussed extensively with you.
You were followed by our nutritionists during your stay. The
importance of nutrition was stressed multiple times during this
hospital stay. You will need to take in at least ___ kcal per
day.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed (listed
below)
- Keep your follow up appointments with your doctors
- Please drink at least 3 Ensures per day and eat at least ___
kcal. Avoid food with salt/sodium and avoid alcohol at all
costs.
- Avoid the use of any NSAIDs (naproxen, ibuprofen, Alleve,
Motrin etc). You make take up to ___ mg acetaminophen (Tylenol)
per day.
- Please call your doctor or present to the emergency department
if you experience any of the danger signs listed below.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | Ms. ___ is a ___ woman w/newly diagnosed cirrhosis who
presented with jaundice, right upper quadrant pain, and right
leg swelling in the setting of hypotension and large volume
ascites. She was found to have hypoxia with evidence of pleural
effusions on CXR in the ED. She was transferred to the MICU for
hypotension and suspected shock. However, she was negative for
SBP based on diagnostic paracentesis and never required pressors
in the ICU. She was initially hypoxic to 91% on room air; CXR
notable for RLE atelectasis, likely compression from large
volume ascites. Oxygen requirement resolved after therapeutic
paracentesis as below
# Cirrhosis
# Ascite.
# Alcoholic Hepatits.
Newly diagnosed cirrhosis in the outpatient setting, presumed
___ alcohol use, though final workup is still pending.
Decompensated by ascites this hospital stay. Elevated
ferritin:TIBC ratio (1:1), possibly suggestive of iron
overload/hemochromatosis as a contributor, though important to
note that with alcoholic hepatitis, ferritin is expectedly
elevated. Pt endorses a moderate history of EtOH use in the past
(3 drinks per day per her report)., though brother thinks she is
drinking significantly more than this. No evidence of PVT on
RUQUS ___. Underwent paracentesis with removal of 6 L fluid on
___ resultant improvement in subjective dyspnea as well as
hypoxia as below. TTE echocardiogram (___) showed Mitral and
tricuspid valve prolapse with late systolic mitral and tricuspid
regurgitation but normal biventricular systolic function.
Patient was resumed on ___ spironolactone 50 mg daily as well
as furosemide 20 mg daily. Though ascites did slowly increase
over the course of her hospital stay, she did not require repeat
therapeutic paracentesis during her stay here. Patient was
followed by nutrition consul. Due to downtrending MDF and GIB on
___, steroids were not used in treatment of patient's alcoholic
hepatitis. Dobhoff tube placement was attempted on ___ via EGD
that was complicated by laceration as below. Due to downtrending
discriminative function, Dobbhoff tube placement and tube feeds
were ultimately not started though risks and benefits
conversation with patient was had regarding concern for
malnutrition and need for at least ___ kcal/day intake.
#Hypotension
# Asymptomatic Bateruria.
In the ED the patient's BP went from 146/75 to 94/53 suggesting
shock. Differential diagnosis included infection (SBP), systemic
vasodilation ___ liver disease, medication effect or other
infectious source. No evidence evidence of infection on
diagnostic or therapeutic paracentesis on ___ and ___
respectively. Blood cultures with no growth. Chest x-ray with no
evidence of pneumonia. Urine with growth of enterococcus species
___. This was deemed an asymptomatic bacteriuria as patient had
no signs or symptoms of urinary tract. It was not treated. She
notea that
she and her family have always had low blood pressure
# Esophageal Laceration. Patient underwent EGD on ___ for
scheduled Dobhoff tube placement and suffered an esophageal
laceration. She was initially treated for an upper GI bleed with
IV pantoprazole 40 mg Q12H, IV ceftriaxone and octreotide. She
had no signs of repeat bleed and remained hemodynamically stable
with stable hemoglobin. Diet was advanced to a regular diet over
the course of a 24 hour period. She was discharged on oral
pantoprazole 40 mg Q12H and 7 days of oral antibiotic
prophylaxis as below.
# Anemia
# Thrombocytopenia. Likely a chronic issue secondary to her
cirrhosis. No acute management.
# Hypoxia (resolved). Patient initially required up to 2 L O2
via NC. CXR revealed pulmonary vascular congestion and L sided
effusion, likely related to cirrhosis and volume overload as
below. Resolved with therapeutic paracentesis as above.
Transitional Issues
===============
- Code status: Patient states that she would not want
interventions done "if
there were no point." However, she does feel frustrated that she
continues to get asked about code status questions in the
hospital. This conversation should be continued in the
outpatient setting.
- She should have follow up iron studies in ___ months given
elevated ferritin and TIBC
- Antibiotics: She should remain on antibiotics for a total of 7
days after her GI bleed on ___ (start date ___ | projected end
date ___
- Consider increase of diuretics as an outpatient
- Patient suffered an esophageal laceration during EGD. She was
intially managed on IV PPI, octreotide and IV ceftriaxone and
de-escalated to p.o. pantoprazole every 12 hours and
ciprofloxacin p.o. for prophylaxis as above. Please reassess the
need for PPI in the outpatient setting.
- Diuretic: Spironolcatone 50 mg/Lasix 20 mg. ___ uptitrate in
outpatient setting as tolerated
- Please repeat chem10 one week after discharge to monitor for
electrolyte stability on current diuretic regimen
- Continue sucralfate for 9 days after discharge | 287 | 748 |
11798066-DS-15 | 27,241,769 | Dear Mr. ___,
It was a pleasure taking care of you while you were here. You
came to us with jaundice and after extensive testing and workup
we found a cancer in your bile duct, called cholangiocarcinoma.
We placed a metal stent to open the occluded duct to allow bile
to drain. We also placed markers to help the radiation
oncologists give you directed radiation treatment. You will have
close follow up with interventional radiology for the bile
drain, with radiation oncology and medical oncology for chemo
and radiation, and with your liver doctor. | ASSESSMENT/PLAN: ___ with PSC Child's B MELD 16, UC/Crohn's,
autoimmune thyroiditis, achalasia, ITP, DMI who presented for
evaluation of jaundice, found to have stricture of common
hepatic duct now confirmed to be cholangioCA after 2 biopsies
and FISH studies. Patient developed VRE and Dapto resistent SIRS
after stent placement through the stricutre caused by the
cholangiocarinoma. Last positive blood cultures was ___. After
biopsy results, pt was not longer a candidate for tranplant at
this institution; however, ___ in ___ will
perform. Pt was given that option, however, declined and wanted
to move forward with chem and radiation here. In prepartion for
treatment, a metal biliary stent replaced the plastic one and
three fiducial markers were placed for raditation treatment. Pt
started and discharged on 2 week course of Linezolid ___ BID
since first negative Bcx--with stop date ___. He is to follow
up with rad onc, heme one, liver clinic, and ___. | 94 | 155 |
14550969-DS-15 | 23,103,134 | Dear Mr. ___,
You were admitted for vertigo. This is likely due to a middle
ear problem. Your MRI of your brain did not show a stroke. Of
note, you were also found to have a community-acquired
pneumonia. We treated you with IV antibiotics while you were in
the hospital. You ___ continue azithromycin for an additional
three days at home.
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
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team | ___ is an ___ M with h/o tobacco abuse, COPD who presents
to the ___ ED with vertigo starting very early this morning.
Symptoms have been somewhat fluctuating in intensity, but
relatively continuous and brought on more severely with bending
the head downward. His exam is notable only for gait
instability. There are no other clear signs of cerebellar
dysfunction. HIT is inconclusive. Given gait instability and
continuing vertigo, admitted for and MRI of his head. MRI
negative for stroke, evaluated by ___ who recommended outpatient
___ rehab.
Also found a pneumonia on CXR in the ED, given levaquin once,
started on Z-pak for a 5 day course to be finished as
outpatient. | 198 | 114 |
12918803-DS-4 | 21,831,388 | Dear Mr. ___,
You were admitted to the hospital for a bowel obstruction.
Typically we treat this with bowel decompression by an NG tube.
You asked that the NG tube be removed after it was initially
placed. Your bowel obstruction was not resolving spontaneously,
so surgery was consulted. They were willing to consider surgery
in you, but you declined. Your bowel obstruction gradually
resolved spontaneously. You abdominal pain resolved on ___ and
you started passing gas. On ___ you started passing stool. You
diet was advanced and you were able to tolerate a regular diet.
For the subsequent days in the hospital you continued to pass
normal bowel movements and continued to tolerate a regular diet
without abdominal pain or nausea. After your small bowel
obstruction resolved, you were evaluated by physical therapy.
They felt that you were physically deconditioned and would
benefit from acute rehab prior to returning to your assisted
living facility. Initially your kidneys were injured, but they
returned to your baseline as your small bowel obstruction
resolved. You were also treated for a urinary tract infection.
It will be important to take your medications as directed below
and follow up with your primary care doctor.
Best of luck with your continued healing.
Take care,
Your ___ Care Team | Mr. ___ is a ___ male with history of recurrent
parastomal hernia related SBO, CKD stage V, CAD s/p MI, atrial
fibrillation, chronic diastolic heart failure, severe AS s/p
TAVR, complete heart block s/p PPM, bladder cancer
s/p cystectomy and ileal conduit with urostomy, prostate cancer
s/p radical prostatectomy who presents as transfer from
___ for SBO on ___. | 209 | 58 |
18566482-DS-5 | 20,763,793 | Ms. ___,
You were admitted with back pain and found to have lymphoma. You
were started on chemotherapy for this and will continue this
outpatient with Dr. ___.
During your hospitalization, you were found to have an elevated
heart rate, this was treated with medications and you will
continue to follow up with the cardiology team outpatient to
manage this. You also were found to have a bleed in your brain
due to low blood counts associated with your lymphoma. This
resolved with time.
You will follow up in the clinic as stated below. It was a
pleasure taking care of you. Please call in the meantime with
any questions or concerns. | This is an ___ originally presenting with 3 weeks of back pain,
forgetfulness and hemoptysis found to have high grade B cell
lymphoma now s/p 1C of mini CHOP.
#High grade B cell lymphoma: with peripheral/bone marrow
involvement at diagnosis. initiated C1 mini CHOP per primary
attending recommendations (multiple comorbities/age limited use
of EPOCH)
CycloPHOSPHAMIDE 720 mg IV Day 1. (___)
(750 mg/m2 - dose reduced by 47% to 400 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
DOXOrubicin 45 mg IV Day 1. (___)
(50 mg/m2 - dose reduced by 50% to 25 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
VinCRIStine (Oncovin) 1 mg * IV Day 1. (___)
(1.4 mg/m2 [cap at 2 mg] - dose reduced by 50% to 1 mg)
Reason for dose reduction: mini-CHOP, elderly
PredniSONE 100 mg PO Q24H Duration: 5 Doses
Give on Days, 2, 3, 4 and 5.
Filgrastim-sndz 480 mcg SC DAILY until ___ recovery, plan to
d/c once ___ >1000, D/C ___ prior to discharge
- Transfuse for Hgb < 7 and plt < 50 fibrinogen < 150 in
setting
of SDH--less frequent due to count recovery
- give low dose Rituxan 100mg IV once only on ___ (high risk of
reaction due to circulating disease, age, comorbities) pre-med
appropriately and do not escalate per primary attending
recs--tolerated well
-plan for POC placement prior to next cycle of mini CHOP--need
to schedule outpatient
-will f/u in clinic every other day for possible plt transfusion
and will see Dr. ___ on ___
# Subdural Hematoma
Discovered on ___ ___omplained of headache.
Neurosurgery
as immediately consulted, who recommended rescanning the next AM
and ppx Keppra 500 mg BID. Will follow with interval scans.
- last repeated ___ and reviewed with Dr ___
25mg BID to prevent seizures and plt threshold >50K
- repeat NCHCT for any new neurologic symptoms
- Transfuse for plts < 50
- SBP < 160
- see neuro surg notes for further recommendations
# Sinus tachycardia - evaluated by cardiology--will f/u
outpatient as well
- tapered off short acting meto (patient has been responding to
IV diltiazem over meto )
- Change short acting diltiazem 30 mg q6h to 120mg daily long
acting starting ___, increased to 180mg in setting of low grade
tachycardia over weekend of ___
-monitor rate/symptoms, last EKG NSR ___
# Fever
# Multifocal PNA
resolution.
- Continue cefepime until count recovery (___), d/c
with ANC >900 on ___
# AMS: waxes/wanes
Differential diagnosis includes delirium, toxic metabolic
encepholopathy, dementia, EtOH withdrawal, leukostasis. Will
continue to monitor closely. Psychiatry has evaluated, suspect a
combination cultural factors, educational factors, baseline
argumentative personality, with overlying significant delirium.
-continues Seroquel @hs, rec while receiving steroids and could
consider peeling off when off, will continue for now while
inhouse for long period of time and re-introducing high dose
steroids every ___ weeks with chemo regimen.
# Unclear ___
Records from PCP office suggest pt was in good health with only
___ knee replacement and glaucoma surgery prior to this
hospitalization.
# EtOH use disorder
Son reports daily EtOH use, concerning for alcohol use disorder.
Unknown history of seizures. s/p CIWA protocol. Pt has not
required diazepam.
# Hep B core Ab positivity: Will continue lamivudine
# latent TB : +quant gold, to treat per ID. on INH/B6
# FEN: Gentle IVF/ Replete PRN/ Regular low-bacteria diet
# ACCESS: ___--line care outpatient due to frequent
transfusions
# PROPHYLAXIS:
-Bowel: senna, colace
-DVT: none indicated, thrombocytopenic
-viral: acyclovir
-fungal: fluc while neutropenic, d/c on discharge
-PCP: bactrim
# CODE: Presumed Full
# DISPO: home with 24hr supervision confirmed with son and
grand-daughter with multiple services in place--see case
management note | 112 | 590 |
10873456-DS-9 | 26,799,783 | Dear Mr. ___,
You were admitted to the hospital because you were having
abdominal pain. You were found to have inflammation in your
abdomen around the first part of your small intestine called the
duodenum. There was evidence of inflammation but no signs of
infection. Your abdominal pain improved significantly while you
were in the hospital. It's important that you follow up with
your primary care doctor who will be able to refer you for an
upper endoscopy to further investigate the fluid collection once
the inflammation has resolved.
You are now ready to be discharged. Please continue taking your
medications as instructed.
It was a pleasure taking care of you,
Your ___ Care Team | ___ y/o gentleman with PMH of HTN and gastric ulcer presenting
with abdominal pain found to have duodenitis.
#Abdominal pain/duodenitis: The patient presented to the
hospital with abdominal pain, malaise, nausea, and vomiting for
one week. CT Abdomen/Pelvis in the ED shows finding consistent
with severe duodenitis. No obvious free air but small underlying
rupture cannot be excluded; reassured by no evidence of perf on
imaging though. Given the acute inflammation, there was no role
for endoscopy on this admission. The patient was initially
started on IV cipro/flagyl, IV pantoprazole, and was made NPO.
His pain significantly improved overnight. According to the
___ stewardship team, there is no definitive role
for antibiotics in the treatment of duodenitis and thus his
antibiotics were discontinued on his second hospital day (___)
without clinical deterioration. His abdominal exam remained
benign without evidence of peritonitis. The patient's diet was
advanced without issue. He did have some mild abdominal pain on
his ___ hospital day for which he was started on sucralfate with
good response (total course 14 days ending ___. He was
discharged home with resumption of home services. The patient
should have an endoscopy after resolution of acute inflammation
(> approximately 6 weeks).
#HTN: Stable while admitted. Home metoprolol was continued.
#Hypothyroidism: Stable while admitted. Home levothyroxine was
continued.
Transitional Issues:
- DNR, ok to intubate
- The patient should have an upper endoscopy in > 6 weeks or
when acute inflammation resolves
- The patient should follow up with his PCP upon discharge
- Stool h. pylori and h. pylori antibody test pending at
discharge | 115 | 263 |
12612603-DS-18 | 21,332,395 | Dear Mr. ___,
You were admitted to the hospital because of dizziness. Please
see below for more information on your hospitalization. It was a
pleasure participating in your care!
What happened while you were in the hospital?
- Examination of your heart using a catheter showed that it
needed mechanical support.
- You had an intra-aortic balloon pump placed, then an impella,
and finally these were changed to a left ventricular assist
device to help your heart pump.
- A CT scan of your arm showed a blood clot.
- Our pulmonary team drained fluid from your left lung twice.
- A chest tube was placed in your lung to help drain additional
fluid.
- You received multiple blood transfusions to keep your blood
counts up.
- You received 4 weeks of antibiotics for a blood stream
infection.
What should you do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
For your LVAD,
- Please shower daily
- Wash incisions gently with mild soap, no baths or swimming,
look at your incisions daily
- NO lotion, cream, powder or ointment to incisions
- Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
- No driving for approximately one month and while taking
narcotics
- Clearance to drive will be discussed at follow up appointment
with surgeon
- No lifting more than 10 pounds for 10 weeks
- Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
We wish you the best!
- Your ___ Healthcare Team | Mr. ___ is a ___ year-old-man with PMHx of mixed
ischemic/non-ischemic cardiomyopathy (LVEF 25%) s/p elective
single chamber ICD placement ___, CAD s/p DES to RCA
___, OSA and T2DM who was admitted after episode of dizziness
and hypotension thought to be secondary to over diuresis. While
admitted the patient was transitioned from dobutamine to
milrinone because of eosinophilia. A RHC was completed that
showed poor CI and high PVR. The patient did not improve on
inotropes, and it was felt he needed mechanical support. He was
transferred to the CCU and a balloon pump was inserted while
awaiting LVAD placement. On ___ his IABP was removed and
replaced with impella 5.0 to bridge to LVAD, which was placed on
___. His course was complicated for a CoNS blood stream
infection, for which he received 4 weeks of IV antibiotics,
anemia, for which he received multiple pRBC transfusions, and a
challenging anticoagulation course.
# CORONARIES: R-dominant; LMCA, LAD, LCx without flow limiting
disease, DES to RCA ___
# PUMP: EF 25%
# RHYTHM: Sinus
ACTIVE ISSUES
=============
# Mixed ischemic/non-ischemic HFrEF (Stage D, EF 25%) Patient
admitted for hypotension/presyncope, but found to have
eosinophilia thought to be secondary to dobutamine. Patient was
transitioned to milrinone, then to digoxin and sildenafil.
Patient worsened to the point that he needed mechanical support
in the CCU w/ a balloon pump while awaiting LVAD, which was
placed on ___. The IABP was removed and replaced with
impella to bridge to LVAD, which was placed on ___ (of note,
impella graft was left in). He was then transferred to the floor
where he stabilized on a PO Torsemide regimen. He was initially
on milrinone for right ventricular support, but was able to
transition to sildenafil and digoxin. Physical therapy worked
with him extensively to improve his strength and he and his
family members received LVAD training. He had some challenges
with anticoagulation, which are detailed below. His course was
also complicated by persistently low hemoglobin, continued fluid
reaccumulation, a blood clot in his arm, and a major life event. | 293 | 337 |
17195628-DS-4 | 22,569,559 | You were admitted for low sodium, which is an electrolyte that
circulates in your blood. After changing some of your medicines
and starting a new one called tolvaptan, your number improved.
You also had evidence of an infection in your belly, which we
treated with 5 days of IV antibiotics. You should start an oral
antibiotic to prevent this type of infection from developing
again in the future. We also changed your atenolol to nadolol,
which is a better medication to lower your heart rate and helps
prevent bleeding related complications of your liver disease.
.
You should also follow-up with your primary doctor regarding
your diabetes and blood sugars, which were elevated during this
hospitalization. You should also have lab-work done on ___
when you see your PCP, and make sure Dr. ___ a copy
of the results.
.
You should follow-up with your doctors, as listed below.
.
Please note the following medication changes:
-Please STOP atenolol
-Please START nadolol
-Please START tolvaptan
-Please START ciprofloxacin
-Please STOP aspirin until you see your PCP on ___ and ___
whether it is safe to restart this medicine. | Summary: ___ M with decompensated cirrhosis with ascites and
varices, admitted for hyponatremia noted prior to planned AAA
repair, with SBP diagnosed on ___.
.
# Hyponatremia - No symptoms. Initially managed with fluid
restriction and holding of lasix/spironolactone. Tolvaptan was
later initiated, and the patient demonstrated a good response,
with peak Na of 132 (levels were trended carefully to ensure
sodium did not correct too rapidly). Lasix/spironolactone were
restarted. After tolvaptan was stopped, the patient's sodium
decreased to 126. Subsequently, this was restarted prior to
discharge. The patient was instructed to follow-up with his
primary care doctor, and to obtain basic labwork shortly after
discharge to monitor sodium levels closely.
.
# SBP: Initial diagnostic paracentesis was negative. however,
the cultures grew coagulase negative staph in very low numbers,
raising suspician for contamination. The patient had a repeat
paracentesis (with 3L of fluid removed), which was positive for
SBP. This infection may have been the precipitant of his
hyponatremia, however it was suspected that the coag negative
staph was likely an unrelated contaminant. He completed a 5 day
course of Ceftriaxone 2g on ___, with Albumin given on D1 and
D3. Ciprofloxacin was initated for prophylaxis upon discharge.
.
# Pancytopenia, low fibrinogen, and coagulopathy: Likely
related to low-grade DIC from infection or liver failure, or a
combination of the two. He had no evidence of bleeding, with
the exception of during peripheral lab draws. Aspirin was held,
and the patient was instructed to follow-up with his primary
doctor regarding whether to restart this medicine. His CBC,
Fibrinogen, and coags were stable or improving at the time of
discharge.
.
# Decompensated cirrhosis - Likely secondary to NASH. history of
grade 1 varices, ascites, and SBP; no history of encephalopathy.
Diuretics were restarted after initially being held. Nadolol
was added with resting HR in ___ (atenolol was stopped).
.
# T2DM: Treated with metformin at home. His blood sugars were
elevated this admission, and the patient was instructed to
follow-up closely with his primary doctor regarding additional
treatment options.
.
# HTN: Started nadolol in lieu of atenolol as above.
.
# Vitamins: Continued Vitamin B12, Vitamin C. Vitamin D weekly
at home.
.
# Primary prophylaxis: Holding aspirin for now, to follow-up
with PCP.
.
========== | 181 | 398 |
17756027-DS-10 | 21,089,394 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
a severe headache. Scans of your brain were performed which came
back normal. A lumbar puncture was attempted multiple times
without success in order to rule out dangerous causes of
headache. Your headache improved on its own. It was most likely
due to a migraine rather than something dangerous. We recommend
you keep a journal of your headaches to help identify any
triggers. For your shoulder pain, I would recommend speaking
with your primary care physician about an appropriate pain
regimen. In the meantime, use ibuprofen sparingly and ice packs
on the area.
We made the following changes to your medications:
START ibuprofen as needed
START tylenol as needed
If you experience another migraine, you can call ___ to
speak to the neurology urgent care line. | ___ yoF with h/o HTN, asthma, and recent rotator cuff surgery on
___ who presents with severe headache and dizziness.
#Headache: Thought to be due to ___ initially based on
presentation. Multiple failed attempts at LP. No signs of acute
bleed on head CT or brain MR. ___ the following morning.
Seen by neuro, who felt this to be most consistent with
migraine. Pt educated on migraine triggers and recommended HA
log.
# Dizziness: Resolved following AM. Likely component of
headache.
# Chest pain: CTA negative for PE. Troponins negative x2, no EKG
changes. Resolved the following AM. Likely anxiety or GERD.
Unlikely ACS.
# HTN: continued home HCTZ and lisinopril
# Anemia: At recent baseline. no signs of bleeding. Did not
receive transfusions.
# Depression: continued ome meds. | 137 | 128 |
16527660-DS-22 | 28,429,361 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital from
clinic due to an increase in your liver enzymes (showing damage
to your liver). You underwent a liver biopsy which showed no
graft rejection but was concerning for Hepatitis C reactivity or
bile duct obstruction. You underwent an ERCP which showed no
bile duct obstruction, making recurrent Hepatitis C the most
likely cause of your elevated liver enzymes.
You also came in with injury to your kidneys. This was thought
to be due to your Prograf level being too high. Your dose was
decreased and your kidney function improved. This will continue
to be followed.
It is VERY important that you follow up with your GI
appointments listed below. It is also VERY important that you
have repeat laboratory testing tomorrow, ___, to
ensure your kidney function continues to improve and your
Prograf levels remain at goal.
Once again, it was a pleasure participating in your care. | REASON FOR ADMISSION
Mr. ___ is a ___ gentleman with a history of
hepatitis C cirrhosis who received an orthotopic liver
transplant on ___. His post-transplant course has been
complicated by recurrent hepatitis C (HCV), acute cellular
rejection, and stage I fibrosis. He was admitted from clinic
with hyperkalemia, acute-on-chronic renal insufficiency, and
transaminitis.
ACTIVE ISSUES
1. Transaminitis: As noted in the HPI, Mr. ___ was recently
admitted for acute cellular rejection, which was treated with a
dose of IV methylprednisolone and an increase in his
immunosuppression from sirolimus to tacrolimus. Biopsy during
his prior admission also showed evidence of recurrent HCV. Mr.
___ now presents with elevation of his AST/ALT/Tbili to
183/85/5.6 from his prior discharge values of 98/76/2.3 on
___. Liver biopsy this admission was negative for acute
cellular rejection but did show recurrent HCV vs. biliary
obstruction. A repeat ERCP showed a tortuous duct but no
evidence of obstruction. He has had recent negative CMV viral
load in ___ and ___. HCV viral load has increased
steadily and is now 21,737,817. Patient's LFT's improved
slightly during hospital stay. His tacrolimus was
supratherapeutic at 14. Given recent evidence of rejection,
tacrolimus goal is 10. His dose was reduced to 1 mg BID. He was
continued on home dose of mycofenalate mofetil 1000 mg BID. He
will be discharged with close outpatient follow-up and
consideration of outpatient treatement for his recurrent HCV.
2. Acute-on-Chronic Renal Failure: During his previous
admission, Mr. ___ immunosuppression was changed from
sirolimus to tacrolimus to better treat acute cellular rejection
of his liver graft. He was noted to have elevation of his
creatinine from a baseline of 1.0 to 1.5 at the time of
discharge, which was attributed to tacrolimus toxicity given his
history of tacrolimus-induced kidney failure and the fact that
it did not respond to fluids or to reductions in diuretic dose.
His providers agreed to tolerate the elevation in creatinine
given the importance of treating his rejection. Upon admission,
creatinine had increased to 1.9 in the setting of a
supratherapeutic tacrolimus level. Fractional excretion of Urea
was 24% and fractional excretion of sodium, 0.5%, both of which
supported a pre-renal etiology such as tacrolimus toxicity.
Patient's tacrolimus dose was decreased from 3 mg BID to 1 mg
BID with a goal trough of ___. His valganciclovir was
decreased to 450 mg daily given CrCl < 50. Patient's creatinine
improved to 1.5 on day of discharge. He will need close
monitoring of renal function as an outpatient.
3. Hematocrit Drop: Mr. ___ had a drop in his hematocrit
from 38 to the low 30's during admission. There was no obvious
source of bleeding, and he remained hemodynamically stable. It
is possible this drop was due to dilution and frequent
phlebotomy. Hematocrit remained stable after liver biopsy.
Please continue to monitor hematocrit as an outpatient.
4. Hepatitis C Cirrhosis, s/p Liver Transplant: As discussed
above, patient's tacrolimus dosing was decreased to 1 mg BID
with a goal trough of ___. He was continued on MMF 1000 mg
BID. For prophylaxis, he was continued on Bactrim SS 1 tab
daily. His Valgancyclovir was decreased from 900 mg to 450 mg
daily due to renal failure. He continued Ursodiol 300mg BID and
Femotidine 20mg q12h.
CHRONIC ISSUES
1. Hypertension: Patient's furosemide was initially held in the
setting of acute renal failure. It was then restarted. He was
continued on home metoprolol.
2. Diabetes Mellitus: Patient continued his home regimen of
glargine 30 units QHS. In addition, he received a Humalog
sliding scale.
3. Back pain: Patient continued home oxycodone and oxycontin.
4. HLD: Patient's home fenofibrate was held given LFT
abnormalities.
TRANSITIONAL ISSUES
1. Follow-up pending tacrolimus level from ___
2. Patient will walk in for a repeat chemistry, liver panel, and
tacrolimus level on ___
3. Adjust Valgancyclovir dose as creatinine improves
4. Consider treatment of HCV as outpatient once appropriate
5. On discharge medication reconciliation, I inadvertently
checked that patietn should restart fenofibrate. This is
incorrect; he should continue to hold his fenofibrate given his
transaminitis. I will call him to clarify the instructions.
6. Goal tacrolimus level ___ | 169 | 686 |
15781155-DS-19 | 22,176,030 | Dear Ms. ___,
Thank you very much for allowing us to care for you during your
hospitalization at ___. During your hospitalization:
- We noticed you had facial pain and twitching and treated you
with pain medication. We also made sure you were not having a
stroke.
- We found that you had blood clots in your lungs and treated
you with blood thinning medications.
When you are discharged, it is important that you:
- Take all of your prescribed medications, especially a new
medication called apixaban.
- It is important that you follow up with your primary care
physician, ___. We will make you an appointment
- It is important that you follow up with your neurologist, Dr.
___ your facial pain and twitching. We will make
you an appointment.
It was a privilege to participate in your care.
Best wishes,
Your ___ Team | ===========================
Patient summary statement for admission
===========================
Ms. ___ is a ___ with history of migraines, prior admission
for L sided facial pain with negative work up for temporal
arteritis, presenting with bilateral episodes of facial pain and
spasms, associated with tearing that started night prior to
admission. Patient had CTA head and neck for stroke workup, and
bilateral filling defects in upper lobes of lungs were found
incidentally.
============================
Acute medical/surgical issues addressed
============================
#Bilateral lobar pulmonary embolism
Patient with incidental finding of bilateral pulmonary embolisms
found on CTA head and neck, confirmed later by CTA chest. Due to
stranding appearance, PEs thought to be chronic. Not a candidate
for thrombolytics. Upon further questioning, patient stated she
did have shortness of breath with exertion, new in the last 2
weeks. Did have a long trip several months ago but unclear if
related. Lower extremity ultrasound were negative for DVTs.
While admitted, patient was hemodynamically stable with good O2
sat on RA. Started on heparin drip initially but transitioned to
Apixiban 5mg BID ___. Moderate Pulmonary hypertension as a
result of PE was demonstrated on TTE, this will need pulmonary
follow up.
#Bilateral facial pain and spasms
#History of trigeminal neuralgia
Patient presented after worsening facial pain/headache and
facial spasms that started the evening prior to admission.
Neurology was consulted in the ED. Patient was found to have
intact temporal pulses and normal visual acuity. CK/CRP were
WNL. CTA head and neck showed no arterial dissection or
structural abnormalities. Since patient with no focal deficits,
Neurology recommended deferring further stroke workup. Per
neurology facial pain and twitching could be due to autonomic
neuralgia in setting of her underlying trigeminal neuralgia vs
autonomic dysfunction due to SUNCT. Headache improved with
Tylenol and increased Gabapentin dose. Facial twitching subsided
the following day. Patient to follow-up with outpatient
Neurologist, Dr. ___.
=========================
Chronic issues pertinent to admission
=========================
#Hypertension
Started losartan 25mg and continued hydrochlorothiazide with SBP
in 130s to 150s. Will transition to home irbesartan at discharge
#Thyroid nodule
1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
# h/o depression
continued duloxetine
#insomnia
continued zolpidem in lower dose (ER nonformulary). Continued
Seroquel
================
Transitional issues
================
- Gabapentin dose increased from 300 mg PO QHS to TID
(___)
- Patient started on Apixaban 5mg BID for PE
- 1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
- Patient with evidence of pulmonary hypertension on CTA chest
not noted in previous ECHO (___) and on Echo trom ___-
Moderate Pulmonary HTN.
- Given PEs diagnosed on this admission, please ensure patient
has age-appropriate cancer screening
- Please consider hypercoagulability work-up in 6 months, when
patient has completed appropriate course of apixiban | 136 | 446 |
10672798-DS-17 | 25,570,042 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were noted to have high blood sugars and low blood counts
in clinic.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a colonoscopy to look into your gut which showed
inflammation. We also took a sample of the tissue in your
colon, which did not show cancer or inflammatory bowel disease
that would require further treatment.
- You were found to have a blood clot in your leg. You were
placed on blood-thinning medications to treat this.
- You also underwent full body imaging, given recent weight
loss. Based on this imaging, we took a sample of your spleen,
which was inconclusive. Because of this, we strongly recommend
that you continue to meet with our hematology/oncology team and
undergo imaging per their recommendation.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below. It is very important
that you take the warfarin and insulin every day as prescribed.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[ ] Discharge Hgb 8.2
[ ] Discharge Cr 1.1
[ ] Discharged on warfarin, though displayed poor understanding
of dosing of medication. Please closely follow his INR. Next INR
should be drawn on ___. He will require 3 months of
anticoagulation as provoked DVT (___). INR on discharge
2.0.
[ ] He has a history of medication noncompliance with his
diabetes regimen. ___ was consulted to try to simplify his
diabetes regimen, as detailed below. IF ___ follow up is
preferred, please contact ___ Central Appointment at (___) or email ___.
[ ] Please obtain repeat INR and FSBG on ___. We
discharged him on 7.5mg warfarin daily (for one week, please
adjust as indicated by INR), and added Repaglinide at dinnertime
to compensate for removal of dinnertime insulin.
[ ] Hep B nonimmune, so will need Hep B vaccine series
[ ] His spleen biopsy was nondiagnostic, and hematology oncology
recommended outpatient PET/CT scan. They have set up an
appointment and imaging time.
[ ] Can consider discontinuing PPI after 1 month (___)
if symptoms have resolved.
[ ] Need for tooth extraction, but is on warfarin now. Patient
has private dentist that he wants to see upon discharge.
Recommend at least 1 month of uninterrupted anticoagulation
(AC), though preferably should complete 3 month of AC and then
get dental procedure done. Patient should see outpatient dentist
post discharge and see how urgent this procedure is and what his
dentist recommends regarding timing off AC.
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ man with a history of type 2
diabetes, hypertension, large bowel obstruction s/p colostomy,
poor social support at home, deficiencies in cognitive
functioning, and recent traumatic subarachnoid hemorrhage who
presented with hyperglycemia, anemia with concern for
gastrointestinal bleed, and left lower extremity deep venous
thrombosis (DVT). For his DVT, he was started on a heparin drip
which was bridged to warfarin. He underwent colonoscopy with
biopsy, which showed pouchitis and colitis. He had a CT
abdomen/pelvis which showed multiple splenic lesions, which were
biopsied and nondiagnostic, prompting recommendation for further
outpatient work-up with hematology oncology. His diabetes
medication regimen was also optimized to maximize non-injectable
medications.
=============
ACUTE ISSUES
=============
#Provoked DVT
#Non-occlusive popliteal vein clot
Patient was found to have a non-occlusive popliteal vein clot,
considered provoked given recent hospitalization and prolonged
immobility. No evidence of pulmonary embolus. Given concern for
acute anemia, GIB with oozing colitis, risk of falls, and head
bleed, discussed anticoagulation with neurosurgery and GI teams
with plan to start heparin drip with subsequent coumadin bridge,
given easy reversibility of the latter. He was successfully
bridged to warfarin with 48 hour overlap period. Given history
of medication noncompliance with diabetes regimen, had
considered DOAC or Lovenox; however, neurosurgery, in the
context of head bleed, recommended against those agents, with
preference for warfarin, given easy reversibility. Will plan for
3 months of anticoagulation as provoked DVT.
#Iron Deficiency Anemia
#Gastrointestinal bleed
Patient admitted with Hgb 7.6, from 12.6 on ___, and
hematochezia. Patient was transfused as needed and remained
hemodynamically stable. Colonoscopy ___ showed pouchitis and
colitis up to cecum with terminal ileum sparing, with very
friable and oozing mucosa, concerning for IBD, and biopsy was
taken. Given cachexia/weight loss/lymphadenopathy and bright red
blood per rectum, there was also concern for malignancy;
however, no findings of mass seen on colonoscopy. CRP was
elevated at 75.2. Biopsy showed severely active chronic colitis,
without evidence of inflammatory bowel disease or malignancy. He
was placed on a proton pump inhibitor for a 1 month course, plan
to end ___.
#Severe Malnutrition
#Cervical Lymphadenopathy
#Splenic lesions
Patient was noted to have right-sided cervical lymphadenopathy
on exam. He has also had weight loss, which raises concern for
malignancy. He does also have poor dentition and supposed to get
teeth extracted so palpated LN could be reactive LAD. Neck U/s
on ___ showing normal-appearing LNs with no abnormality.
Colonoscopy did not show mass; it did show mucosal friability
and inflammation. CT A/P showed multiple hypoenhancing splenic
lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in spectrum of extramedullary
hematopoiesis. CT chest negative. LDH negative. Beta 2
macroglobulin mildly elevated. Splenic biopsy was inconclusive,
and hematology/oncology recommended outpatient PET/CT scan.
#Hyperglycemia
#Type 2 diabetes mellitus
Patient was admitted with significant hyperglycemia but no
evidence of DKA/HHS. He showed initial improvement with addition
of long acting insulin. Discharged home on Glargine 22u in the
morning and Repaglinide at breakfast and dinner.
#Tooth Pain
Patient reported significant left-sided dental pain. Poor
dentition on exam with gum tenderness, erythema, no clear
collection. Soft tissue swelling overlying. Patient needs teeth
extraction, but will defer to the outpatient. He completed a 5
day course of amoxicillin.
#H/o traumatic SAH
Patient has a small frontal SAH. Repeat imaging on admission and
upon reaching therapeutic heparin PTT was stable. No neurologic
deficits. Neurosurgery following, with discussion re:
anticoagulation as above. | 203 | 802 |
14930745-DS-6 | 29,716,412 | Dear Ms. ___,
You were admitted to ___ with acute appendicitis. You were
taken to the Operating Room where you underwent laparoscopic
appendectomy. You have recovered well and are now ready for
discharge. Please follow the instructions below to ensure a
speedy recovery:
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.
Thank you for allowing us to participate in your care. | Ms. ___ presented to ___ ED on ___ with abdominal pain.
CT scan showed acute appendicitis. She was given IV antibiotics
and taken to the Operating Room where she underwent a
laparoscopic appendectomy. For full details of the procedure,
please refer to the separately dictated Operative Report. She
was extubated and returned to the PACU in stable condition.
Following satisfactory recovery from anesthesia, she was
transferred to the surgical floor for further monitoring.
Diet was advanced to regular post-operatively which she
tolerated well. IV fluids were discontinued when oral intake was
adequate. Pain was well controlled with oral medication. She had
no issues voiding spontaneously and ambulating independently.
She was discharged home on ___ with instructions to follow up
in ___ clinic in 2 weeks. | 726 | 126 |
15336394-DS-3 | 22,749,132 | 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 right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for surgical fixation
of right femoral neck fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to 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 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. | 563 | 261 |
18603767-DS-13 | 28,462,765 | 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:
- Weight bearing as tolerated
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 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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for CRPP, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on Lovenox 40mg daily 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. | 543 | 260 |
17845678-DS-17 | 29,708,122 | Dear Mr. ___,
It was pleasure to take care of you at ___
___. You were admitted to the hospital with confusion
and unsteady steps and were found to have low sodium level. Your
sodium level was difficult to control, so couple of different
medications were tried in the hospital. Tolvaptan (Samsca)
worked very well but as it was too expensive and could not be
continued at home, it was discontinued. You were started instead
on furosemide (Lasix).
These CHANGES were made to your medications:
START furosemide (Lasix) 10 mg daily
DECREASE dexamethasone (Decadron) to 1 mg daily. Take this until
you are instructed by Dr. ___ to change the dosing.
STOP taking your salt tablets. | TRANSITIONAL ISSUES:
[ ] Chem 7 check on ___ with Dr. ___. Patient
instructed to call Dr. ___ office on ___ morning to
make an appt.
==================================
Mr. ___ is a ___ M w h/o metastatic lung ca s/p ___
sessions total brain irradiation presenting with acute
confusion/MS changes, found to have hyponatremia. His
hyponatremia was thought to be due to SIADH and treated with
volume restriction and salt tabs without much improvement.
Demeclocycline was tried without effect. Patient responded well
to tolvaptan, however, given the cost, there was no feasible way
that the patient could be on it as an outpatient. He was started
on lasix and fluid restriction and his sodium remained stable.
# Hyponatremia: Most likely due to SIADH ___ lung cancer and
brain metastasis (similar presentation as last admission, and
improved with fluid restriction and salt tabs at that time).
Given FeNA of <1% during this admission, he was fluid challenged
without improvement. Other causes of hyponatremia was checked
and his TFT panel was wnl except for slightly low T3, and AM
cortisol was slightly low, but thought to be due to
dexamethasone he is on. As his Na did not improve on 1L fluid
restriction daily and salt tabs, he was started on
democlocycline without effect. Renal was consulted and
recommended trial of tolvaptan, which increased his Na to 136
(from 122). However, patient could not afford the medication as
outpatient, so he was changed to lasix with ___ L fluid
restriction and his Na remained stable in low 130s. His mental
status remained clear throughout.
# Toxic metabolic encephalopathy from hyponatremia: Confused on
initial presentation, most likely related to hyponatremia. As
his sodium improved and remained in 120s, he felt well with
resolution of confusion, and remained AOX3.
# Brain metastases: Had recently completed his outpt course of
whole brain radiation for brain mets. He was continued on
dexamethasone 2 mg daily per outpt taper, with pulse dosing for
his pemetrexate. He was tapered down to dexamethasone 1 mg daily
prior to discharge and will follow further instruction from Dr.
___ his taper.
# Metastatic lung adenocarcinoma: Diagnosed in ___ with
metastatic disease to vertebrae. Brain mets found in ___ and
treated with a course of whole brain radiation, and started on
Pemetrexed (last dose ___. Further treatment per outpatient
oncologist (Dr. ___
# Reported unsteady gait without falls: patient was evaluated by
physical therapy and was cleared to go home with home physical
therapy. | 113 | 407 |
11307171-DS-12 | 20,965,306 | 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 can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing right lower extremity | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bimalleolar ankle
fracture-dislocation and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for ORIF left ankle fx, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with ___ as decided after ortho follow up was appropriate. The
patient was kept until ___ to evaluate his soft tissues.
Silvadine cream was applied to the blisters and soft tissues on
___ before redressing and applying the bivalve cast. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 156 | 276 |
11965254-DS-31 | 24,881,849 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted to ___ with abdominal
pain,nausea and vomiting.You were treated with bowel rest and
pain medications. You had an MRI of your abdomen which showed
evidence of chronic inflammatory bowel disease but no acute
changes. Your nausea and vomiting improved with time. It is
possible that your symptoms were due to a partial small bowel
obstruction. | ___ yo female with history of ileocolonic Crohn's disease s/p
laparoscopic left hemicolectomy, proctectomy, end colostomy and
subsequent completion colectomy with end ileostomy on ___ and
revisions in ___ and ___ currently on tofacitinib 5mg bid
since ___ presenting with recurrent abdominal pain.
#Abdominal pain, possible small bowel obstruction:
She has had three episodes of abdominal pain over the past 6
weeks. She has been scoped through these episodes without
evidence of recurrent disease or fixed obstruction of her
ileostomy, however there may be some mechanical kinking in
conjunction with her delayed small bowel emptying due to
narcotics. Recurrent Crohn's proximal to the points evaluated
by ileoscopy is also possible especially in the setting of
microcytosis, thrombocytosis, and elevated CRP. She was followed
by gastroenterology while hospitalized. The patient underwent
MRE without evidence of active inflammation. She was treated
with bowel rest, IVF and pain medications with improvement in
her symptoms. Her CRP trended down to 2.9 without intervention.
LFTs were rechecked and trended down. It is possible that her
symptoms were due to intermittent partial SBO which resolved
during the course the patient's hospitalization. Pain control
was challenging but was ultimatley achieved with liquid
oxycodone. She was tolerating a regular diet prior to discharge.
# Chronic LLQ pain at site of prior stoma. Differential
includes fibrous tissue with nerve involvement versus fistulous
disease, the latter of which would necessitate switch to another
medication for Crohn's disease.
-ultrasound of the abdominal wall to evaluate for fistulous
disease (may be done as outpatient)
# Ileocolonic Crohn's disease on tofacitinib
Continued tofacitinib
# Transaminitis.
Resolved without intervention
#Microcytosis without anemia.
___ be due to chronic inflammmation. Consider further w/o if
persists.
# Depression
Patient was intermittently tearful, and labile. She was seen by
social work for coping support and encouraged to follow up with
her outpatient therapist. Citalopram and lorazepam were
continued | 72 | 311 |
17276545-DS-17 | 24,718,701 | You were admitted for pneumonia and were started on antibiotics.
You initially required oxygen but your pulmonary status improved
and you are now off oxygen. You will complete your antibiotics
course ___ rehab.
You had blood ___ your urine but the urology team feels this is
secondary to your chronic radiation cystitis and will be a
chronic problem. They have given instructions to your rehab for
how to manage blood ___ your urine if and when it comes. | ___ year old male with atrial fibrillation, HTN, diastolic heart
failure and prostate CA s/p distant XRT presents with fevers and
malaise.
# Pneumonia: patient presented with fever, elevated white count,
and new infiltrates on CXR, concerning for pneumonia. The
patient was started on vancomycin and cefepime on the evening of
___. The patient is to complete an eight day course so he
should receive his final dose on the morning of ___. The
patient clinically improved and was asymptomatic and off oxygen
at the time of discharge.
# Hypotension: The patient had an episode of hypotension ___ the
ED with SBPs ___ ___, which resolved after 2L of IVF. Likely
related to hypovolemia due to poor PO intake and dysphagia for
past two days. BUN/Cr c/w pre-renal azotemia and hypovolemia.
The patient's blood pressures remained stable for the remainder
of his admission.
# Dysphagia: The patient complained of new onset dysphagia for
the 2 days prior to admission. Says to both solids and liquids.
He tolerated a normal diet well. Speech and swallow consuled and
recommended normal diet. Video swallow was done and was normal.
# ___: Patient with elevated BUN and creatinine from baseline on
admission. Creatinine 1.2 from baseline of 0.9. Likely from
hypovolemia. The patient's creatinine on discharge was 0.9.
# AMS: On admission had a report of AMS per report of rehab
attending and daughter ___ law. On admission to MICU no evidence
of AMS, no focal neuro deficits. Most likely was related
toinfection.
# Hyperkalemia: Increased K on admission to 5.5, likely ___ home
potassium supplements ___ setting of ___. Resolved.
# Hyponatremia: patient with sodium of 131 on admission,
appeared dry on exam, likely hypovolemic hyponatremia.
# Right lateral hip pain: Likely trochanteric bursitis. Previous
admission no fracture on CT with MRI showed evidence of greater
trochanteric bursitis versus gluteus medius tendinosis with a
small labral tear. Pt treated with oxydocone.
.
# Radiation cystitis: The patient did have evidence of hematuria
on exam. Urology was consulted and recommended conservative
management: they recommended not starting bladder irrigation and
monitoring the patient. His hematocrit was stable throughout the
hospitalization. His last hematocrit was 34 on ___. Explicit
instructions from urology for managing hematuria are attached to
this discharge summary.
.
# Chronic diastolic CHF: No increased evidence of worsening
heart failure. Lasix was initially held due to hypotension ___
ED.
.
# Atrial fibrillation: currently with good rate control.
Continued ASA, digoxin.
.
# HTN: Pt normotensive on admission. His lisinopril was held ___
setting ___ but then restarted. | 77 | 419 |
18588433-DS-29 | 27,533,675 | You were admitted because you were feeling short of breath and
having jaw pain. Your cardiac enzymes were normal and initial
ECG findings were thought to be non-specific and did not warrant
further testing at this time. We felt your shortness of breath
was likely related to decreased oxygenation while you walk so we
started you on home oxygen to use when you are exerting
yourself. | ___ yo M with PMH of CAD, lung CA s/p VATS and wedge resection of
spicukated LUL nodule on ___ presenting with dyspnea and jaw
pain found to have new TWI on EKG in ED during ___.
.
ACUTE ISSUES
# Jaw pain, EKG changes: New TWI on V2-V3 along with jaw
pain/dyspnea initially concerning for cardiac ischemia. However,
finding in V3 is non-specific, patient had no recurrence of
symptoms and his trops were negative x 4. Also, pt had normal
Stress MIBI last month so likelihood of new obstructive CAD is
unlikely. Patient was discharged on his home regimen of aspirin,
beta-blocker, and statin.
.
# Dyspnea on exertion: CTA Chest negative for acute
intrathoracic process. Patient was found to be mildly hypoxic
with ambulation so he was started on supplemental oxygen with
exertion for symptom relief.
.
# Adenocarcinoma pT2a w/o lymph node involvement s/p recent
VATS. CTA Chest on admission showed no acute post-surgical
changes that could account for symptoms.
.
# Anxiety: Likely a large contributor to patient's symptoms.
Continued ativan
.
CHRONIC ISSUES
# Hpothyroidism: continued levothyroxine
# Gout: continued allopurinol
# GERD: continued omeprazole
# COPD: continued tiotropium; fluticasone causes nose burning so
was held
.
TRANSITIONAL ISSUES
#CODE: Full
#Patient would benefit from further treatment of his anxiety | 66 | 208 |
11159148-DS-7 | 20,832,839 | You were admitted for evaluation of blood in the urine as well
as abdominal pain. You underwent imaging and you were found to
have a mass on/near your kidney. It is unclear at this time what
this mass represents. You were seen by the urology team who will
be following up with you to discuss options for ongoing
treatment of this mass. Please be sure to contact Dr. ___
___ office on ___ to ensure that follow up is arranged
if you have not heard from them.
.
Your MRI and CT scan reports are not finalized at this time and
will need to be followed up by the urology team as previously
planned.
.
You were given a small supply of pain medication to help with
any pain that may be associated with this mass. Please only take
this medication as prescribed, take with stool softeners and do
not drive while taking this medication. This medication can
cause sedation. | ___ y.o male with h.o asthma who presented with hematuria and
flank pain.
#RENAL MASS/HEMATURIA: Pt presented with one day of gross
hematuria and transient episode of flank/testicular pain and was
found to have 5.7 x 6.9 x 8.9 cm homogeneously hypoenhancing
mass arising from the left renal collecting system. Initial
different considered included TCC, RCC vs. lymphoma. MRI
abdomen was obtained for further characterization which
preliminary revealed concern for angiomyolipoma with former
bleeding vs. less likely papillary carcinoma. Differential is
still unclear at this time. Urine cytology was ordered twice and
does not appear to have been logged at the time of discharge.
The urology service was consulted (Dr. ___ who recommended
that pt could be discharged and the urology service will follow
up with the patient to schedule a follow up appointment to
discuss his options diagnosis and treatment of the underlying
mass. Pt is aware of this plan and was also provided with the
contact information to Dr. ___. Pt was given a small
supply of oxycodone and a bowel regimen to help with any flank
pain. Hematuria had resolved by the time of discharge and pain
was much improved.
.
#pulmonary nodule-Surveillence type of this lesion will depend
on if renal mass is malignant.
.
Transitional care
___ MRI abdomen and CT chest results
2.urine cytology
3.pulmonary nodule
4.pt will need urology f/u | 156 | 224 |
18369045-DS-18 | 29,346,557 | You were admitted to the hospital because you had a seizure and
fall. This was most likely because you were withdrawing from
your lorazepam [Ativan] and possibly your Percocet. You received
treatment and did not have any evidence of additional seizures.
You did not have any additional concerning symptoms of
withdrawal. Your situation was discussed with Dr. ___
primary care physician. All of your care provider agree that you
showed behavior and symptoms highly concerning for prescription
drug addiction and abuse. Your daughters and other family
members agree with this assessment. You will no longer receive
prescriptions for benzodiazepines including lorazepam [Ativan]
from our healthcare institutions. You will also no longer
receive prescriptions for Percocets or similar strong opiate
pain medications from our healthcare institutions. You have been
given a prescription for acetaminophen [Tylenol] and tramadol to
use for pain as needed. We have also made an appointment for you
to see a pain specialist at the ___, who may perform
injections for your lower back and upper leg pain.
Your blood labs showed signs that were concerning for possible
atypical changes in your bone marrow. You were seen by our blood
and cancer specialists who performed a bone marrow biopsy. You
had several x-rays of the bones of your body, which did not show
any evidence of cancer. Many of your bone marrow test are still
in progress. Our blood specialists will be in touch with you
regarding your results. You also received a blood transfusion.
You may also need a colonoscopy as an outpatient, to be arranged
by Dr. ___. | ___ with PMH depression, anxiety, chronic back pain, ?renal cell
carcinoma, seen in ED on ___ for low back pain and anemia now
presenting s/p fall and seizures likely due to benzo and opiate
withdrawal and worsening anemia and thrombocytopenia.
# withdrawal seizure: reports only 1 seizure in a past about ___
years ago, back when she was "partying too much" which she had
attributed to drugs and alcohol (which she denies currently).
Pt's recent seizure was most likely due withdrawal from
lorazepam and percocets. Pt was restarted on her home regimen of
lorazepam 1mg TID in the MICU with no further signs of seizures.
Per Pt's daughter, Pt started overusing lorazepam when her
percocets were controlled by her daughters. Other possible
etiologies include hyperviscosity syndrome given her previously
known IgM MGUS (see below), but serum viscosity was checked and
normal. Social work was consulted and met with patient for
prescription medication abuse, but she perseverated on obtaining
more benzos and opiates. Pt did not scoring significantly on the
___ and never needed another dose of diazepam. ___ was
discontinued on ___. Pt's condition was discussed in detail
with PCP and new anxiety and pain control plan instituted (see
below). Pt was tapered completely off her lorazepam and
percocets by ___.
# prescription opiate and benzodiazepine abuse: Pt's behavior is
highly concerning for prescription opiate and benzodiazepine
addiction and abuse. Pt's daughters feel that she is addicted
and report that she became extremely belligerent when they
attempted to control her medications. Situation was discussed in
detail with Pt's PCP ___, who agrees that she cannot be
prescribed strong opiates or benzos. Pt was transitioned
completely off lorazepam and percocets during her admission. For
her reported pain, she was started on acetaminophen 650mg po q6h
prn and tramadol 25mg po q6h prn. A pain clinic appointment at
the ___ was arranged for 3 days after discharge. She
was encouraged to try acetaminophen first and only use tramadol
if needed. She was also started on mirtazapine for anxiety and
insomnia per her daughter ___ suggestion (see below). Her
pharmacy was called to cancel the remaining refills on her
lorazepam. Her daughters and family members were also informed
to secure their own supplies of these medications (her son, who
lives with her also uses lorazepam). Pt remained highly
insistent that she be prescribed her old regimen of percocets
and lorazepam on discharge, which was not provided.
# normocytic anemia, thrombocytopenia: possibly due to
underlying MGUS, however Pt's daughter reports that she has now
with small dark guaiac positive stool raising possibility of
some acute GI bleeding. Plts were previously elevated and Pt is
positive for JAK2 V617F mutation, but Plts have been dropping
for the past few months, suggesting possible progression of MGUS
to MDS. ___ is also possible that Pt has a GI malignancy given
her heavy smoking history, two guaiac positive stools in MICU,
lack of any screening colonoscopy, and reported weightloss.
Hematology was consulted and concerned for possible progression
with hyperviscosity syndrome as a potential etiology of her
seizures, and recommended workup with repeat SPEP showing
monoclonal IgM Kappa now representing 6% of total serum, serum
viscosity normal, UPEP not collected, B2 microglobulin 4.3,
quantitative Ig's with elevated IgM, peripheral smear with
evidence of possible infiltrating or fibrotic marrow, iron
studies normal, retic index low, and skeletal survey that showed
no evidence of lytic lesions. Bone marrow biopsy was performed
on ___ with results pending. Pt was transfused 1 x pRBCs with
appropriate increase in serum hemoglobin. Pt has follow-up with
heme-onc in three weeks. Pt has never had a colonoscopy and
given anemia and guaiac positive stools, should have a
colonoscopy as an outpatient.
# weightloss: daughter reports that Pt has lost a significant
amount of weight over the last six months unintentionally.
States that she was generally 170 lbs, though per OMR PCP
records, she ___ been this that weight since ___. She was
in the 130lb range in ___, and ~120 lbs [54.4 kg] for the
later half of ___. Given Pt's long smoking history and absence
of screening colonoscopy, together with now guaiac positive
stools, concern for possible colonic malignancy. Pt also reports
reduced appetite, which could also be due to rx medication
abuse. Pt's weight is 51.2kg, which indicates ~ 7 lb weight loss
over 6 months. Albumin is normal. Pt's weight should be closely
monitored. | 261 | 727 |
12276520-DS-20 | 25,513,624 | Dear Ms. ___,
It was a pleasure to take care of you during your
hospitalization at ___. You were admitted to the hospital with
severe right knee pain which was limiting your ability to walk
and use your knee. You were found to have excess fluid in the
knee joint which was drained and showed a type of inflammatory
arthritis with crystal deposition called pseudogout. The
rheumatology (joint) specialists saw you for this problem and
removed some fluid and injected a steroid to help with the pain.
You were treated with a medication called indomethacin for pain
control which you should stop taking once your knee pain stops.
You were also treated with oxycodone for pain not controlled by
the indomethacin. We will give you a small supply of this
medication to only be taken for breakthrough pain at home.
In addition while you were in the hospital you were found to
have a very low iron level. We started you on iron supplements
which we would like for you to continue taking.
Finally, you were also continued on the Nafcillin which you were
started on at your last hospitalization for the blood stream
infection. You should continue to take this for a full 4 week
course. Please follow up with the infectious disease specialists
as scheduled from your previous admission.
Please continue to take the rest of your medications as
prescribed. ___ of luck to you in your future health.
Sincerely,
Your ___ Health Care Team | Ms. ___ is a ___ year old woman with a history of atrial
fibrillation, anxiety/depression, and breast cancer s/p
bilateral mastectomy, bilateral tissue expander placement and
implant removal from the left breast in ___ secondary to
infection who presents with right knee pain, with joint aspirate
consistent with calcium pyrophosphate crystal deposition. | 244 | 54 |
12973912-DS-19 | 23,296,559 | Dear Ms. ___,
You were admitted to the ___ for pneumonia. Your breathing
improved and fever resolved once we started you on antibiotics.
You have a PICC line placed on your arm. You will be receiving
antibiotics through this for the total 8 day course. It is
important to complete all prescribed antibiotics.
You were also evaluated by the speech and swallow consult, who
recommended ground food and thick nectar fluids for your diet.
We found small amount of fluid in your left lung. This could be
related to pneumonia or something else. We would like you to
follow up with your PCP on this issue as well as your current
PNA after dischrage.
We have made the following changes to your medications:
- ADDED vancomycin- last day- ___
- ADDED azithromycin- last day ___
- ADDED ceftriaxone- last day ___ | ___ h/o L-LCIS s/p lumpectomy ___ and paranoid schizophrenia
referred from ___ with fever, hypoxemia, and
leukocytosis.
# PNA
Pt presented with fever of 101, chills, O2 sat 88%,
leukocytosis. CXR showed LLL opacity most concerning for
pneumonia. UA was negative for infection. Legionella Ag was
negative. She had no neck pain or HA. Patient was treated for
healthcare-associated pneumonia given residence at a care
facility and recent ED stay. She was started on vancomycin
(start: ___, azithro (___), and ceftriaxone (___). Patient's
respiratory improved rapidly. She came off O2 and was satting
mid-90s on RA by the time of discharge. She had transient chills
but remained aftebrile and HD stable. She had a PICC line placed
for the total 8d course of abx. Azithromycin will continue for
1 more day (5 days total- last day ___, vancomycin for 5 more
days (8 days total- last day ___, and ceftriaxone for 4
more days (8 days total- last day ___. BCx is pending at
the time of discharge.
.
# ASPIRATION
Patient's history of cough after meals (esp. solids), no
dentures, and CXR notable for chronic bibasilar findings raised
a concern for aspiration. Speech and swallow found no acute
process with good muscle strength but silent aspiration could
not be ruled out. Patient was maintained on ground foods and
thick nectar as well as on general aspiration precautions. This
should be followed up outpatient along with proper denture
fitting.
.
# PLEAURAL EFFUSION
There was L-small pleural effusion increased from prior imaging
on ___. There was no clinical signs or symptoms of heart
failure. Differentials included parapneumonic effusion vs.
recurrent malignancy given her recent history of breast cancer
on the same side. Repeat CXR on ___ showed stable or decreased
effusion although comparison was limited due to portal CXR. We
recommended outpatient follow up.
.
# HISTORY OF BREAST CANCER
Patient has history of L-DCIS and LCIS. Her last mammogram and
follow up was in ___ per OMR. Her providers were contacted
regarding any recent followup. We recommend that patient gets
reconnected with outpatient followup especially given the new
pleural effusion on the same side.
.
# CHRONIC ANEMIA
Patient's Hct was 40 upon admission, which dropped to 35, which
was her baseline from ___, after IV fluid. This stayed stable
throughout. There was no overt active bleeding. MCV was wnl.
Iron studies 32, TIBC 209, Ferritin 166, TRF 161.
.
#Paranoid Schizophrenia
Remained stable with no auditory or visual hallucination or
suicidal or homocidal intentions. She remained alert and
oriented to time, place, and person. Her attention remained
intact with fluent days of week forward and backward. She was
continued on home resperidone, clonazepam, and trazodone.
.
#Chronic constipation
This remained stable on home regimen.
.
#Bradycardia
Patient has baseline bradycardia in 40-50s. This remained stable
on sinus bradycardia throughout.
.
# TRANSITIONAL ISSUES:
- Follow-up final read blood culture
- Proper denture fitting
- Follow up of possible silent aspiration given bibasilar
findings on CXR and h/o cough with meals
- Follow-up of breast cancer and if she desires consideration of
future treatment
- Follow-up of resolution of the non-tender L palpable cord
extending from the L popliteal fossa to the mid calf (chronic
thrombophlebitis)
- CODE: DNR/DNI (confirmed with patient)
- CONTACT: Sister, ___ | 136 | 531 |
14454079-DS-14 | 21,371,131 | Mr ___,
You were seen in the hospital for a suicide attempt with cocaine
and bleach. You were monitored and no issues were found. The
pain in your arm is likely a local irritation of the veins and
can be treated with warm packs. You have continued to endorse
suicidal ideation and are now being transferred to a psychiatric
unit for further care.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | ___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTSD, chronic SI with multiple
suicide attempts presenting after suicide attempt with injection
of bleach and cocaine which he has done before. He has been
medically stable since admission.
# Suicide attempt
Pt presenting after suicide attempt with injection of bleach and
cocaine. There is limited literature regarding parental
injection of sodium hypochlorite (bleach). Patient initially
appeared somnolent with induration at the injection site but no
evidence of bradycardia or cardiac arrhythmia. Likely secondary
to benzodiazepine use. On reassessment was placed on ___.
Restarted home psychiatric medications which were well
tolerated. Was kept with one to one sitter.
#Phlebitis
From injection of irritant bleach. ___ possibly contain
superficial thrombus. Pain localized and improved during stay
with hot packs as only treatment.
# Polysubstance abuse
Monitored on ___ without withdrawal. Restarted home suboxone.
# Anemia
Baseline Hemoglobin ___. Was stable in this range | 72 | 149 |
14822057-DS-17 | 22,353,655 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity touch down weight bearing
- LLE ROM as tolerated
- Activity as tolerated
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing, passive/active
range of motion as tolerated
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Staples to be removed at 2-week follow-up visit. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femur periprosthetic fracture with hardware
failure and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for a
removal of hardware and open reduction/internal fixation, 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 touch down weight bearing in the
left lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 177 | 248 |
13738452-DS-8 | 29,286,905 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity
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 aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of the right ankle, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity, and will be
discharged on aspirin 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. | 501 | 257 |
19345192-DS-21 | 29,356,212 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with pain after a fall and you were found to have an obstruction
in your urinary tract. This resulted in kidney injury and an
infection in the kidney. You had a catheter placed in your
bladder to drain your urine. You were also treated with
antibiotics. With these interventions, your kidney function
improved. You also worked with physical therapy to improve your
strength and coordination. Please continue to take your
Augmentin antibiotics until XXX. You will also be discharged
with your urine catheter. Please leave this in place until you
see the urologist on ___. Thank you for allowing us to
participate in your care.
Sincerely,
Your ___ Team | Ms. ___ presented with abdominal pain and urinary retention.
She also had flank pain after a traumatic fall. She was found to
have hydronephrosis on imaging and had a foley catheter placed.
She was started on antibiotics for and UTI and pyelonephritis.
She will be discharged on augmentin and will continue this until
___. She was also seen by the spine service for her vertebral
fracture and will follow up with them on an outpatient basis.
# Acute Kidney Injury: Pt presented with acute kidney injury
from obstructive uropathy. This was evidenced by the
pyelonephritis on imaging. Her Cr on admission was 4.3 and her
Cr on discharge was 1.5. Her baseline Cr is approximately 1.3.
She had a foley catheter placed and will be discharged with the
foley catheter and will have follow up with urology on ___.
# UTI, pyelonephritis: The pt had a positive UA and met severe
sepsis criteria on admission. She reported rigors at home
before admission, had a leukocytosis with a left shift, had an
elevated lactate, and had a suspected source (urine).
Obstructive uropathy leading to urinary stasis put Ms. ___ at
increased risk of urinary infection. A foley catheter was
placed to relieve the obstruction and she was treated with
antibiotics. She was initially started on ceftriaxone in the ED
and was broadened to ampicillin/sulbactam on the floor. When
the urine cultures came back, she was transitioned to
amoxicillin/clavulanic acid. She will be discharged on
amoxicillin/clavulanic acid to complete a 14 day course to end
on ___. She will also be discharged with the foley
catheter in place for source control.
# Obstructive Uropathy: The cause of the obstructive uropathy
was not clear. On imaging, bladder wall thickening was seen and
UV junction blockage was suggested. This raises concern for
possible bladder mass. Urology was consulted and recommended
maintaining the foley catheter after discharge for urinary
drainage. She will follow up with urology in clinic on ___.
# Fall: The pt had multiple falls in the time period prior to
presentation. She had a fractured ___ right rib from a fall.
Her pain was managed and she was seen by both physical and
occupational therapy. They recommended that she have continued
outpatient services and that she be observed at all times.
# L4 Fracture: Pt had L4 compression fracture on admission. She
was seen by the orthopedic spine service on the ED. She was
given a TLSO brace for comfort but found it uncomfortable and
did not use it. She will follow up with the orthopedic spine
service in clinic.
# Hypertension
- Continued amlodipine
# Hyperlipidemia
- Continued simvastatin
# Hypothyroid
- Levothyroxine 75 mcg PO daily
# Depression
- Continued fluoxetine | 131 | 459 |
12199937-DS-20 | 25,088,164 | Dear Mr. ___,
You were admitted for abdominal pain and bloody diarrhea
concerning for an ulcerative colitis flare. You were treated
with antibiotics, steroids and received multiple blood
transfusions. You were evaluated by the gastroenterologists and
colorectal surgery team who both agreed surgery was the best
option. You underwent a laparoscopic total abdominal colectomy
with end ileostomy. You recovered from this procedure well and
are now ready to return home to continue your recovery.
You have a new ileostomy and stool no longer passes through the
colon (part of the body where water and electrolytes are
reabsorbed back into the body), so your output will be liquid.
The most common complication from an ileostomy is dehydration.
You must measure your ileostomy output for the next few weeks-
please bring your I&O sheet to your post-op appointment. The
output should be no less than 500cc or greater than 1200cc per
day. If you find that your output has become too much or too
little, please call the office. Please monitor for signs and
symptoms of dehydration. If you notice these symptoms, please
call the office or go to the emergency room. You will need to
keep yourself well hydrated, if you notice your ileostomy output
increasing, drink liquids with electrolytes such as Gatorade.
Please monitor the appearance of your stoma and care for it as
instructed by the ostomy nurses. ___ you notice that the stoma is
turning darker blue or purple please call the office or go to
the emergency room. The stoma may ooze small amounts of blood at
times when touched which will improve over time. Monitor the
skin around the stoma for any bulging or signs of infection. You
will follow up with the ostomy nurses in the clinic ___ weeks
after surgery. You will also have a visiting nurse at home for
the next few weeks to help to monitor your ostomy (until you are
comfortable caring for it on your own).
You have one laparoscopic surgical incision on your abdomen
which is closed with internal sutures. It is important that you
monitor this area for signs and symptoms of infection including:
increasing redness of the incision lines,
white/green/yellow/foul smelling drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. You may shower; pat the incisions dry with
a towel, do not rub. Please do not take a bath or swim until
cleared by the surgical team.
Pain is expected after surgery. This will gradually improve over
the first week or so you are home. You should continue to take
2 Extra Strength Tylenol (___) for pain every 8 hours around
the clock. Please do not take more than 3000mg of Tylenol in
24hours or any other medications that contain Tylenol such as
cold medication. Do not drink alcohol while taking Tylenol. You
may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days.
Please take Advil with food. If these medications are not
controlling your pain to a point where you can ambulate and
perform minor tasks, you should take a dose of the narcotic pain
medication tramadol. Please do not take sedating medications,
drink alcohol, or drive while taking the narcotic pain
medication.
You are being discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this medication for a
total of 30 days (including doses in hospital), please finish
the entire prescription. Please monitor for any signs of
bleeding: fast heart rate, bloody bowel movements, abdominal
pain, bruising, feeling faint or weak. If you have any of these
symptoms please call our office or seek medical attention
immediately. Please avoid any contact activity and take extra
caution to avoid falling while taking Lovenox.
Please follow the outlined steroid taper below:
Prednisone 20mg Daily ___
Prednisone 15mg Daily ___
Prednisone 10mg Daily ___
Prednisone 5mg Daily ___
Off
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs and
go outside and walk. Please avoid traveling long distances
until you speak with your surgical team at your post-op visit.
Thank you for allowing us to participate in your care, we wish
you all the best! | Mr. ___ was initially admitted to the medicine service on
___ with an acute ulcerative colitis flare. The GI service and
colorectal surgery were consulted in the emergency department
for steroid or biologic recommendations and possible colectomy
given concern for fulminant colitis.
#Severe UC Flare
#Acute blood loss anemia
Initially he was treated with Zosyn but per GI recommendations
was switched Rocephin/flagyl. He was also given ganciclovir
empirically for CMV (which later came back negative so
ganciclovir was stopped). On admission he was started on
methylpred 20mg IV q8hrs. Stool samples were sent to rule out
cyclospora, microsporidium, giardia, EHEC, shigella,
campylobacter, salmonella, and c.diff all of which were
negative. He got a daily KUB to monitor for perforation. On
___ overnight he went from little to no blood in bowel
movements to several bloody BMs, heart rate went from ___ to
140s, and his Hgb dropped from 9.9 to 5.9. CRS was called,
abdominal exam is slightly worse but felt no acute surgical
indication. He was transfused 2 units, blood cultures were
drawn, and his antibiotics were broadened back to zosyn. He
reports significant abdominal pain only improved with morphine,
with any motion setting of ___ sharp pain throughout his
abdomen. On ___ the patient had a pre-syncopal episode and
became hemodynamically unstable in the setting of acute blood
loss anemia. His labs were sent and his Hgb/Hct was notable for
___. He was transfused with 3 units of PRBCs and 3 units of
FFP. He was urgently taken to the operating room on ___ for a
laparoscopic total abdominal colectomy with end ileostomy. He
tolerated the procedure well without complications (Please see
operative note for further details). After a brief and
uneventful stay in the PACU, the patient was transferred to the
floor for further post-operative management.
Neuro: Pain was well initially well controlled on IV Tylenol and
a dilaudid PCA for breakthrough pain. Once tolerating oral
intake, the patient was transitioned to oral Tylenol and
tramadol for breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored and the patient
was placed on continuous cardiac monitoring. The patient was
noted to be slightly tachycardic to the low 100's and up to the
150's with ambulation in the immediate post-op period, EKG
obtained and revealed sinus tachycardia. As the patient became
more mobile and active, his tachycardia improved.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
ID: The patient was given an additional 4 days of Zosyn. He was
closely monitored for signs and symptoms of infection and fever,
of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He was encouraged to get up and ambulate
as early as possible. The patient is being discharged on
prophylactic Lovenox.
#Post-op ileus
The patient was initially kept NPO after the procedure. The
patient was later advanced to a regular diet. On ___, the
patient had an episode of emesis. A KUB was obtained which
showed dilated loops of bowel. A nasogastric tube was placed and
the patient was given IV fluids and IV pain medication the NGT
was removed on ___ due to severe discomfort causing ongoing
tachycardia for the patient. His stoma was thus intubated with a
red rubber catheter. The patient began to have output from his
stoma (both stool and gas) and on ___, he was advanced to a
regular diet which was well tolerated at time of discharge.
Patient's intake and output were closely monitored.
#Acute urinary retention requiring foley replacement:
The patient had a foley catheter in the operating room that was
removed in the PACU. At the time the patient was DTV, he was
bladder scanned for >1L. The foley catheter was replaced on
___ and the patient continued to have good urine output. It
was discontinued on ___ once again and at the time the patient
was DTV, he was bladder scanned for 800cc of urine. A foley was
once again placed on ___ and ultimately removed on ___. The
patient was able to void on his own without difficulty for the
remainder of the hospitalization. Urine output was monitored as
indicated.
#Severe protein calorie Malnutrition
Due to significant weight loss, a nutrition consult was placed.
Initially, due to concern for bacteremia, TPN was held and PPN
was given. Once blood cultures came back negative, a PICC line
was placed on ___ and the patient was started on TPN. The
patient continued on TPN until he was fully tolerating a diet
and TPN was discontinued on ___. The patient will be
discharged home on a multivitamin recommended by nutrition.
#Hyponatremia:
Likely hypovolemic hyponatremia in setting of poor po intake.
TPN adjusted accordingly.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge. | 735 | 836 |
17624628-DS-14 | 20,819,274 | Dear Mr. ___,
You were admitted to the hospital for chest pain. You underwent
tests to look at your heart and lungs, which fortunately did not
show any damage to either. We still do not have a good
explanation for your chest pain, so we encourage you to follow
up with your doctor to keep investigating it.
Though we do not think that your chest pain is due to your
heart, you were started on daily aspirin to protect your heart
in the future. All of your medications are detailed in your
discharge medication list. You should review this carefully and
take it with you to any follow up appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ with hx of DM, HTN, and HLD p/w CP x 1 day.
# Chest pain: He reports a sudden-onset of pressure sensation
radiating to L arm. Denies SOB, N/V, diaphoresis, PND, or
orthopnea. At OSH, ECG reported to have hyperacute T waves
anteriorly and biphasic T waves inferiorly. He was placed on
heparin gtt and transferred to ___ for further management.
Patient was given atorvastatin 80, heparin gtt, nitro gtt,
methylpred 125 mg IV and sent directly to the cath lab. Cath was
notable for ___ lesion 50-60% occluded with no intervention.
After cath, patient continued to complain of pleuritic chest
pain for which he was admitted. He underwent a CTPA which did
not show any evidence of PE. His pain resolved with rest and
nitro drip. The nitro drip was weaned and his home medications
were restarted without any recurrence of his pain. Pain thought
to be non-cardiopulmonary in nature. He is being discharged on
81mg daily aspirin with PCP follow up. | 128 | 165 |
16248501-DS-20 | 24,023,466 | Dear Mr. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted to ___ for blood clots found in your lung.
What was done for me here?
- You were seen by the blood clot specialist team in the ER who
felt that you did not need any invasive procedure to remove the
clots.
- You were continued on IV heparin as a blood thinner.
- You had ultrasound of your legs which showed a large amount of
clot in the veins in your right leg.
- You had an ultrasound of your heart which showed some dilation
of the right side of your heart and some elevated pressures in
the right side of your heart.
- You were switched to Coumadin when you were feeling better.
What should I do when I go home?
- You should take your Lovenox shots twice a day.
- You should wean your Primidone medication as follows: Decrease
to 50 mg Primidone every morning and 100 mg Primidone every
evening x 3 days. On ___ decrease to no Primidone in the
morning and 50 mg Primidone in the evening x 3 days. On ___
stop taking all Primidone.
- You will start Propranolol 40 mg twice a day for your tremor.
- You have appointments with your primary care doctor,
___, urologist, and hematologist that you need to go to.
- You should discuss with your doctors before ___ to
exercise.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old M w/ no significant PMH who
presented to ___ with SOB and was found to have a
submassive PE with evidence of right heart strain, transferred
to ___ for further management of submassive PE.
#Submassive PE: Patient presented with acute onset SOB and was
found to have significant clot burden in bilateral pulmonary
arteries with positive troponin and signs of right heart strain
on CTA. Started on heparin gtt and transferred to ___. In the
ED, cardiology was consulted and felt that patient did not have
current indication for thrombectomy or more invasive treatment.
Patient s/p ortho knee surgery ___ with intermittent RLE
swelling. Patient up to date on colonoscopy (next scheduled
___. ___ with DVT extending from proximal right femoral
vein, throughout the right popliteal vein, and into 1 of the
right peroneal veins. TTE with evidence of right heart strain
and elevated pulmonary pressures. He was treated with heparin
gtt and transitioned to Lovenox as bridge to Coumadin. He could
not be on NOAC due to interaction with primidone.
#Gout: patient had new left toe tenderness and edema; per
patient felt similar to prior gout flare. Started colchicine 1.2
mg loading dose with 0.6 mg daily after that.
#Splenomegaly: Seen on CT-A for PE study. Unclear etiology.
Could consider work up if concerned for occult malignancy as
cause of PE.
#Essential tremor: Continued primidone 100 mg qAM and 150 mg qPM
during admission. Discussed with outpatient neurologist Dr.
___ we would like to wean off primidone if possible due
to wanting to put the patient on a NOAC as ultimate
anticoagulation. She agreed with weaning off primidone with 50
mg decrease in dose every 3 days until off the medication.
Started 40 mg propranolol to treat essential tremor with plan to
f/u with neurology. | 235 | 299 |
12868753-DS-17 | 20,749,339 | Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for fever and gastrointestinal symptoms. You were found
to have two types of bacteria causing your infection (shigella
and clostridium difficile). You received medications for these.
We strongly recommend that you avoid use of any recreational
drugs in the future. Please talk to your doctor about
re-initiation of long-term treatment for your HIV. Treatment can
lower the risk of such infections drastically.
You also reported floaters in your left eye. You were schediled
for an urgent ophthalmology appointment.
We wish you well.
Your ___ Medicine Team | Mr. ___ is a ___ with history of HIV/AIDS (non-adherent to
ARVs, last CD4 147 ___K ___, HTN, HLD, DM2 who
presented with fevers, nausea, vomiting, diarrhea, and abdominal
pain who was found to have C. diff colitis and Shigella.
# Severe sepsis secondary to C. diff: Patient presented with
___ SIRS criteria (fever, leukocytosis) and evidence of
end-organ damage (lactate 2.8). He was aggressively fluid
resuscitated. CT A/P revealed ileocecitis and patient stool
studies returned positive for C. diff. Patient was initially
started on broad coverage with IV vancomycin, cefepime, high
dose PO vancomycin, and metronidazole. Once C. diff returned
positive, IV vancomycin and cefepime were discontinued. Patient
remained clinically stable so metronidazole was discontinued and
PO vancomycin dose was decreased to 125 mg q6h (from 500 mg
q6h). Patient's pain was controlled with morphine. His
abdominal pain resolved and his diarrhea improved. He was able
to tolerate a regular diet.
# C. diff: Patient met criteria for severe C. diff (based on
admission ___ of stools/day). Given severe sepsis,
worsening leukocytosis, and rising lactate, he was treated as
severe-complicated initially with high dose vancomycin and IV
metronidazole. Once he clinically improved, metronidazole was
discontinued and vancomycin dose was decreased to 125 mg q6h.
He was discharged on a 14 day course of PO vancomycin.
# Shigella: In addition to C. diff, patient's stool studies
returned positive for Shigella. He was started on ciprofloxacin
and will complete at 7 day course.
# HIV: Last CD4 147 ___K ___. He has not been
adherent to ARVs for several months, possibly years. ARVs were
held and decision to restart should be addressed by his PCP.
Patient was continued on Bactrim for PCP prophylaxis as he has
intermittently been taking this at home.
# Drug abuse: Patient reports using daily methamphetamine. His
withdrawal symptoms were controlled with ___ scale (using
diazepam). He was seen by social work and offered resources for
substance abuse.
# Transaminitis: LFTs on admission notable for ALT/AST 43/42.
CT A/P notable for hepatic steatosis. Review of ___ records
reveals a ?history of (and treatment of) hepatitis C. LFTs
normalized.
# Hypertension: Home amlodipine-benazepril was held initially
in the setting of sepsis. Once he clinically improved, he was
restarted on amlodipine and lisinopril in equivalent doses
(amlodipine-benazepril is not on formulary).
# Diabetes: A1c 8.3. Patient has not been compliant with
metformin. His blood sugar was controlled on a Humalog sliding
scale. He was encouraged to continue metformin on discharge.
# HLD: Patient was restarted on atorvastatin and ASA.
# Depression: Patient's Effexor was held as he has not been
taking it.
# GERD: Held home PPI given C. diff, but restarted on
discharge.
Transitional Issues
- Lung nodule on prior CT in ___, may require follow-up CT
- Please continue to address substance use and medication
non-adherence
- Please discuss re-initiation of HAART with patient when he is
ready to re-start medications
- Please note, patient developed dark scotomata in L eye. Neuro
exam otherwise intact. Urgent Ophthalmology appointment
scheduled. | 102 | 538 |
16653212-DS-21 | 21,033,948 | Dear Ms. ___:
You were admitted to ___ because you had a broken bone in your
right arm as well as some confusion. Your confusion was most
likely due to getting some pain medications that cause confusion
as a side effect.
You were found to have a urinary tract infection for which you
were treated with an antibiotic which you will continue for 7
days (day ___.
It was a pleasure to care for you!
Your ___ Team | ___ yo F with history of dementia, htn, hld, h/o c diff s/p
colostomy who is admitted s/p mechanical fall, found to have a
humerus fracture for which ortho recommended non operative
management, who was admitted due to delirium. | 74 | 39 |
19150392-DS-24 | 20,761,907 | Dr. ___,
You were admitted to the hospital for your vision changes. We
started you on IV steroids. The clinic is going to set up the
remaining treatments for the steroids. We are going to try to
coordinate this over the weekend however you will likely come
back for the next treatment on ___. | The patient is a ___ year-old right handed woman with a history
of relapsing-remitting MS on ___, migraine headaches with
aura, bipolar depression who presents to the ED with bilateral
vision changes. Her neurological exam was notable for visual
acuity corrected ___, left RAPD, bilateral INO (L worse than
right) and subtle left NLFF. It appears that the patient is
having worsening visual symptoms likley representing an MS
___. She underwent MRI and one dose of IV steroids prior to
___ with plans to continue IV steroids as an out patient. | 54 | 93 |
15670611-DS-22 | 22,559,396 | Dear Mr. ___,
It was a pleasure to take care of ___ at ___. ___ were
admitted with bleeding in your GI tract and required surgical
resection with colostomy. Your hospital course was complicated
by a fast heart rate requiring changes in your medications. ___
also had decompensation of your cirrhosis after surgery and
infection of the fluid in your abdomen for which ___ received
antibiotics. ___ had fluid removed from your abdomen and ___
were started on diuretic pills to continue to remove fluid. ___
may need another procedure to remove fluid from the abdomen in a
couple of weeks while will be determined by your outpatient
physicians. ___ were set up with follow up appointments with
your oncologist, new primary care physician, ___, and liver
specialist. It is very important that ___ continue to take your
medications as prescribed and attend your follow up
appointments. If ___ develop any fevers, abdominal pain,
confusion, bleeding, or increasing abdominal distention please
call your physicians or go to the emergency room.
Sincerely,
Your ___ medical team
Surgery notes:
Please monitor your bowel function closely. Some loose stool and
passing of small amounts of dark, old appearing blood are
expected. However, if ___ notice that ___ 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 ___ are taking narcotic pain
medications there is a risk that ___ 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 ___ 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 colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
stool from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The 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.
___ have an incision on your abdomen and the staples have been
removed. This incision can be left open to air or covered with a
dry sterile gauze dressing if it become irritated from clothing.
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 ___ 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.
There is an incision on your bottom where your rectum was
removed. This is healing well.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___ may
gradually increase your activity as tolerated but clear heavy
exercise with your surgical team.
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. ___ is a ___ M with ETOH cirrhosis (c/b gastric and
rectal varices), afib (not on coumadin since ___, stage
IIIcT3N2M0 rectal cancer s/p neoadjuvant chemoradiation w/ ___ ___
(last ___ C2D1) and radiation therapy stopped prematurely due
to development of severe proctitis c/b GI bleed ultimately
requiring abdominoperineal resection and colostomy with course
complicated by afib with RVR and decompensation of cirrhosis
with ascites and secondary bacterial peritonitis.
# GI bleed: Patient recently had hospital admission for which he
had severe GI bleeding ___ rectosigmoid colitis ___ likely
radiation colitis, erythematous tissue around ca site, and
possible superimposed ischemic colitis during period of GI
bleeding. On admission to hospital and subsequent immediate
transfer to MICU from ED, it was noted that patient likely had
bleeding from prior rectosigmoid site. Patient was transferred
from ED to MICU on ___, and had 8 units of pRBCs, 2 units of
FFP and 1 unit of platelts transfused. Patient had bedside
sigmoidoscopy in MICU on ___ which showed few ulcerations was
noted in the rectosigmoid consistent with prior findings, and a
single oozing clot overlying a presumed ulcer was found in the
above the anal verge, which was subsequently injected with
epinephrine and clipped. After procedure, patient did not have
episodes of further bleeding. His home nadolol was held during
hospitalization, and metoprolol was used for rate control of
Afib with RVR. In the setting of a recent GIB his Coumadin was
held. He was transferred to the floor on ___ in stable
condition, with stable H/H s/p transfusions. However on ___ he
had more BRBPR and received 1u RBCs. He was taken back to GI
suite for flex sig and the clip had fallen out but there was no
intervention able to be undertaken. He had more significant
bleeding the early morning of ___ and required 2u RBCs, 1u
FFP, and had SBP in the ___. He was volume resuscitated also
with 1.5L IVF at that time. HR was controlled also with rate
control see below. He was taken to the OR on ___ (see below)
and had an abdominal perineal resection with end colostomy. His
H/H remained stable and he did not need any transfusions after
the immediate postop period.
# Afib/RVR: Pt with longstanding history of Afib, not currently
on anticoagulation given GI bleed as above. Rate was difficult
to control preoperatively in the setting of large volume active
bleeding. Pt required ongoing transfusions prior to the OR and
was clearly volume depleted. In that setting, combined with
lower BPs on ___, rate control was pursued cautiously, however
on ___ pt finally achieved good control with HRs down to the
___ 100s. This was with 50mg metop q6 po and continued on
dig with 1x extra dose given of 0.125 mg on ___ (for dig level
slightly low at 0.5). His bleeding improved a bit which also
contributed to improvement in volemic status and improved heart
rates. Echo was done that showed very dilated atria and combined
with his interesting but not fully explained history of liver
dysfunction/cirrhosis, cardiology raised the possibility of
amyloidosis. Accordingly, SPEP/UPEP were sent which were
negative. TSH/T4 was normal. | 737 | 525 |
12229001-DS-8 | 21,511,543 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for blood in your stool.
What was done for me while I was in the hospital?
- You were given a blood transfusion and fluids.
- You had an endoscopy which found ulcers in your small
intestine that were the likely source of bleeding. These ulcers
were treated to prevent future bleeding.
- You were treated with a medication to decrease stomach acid
production.
- You were found to have pneumonia and were treated with
antibiotics.
What should I do when I leave the hospital?
- Take your medications as prescribed.
- Keep all of your follow-up appointments.
Sincerely,
Your ___ Care Team | SUMMARY
___ man with PMH DM, HTN, HLD presenting with hematochezia and
weakness x 1 day, s/p ___ which found duodenal ulcer.
Patient received blood transfusions as needed with cauterization
of ulcer, with H. pylori stool antigen pending on discharge. He
was also found to have pneumonia as well as ___ proteus
mirabilis on urine culture and treated with ceftriaxone,
transitioned to cefpodoxime on discharge for total 7 day course,
to end ___, for combined coverage of community acquired
pneumonia/UTI. Azithromycin was discontinued given prolonged QTc
(530) | 133 | 85 |
13750301-DS-10 | 21,450,488 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a skin infection of your right middle
finger.
What was done for me while I was in the hospital?
- You were given intravenous (IV) antibiotics and switched to
pills as you continued to improve.
- Hand surgery specialists saw you and thought it was unlikely
that you had a more serious or deep tissue infection requiring
more intervention.
- An Xray was obtained of your right hand and showed no
fractures or anything more concerning than a superficial
infection.
What should I do when I leave the hospital?
- Please finish your course of antibiotics, even if you are
feeling better.
- Please follow up with your primary care physician.
Sincerely,
Your ___ Care Team | Information for Outpatient Providers: ___ M R___
p/w ulcer, erythema, and swelling of the ___ digit of his R hand
admitted for management of uncomplicated cellulitis. | 152 | 27 |
17975771-DS-3 | 23,270,765 | You were admitted to ___ for abdominal pain and were found to
have an inflammation of your pancreas and duodenum (first part
of your intestine). This may have been due to gallstones.
Over the next few days, please eat bland foods. AVOID alcohol
entirely. | \The patient is a ___ year old female with h/o depression,
migraines, HLD, smoking history who presents with acute
pancreatitis found to have intrahepatic dilatation, CBD
dilatation and pancreatic ductal dilation concerning for
possible obstruction.
.
Abdominal Pain: Patient with evidence of active pancreatitis
and duodenitis seen on MRCP with clear evidence of ductal
dilation. LFTs normal, but elevated lipase. This clinical
picture may be secondary to a gallstone. No gallstone clearly
seen on MRCP. There was mention of slight ampullary dilation on
MRCP. As such, she needs outpatient f/u with our ERCP staff to
consider ERCP given mention of ampullary dilation. Would
proceed with this workup prior to consideration of
cholecystectomy.
** Patient was discharged with a prescription for oxycodone 5 mg
(15 tabs) but then called the medical floor the day after
discharge to request a new prescription; we told her that we
have strict policies against replacing narcotic prescriptions so
she was not given an additional one.
HTN: Continued on clonidine only given her bradycardia.
Bradycardia: Metoprolol held, and EKG showed sinus arrhythmia.
QTC also prolonged at 480. Needs outpatient recheck and patient
notified not to take any medicines that prolong the qtc. | 47 | 203 |
17967161-DS-28 | 25,596,245 | Dear Mr. ___,
You were admitted to ___ after you had a large bleed in your
gut. You required several units of blood and you had to spend a
few days in the ICU. We think the bleed came from your colon.
Over time the colon wall can become weak and develop pouches
(diverticula) that can bleed. The way to prevent this from
happening again is to eat a high fiber diet. Also, when we
looked inside your colon we found a lot of polyps. Polyps are
not cancer but they can develop into cancer and so it is
important that you follow up with your doctor and GI specialist
in order to discuss the best way to treat them.
Because of your bleed we had to stop your blood thining
medications. When we restarted them we put you on heparin
temporarily until your coumadin levels came up. It is important
for you to continue taking coumadin in order to prevent clots or
strokes. You will have your levels checked while you are at
rehab.
Your heart failure was pretty well controlled while you were
here. However, it is still very important that you weigh
yourself every morning and call your doctor if weight goes up
more than 3 lbs.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ team | ___ with complicated history of maximally-medically managed
systolic heart failure, severe peripheral vascular disease and
poorly-controlled diabetes who presented from rehabilitation
with BRBPR while on lovenox and coumadin for anticoagulation.
# GI BLEED: Thought to be lower in etiology given history but
could not rule out upper GI bleed on admission. He was
hemodynamically unstable in ED and massive transfusion protocol
was activated. Patient continued to have bleeding in the ICU
requiring additional 3u pRBCs and fluid. He underwent NGT
placement for gastric lavage which was negative. Given his
ongoing bleeding and hemodynamic instability he underwent CTA in
attempt to localize the bleed. This was unfortunately
unrevealing as to source but did show evidence of diverticulitis
in the hepatic flexure. There was also concern for CBD
dilation. Patient underwent EGD per GI which showed evidence of
gastritis but no obvious source of bleeding. A biopsy was not
taken at the time. Had continued slow downtrend in Hct. Became
hypotensive requiring low dose norepinephrine, with marked
improvment by the end of ___ s/p 3U pRBCs and 2L NS. His H/H
then normalized with no further melena or hematechezia. A repeat
EGD and colonoscopy was performed on ___ which showed
intestinal metaplasia in the esopagus and diffuse diverticular
and adenomatous disease in the colon. However, no source of
bleed was clearly located. It was thought that this event likely
represented a brisk diverticular bleed, which spontaneously
resolved. He will need to follow up with gastroenterology as an
outpatient in order to discuss management of adenomatous disease
of colon. GI differed excision during this admission because of
need to anticoaulate given other comorbidities (see below). The
risks and benefits should be discussed with PCP and GI.
# H/O DVT/PE and LV THROMBUS: Anticoagulated with coumadin and
being bridged with lovenox since late ___. INR noted to be
highly variable, from 1.04 to >10 on ___. Was on 7mg warfarin,
last dose ___. In the setting of bleed his anticoagulation was
held. Becuase of his LGIB and ___ it was thought that restarting
lovenox would carry too much risk for further adverse events. He
was therefore started on a heparin drip as a bridge to coumadin.
On day of discharge he is taking 7.5 mg PO daily of coumadin and
his INR is at goal at 2.0 (___). He will need close follow up as
he recently discontinued antibiotics, which could cause
fluctuations in INR.
# ACUTE KIDNEY INJURY: On admission creatinine elevated to 2.5,
baseline appears to be 1.5-2.0, although the patient has
suffered fluctuations over his multiple hospitalizations.
Etiology is likely pre-renal given history of blood loss, and
likely concurrent diuretic use. No evidence of heart failure
exacerbation to suggest cardiorenal etiology. With volume
resuscitation, renal function improved to baseline Cr of
1.2-1.5. Of note, his lisinopril was held for hypotension and
was not restarted in the setting of ___. His BPs have been at
goal but should consider restarting it for renal/cardiac
protective effects.
#Bradyarrhythmia/Hyperkalemia: Patient with single episode of
unclear bradyarrhythmia to ___ caught on monitor late on ___.
Likely wenckebach AV block with intermittent ventricular escape
beats. K that morning had been 5.7. Pt refused lab draws. Pt
treated empirically with 2g IV calcium gluconate. 12 lead EKG
did not capture rhythm or show evidence of acute ischemia. No
further episodes were appreciated during the course, and his
potassium normalized.
#Diverticulitis: CTA on ___ with incidental finding of
uncomplicated diverticulitis. He was treated with intial bowel
rest and a 10 day course of ciprofloxacin and flagyl.
# PERIPHERAL VASCULAR DISEASE: s/p right toe amputation c/b
poor healing and polymicrobial wound infection with recent
bypass surgery from femoral to dorsalis pedis. Vascular surgery
was notified of admission given blood filled bullae at incision
site. His anticoagulation was initially held on admission given
bleed as above (see above). He had a vascular surgery
appointment scheduled during this admission and will therefore
have to reschedule. | 223 | 666 |
17805792-DS-7 | 21,408,406 | Dear ___,
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were in the hospital because you were having
hallucinations and became paranoid and agitated at your
psychiatric facility. Shortly after receiving sedating
medications at your facility, your heart rate went up and you
became lethargic. You were transferred here to make sure you did
not have any underlying medical problems causing these symptoms.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received CT scans and ultrasounds to make sure you did
not have any clots in your lungs that would cause you to have a
fast heart rate.
- You were seen by our toxicology team who made sure that you
did not have any major drug interactions or reactions from the
sedating medications you received at your facility.
- You were seen by our psychiatry team and neurology teams.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team | Patient Summary:
===================
___ female with a history of bipolar disorder with
psychotic features. Prior to admission she was admitted to
___. At the facility she was not
reliably taking her prescribed aripiprazole 2 mg/day. She been
complaining of auditory and visual hallucinations and became
increasingly paranoid/agitated. She ended up requiring chemical
sedation at ___ consisting of 200 mg of Thorazine, 100 mg
of Benadryl, and 2 mg of Ativan. She subsequently became
lethargic, hypotensive, and tachycardic so EMS was called. She
was transferred to our emergency department. She was evaluated
by our toxicology department and was found to have minor
anticholinergic toxicity which did not require physostigmine. We
held anticholinergic meds briefly with improvement in her
symptoms. However, she remained significantly tachycardic with
heart rates in the 120s to 140s with activity. We conducted
further work-up to exclude underlying medical disorders which
could be causing tachycardia. Lower extremity Dopplers, and a
CTA chest were negative for DVT/PE. Basic infectious work-up was
negative. While inpatient, the patient continued to struggle
with psychosis. She required as needed Haldol in order to
control her agitation, after receiving Haldol her LFTs were
mildly elevated. She did not complain of any abdominal pain. We
have performed a right upper quadrant ultrasound which was
unrevealing. We performed a hepatitis panel which was
unrevealing. We attributed the patient's transaminitis to
drug-induced liver injury from Haldol. During this time the
patient's CK was also significantly elevated. We reconsulted
toxicology to rule out NMS, and the toxicology department agreed
that she did not have any concerning signs for NMS. We
attributed the CK elevation to rhabdomyolysis from restraints.
She was seen by our neurology department who will work-up
outpatient for possible myositis as well to exclude this as a
cause of her CK elevation.
The patient was sent here on a ___. | 217 | 302 |
16084081-DS-7 | 21,446,168 | Dear Ms ___,
You were hospitalized due to symptoms of dizziness resulting
from Benign paroxysmal positional vertigo (BPPV). You underwent
an MRI which showed that you did not have a stroke.
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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Ms. ___ is a delightful and fiercely independent ___ year
old lady with history of prior left frontal stroke, as well as
HTN, CHF, and CAD who presented with vertigo. Her exam was
notable for positive HIT to the left. MRI was negative for acute
infarct. The patient was admitted due to trouble with ambulation
___ her peripheral vertigo. She improved during her stay after
working with ___ she will go home with home ___. | 235 | 76 |
15760156-DS-10 | 29,771,618 | Dear ___,
___ were seen and evaluated for your chest pain and found to
have inflamation of your gallbladder (acute cholecystitis)
likely secondary to gallstones. ___ had a tube placed to help
relieve the pressure and your symptoms improved.
___ will still need follow up with surgery to evaluate ___ for
surgery and with interventional radiology to evaluate your tube
and set up a time to have your gallbladder removed.
Please continue to take your medications as prescribed.
PLEASE DO NOT STOP TAKING YOUR PLAVIX (CLOPIDEGREL) UNLESS
DIRECTED BY YOUR CARDIOLOGIST.
Please instill 10mL of sterile water into your tube daily as
instructed.
It was a pleasure taking care of ___!
Sincerely,
Your ___ Healthcare Team | ___ year old woman with recent mLAD stent (___) on DAPT and
new diagnosis of cardiomyopathy who presented with chest pain
and was found to have acute cholecystitis, had a percutaneous
c-tube placed, and improved.
# Acute cholecystitis: Initially concerned for ACS or other
cardiac cause given recent diagnosis of cardiomypathy and LAD
stent, however workup was negative. Ultimately found to have
acute cholecystitis on ultrasound with white count of 20K. Not
deemed to be a good surgical candidate because of recent cardiac
issues and current anticoagulation. Percutaneous cholecystostomy
successfully performed though did drain some blood which
continued until discharge in small quanities likely due to dual
anti platelet therapy and HGB dropped from 11.9 on admission and
was 11. 3 on discharge. Started on ceftriaxone. Patient's pain
was much improved, and antibiotics switched to oral amox/clav
for a total of a 5 day course. Will follow up with surgery for
definitive surgical management.
# Cardiomyopathy and heart failure: Patient with new
cardiomyopathy and reported outside EF of ~35% per primary
cardiologist. All troponins negative and no other concerning
findings in cardiac workup. Echo performed and current EF at
55%. Following percutaneous cholecystotmy, chest pain improved.
Patient discussed with outpatient cardiologist and recommended
no additional workup in hospital.
#Pain control - Tylenol and oxycodone 5mg
#GERD- Pantoprazole 40mg daily continued from home medications
Transitional Issues
====================
- Patient is on dual antiplatelet therapy and should remain
until approved by cardiologist to stop treatment.
- Amox/Clav started for 5 day total course of antibiotics to be
completed ___
-Follow up with ___ surgery in 6 weeks for planning ongoing
surgery.
- Follow up with interventional radiology in 6 weeks for
evaluation of cholecysostomy tube.
- Patient's EF on echo in hosptital is >55% which is improved
from prior. Recommend continued workup for cause of heart
failure symptoms and dose adjustment/need for beta-blocker and
ace inhibitor | 111 | 304 |
12638327-DS-12 | 21,411,796 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with L leg pain and were found to have an infection of your hip
joint. You were seen by infection doctors and ___
___. You underwent drainage of your hip infection, and an
operation on the infected bone ("girdlestone procedure"). You
were treated with antibiotics and improved. You are now ready
for discharge to rehab.
It will be important for you to complete your course of
antibiotics and follow-up with the ___ infection doctors. | This is a ___ year old female with past medical history of
uterine cancer admitted with L hip septic arthritis and acute L
hip osteomyelitis now status post L hip incision and drainage
and L hip girdlestone procedure, course complicated by
constipation, orthostatic hypotension, subsequently improving on
antibiotics and able to be discharged to a rehab facility on
prolonged course of IV antibiotics.
# L hip septic arthritis
# Acute L hip osteomyelitis
Patient was admitted with L hip pain, fever and joint swelling.
Imaging showed a large left hip effusion as well as bony
destruction. ___ guided fluid aspiration revealed joint fluid
with WBC > 50K. Patient was started on empiric antibiotics.
Fluid culture grew coag neg staph and group C strep. She was
seen by orthopedic surgery consult service and infectious
disease consult service, and underwent left hip I&D, girdlestone
procedure on ___. TTE did not reveal signs of endocarditis.
Patient was recommended to complete ___ weeks of IV ceftriaxone,
to be determined by ___ ID OPAT follow-up. Patient had a PICC
line placed, and was able to be discharged to a rehabilitation
facility. At time of discharge, she was using oxycodone prn for
pain.
# ___ course complicated by orthostatic hypotension in
setting of poor PO intake from recent surgical procedure. This
resolved with IV fluid resuscitation and improved PO intake, and
did not recur for the remainder of the admission
# Constipation
Post-operatively patient developed constipation. Resolved with
augmentation of bowel regimen.
# Peripheral neuropathy
Continued home gabapentin
# History of Venous Thromboembolic disease:
The patient has a history of a uterine vein clot ___ ago. She
is on lifelong anticoagulation with lovenox ___ mg daily.
Lovenox was briefly held for her surgical procedure and then
restarted once surgically safe to do so.
# Abnormal MRI Pelvis - Admission MRI read as "Multiple
insufficiency fractures and
apparent bone infarcts in the sacral ala". Discussed this
finding with orthopedics who believe most likely result of her
prior radiation and not concerned re: embolic process--no
additional workup or management was recommended.
# Hypothyroidism:
Continued home levothyroxine
# Hyperlipidemia
Continued statin
Transitional Issues
- Discharged to rehab
- Discharged with PICC in place; would remove PICC on completion
of antibiotic course;
- Planned for ___ week course of IV ceftriaxone to be determined
by ___ ID OPAT follow-up appointment (see below)
- TTE incidentally showed "Mild to moderate tricuspid
regurgitation."; "Possible small asd vs stretched pfo."; Defer
to outpatient regarding potential need for additional workup or
referral.
- MRI incidentally showed "Multilevel, multifactorial
degenerative changes throughout the lumbar spine, with irregular
contour at the endplates, more significant at the superior
endplate of L2 consistent with Schmorl's nodes."; | 93 | 449 |
19410285-DS-28 | 23,193,356 | Dear Ms. ___,
It was a pleasure caring for you here at ___.
What happened while you were at the hospital?
- You were admitted for fever, worsening abdominal pain and
blood in your urine.
- Your physical exam was notable for significant right abdominal
tenderness and a fever.
- It was very concerning you were febrile despite being on such
serious antibiotics. We searched for an infectious source and
your work up showed your urine was concerning for an infection,
likely from your kidney. We had the infectious disease doctors
___ and they recommended an antibiotic/antifungal regimen
that you did very well on and completed on ___.
- Your course was complicated by cyst rupture which happened
over three times. These manifested as severe pain and blood in
your urine. We treated your pain with pain medication and the
blood in your urine with irrigation to ensure there was no
clotting. You required blood transfusions and we took you off
your blood thinner (warfarin). Urology did a cystoscopy on you
to investigate the source of the bleed, and there was a
complication during the procedure. Your ureter (the tube that
connects the kidney to your bladder) was nicked, a stent was put
in place to close the small cut. You will need to follow up with
urology to eventually remove the stent.
- Interventional radiology also did a renal angiogram to
investigate the bleed. They found one bleeding vessel and two
large vessels with high potential to bleed in your kidney. They
coiled off both of them. You tolerated the procedure well.
What to do on discharge?
- Please follow up with your primary care doctor for further
management of the following :
1. pain- right abdominal pain and suprapubic (lower central)
abdominal pain
2. Blood in your urine
3. Ostomy prolapse
4. Pain management
- Please follow up with urology to get the stent removed.
- Please follow up with nephrology during your next hemodialysis
session.
- If you start to experience any worsening right lower abdominal
pain or suprapubic pain, fevers, chills please seek immediate
medical help.
We are so happy to see you feeling better.
Sincerely,
Your ___ team | Ms. ___ is a ___ woman with a history of hypertension,
hyperlipidemia, diabetes, recently diagnosed paroxysmal atrial
fibrillation on Coumadin, autosomal dominant polycystic kidney
disease (ADPKD) complicated by end stage renal disease status
post left renal transplant in ___, complicated by graft failure
in ___ on tacrolimus, now on dialysis and with recent admission
for peritoneal dialysis catheter infection and colon perforation
requiring transverse colectomy and end colostomy, peritonitis
(end date of cipro, flagyl, dapto, fluconazole ___, who
presented on ___ with 2 days of fevers, abdominal pain, and
hematuria despite broad spectrum antibiotics.
#Pyelonephritis: Presented with fevers, chills, rigors.
Infectious work up notable for positive UA, negative cultures to
date, otherwise negative CT abdomen for intraabdominal abscess.
Hematuria and pain consistent with patients presentation of cyst
rupture. Diagnosed with cyst rupture complicated by likely
pyelonephritis, treated with meropenem (___) and micafungin
(___) and then transitioned to daptomycin (___),
ceftazidime (___), and fluconazole (___) with ID
consulted. On ___, patient was febrile to 101.8 and
asymptomatic with negative work up, cultures pending. Decision
was made to monitor closely for 24 hours. No recurrent fevers,
and patient continues to look well so was discharged with close
follow up.
#Ruptured Cyst: Presented with hematuria and abdominal pain. INR
peaked at 4.0, given no afib (likely brought on during last
hospitalization in the setting of infection) and significant
hematuria, warfarin was discontinued. Hematuria and pain
consistent with patients presentation of cyst rupture. Her
course was complicated by recurrent cyst rupture causing
significant hematuria and pain, needing continuous bladder
irrigation and pain management with dilaudid. Patient had a
cystoscopy done which showed old blood in right ureter,
procedure was complicated by a perforation of right ureter
status post stent placement. Given recurrent hematuria with 3
units of RBC transfusion, ___ got involved to find the source of
the bleed through renal angiogram. ___ performed renal
arteriorgram and identified 3 potential sources of bleeding
(pseudoaneurysms) including 1 actively bleeding vessel. All 3
were coiled. Hematuria on discharge still persistent, but
urinating well so CBI discontinued. Patient advised to monitor
for frank blood on urination, and tolerate dark colored urine.
CBC should be monitored at her HD sessions to ensure stability
and not requiring additional pRBC transfusion. On discharge,
pain from PKD cyst rupture and recent ___ procedure was well
controlled on the oral regimen, which should be able to be
tapered down over the course of the next days to weeks.
#Ostomy prolapse: Course complicated by ostomy prolapse,
transplant surgery and ostomy nurse visited often with
instructions to hold cold compress with improvement.
# Nutrition: ___ removed secondary to great PO intake.
Nutrition recs:ensure clear TID, CIB w/ whole milk TID,
nephrocaps, monitor weight post-HD ___.
#Hypocalcemia / Vit D deficiency: Continued Vit D.
#Thrombocytosis: In the setting of sepsis, resolved. | 353 | 467 |
19530616-DS-7 | 26,222,062 | You came to the hospital for numbness and tingling in the hands
and arms. You had a CT of the head that shows evidence of a
prior parasitic infection which is unrelated to your current
presentation. You had an MRI which showed no sign of stroke. We
feel your numbness and arm weakness are due to pinching of nerve
roots in your neck. We recommend physical therapy for this. You
should also follow up in neurology clinic. | Ms. ___ is a ___ year old female with no
significant stroke risk factors who presents with a subacute
presentation of left arm numbness (tingling) that progressed to
involve the back of her head, her face and tongue. She also had
a
sense of oscillopsia and lightheadedness.
The patient was admitted to the Neurology service. She had a CT
of the head which shows likely old neurocysticercosis infection.
She had an MRI of the brain and cervical cord which showed no
stroke and mild degenerative change. The patient's numbness and
weakness are most likely due to cervical radiculopathy. She was
discharged with outpatient ___ and to follow up in neurology
clinic. | 77 | 106 |
11742857-DS-15 | 28,177,957 | Dear Ms. ___,
You were admitted to ___ with
symptomatic cholelithiasis (stones in your gallbladder) and an
elevation in your liver enzyme levels. While you were here, we
took you to the operating room and removed your gallbladder
laparoscopically. We also took a biopsy of your liver. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Also, your urine showed that you have a urinary tract infection,
which was present upon your arrival to this hospital. We are
treating this with oral ciprofloxacin, which you should continue
when you are discharged from the hospital for a total ___est wishes,
Your surgical team | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed an echogenic liver
consistent with steatosis, cholelithiasis without sonographic
evidence of cholecystitis and a 7 mm with no gallstone
visualized. Her labwork was significant for transaminitis, which
was also seen ___ years ago.
The patient underwent laparoscopic cholecystectomy and liver
biopsy, 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 a
regular diet, on IV fluids, and oral oxycodone for pain control.
The patient was hemodynamically stable.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 834 | 211 |
10561450-DS-21 | 22,771,384 | You were seen in the hospital for acute perforated
appendicitiis. You were treated nonoperatively. You were
started on antibiotics which you will complete a full course at
home. You were also found to have an abnormal heart rythm
called atrial fibrillation which we were able to control
medically. You were started on two medications (aspirin and
diltiazem) which you will continue to take until otherwise
directed by a cardiologist.
* Take your full course of Cipro (ciprofloxacin) and Flagyl
(metronidazole) as prescribed until the pill bottles are empty.
* Take one 325mg aspirin and one 180mg diltiazem extended
release pill daily.
* Follow up with your primary care provider within two days of
discharge.
* Follow up with cardiology (Dr. ___ within 2 days of
discharge. Call the office to make an appointment, or ask for a
referral from a cardiologist from your primary care physician.
We would ask that you make an appointment within ___ days of
discharge.
* Follow up with acute care surgery as directed below. We would
like to see you in ___ weeks. There you will discuss if further
surgery is indicated to remove your appendix.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* No strenuous activity until instructed by your surgeon. | This is an otherwise healthy ___ year old woman who was found in
the emergency department to have acute perforated appendicitis.
She was admited to observation where she was monitored and
treated medically for her abdominal infection. No surgery was
required. She was clinically stable and responded apporpriately
to antibiotics. She was found in the hospital to have no onset
Afib with RVR. The majority of her hospital stay was spent
managing this condition. The patient had low blood pressures at
baseline. We attempted to control her Afib with metroprolol but
it caused asymptomatic hypotension in the patient and it was
held. She was started on diltizem which was able to control her
Afib. Cardiology was consulted who said warfarin was not
required for ___ CHADS of 1. She was started on daily aspirin.
She tolerated diet well and was fully ambulatory and was
clinically able to meet all of her ADLs. She was discharged on
HD7 to home to finish out a 2 week course of antibiotics. | 325 | 180 |
13203522-DS-14 | 22,694,383 | Dear Ms. ___,
You came to the hospital after falling and fracturing your leg
bone. You underwent surgery for this with good result.
While you were in the hospital you developed a condition called
atrial fibrillation where you developed a rapid irregular heart
rate. This condition increases your risk of stroke. In
discussion with your outpatient Cardiologist Dr. ___ started
you on blood thinning medication called warfarin and lovenox. We
will have you continue the warfarin long term with monitoring of
your "INR." The use of the lovenox will be short term and Dr.
___ or your primary care physician ___ instruct you
on when to discontinue this medication once your INR is within
range.
While working with physical therapy, you had low blood pressures
while standing and walking. We recommended that you stay in the
hospital until these low blood pressures resolved. Low blood
pressures with standing can cause dangerous falls and injuries.
You indicated that you would like to go home despite these blood
pressures and voiced to us your understanding of the risk of
falling and bleeding.
You also expressed that you would have one-to-one help from your
husband. As a reminder, please be careful when standing up from
sitting or laying down. Always have something to brace yourself
(table, walker). If you feel dizzy, lightheaded or have vision
changes, please sit down immediately. Please call your doctor if
this continues to happen.
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:
- Partial weight bearing left 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.
ANTICOAGULATION:
- You will be on warfarin and lovenox for atrial fibrillation.
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.
- 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:
Your appointments have been scheduled for you. See discharge
paperwork for details.
It was a pleasure being involved in your care.
-Your ___ Team | ___ w/ HTN, MVP s/p repair, OA s/p R THA admitted for mechanical
fall with L tibial and ___ metatarsal fracture:
#s/p mechanical fall
#left tibia fracture
#left ___ metatarsal fracture
The patient was found to have a left tibia fracture and was
taken to the operating room on ___ for left tibia IMN and ORIF
L medial malleolus which the patient tolerated well. She was
evaluated by ___ during hospital course and was discharged as
non-weight bearing LLE until re-eval as outpatient with boot
placement. At the time of discharge the patient's pain was well
controlled with oral medications (Tylenol only), incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. 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 ___ care. The patient expressed readiness
for discharge.
#Atrial fibrillation:
On POD 2 patient developed new onset atrial fibrillation with
RVR noted incidentally on telemetry and EKG. She remained
hemodynamically stable without symptoms. Potential causes for
her include volume overload/CHF, which is not unlikely given
cardiomegaly and vascular congestion on imaging, and elevated
proBNP. No current or recent ischemic event (Q waves noted in
the inferior leads in EKG are unchanged from many years prior).
TTE was done which showed biatrial enlargement with normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. TTE also demonstrated mild
mitral regurgitation, pulmonary artery diastolic hypertension,
and right ventricular free wall hypokinesis. Other risk factors
for afib include obesity w/ likely OSA, hx of MVR, and
catecholamine surge post operatively. TSH normal. She has an
CHADS2-Vasc2 score of ___ (HFpEF, HTN, female, age ___,
making her high risk (4% annual risk of stroke) requiring
anticoagulation. Given her history of GI bleed and recent
surgery, warfarin was initiated for reversibility compared to
NOACs. Patient discharged on warfarin 2.5 mg daily with lovenox
bridge (goal INR ___. Patient will have long term ___ for
INR w/ cardiologist (Dr. ___. Rate control was achieved with
metoprolol mg q6hr and patient was ultimately discharged on
metoprolol XL 100 mg BID.
#Pleural Effusion:
Patient was noted to have left lower lobe pleural effusion on
CXR. This was thought to be ___ volume overload iso HFpEF vs.
___ post-surgical atelectasis. Patient was given 20 mg IV lasix
w/ -2L fluid off. The patient was noted to have normal oxygen
saturation prior to discharge.
#Orthostatic Hypotension: Patient diuresed for c/f for volume
overload iso of cough/desaturation not responsive to
bronchodilators. CXR c/f vascular congestion. Patient given 20
mg IV lasix with -2 L net negative. Upon working with ___ the
following day, she was orthostastic. It was recommended that she
stay in the hospital until this resolved because of the risk of
falls and injuries. She expressed understanding of the risk of
falls and injuries, but still insisted on leaving against
medical advise. Patient agreed to fluids prior to discharge.
Orthostatics vital signs improved, but patient still refused
further monitoring and further fluids. She continued to express
understanding of risks of leaving AMA. Patient was instructed to
avoid stairs, but to have help if she needed to use stairs. She
was also educated regarding using a walker/table to stabilize
herself when going from seated/laying to standing position.
---------------
CHRONIC ISSUES:
---------------
# HTN: Stabilized on metoprolol 100 mg XL by outpatient
cardiologist. Uptitrated to 100 mg XL BID for better rate
control.
#Depression/Anxiety: Patient had anxiety during hospital stay
requiring a dose of Ativan. She has a history of depression
treated with Paroxetine at home; however, this was not restarted
on admission initially. Withdrawal effect from Paroxetine may
have contributed to anxiety. Patient's anxiety was also
exacerbated by a patient sharing the room with her who was
suffering from delirium and agitation. Patient's home Paroxetine
was resumed.
# HLD: Continued Atorvastatin 40 mg PO/NG QPM
-------------------- | 509 | 667 |
11905922-DS-7 | 26,741,128 | Ms. ___ you were admitted to ___ neurology service with new
vision changes. Opthalmology saw you in the ED and saw you had a
normal exam. An MRI brain was performed and you were not found
to have a stroke. An Echo of your heart was normal with no
evidence of blood clots. We have tried you on medication for
neck pain and suggest you ___ with your regular primary
care doctor regarding this problem. Also you may want to try a
pillow with neck support while sleeping. We have set you up with
outpatient opthalmology ___. We have drawn several labs to
evaluate if you are prone to blood clots, so far these are
normal but several are pending. Please have your primary care
doctor ___ on these results. | Upon further interviewing during the hospitalization, the
following information was obtained by Dr. ___. "She was at a
medical office when she
noticed a dark shade come down over her left eye's field of
vision from the top to the bottom. This shade descended over
seconds and stayed for several seconds. She is not clear on the
pattern with which the shade went away. She did close one eye at
a time and confirmed that it was the left eye that was affeted.
Once her vision returned, she also had a sensation of a black
area closing in on her left eye's field of vision. There was a
pressure and "lightheadedness" behind her left eye.
The temporary loss of vision of the left eye due to a shade
descending occurred eight to ten times. It happened ___ times
while she was walking down the hallway of the office, and then
again several times while she was sitting down. These episodes
occurred over one hour."
She was not considered to be at risk for temporal arteritis. ESR
and CRP were within normal limits. She had intact temporal
artery pulses bilaterally. Optho was consulted and she was found
to have a normal exam without evidence of intraocular pathology.
Her vision disturbances were not thought to be related to the
right paraclinoid ICA aneurysm. Neurosurgery was also consulted
regarding this right paraclinoid ICA aneurysm but no
intervention was needed. MRI brain did not show evidence of a
stroke. Echo did not show evidence of PFO or cause for emboli to
cause a TIA. A limited hypercoagulable panel and sent and was
still pending at the time of hospital discharge. Overall it was
felt that the transient loss of vision of the left eye could be
a retinal migraine. Transient monocular vision loss due to
thrombosis was thought to be less likely.
She was recommended to continue aspirin 81mg daily for now for
protection against the possibility of thrombosis and TMVL. She
was encouraged to cease smoking cigarettes. She was given a
nicotine patch.
She had right sided severe neck pain that was non radiating.
This neck pain may possibly due to degenerative cervical disc
disease and muscle spasm. She was given tramadol, flexeril, and
a lidocaine patch which were helpful. She did not feel that a
soft cervical collar was helpful. She should follow up with her
outpatient provider for continued evaluation and management of
the right sided neck pain and to obtain rescheduling of her MRI
cervical spine. | 130 | 404 |
13389305-DS-20 | 25,424,652 | Dear Ms. ___,
It was a privilege to care for you at the ___. You were
admitted for further monitoring after presenting with abdominal
pain and fevers secondary to underlying mono. There are no
complications that warrant further hospitalization, but
unfortunately, it will take a few weeks for your symptoms to
fully resolve. We are prescribing some medications to take for
nausea. It is very important that you remain hydrated. If you
participate in any contact sports, then this should be avoided
for a total of eight weeks.
We expect that your fever will resolve over the next few days to
one week. Due to elevated liver enzymes from the mono, we
recommend that you do not take more than 2.5g of Tylenol total
in one day. It is safe to take ibuprofen as directed on the
packaging.
Lastly, we recommend arranging a follow up appointment with your
doctor once you arrive home. It is recommended that you have
repeat blood work including liver function tests and a CBC.
We wish you the best!
Sincerely,
Your ___ Team | ___ with acute EBV presenting with fever and abdominal pain,
admitted for ongoing supportive care.
# Acute EBV "Mononucleosis"
Presented with fever, Abdominal Pain Sore throat and fatigue
with positive monospot and contact with roommate who recently
had mono. No concern for major complications such as splenic
rupture or airway compromise from tonsilitis. Noted to have
cholestatic hepatitis . Treated with supportive care including
IVF and antipyretics. Patients able to tolerate PO prior to
discharge.
# Abnormal LFTs:
Cholestatic hepatitis due to acute EBV infection. RUQ-US without
stones or biliary obstruction. No concern for acute liver
failure. LFTs elevated but stable at time of discharge.
> 30 mins spent in discharge planning. | 176 | 112 |
13450581-DS-27 | 24,542,693 | Dear Mr. ___,
You were admitted to the hospital for a biopsy of your bone
where you have an ulcer with concern for possible infection. The
orthopaedic surgeons took you to the operating room and on
closer examination, appears that it may not be infected.
However, final cultures are pending.
Our infectious disease doctors also saw ___ and recommended not
treating you with antibiotics unless the cultures grow.
As a result, if there is no infection, the plastic surgeons may
decide whether or not a flap over the area would be appropriate.
You will also need to follow-up with dermatology as an
outpatient as you might have a small skin cancer on your leg.
The doctors at the facility ___ also continue to help manage
your ongoing medical problems including blood sugars.
Take care.
- Your ___ Team | ___ y/o M with quadriplegia, cirrhosis, DM2, history of
osteomyelitis admitted with recent CT imaging indicating
possible acute on chronic osteomyelitis for planned bone biopsy
with further management to be coordinated with ID and plastic
surgery as an outpatient. | 131 | 41 |
19724632-DS-23 | 22,994,275 | Ms. ___,
It was a pleasure caring for you at ___
___. You came to us with very low blood pressures and
very low blood sugar and were found to have several infections,
including an infection of your colon called Clostridium
difficile colitis and wound infections on your back (HSV 2). We
also switched your blood thinner from Coumadin to a medication
called apixaban because Coumadin was felt to be unsafe for you
with your nutritional deficit.
Please take all of your medications as detailed ___ this
discharge summary. If you experience any of the danger signs
below, please contact your primary care doctor or come to the
emergency department immediately.
Best Wishes,
Your ___ Care Team | Ms. ___ is a very pleasant ___ yo woman with history of NIDDM,
DVT/PEs (on Coumadin), HTN, IBD (s/p distant colectomy c/b
abscess then repeat colectomy and small bowel resection
(___) w/ recent admission for purulent drainage from midline
incision c/b MSSA bacteremia who was admitted to ___ with
sepsis physiology, was initially treated for HAP and then
developed c diff and persistent leukocytosis. Over the course of
her hospital stay, the following issues were addressed:
# Goals of Care. Patient's healthcare proxy and nephew ___
___ expressed
concern that she Ms. ___ has been chronically ill for a long
time and had
reached a point where he was more concerned about her overall
well-being. Ms. ___ expressed being tired of hospitalizations
and invasive diagnostic testing/intervention multiple times
throughout hospital stay. Patient was followed by our palliative
care team and several goals of care discussions were initiated
___. ___ was connected with home hospice liaisons.
Eventually plan was decided to start Hospice at home, and
patient had MOLST filled out stating she was DNR/DNI.
# Sepsis. Hypotensive ___ ED to systolic ___, but fluid
responsive and never required pressor. CXR showed RLL pneumonia.
UA with pyuria, hematuria, and many bacteria though culture
showed polymicrobial growth. Denied respiratory symptoms and was
not hypoxic. Difficult to determine other symptomatology as she
said "I hurt all over." MRSA swab negative. Treated with
Vanc/zosyn and rapidly narrowed to vanc/cefepime (day ___.
Due to lack of symptoms and no improvement ___ leukocytosis with
initiation of abx and the fact that patient was discovered to be
C. Diff positive, the source of her leukocytosis was more
consistent with C. Diff colitis and vancomycin and cefepime were
stopped on ___ after 6 days of antibiotics. Transferred from
MICU to floor on ___.
#C. Diff Colitis. Stool tested positive for C. Diff. Stool
output was variable throughout stay and patient remained
afebrile and hemodynamically stable. However, significant
leukocytosis >15 and serum albumin <3 indicative of severe
disease. She was maintained on PO Vancomycin 125 mg Q6h (start
date ___ IV flagyl was added from ___ due to transient
decrease ___ stool output (with concern for developing ileus) and
persistent leukocytosis as below. Ceftriaxone was administered
___ to ___ and Vancomycin was extended until ___ to cover 7
days after all other antibiotics (start date ___ | projected
end date ___.
# Leukocytosis & intermittent monocytosis. Patient was noted to
have a persistent leukocytosis from ___ for entire length of
hospital stay as well as intermittent monocytosis (15% ___ and
16% ___. No improvement on treatment of c diff as above. UA
with 33 RBC's, 22 WBC's, yeast, but negative for bacteria and
nitrates. No coughing, SOB, fever, and CT does not not show
evidence of pulmonary infiltrate suggestive of pneumonia. No
change ___ collapsed abscess or new abscess formation on repeat
CT. Patient had purulent, beefy red sacral ulcers over back
entire hospital stay which eventually tested positive for HSV 2.
Leukocytosis began downtrending on administration of acyclovir
and rectal hydrocortisone below.
# Sacral Ulcers
# HSV 2. Patient presented with areas of macerated skin over
thighs and sacrum and developed further desquamation with areas
of ulceration on gluteals and posterior thights with exudate.
She was treated with ceftriaxone from ___ to ___ with some
improvement ___ leukocytosis. Eventually grew HSV 2 from wound
swab culture (confirmed with DFA). No discrete ulcers noted on
vaginal exam or vesicles noted over sacrum but certainly
possible that this is contributing to patient's leukocytosis and
even to her urinary retention (rare extravaginal complication).
Started acyclovir 200 mg five times per day for 10 days (start
___ | projected end date ___. She also grew pseudomonas from
these wounds but these were felt to be colonizers.
# Diversion Colitis. Patient with persistent leukocytosis and
oozing blood per rectum noted ___ concerning for diversion
colitis of ___ pouch vs IBD flare ___ rectal stumpy.
Flexible sigmoidoscopy of rectal remnant was attempted but
patient refused. Due to patient's underlying IBD, Hydrocortisone
Acetate 10% Foam ___ID was initiated (start ___. She
will need to be on this medication BID for 2 weeks, and then
every other day for 1 week and then twice a week for 2 weeks and
then stop.
# Bacterial PNA: Patient initially presented with tachycardia,
leukocytosis and hypotension. Found to have right lower and
middle lobe infiltrates on imaging and started empirically on
vancomycin and zosyn for suspected pneumonia, then transitioned
to vancomycin and cefepime(D1= ___. Patient had no respiratory
symptoms and no improvement ___ leukocytosis with initiation of
abx. GPC's ___ clusters on blood culture from ___ were likely
contaminants. MRSA swab negative. ___ light of this, and the fact
that patient was discovered to be C. Diff positive, the source
of her leukocytosis was more consistent with C. Diff colitis and
vancomycin and cefepime were stopped on ___.
# Bilateral knee pain and back pain. Chronic, secondary to
osteoarthritis. Significant cause of pain. Pain regimen was
titrated with aid of pain and palliative consult service. Final
regimen: Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch
to each knee, OxyCODONE (Immediate Release) 2.5 mg PO/NG TID,
Gabapentin 200 mg PO/NG BID, acetaminophen 1 g Q8H, OxyCODONE
(Immediate Release) 2.5 mg PO/NG Q4H:PRN BREAKTHROUGH PAIN.
# History of DVT/PE. Patient had initial LLE DVT at ___
___, placed on lovenox to warfarin bridge with goal INR of
___. Patient represented to ___ ___ with GIB during which
time warfarin and heparin were held. She subsequently developed
right UE PICC-associated DVT and later ___ that hospital stay had
CT angiogram of the chest performed and was found to have
multiple subsegmental PEs. She has thus been on coumadin for 4
continuous months, with all INRs ___ our system ___ the
therapeutic to supratherpeutic range. INR was reversed ___
but was labile and increased above ___ several times during
hospital stay despite administration of both PO and IV vitamin
K. She was first maintained on a heparin drip and then
transitioned to apixaban 2.5 mg BID (originally on 5 mg BID but
dose-reduced to 2.5 mg BID due to patient's weight and concern
for bleeding).
# Severe Malnutrition. Ms. ___ had poor PO intake throughout
hospital stay, with ongoing coagulopathy and poor wound healing.
She was given multivitamin with minerals and nutritional
supplements. Nutrition recommended supplementation with tube
feeds but patient refused placement of Dobhof tube. Zinc and
copper levels were within normal limits.
# Hypoglycemia. Per collateral from ___, FSBS ___ on
metformin and glipizide. Likely due to sepsis and glipizide.
Treated with IV D5W on day 1 and quickly dc'd with stable BS
throughout hospital course.
# ___. Creatinine 2.4 on admission from baseline 0.7. Likely
pre-renal/ATN from sepsis. Improved to baseline with IVF and
antibiotics.
# Type II NSTEMI. Troponin T elevated to 0.07 on admission, and
subsequently downtrended. No chest pain or ischemic EKG changes.
# Anemia: Hypoproliferative, normocytic anemia. Pattern of
down-trending Hgb following pRBC transfusions. Low Fe, low TIBC,
normal haptoglobin, increased ferritin, and decreased
transferrin portray anemia of chronic disease. Consistent with
hx of IBD and multiple bowel resections. Elevated D-dimer and
fibrinogen reassuring that patient was not ___ DIC. Has a hx of
UGI bleed ___ setting of previous supratherapeutic INR and
anastomosis. Less suspicious for current GI bleed given that she
has not had any episodes of hemoptysis, melena from ostomy site,
and is remaining normotensive. Hb was labile and patient
received a total of 4 units pRBCs ___ due to downdrifting
Hb below 7. Only clinical sign of bleeding was scant rectal
bleeding from rectal pouch as described above. | 115 | 1,262 |
17824313-DS-8 | 20,640,266 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for an enlarging belly,
belly pain, and dark stools
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- We started you on an antibiotic to protect you from infections
- You have been diagnosed with cirrhosis and underwent testing
for the cause of this. It is felt to be secondary to alcohol.
- We gave you some vitamin K to boost your blood functions
- You got some medication to decrease the amount of acid in your
stomach to protect you from bleeding
- We gave you some medication to help decrease the amount of
fluid in your belly
- We used a video camera scope to look at your esophagus to make
sure there wasn't any bleeding
- You developed a kidney injury during your stay, and we gave
you several medications to help improve blood flow to your
kidneys and keep your blood pressure up
- You received several procedures (paracentesis) to help remove
fluid from your belly to help you feel better
- Lab studies of the fluid removed from your belly did not show
any evidence of infection
- You had some fevers during your admission so we started you on
a course of antibiotics
- You had a discussion about possible liver transplant in the
future with the liver team
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Avoid drinking alcohol as it has caused your liver disease and
may result in premature death or other health complications
- Try not to drink more than 1 liter of fluids (half of a large
bottle soda) because it can make your belly larger
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- Eat a heart healthy diet (less than 2 grams of sodium per
day). This is important because it prevents your belly from
becoming bigger, which will help with pain, nausea, and
shortness of breath it may cause.
- Call your doctor or the liver doctors ___ your belly
becoming bigger, if you have shortness of breath, if you have
pain in your belly, or if you vomit blood.
We wish you the best!
Sincerely,
Your ___ Team | ___ with history of alcohol use disorder p/w abdominal
distension and dark stools, found to have cirrhosis and moderate
volume ascites, with diagnostic/therapeutic paracentesis on
___, and ___ negative for SBP. Her hospital course
c/b initially worsening ___ c/f HRS vs sepsis vs volume
overload, and fever of unknown source s/p Zosyn (___).
Her Cr and urine output began to improve after a week of albumin
challenge, octreotide, and maximum dose midodrine.
TRANSITIONAL ISSUES
===================
[] Noted to have low grade temperatures during week of
discharge, most recently 100.2, no source of infection found
after multiple paracentesis and asymptomatic. Would continue to
monitor for true fever and evaluate if concern for infection
[] Evaluate abdominal ascites at next appt- may need
paracentesis
[] She is being discharged off diuretics due to recent profound
kidney injury, concerning for HRS now improved.
[] Will need outpatient GI ___ w/ hepatology after D/C within
one month
[] Will need PCP ___ after D/C in ___ wks
[] Has iron deficiency anemia, will need iron supplementation
[] Had duodenal polyp removed, will need follow-up upper
endoscopy in 6 months (___) for eval of adenoma removal and
foveolar metaplasia eval
[] Discharge creatinine 1.2
[] Discharge weight 141.8 lbs
[] Patient has not had routine healthcare screening and has had
limited access to healthcare prior to this hospitalization. It
will be very important for this patient to have all
age-appropriate routine screening (mammography, colonoscopy, pap
smear) so that she can be further considered for a liver
transplant in the future.
[] Patient needs hepatitis B immunization | 380 | 252 |
14912045-DS-3 | 25,276,575 | Dear Ms. ___,
You were admitted to ___ for evaluation of hip pain. You had
an X ray and an MRI which showed ___ evidence of infection,
fractures, or muscle tears. Please follow up with your primary
care physician in the next ___ days. | Ms. ___ is a ___ yo woman w/ PMHx of SLE on
hydroxychloroquine, depression, hypothyroidism, who presents
with increased pain on the internal side of her right hip.
# Right hip pain: patient is on hydroxychloroquine and given her
SLE would question whether avascular necrosis or a septic
arthritis is possible. Patient has not had fever, CRP is wnl
making septic arthritis less likely. MRI showed ___ acute
abnormality and patient's pain was resolved. Recommend she
follow up with her PCP for further work up.
-cont colchicine for pseudogout in shoulder per rheumatologist
# SLE
- Continue hydroxychloroquine.
# Hypothyroidism
- Continue levothyroxine.
# Asthma
-patient reports taking advair only as needed, which seems
incorrect. On albuterol as well.
#GERD: cont home medications
[] Code: Full.
[] Dispo: pending results of MRI
[x] Discharge documentation reviewed, pt is stable for
discharge
[ ] >30 minutes was spent on day of discharge on coordination
of care and counseling
Electronically signed by ___, MD, pager ___ | 44 | 163 |
18376342-DS-72 | 29,563,370 | It was a pleasure taking care of you at ___.
You were admitted for abdominal pain. We felt that this was
consistent with your previous diagnosis of chronic pancreatitis.
You were given IV pain medications and your diet was held for 2
days to let your pancreas heal. After a few days, you were able
to tolerate food without worsening abdominal pain and were able
to take oral medications.
You are being discharged with the following changes to your
medications:
Please INCREASE
Omeprazole to 40mg by mouth once per day
Ranitidine to 300mg by mouth twice per day
Please STOP
Cinacalcet
Otherwise please take all medications as prescribed, including
your home doses of narcotics.
Due to your low blood sugars while in the hospital and at home,
we would like you to follow up with endocrinology. | ___ hx ESRD on HD, CAD s/p MI, HIT, COPD and schizoaffective
disorder who presents approximately 1.5 weeks after discharge
with recurrent epigastric abdominal pain radiating to her back,
consistent with prior episodes of her chronic abdominal pain.
.
#Abd pain: pt states exactly like her previous episodes of
chronic abdominal pain thought to be chronic pancreatitis, which
were also a/w n/v/d like this episode. Lipase wnl. Has had
extensive w/u for this in the past including EGDs with biopsies.
EUS ___ showed some changes consistent with chronic
pancreatitis but not enough to declare a diagnosis. Treated per
her usual care for chronic pancreatitis with NPO, IVF and IV
pain medications. At the time of discharge, she was tolerating
PO well without pain or nausea/vomiting.
.
#hypoglycemia: unclear etiology for persistent hypoglycemia.
Per pt report, has had episodes of hypoglycemia at home over the
recent past as well. Not receiving insulin or other
hypoglycemic medications. Was found to have glucose of ~40 on
multiple occasions throughout her hospitalization while NPO.
Combination with new thrombocytopenia suggests possible liver
etiology, however this is unlikely in this woman who has minimal
risk factors for liver pathology with has normal LFTs. It is
possible that she has reduced glucagon secretion from her
chronic pancreatitis. Other etiologies include thyroid related
illness versus adrenal related versus insulinoma vs IGF-1
overproduction. During the admission, she also had some
hyponatremia that suggested possible adrenal cause but her
fasting AM cortisol was within normal limits. She had
c-peptide, insulin and beta-hydroxybutyrate levels drawn which
will be followed up as an outpatient. She has been scheduled to
see endocrinology as an outpatient for followup.
. | 130 | 280 |
17347036-DS-9 | 22,559,725 | Dear Ms. ___,
You were hospitalized due to symptoms of vertigo/dizziness.
These symptoms are likely caused by a lesion in your brainstem -
one of the places in your brain that helps to control balance.
The exact nature of this lesion is unclear, but it is probably
related to your lupus. It appears to be stable on 2 sets of
imaging (it did not increase in size during your
hospitalization).
Your warfarin (Coumadin) was held for several days during this
admission. Please restart this medication tomorrow. | ___ F w PMHx SLE ___ years, +lupus anticoagulant and
+anti-cardiolipin antibody (on home coumadin), membranous GN
with vascular occlusion in ___ (seen on kidney biopsy), HTN,
and prior cerebellar infarct presents with sudden onset vertigo
beginning 3 days prior to presentation. Her exam is notable for
direction changing nystagmus evoked with lateral and superior
gaze. CTA preliminary read is without abnormality. MRI brain w/o
contrast: focus of FLAIR hyperintensity along the right medulla
extending to the facial colliculus, that could be compatible
with sequela of remote infarct. Pt discussed w outside
___, Dr. ___ recommended ___
Rheumatology consultation. ___ Rheumatology consult
recommended solumedrol 1g IV x3d. Pt reported signficant
improvement in subjective well being after steroid course. Her
neuro Repeat MRI Brain W/ and W/O contrast on ___ showed an
ill-defined area of FLAIR signal abnormality in the right
posterior pontomedullary junction. The appearance is nonspecific
but given the absence of mass effect and the clinical history of
lupus, it may be a vasculitic lesion. It is not significantly
changed in appearance from prior MRI four days ago given
differences in technique. It was considered less likely that
this lesion was a chronic ischemic infarct. Another small focus
of FLAIR signal abnormality in the right frontal subcortical
white matter is also unchanged and may be a
vasculitic/demyelinating lesion secondary to lupus. She should
follow up with her outpatient Rheumatolgist Dr. ___
determination of the appropriate long term therapy for her
lupus. As pt had significant clinical improvement in the inteval
between her MRI studies, decision was made to discharge with
suggested imaging follow up (MRI brain with and without
contrast) at one month, but will defer to her outpatient
neurologist Dr. ___. | 85 | 284 |
10292353-DS-3 | 24,276,528 | Please call Dr. ___ ___ if you have any of the
following: temperature of 101 or chills, nausea, vomiting,
jaundice (yellowing of whites of eyes/skin), abdominal
distension, incision redness/bleeding/drainage, constipation or
diarrhea
Empty abdominal drain when half full and record all output.
Change dry gauze dressing daily and as needed. | ___ M with one month h/o RUQ pain, fevers, found to have right
lobe abscess adjacent to the gallbladder. He was pan-cultured
and started on IV antibiotics then underwent ___ drainage on
___. Ultrasound demonstrated an enlarged, distended gallbladder
with complex echogenic internal material, ___ addition to a 6.5 x
6.0 cm hepatic collection adjacent to the gallbladder fossa.
There was visible disruption ___ the gallbladder wall measuring
up to 2.2 cm. The findings were highly
suggestive of perforated cholecystitis with associated liver
abscess. An 8 ___ drain was placed into the collection that
appeared purulent and a sample sent to microbiology. Micro
isolated no pmns, 2+GPC, 2+GNR, 1+GPR and sparse growth GPC. IV
Unasyn continued pending finalization of abscess culture. An MRI
was done to assess whether abscess represented a perforated
cholecystitis or an underlying tumor. MRI was done on ___ that
demonstrated the following:
1. Hepatic abscess ___ direct continuity with a perforated
gallbladder, as
described above. No definite mass is identified. Follow-up
after treatment
is recommended to exclude a subtle underlying lesion which may
be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle
hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and
several smaller
stones upstream. There is associated mild intra and
extrahepatic biliary duct
dilation.
4. Borderline splenomegaly
Tumor markers were sent off. CEA was elevated at 5.0 and AFP was
0.6. CA ___ was 27.
Upon learing MRI findings, ERCP was consulted and on ___, he
underwent ERCP with the following note:
note of small filling defects ___ the lower bile duct suggestive
of sludge/stone. There was mild diffuse biliary dilation,
including mild saccular dilation of the lower CBD. The cystic
duct was filled with contrast, and the intrahepatics were
well-visualized and only mildly dilated. A sphincterotomy was
performed and a moderate amount of sludge was extracted.
Completion cholangiogram was normal. Otherwise normal ERCP to
___ portion of duodenum.
Post ERCP, he received IV fluid hydration. Labs were improved
and diet was resumed and tolerated.
He was hyperglycemic. Sliding scale insulin was used to control
his glucoses. HgA1c was elevated at 8.2. A ___ consult was
obtained and insulin was adjusted with improved control. At time
of discharge to home, home meds (actos/glipizide)were resumed.
He was instructed to hold his Januvia for a week and f/u with
his PCP for DM management. A Humalog sliding scale was
recommended for home. The ___ DM educator reviewed glucometer
teaching and injection with an insulin pen. He was provided with
scripts for Humalog pen with pen needles, strips, lancets.
A time of discharge, antibiotics were switched to Augmentin for
2 weeks from drain placement. Drain output was averaging 570cc.
___ was arranged to see him at home to assess management.
Of note, he will see Dr. ___ consult)for
evaluation of pulmonary nodules that were noted on OSH CT scan
uploaded on ___ imaging(1.3cm nodule ___ the right apex with
small peripheral calcification and adjacent scarlike opacity,
7.5mm supleural nodule ___ the right lung base, 5mm subpleural
nodule ___ the right middle lobe and 5mm subpleural nodule ___ the
left upper lobe posteriorly). | 49 | 540 |
11334064-DS-13 | 22,793,373 | You were admitted for workup of a Sellar MAss consistent with
Pituitary macroadenoma found on imaging after you complained of
headache, anusea, and vomiting. You underwent a MRI of your
pituitary gland and had an endocrinology workup to assess if the
lesion was causing abnormal levels of hormones to be secreted.
All work-up shows that the lesion is non-secreting. Given its
size and compression of the optic nerve, Dr. ___ has
recommended surgical intervention. | Patient was seen and evalauted in the emergency department as a
transfer from an outside hospital on the evening of ___.
Iamging had revealed a sellar lesion. Workup was initiated to
assess if tumor was causing abnormal secretion of hormones and a
dedicated Pituitary MRI was obtained. On ___, the patient
remained neurologically stable and waiting for the MRI of the
brain. On ___, the patient's MRI of the brain was completed
confirmed a pituitary macroadenoma. The endocraine service was
consulted to follow along for the suprasellar mass. Prolactin
was normal. Dr ___ met with the patient and his wife on
___ to discuss surgical options. The plan was made for the
patient to return the following week for surgery. Pre-op testing
and mapping would be done during this admission and the patient
will dc home ___.
On ___, patient reported an episode of LOC while in the
bathroom and came to on the floor with a small laceration to his
left cheek. Patient was evaluated and was neurologically intact.
A STAT CT head was performed and showed more blood within the
lesion. Dr ___ was made aware, the patient was transferred
to the SDU. Given no deficits he will continue to be monitored
and DC was cancelled. An EKG showed no changes and labs were
sent. His K was mildly low and repleted. His NA is trending up
compared to 129. The midlevel spoke to his wife to update her.
___, the patient was discharged home in stable condition with
instructions to return for visual field testing and a planned
resection. | 74 | 263 |
19554213-DS-4 | 24,363,578 | You were admitted to the hospital with abdominal pain. You
underwent cat scan imaging which was suggestive of appendicitis.
You were started on antibiotics and taken to the operating room
to have your appendix removed. You are recovering from your
surgery and you are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | The patient was admitted to the hospital with right lower
quadrant abdominal pain and an elevated white blood cell count.
He was made NPO, given intravenous fluids, and underwent
imaging. A cat scan of the abdomen showed acute appendicitis.
Based on these findings, the patient was taken to the operating
room on HD #1 where he underwent a laparoscopic appendectomy.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. His post-operative course was stable. He was
started on a regular diet. His incisional pain was controlled
with oral analgesia. He was voiding without difficulty. On the
operative day, the patient was discharged home in stable
condition. An appointment for follow-up was made with the acute
care service. | 832 | 143 |
10150056-DS-16 | 28,370,219 | Dear ___,
___ was a pleasure participating in your care. You were
admitted for a fall and found to have a small hip fracture. You
were also found to have anemia worse than your baseline, and
worsening kidney function. You were treated with your home
medications and improved. You were also seen by ___ who felt you
would benefit from ___ rehab.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ with PMHx diastolic CHF, hemolytic anemia, who presents to
the ED after a unwitnessed fall, found to have hemolytic anemia.
# ___: Pt presented with Cr. 1.6 from baseline of 0.7-1. FeUrea
16%, peaked at 2.1, now 1.4. Initially thought ___ anemia and
hypovolemia from increased lasix, however pt appeared volume
overloaded and creatinine worsened with IVF and holding
diuretics. Renal spun urine and saw some yeast and acanthocytes,
wanted to consult, however repeat spin showed only one
acanthocyte, per renal no e/o vasculitis. The pt was restarted
on her home lasix 60mg PO BID and her cr downtrended. On day of
discharge cr was 1.4.
# Weakness: Likely multifactorial, due to deconditioning,
anemia, accidentally doubling her medications at home. Anemia
managed as stated below. ___ worked with pt and felt she would
benefit from rehab. Of note, TSH was elevated at 7 and free T4
0.91. PCP was notified and will follow-up as an outpt.
# Paroxysmal Afib: Pt with baseline sinus rhythm, found to have
afib with RVR for several hours. The pt was started on metop
12.5mg BID with good rate controle, however subsequent reverted
to sinus braycardia. Metoprolol was dced and the pt remained in
normal sinus. Given pt was asymptomatic with afib with rvr,
unclear if this was an isolated event or if she has ongoing
paroxysmal afib. Given the pt's CHADS2 score of 2,
anticoagulation was consider, but felt to be contraindicated in
the setting of her frequent falls. High dose aspirin was also
considered, however pt also with hx of esophageal ulcerations
and ongoing issues with anemia. Pt was continued on aspirin 81mg
daily.
# Anemia: The pt presented with a macrocytic anemia with HCT 23
from baseline of ___, down to 20. The pt has an extensive hx
of hemolytic anemia, and was found to have LDH elevated, hapto
<5, +DAT. GUAIAC negative. She was very difficult to crossmatch
but received 2u prbc with bump to 28. Hemonc was consulted, and
felt she should f/u as an outpatient given her hcts stabilized.
Vitamin B12 greater than assay, folate wnl, however folate 1g
daily started per hem recs.
# s/p fall: Per pt history, likely mechanical, and ___ weakness
from extra medication and anemia. Management of anemia as above.
___ recommended rehab.
# Possible nondisplaced fracture of the left superior pubic
ramus. Pt comfortable, able to ambulate, full ROM. ___ as above.
Should continue lovenox 30mg q24h for DVT ppx while in rehab.
# Funguria: Presented with significant pyuria. Ucx ___. Pt
treated with diflucan 150mg PO x1 per renal recs.
# Heel pain: On day of discharge pt complained of worsening R
heel pain, which, per grandson, has been ongoing for a few
months. Pt has spent a lot of time in bed, and heels appear
slightly cracked and tender, likely applying more pressure than
at baseline. Wound care recs below. Tramadol prn pain. If pain
worsens, can consider outpt eval by podiatry or xray foot.
# Diastolic heart failure: continued home meds. Losartan was
held due to decreased creatinine clearance. Should be restarted
as pt renal function improves, as tolerated by BPs.
# BLE traumatic ulcerations: chronic from crawling on the floor
after prior fall. Wound care evaluated, recs below.
# Asthma: continued home meds
# Hypothyroidism: continued home meds. Of note, TSH was elevated
at 7 and free T4 0.91. PCP was notified and will follow-up as an
outpt.
# HLD: continued home meds | 78 | 584 |
16907944-DS-36 | 20,431,988 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted with
abdominal pain consistent with previous episodes of pancreatitis
in the setting of alcohol use and an episode of bloody vomiting.
A study of your upper gastrointestinal tract showed severe
inflammation of the esophagus, for which you were treated with
medication (pantoprazole), which you should continue to take
after discharge. You were treated with pain medication for
pancreatitis, and you were monitored, but did not show signs of
alcohol withdrawal. It is very important that you try to cut
down on your drinking in order to avoid further complications of
heavy alcohol use. | Mr. ___ is a ___ with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites who p/w abdominal pain c/w
previous flares of chronic pancreatitis, as well as hematemesis.
#Hematemesis: Patient with known h/o esophageal varices s/p
banding p/w single episode of hematemesis without active signs
of bleeding or HD instability on admission. EGD ___ demonstrated
severe esophagitis, nonbleeding grade 1 varices, lesions c/w
___, and mild portal gastropathy, for which he was treated
with IV pantoprazole, transitioned to PO at discharge. He
remained HD stable throughout admission without recurrent
hematemesis. From 40.4 on admission, Hct remained stable at
34-35, with initial decline likely at least partially
dilutional.
#Abdominal pain: Patient with known h/o chronic EtOH
pancreatitis p/w epigastric pain radiating to the back, entirely
c/w past episodes of acute-on-chronic pancreatitis. Abdominal
exam was notable for epigastric TTP without peritoneal signs.
LFTs were at baseline, and lipase was within normal limits on
admission. There was no e/o free air on CXR. He was treated
initially with IV Dilaudid, with transition to PO Dilaudid once
tolerating clears. He was tolerating solids by the time of
discharge.
#EtOH dependence: Patient continues to drink heavily despite
explicit knowledge that his EtOH use leads to recurrent
admissions. He remained HD stable without signs of withdrawal or
benzodiazepine requirement throughout admission.
#EtOH cirrhosis: Patient with known h/o EtOH cirrhosis c/b
varices and ascites in the past. There was no e/o
encephalopathy, ascites, or asterixis on admission, and LFTS,
platelets, and INR were c/w baseline. Home nadolol was
continued.
#Bipolar disorder: Patient with known h/o bipolar disorder
without manic or depressive symptoms or SI/HI on admission. He
reported taking Seroquel, trazodone, and an antidepressant,
identity unknown to him, in the past, but also indicated that he
had not been seen by a psychiatrist for some time. Psychiatric
medications were held on the last admission concluding ___,
given reports that his psychiatrist had discontinued his
medications due to drug-seeking behavior, and continued to be
held on the current admission.
#Transitional issues:
- Patient will need GI follow-up for esophagitis, discharged on
pantoprazole, and EtOH cirrhosis, continued on nadolol. It was
unclear as to whether he had been seeing a GI provider at an
outside location, given his h/o visiting multiple providers and
hospitals with similar complaints.
- Patient readily acknowledged heavy EtOH use and received some
counseling from medical team, but was not amenable to further
discussion on this admission, noting that he had taken part
in/continues to take part in programs without success. He should
continue to be encouraged to seek counseling, detoxification,
and will be discharged to ___ House.
- Patient's current psychiatric medication regimen was not
clear, and he will need psychiatric follow-up. | 106 | 444 |
16059753-DS-50 | 24,063,556 | Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an upper respiratory tract infection. You had a life
threatening reaction to an antibiotic administered to treat your
upper respiratory infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You required CPR to revive you following a dangerous reaction
to an antibiotic (Zosyn).
- You were monitored in the intensive care unit.
- Your blood counts were low and you required a blood
transfusion.
- You were treated with antibiotics for an upper respiratory
tract infection.
- You pain was controlled with IV pain medications.
- You improved and were ready to leave the hospital.
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
=========
___ is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D18 (last dose ___ c/b
bowel obstruction resulting in diverting colostomy, Hx L tibia
osteosarcoma (s/p ___ resection/reconstruction and ___ wide
excision of recurrence), and sickle cell disease (c/b splenic
infarction, acute chest syndrome, pulm infarction, AVN), who
presented from ___ clinic on ___ with URI symptoms,
course complicated by unresponsiveness and pulselessness caused
by Zosyn infusion, now called out from ___ for further
management of URI and post-anyphylactoid reaction care.
ACUTE ISSUES
============
# Unresponsiveness
# Cardiac arrest
She became unresponsive, apneic, and rigid and her pulse could
not be detected after brief administration of zosyn. ROSC was
obtained after 2 minutes CPR and epi 1 mg x1. Unknown rhythm
before/during this episode, reportedly sinus tach (140s-150s)
following ROSC. Ddx for this episode includes anaphylactoid
reaction to Zosyn causing hypotension/syncope, and vasovagal
reaction. Bedside TTE in ED without RHC to suggest PE or other
obvious abnormalities. Seizure was felt to be unlikely as she
had no post-ictal period. Formal TTE unremarkable except for
mild MR. ___ was monitored in the ICU following this episode and
lidocaine 5% patch was applied to chest for sternal pain. She
was subsequently called out to the floor for further monitoring.
She was monitored on telemetry and electrolytes were monitored
and repleted as needed. Pain was controlled with IV and PO
dilaudid and Tylenol.
# Anemia
# Thrombocytopenia - improving
Cell count derangements were noted in the setting of malignancy
(currently C2D19 on FOLFOX) and probable sequestration. The
patient's Hgb was noted to be 7.1, and she was given 1 u pRBCs
with appropriate response. Her platelets were noted to be 29
following cardiac arrest episode, an abrupt decrease from plts
404 noted 8 hours prior, raising concern for epinephrine
mediated thrombocytopenia. However her platelet count up trended
and she had no signs of bleeding during the hospitalization.
Concern for immune mediated destruction process given patient's
reaction to zosyn and marked acute thrombocytopenia and worsened
anemia. Hemolysis labs remarkable for low hapto, high LDH, high
indirect bili c/w hemolytic process. She was monitored with a
daily CBC and active T&S was maintained. When her platelets rose
above 50, she was anticoagulated with subcutaneous heparin for
DVT prophylaxis.
# URI
# Leukocytosis
Patient presented from ___ clinic with 2 weeks of fatigue,
pharyngitis, rhinorrhea, productive cough, and myalgias c/w
viral vs. bacterial URI, in setting of immunocompromised state.
CXR reassuring but cannot r/o small focus of consolidation. No
s/s acute chest syndrome. Flu negative. Blood and urine cultures
were drawn, and a respiratory viral screen was obtained.
Leukocytosis downtrended. Following admission to ICU, cefepime
and azithromycin were started, which was switched to
levofloxacin following transfer to medicine floor. She was given
IV fluids as needed during the hospitalization. Her symptoms
improved during the admission. She was instructed to complete a
7 day course of levofloxacin for community acquired URI
(___).
# Metastatic rectal carcinoma
Diagnosed in ___. Complicated by large bowel obstruction
resulting in sigmoid diverting colostomy. Currently undergoing
treatment with FOLFOX C1D1 ___. Last treatment ___.
# Hypophosphatemia
# Hypomagnesemia
Electrolytes were monitored with a daily CMP and electrolyte
sliding scales and phos repletion were used as needed.
# Sickle cell disease
Previously complicated by splenic infarction, acute chest
syndrome, pulmonary infarction, AVN. Not currently on
hydroxyurea secondary to thrombocytopenia expected from
chemotherapy. During this admission she had hip pain consistent
with her pain crises. Anemia and thrombocytopenia were treated
as above. Her home folic acid was continued. Her pain was
controlled with IV Dilaudid and Tylenol, which was converted to
a PO Dilaudid regimen prior to discharge. | 130 | 590 |
19774071-DS-14 | 25,035,229 | Dear Ms. ___,
You were admitted for workup of your nausea, vomiting, and drop
in blood pressure. While you were here you received IV fluids
and medications to help with your symptoms. The palliative care
service was consulted and they helped us manage your symptoms.
You will follow up with Dr. ___ as an outpatient to discuss
further treatment for your lung cancer. We had considered doing
a lumbar puncture to look for causes of your dizziness, however,
as you were doing better, we decided not to do this in the
hospital.
We wish you the best,
Your ___ team | Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis s/p resection and VP shunt placement, s/p
WBRT and crizotinib, now on protocol ___ ___ w/ alectinib
600 mg BID who presented with nausea, vomiting, and orthostasis.
# Orthostasis: likely ___ dehydration in the setting of
significant nausea and poor PO intake. TSH checked in ___ was
wnl and B12 was wnl. Adrenal insufficiency was on the
differential however cortisol/cosyntropin stimulation test was
wnl. Patient received IV hydration and her symptoms improved.
# Nausea/vomiting: etiology was unclear but was initially
attributed to her study drug. During her last admission she had
an extensive workup which consisted of an MRI brain and EGD.
Patient was recently on a steroid taper (which she completed at
home) however states that steroids made her symptoms worse and
therefore steroids were not continued during this
hospitalization. A CT abdomen/pelvis was performed and did not
show an acute process that would explain her symptoms. Her neuro
exam was non-focal and she did not complain of symptoms
suggestive of elevated ICP. Neurosurgery was contacted to
discuss her case and they felt a VP shunt series was not
necessary at this time. Neuro-Oncology was consulted and they
felt that patient may benefit from a LP as an out patient to
evaluate for leptomeningeal carcinomatosis as well as
paraneoplastic syndromes. Patient did not want LP in house as
she was feeling better upon day of discharge. Patient may follow
up with Neurology as an out patient to obtain LP if desired.
# Dysuria/increased frequency: UA negative for infection, Urine
culture ___ negative, chronic. ? interstitial cystitis vs.
autonomic dysregulation. Patient will follow up with uro-gyn as
an out patient.
# Vaginal pain, likely ___ pain as patient does not
have abnormal vaginal discharge or other symptoms/signs
suggestive of infection
-ibuprofen PRN
-phenazopyridine 100mg tid
-pelvic exam as out patient
# h/o PE: continued home lovenox ___ mg daily | 97 | 325 |
16401092-DS-22 | 20,578,882 | Dear. ___,
___ were admitted to the Internal Medicine service at ___
___ on ___ 7 regarding management
of your persistent left hip pain. CT imaging showed fluid in the
hip and thigh, which was likely from post-surgical changes.
Aspiration fo the fluid and fluid culture did not show signs of
infection. Therefore ___ were managed with PCA dilaudid and
ketorolac, before being transitioned to oral dilaudid and
oxycontin for the pain.
It is important to take all of your medications as prescribed.
In addition, please make every attempt to attend your follow-up
appointments, as scheduled.
Please call your doctor or go to the emergency department if:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* ___ develop new or worsening cough, shortness of breath, or
wheezing.
* ___ are vomiting and cannot keep down fluids, or your
medications.
* If ___ 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.
* ___ see blood or dark/black material when ___ vomit, or have a
bowel movement.
* ___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* ___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* ___ develop any other concerning symptoms. | ___ with a PMH significant for hypertension, hyperlipidemia,
depression and anxiety, GERD, degenerative joint disease and
congenital hip dislocation who was recently admitted on ___
with altered sensorium found to have high grade MSSA bacteremia
with a left thigh abscess, right iliacus and SI joint abscess,
epidural abscess and aortic valve endocarditis who underwent
multiple joint washouts and drainage procedures and discharged
on a prolonged course of IV cefazolin who now re-presents with
persistent left hip pain. Her pain is much better controlled
today. | 240 | 84 |
14441563-DS-21 | 21,884,409 | Dear Mr. ___,
It was a pleasure caring for you. You were admitted for a
serious infection and blockage in your urinary tract. For this
you received a tube to relieve the obstruction ("percutaneous
nephrostomy") and antibiotics. Please continue the antibiotics
as prescribed follow up with urology for definitive treatment of
the blocking stone.
Nephrostomy tube instructions: This no longer requires flushing.
You may change the external dressing if it becomes
soaked/saturated with liquid as needed.
Ostomy instructions: You and your wife have been instructed on
ostomy care. You are also going to have an ostomy nurse come to
your house to assist you.
We wish you the best in your recovery!
Sincerely, your ___ Team | Mr. ___ is a ___ male w/ rectal and prostate cancer,
status post end ileostomy ___, who initially presented with
septic shock ___ to genitourinary infection in s/o obstruction
requiring FICU admission, now s/p percutaneous nephrostomy w/
improvement in hemodynamics, transferred to medicine.
Subsequently had resolving ___, toxic metabolic encephalopathy,
as well as anemia/thrombocytopenia.
# UTI, pyelonephritis
# septic shock
# nephrolithiasis
# hydronephrosis
Presented in septic shock. Started on vanc/cefepime empirically
(___), narrowed to ampicillin after cultures returned
sensitive enterococcus. Underwent percutaneous nephrostomy by ___
with return of pus, also growing sensitive enterococcus. Urology
followed and recommended outpatient follow up with them for
definitive stone management and/or stent placement. Will
continue abx until definitive stone management or at least 14
days from PCN placement (ie until ___, whichever is later.
# ___
# obstructive nephropathy
# hydronephrosis
# nephrolithiasis
Initial cr 1.1 (baseline), quickly rose to 2.5 which was likely
a combination of obstructive nephropathy and ATN. Plateaued at
that level and eventually came down with resolution of
obstruction, IVF and time. Repeat u/s showed no more
hydronephrosis. Meds were renally dosed (including switching
morphine on transfer out of ICU to oxycodone). Plan per urology
for nephrostomy to remain in place on discharge until urology
follow up. Cr 1.4 on discharge.
#Toxic metabolic encephalopathy: likely ___ combination of
sepsis and medications in renal failure as well as renal failure
itself. Other than baseline LUE weakness, exam was non-focal. He
continued to improve with time and especially with renal
improvement and reductions in meds (switched morphine to
oxycodone/reduction in clonazepam on transfer from ICU to
floor). On discharge mental status had resolved back to
baseline.
# LUE weakness: pt reports baseline, but at risk for both mets
or bleeding. Unlikely acute. CT with old lacunar infarcts but
these would not explain the weakness. Will eventually need MRI.
# Serosanguinous drainage from nephrostomy in ba: in setting of
low platelets, had some thicker sanguinous drainage when
platelets were particularly low, never with clots. But with
platelets and time this improved, was having light red tinged
urine on discharge.
#LLE swelling: negative ___
#Thombocytopenia, anemia likely ___ chemotherapy. No
schistocytes seen on smear. Per outpatient oncologist, he may
take longer than normal to respond, particularly given the
infection. Was transfused several units of PRBCs (goal >7) and
plts (goal >50 given serosanguinous drainage in PCN bag. Ostomy
without any bleeding. Discussed with oncologist, will get labs
two days after discharge and decision on neulasta at that point.
#Rectal cancer, prostate cancer: recently received FOLFOX. Pain
was controlled with oxycodone in place of morphine given ___ as
above. Chemo on hold until renal issues are resolved.
#Anxiety: on long-standing clonazepam, would not want to stop
this abruptly for risk of withdrawal. Decreased home clonazepam
to 0.5mg po BID for now.
#Stoma prolapse: does not appear incarcerated but given prolapse
could be at risk of such. Was seen by colorectal surgery who
reduced the prolapse. No acute surgical plan given that he's a
poor surgical candidate with comorbidities. ___ RN saw him,
gave him and wife new appliances, taught how to use the
equipment. Ostomy nurse to come see him at home.
#Hyponatremia: On admission due to hypovolemia, resolved with
IVF.
TRANSITIONAL ISSUES
========================
- Will need to continue antibiotics until definitive stone
management or at least 14 days from PCN placement (ie until
___, whichever is later. Has follow-up for KUB on ___ and
urology on ___
- Patient currently does not have PCP because his is on medical
leave and then retiring. He has been instructed to set up with
new PCP, which he will find locally in ___
- PCP: MRI brain w/wo as o/p once creatinine is back to normal
- needs follow up with ___ in ___ weeks, which ___ is planning to
arrange
- nephrostomy to stay in place until definitive treatment of
kidney stones by urology
- repeat labs including creatinine and CBC w/ diff within one
week after discharge | 111 | 642 |
14439892-DS-19 | 26,082,244 | Dear Mr. ___,
You were admitted to ___ due to reactivation of your Hepatitis
B Virus after you stopped taking your antiviral medications.
Your liver tests showed severe liver decompensation while on
tenofovir, so we added another antiviral medication, entecavir,
and your Hepatitis B viral load has continued to downtrend. Your
liver tests have been slowly improving, and you were evaluated
for a potential liver transplant should you need one in the
future.
It is vital that you continue taking all of your medications,
most importantly your two antiviral medications (tenofovir and
entecavir) every day indefinitely to prevent this from happening
again. Please also continue your tube feeds, as your nutrition
is vital for your recovery.
It was a pleasure taking care of you.
Sincerely,
Your ___ Liver Team | Mr. ___ is a ___ year old man with a history of chronic HBV who
presented with liver failure from reactivation HBV in the
setting of medication non-adherence. AST/ALT > 1000s and TBili
of 19 on presentation. The patient was restarted on tenofovir.
However, LFTs did not improve and TBili continued to uptrend, so
entecavir was added with subsequent decrease in HBV viral load.
He reported early satiety throughout admission. He was initiated
on tube feeds via Dobhoff to ensure adequate nutrition. He was
evaluated for liver transplant and listed on ___.
================ | 125 | 93 |
19466866-DS-13 | 25,505,122 | Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted to ___ on ___ for altered mental status and
confusion. You were evaluated by the neuro-oncology team, who
determined your confusion was probably caused by lesions in your
brain. You were started on a new medication, called bevacizumab
(Avastin) for this issue. Unfortunately, you experienced a
pulmonary embolism (a bloot clot in your lungs) probably as a
complication both from your melanoma and your new treatment with
Avastin. You will need to take anti-coagulation with Lovenox
injections twice per day to treat this (prevents worsening of
the clot).
You should keep your scheduled appointments with your doctors
for ___.
Please call Dr. ___ office at ___ or come
to the ER if you experience any of the following: Headache,
change in vision or taste or smell or hearing, numbness/tingling
in any part of your body, weakness or difficulty moving part of
your body, lightheadedness or dizziness, chest pain, trouble
breathing, abdominal pain, nausea, vomiting, diarrhea, new rash
or bleeding, or any other symptoms that concern you. | ___ is a ___ man with known metastatic
melanoma here with weakness, falls, and report of worsening
mental status at home. Significant aspects of his hospital
course by problem are documented below.
(1) Altered Mental Status and Weakness: Patient's altered
mentation remained stable throughout his admission. He remained
oriented to self and person, was able to name year and season
but not specific month or date. As confirmed with wife, he had
pre-admission right-sided strenght deficits on neurologic
examination; throughout his stay his RUE and RLE were motor
strength ___ while the remainder of his examination was ___.
His cognitive difficulties were attributed to his underlying
cerebral metastases. It was presumed his pre-admission taper to
BID dosing of dexamethasone from TID may have contributed to his
new confusion. He was re-started on TID dosing upon admission,
though this was scaled back to dexamethasone 6mg PO daily during
his stay with planned continuation on this therapy for the
forseeable future. He underwent MRI scanning on ___ which
revealed the following: "1. Multiple large metastatic
hemorrhagic lesions, stable in size with stable. No midline
shift. No acute infarct. 2. Stable left cerebellar rim
enhancing and left cerebellar leptomeningeal enhancing lesions."
Given the continuing course of his melanoma, he was started on
bevacizumab (Avastin) on ___. Prior to starting this
therapy, the risks of hemorrhage and subsequent neurologic
deterioration were discussed with both the patient and his
family. All were in agreement to proceed with this course.
Unfortunately, Mr. ___ suffered a pulmonary embolism during
his hospitalization. It was felt this complicationh was
secondary to the hypercoagulable state of his melanoma and also
due to bevacizumab toxicity. He required anti-coagulation for
this PE, as discussed below. An MRI performed prior to
initiating anti-coagulation identified stable cerebral
metastases (no new hemorrhage) as above. His mental status was
unaffected by anti-coagulation; he did not demonstrate evidence
of new cerebral hemorrhage. Upon discharge, he was alert to
place and person, but disoriented to time. He continued to have
mild word finding difficulties, but was generally appropriate
with his communication.
(2) Pulmonary Embolism: As mentioned above, Mr. ___ suffered
the unfortunate complication of a pulmonary embolism. This was
discovered on CTA after the patient desaturated while ambulating
and was found to be tachycardic. This complication was
attributed to his melanoma and bevacizumab therapy. Given the
significant size of the emboli coupled with his stable cerebral
disease (on MRI shortly after CTA), it was felt anti-coagulation
was necessary. He was started on a heparin drip without initial
bolus dosing and at a decreased PTT goal of 50-70 (therapeutic
considered to be 60-100). After 24 hours of stable neurologic
examination and mentation, this anti-coagulation was
transitioned to subcutaneous enoxaparin. Based on his weight,
the recommended dose for anti-coagulation was 60mg BID. Mr.
___ was started on 50mg BID, roughly 80% of suggested dose, in
an effort to both treat the pulmonary emboli and prevent new
cerebral hemorrhage. He did not exhibit signs of new bleeding
with either heparin or enoxaparin. He was discharged on
enoxaparin SQ 50mg BID.
(3) Metastatic Melanoma: Melanoma initially presented at right
cheek and now known to be metastatic to brain, liver, and lung.
Levetiracetam was continued while hospitalized for seizure
prophylaxis given his cerebral involvement. He was started
bevacizumab ___ as above. His next scheduled dose was
___, however, this was delayed given the development of
pulmonary embolism. He was discharged on ___ with
scheduled appointment as an outpatient on ___ to receive
his next dose of bevacizumab.
(4) Diabetes Mellitus: Recent admission to ___ for diabetic
ketoacidosis. Management c/b current steroid use. His serum
glucose levels were well-controlled while hospitalized with his
home dose of insulin and sliding scale adjustment. He was
discharged with a ___ appointment with the endocrinology
service for further evaluation and management.
(5) Pneumocystis Pneumonoia: This was diagnosed on ___ by
___. He was prescribed 3 week course of Bactrim DS TID
(completed on ___. Now, he is on 1 tab Bactrim DS daily
for PCP ___. He will need to continue this regimen
until one month after stopping steroids (likely to be on
dexamethasone for extended period of time).
(6) Hypothyroidism: He continued home dose of levothyroxine.
(7) Oral Thrush: This was documented on ___ during visit
to Dr. ___. Outpatient nystatin was continued
while hospitalized.
(8) Physical Therapy: Mr. ___ performed well on his physical
therapy assessments during his stay, ambulating well with the
assistance of ___ staff members.
========================== | 184 | 779 |
17394776-DS-7 | 25,400,280 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
- You were having fevers and a cough after recently finishing
treatment for a pneumonia.
What was done while you were in the hospital?
- You were found to have a type of cancer called Diffuse Large B
Cell Lymphoma.
- You were given chemotherapy to treat your cancer.
- During your hospitalization you developed kidney failure and
had to be started on dialysis.
- You had a low appetite and had a feeding tube for a while.
Your appetite improved so we let you eat on your own.
What should you do when you go home?
- You should take all your medications as directed.
- Please follow up with your outpatient providers as listed
below.
We wish you the best,
Your ___ Care Team | ___ w/ history of remote cutaneous lymphoma, eosinophilic
granulomatosis with polyangiitis, autoimmune hepatitis/PSC, FSGS
with CKD III and unprovoked PE who originally presented with
constitutional symptoms and concern for pneumonia but was
incidentally found to have aggressive DLBCL that was complicated
by secondary HLH. She was transferred to ___ for worsening
respiratory status and metabolic acidosis due to acute renal
failure requiring urgent renal replacement therapy. The patient
was stabilized in the FICU and was able to be transitioned to
HD. She was transferred back to the ___ service for continuation
of chemotherapy.
# DLBCL
# Secondary HLH
# Pancytopenia
Incidental finding of lymphadenopathy on ___ MRCP was
concerning for lymphoma. Subsequent PET scan showed widespread
disease. Excisional lymph node biopsy confirmed diagnosis of
diffuse large B cell lymphoma. The patient was initially started
on Cytoxan monotherapy however did not tolerate with the
development of renal failure and ongoing cytopenias. Course also
complicated by secondary HLH. She received one treatment of
rituxan, dose reduced etoposide and steroids. With improvement
in cell counts and liver function, the patient was started on
miniCHOP on ___. She was supported with G-CSF with improvement
in cell counts.
# Acute renal failure
# FSGS
Progressive renal failure with acidemia and volume overload
requiring transfer to the FICU for initiation of HD. Renal
failure most likely result of lymphoma invasion of kidneys. HD
sessions c/b A fib with RVR, hypotension, and SVT which resolved
with cessation of HD. Required CRRT for several days and
eventually was transitioned back to intermittent HD which she
then tolerated well. Began making some urine but continued with
HD. Tunneled line placed and continued on HD at discharge.
# Severe Malnutrition
Poor appetite, not meeting caloric needs so DHT placed ___.
Slowly advanced diet but unable to take sufficient nutrition.
Discussed moving towards PEG but decision made to remove DHT and
trial po intake for several days which resulted in some
improvement in appetite, meeting lower-end of calorie needs.
# CAP vs post obstructive pneumonia
Patient treated for PNA with 10 day course of cefepime/flagyl.
# HSV Infection
Developed fevers and had lesions on inner thigh c/f HSV
infection. No c/f MRSA. Treated with course of Valtrex then
transitioned back to acyclovir prophylaxis while neutropenic.
# Afib with RVR, resolved
Developed rapid rates to 170's during HD initiation and
subsequent HD sessions. Resolved outside of HD. Started on amio
during acute event, however this was discontinued.
# Steroid-Induced Hyperglycemia
Started on lantus and sliding scale Humalog to cover blood
sugars.
# ___ edema
# Elevated Pro-BNP
Likely ___ hypoalbuminemia iso lymphoma. No e/o heart failure.
TTE w LVEF 68% with Normal biventricular cavity sizes,
regional/global systolic function. No valvular pathology or
pathologic flow identified. High normal estimated pulmonary
artery systolic pressure. Mild-moderate tricuspid regurgitation.
# PSC
# Transaminitis
Pt with history of PSC. Developed worsening transaminitis during
admission with elevated TBili limiting chemotherapy options.
Unclear etiology for elevation, possibly ___ HLH given
improvement with etoposide. Continued Ursodiol.
# Eosinophilic Granulomatosis with Polyangiitis
Continued 10mg Prednisone (increased home dose in setting of
continued fatigue), additional steroids for lymphoma treatment
as above.
CHRONIC/STABLE ISSUES
=====================
# HTN
Holding home nifedipine given hypotension.
# COPD
Continued home Flovent.
# HLD
Held home statin given LFT abnormalities.
TRANSITIONAL ISSUES
===================
[ ] Monitor fingerstick BG daily, can use sliding-scale insulin
if needed. Not requiring Lantus at time of discharge.
[ ] Continued nutrition assessment to determine if meeting
caloric needs. ___ require PEG if not taking sufficient po.
[ ] Prednisone dose increased from 5mg daily to 10mg daily prior
to admission. Discharged on 10mg after finishing steroids for
chemotherapy.
[ ] Consider BRCA testing (father w h/o breast cancer)
[ ] Held nifedipine given intermittent hypotension here. If BPs
stable, can restart.
[ ] Held atorvastatin given LFT abnormalities. Check LFTs at
least weekly. Can restart as outpatient if LFTs
stable/improving.
[ ] Will need to come back to ___ clinic for cycle 2 of miniCHOP
on ___.
[ ] ___ need port in the future.
# Code: Full, confirmed
# Communication: Husband/HCP ___ (___) | 134 | 637 |
17261183-DS-24 | 26,769,375 | Dear Ms. ___,
You were admitted to the hospital with a cluster of seizures.
You received ativan while hospitalized, but did not need any
changes in your home anti-epileptic drugs because your seizure
frequency was overall unchanged. We looked for causes of your
seizure cluster (such as infection) and did not find anything
concerning. You were monitored on EEG and did not have any
seizures.
.
Please attend the follow-up appointment listed below with your
neurologist Dr. ___.
.
We did not make any changes to your medications. Please continue
taking them as you were prior to hospitalization. | ___ is a ___ yo F with mild static encephalopathy and
___ syndrome who presented with increased frequency
of head drops (one of her typical seizure semiologies).
# NEURO: Patient was admitted to the Epilepsy service for
further workup and EEG long-term monitoring. She underwent
toxic-metabolic and infectious workup which was all negative.
Serum VPA level was therapeutic at 91. She was briefly placed on
a lorazepam "bridge" to treat her increased seizure frequency,
which was tapered and stopped after two days. She was monitored
on EEG LTM for 5 days which showed occasional bursts of
generalized spike and slow wave activity (usually during sleep)
which appeared baseline compared to her prior EEGs. Clinically,
she appeared well and at baseline throughout hospitalization,
with no clinical seizures observed. As she was clinically at her
baseline with no significant seizure activity on EEG, no
adjustments to Ms. ___ AED regimen were made during
hospitalization. She was discharged back to her group home on HD
#5, and will follow up as an outpatient with her epileptologist
Dr. ___. | 95 | 176 |
15633246-DS-9 | 29,912,120 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having chest pain. You
underwent a cardiac catheterization to evaluate your heart
vessels and your heart valves. No intervention was necessary.
You were also noted to have too much fluid in your body which
was likely causing some of your shortness of breath. We gave you
medications to help remove the fluid and optimized your home
medication regimen.
Please take your medications as prescribed and follow up with
your doctors as ___.
Please have your electrolytes checked on ___ and have the
results faxed to your primary care doctor. If you do not hear
back regarding the results for 2 days, the call the office to
ask about your results. | ___ with DM, HTN, HLD, smoker, presents with sudden onset of
severe substernal CP overnight with diaphoresis and dyspnea
which woke her from sleep, then recurring several times since,
radiating to left arm, non-exertional, ST depressions. Cardiac
cath showed 1 vessel disease with elevated end diastolic
pressures in both biventricularly consistent with diastolic
heart failure. Patient has been medically optimized during
admission and has been getting IV diuresis for fluid overload. | 132 | 72 |
Subsets and Splits