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Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital after undergoing repair of your ventral hernia. You have recovered from surgery and are now ready to be discharged to home with services. Please follow the recommendations below to ensure a speedy and uneventful recovery. 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 10 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. - 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 edges. This is normal. - If you have steri strips, do not remove them for 2 weeks. (These are the thin paper strips that are on your incision.) But if they fall off before that that's okay). - You may gently wash away dried material around your incision. - 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, but do not bathe you are seen in clinic for follow-up. 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 fluitds 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. - 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 folloiwng, 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 admitted from the emergency department on ___. He was initially seen at his PCP's office where a KUB was done showing distended loops of bowel concerning for small bowel obstruction. On evaluation in the ED, CT scan of the abdomen showed a complex network of ventral hernias with multiple loops of bowel incarcerated within the hernia. He was admitted to the Acute Care Surgery team for management and operative discussion/planning. Mr. ___ was taken to the OR on ___ and underwent an exploratory laparotomy with bilateral rectus abdominis component separation repair of abdominal wall defect with polypropylene mesh and small bowel resection with primary anastomosis, performed by Dr. ___. He tolerated the procedure well without any complications and was taken to the post-anesthesia care unit in stable condition. At the end of the procedure, Mr. ___ had 2 JP drains in the space overlaying the mesh and an NG tube for decompression of the stomach. In the immediate post-operative period, Mr. ___ at an epidural for pain control and foley catheter while he had an epidural. The NG tube was removed a few days after the operation and he was started on sips of clears, awaiting return of bowel function. However, after a few days, Mr. ___ became increasingly distended and had an episode of emesis. He was again kept NPO, started on IV fluids, and given a PCA for pain control temporarily. An NGT had to be placed to decompress the stomach after a second episode of bilious vomiting. Once he began passing flatus, he was started on a clear diet and diet was advanced as tolerated while he continued to pass flatus. During the recovery period, he was also started antibiotics for some mild non-demarcatable erythema noted over the incision, especially given the risk of mesh infection. The JP drains remained serosanguinous in output. On discharge, Mr. ___ continued to pass flatus, although he had not had a bowel movement. He was tolerating a regular diet without any nausea and vomiting and continued on a bowel regimen. He was eager to be discharged and acknowledge that should he not have a bowel movement in 48 hours, he should call the clinic or return to the ED. He was given instructions for medications and scheduled to follow-up early next week for staple removal and JP drain removal and then another 2 weeks after for follow-up.
760
398
19045496-DS-24
22,343,752
You were admitted to the hospital after walking into a door and hitting your face. You sustained a left eyelid injury. You were seen by the paramedics and declined admission to the emergency room. Shortly afterward, you felt short of breath and felt like your "airway was closing" prompting arrival to emergency room. You had an airway placed for airway protection. You had an elevated INR of 1.8 and was given medication to lower the level. You underwent imaging and you were reported to have a retro-pharyngeal hematoma and an isolated fracture to your neck. You were evaluated by Neurosurgery and no surgery was indicated. Your vital signs have been stable and you are preparing for discharge to a rehabilitation center to further regain your strength and mobility. You are being discharged with the following instructions: return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please return to the emergency room if you have a recurrence of neck pain, headache, and throat pain. If you begin to have difficulty swallowing it is important to return here. You will see Dr. ___ prior to resuming your coumadin
___ year old female with past medical history notable for afib on warfarin and recurrent falls. Per report of primary team, she suffered a fall earlier and struck her head on a doorknob. She initially was able to get up and refused transfer to the hospital, but later (<1 hour after), she noticed swelling in her neck and difficulty breathing. She was brought to the emergency room where a CT scan of the neck was done, which showed a large prevertebral retropharyngeal hematoma with active extravasation of contrast. She was intubated in the emergency room. The patient was admitted to the MICU for monitoring and pulmonary toilet. On arrival to the MICU, the neurosurgical, ENT, and spine teams were consulted, who did not initially plan for surgical intervention. The ACS team was consulted given multiple other areas with evidence of trauma, and recommended transfer to the TSICU. Imaging of the neck showed active extravasation, venous vs arterial but the source was unclear. Per Neurosurgery/ENT, there was no clear surgical intervention to be performed. An MRI of the neck was done which demonstrated an acute fracture involving the anterior C4 vertebral body. The patient was placed in a soft collar for comfort but later discontinue because the spine was stable and there was only 1 column injury. An oral-gastric tube was placed for the initiation of tube feedings. Prior to extubation, the patient underwent a bronch which demonstrated tracheomalacia. She had pneumonia from group B strep and was started a 7 day course of antibiotics: ceftriaxone and azithromycin, which was changed to ancef when culture date was obtained. The patient was successfully weaned and extubated on ___. To provide nutrition after removal of the oral gastric tube, the patient was evaluated by Speech and Swallow and underwent a Video swallow. She was transitioned to a soft diet. Because of the patient's underlying cardiac history, she underwent an echocardiogram which showed an EF 50-55%, and 2+ MR. ___ patient was transferred to the surgical floor on ___. Her hematocrit remained stable. On ___, she reported increased neck and posterior head pain. The Neurosurgery service was re-consulted and recommended a non-contrast head cat scan which showed severe chronic small vessel ischemic changes with no acute process. The patient was given pain medication and warm compresses and her neck pain decreased in intensity. In preparation for discharge, she was evaluated by physical therapy and recommendations made for discharge to a rehabilitation facility. The patient was discharged on HD # 11. Her vital signs were stable and she was afebrile. She was voiding without difficulty and had return of bowel function. Her appetite continued to be decreased and she was provided with nutritional supplements. She had no difficulty with swallowing. Her hematocrit and white blood cell count stabilized. Appointments for ___ were made in the acute care clinic. Discharge instructions were reviewed and questions answered. Her anticoagulation was held during this admission, and should not be continued until discussion with her PCP at ___.
302
515
15071083-DS-16
24,572,540
you were hospitalized for gi bleeding that was from ischemic colitis. you underwent biopsy of your pancreas that did not show cancer. you received transfusion of blood. blood thinner was resumed. you were treated for bacterial infection and are undergoing treatment for C. diff infection. You will need a repeat ERCP in 6 weeks and repeat CT scan of your pancreas in 4 weeks to follow up findings in your pancreas.
___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with LVEF 20%, atrial fibrillation on Coumadin, and a recent history of pancreatitis, cholecystitis, and c. diff colitis presents with BRBPR and UTI and admitted initially to the MICU due to transient hypotension while in the ED. # BRBPR/GI bleeding - Pt. presented with 2 day history of large bloody bowel movements. Rectal exam revealed maroon stools. Despite bloody bowel movements, H/H relatively stable on admission at 9.6/29.8 from 10.6/32.1 one month prior. Pt. responded appropriately to 1U PRBC in the ED. Pt. had one episode of hypotension that resolved with transfusion and IVF. No evidence of source on CT ab/pelvis, though limited by lack of PO contrast. EGD without clear source of bleed in ___. Colonoscopy ___ did show hemorrhoids as well as sigmoid diverticuli. Pt's INR was reversed in the ED with vitamin K and FFP. Pt. was seen by GI who felt that bleed most likely diverticular vs ischemic colitis. Pt. remained hemodynamically stable without further drop in H/H and so was transferred to the floor on hospital day 2 He got one additional unit of RBC and hemoglobin prior to discharge was 9.6. #Pancreas lesion: not consistent with solid mass on endoscopic ultrasound. Underwent pancreas biopsy that did not show malignancy. He will have f/u with Dr. ___ adv endoscopy team for biliary stent removal and can discuss future imaging of abd at that time. CA ___ tumor marker normal level. - ERCP in 6 weeks - CT pancreas protocol in 4 weeks, follow up with Dr. ___ ___ # Hypotension: Pt. transiently hypotensive to 86/40 while undergoing CT scan in the emergency department. Hypotension resolved with administration of IVF and blood transfusion. He never required pressors. Given blood loss and bacteremia, hypotension was likely related to combination of hypovolemia and possibly sepsis. Pt. had no further episodes of hypotension. # E. coli bacteremia and UTI - Per nursing home report, culture from the day prior to admission was growing E. coli, though pt. had not yet been initiated on antibiotics. UA grossly positive on arrival to ___. Pt. initiated on ceftriaxone. Blood and urine cultures, however, grew E. coli resistant to ceftriaxone and so pt. transitioned to meropenem. He received 9 day of antibiotics from first day of negative blood culture on ___ to end on ___. PICC line placed in mid line position to be removed prior to discharge. # C. difficile colitis: Per reports, pt. has history of recurrent C. diff. Pt. admitted on PO vancomycin (DAY ___ END ___. However, consider extending course given recent treatment with Meropenem for UTI # Hyponatremia: Pt. hyponatremic on admission with Na 126. After IVF and blood transfusion, sodium improved to 130. # DM2: At home, pt. is not on insulin, though he is covered by low dose sliding scale at rehab. Pt. was continued on insulin sliding scale during this admission. # Cardiac disease: Pt. with atrial fibrillation (CHADS2 of 4; on Coumadin), CAD, and CHF (EF 20%). Pt's INR was reversed on admission due to active GI bleed with 10 IV vitamin K and FFP. His home torsemide was held in setting of hypotension and then resumed at lower dose. Coumadin resumed prior to discharge. He was continued on home aspirin, digoxin, metoprolol, and pravastatin. - Torsemide may require uptitration # Gout: Continued home prednisone and allopurinol. # BPH: Continued home finasteride. # Transitional issues: - Contact: ___ (wife) ___ - Code: Full
73
579
11669075-DS-16
25,889,399
Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL: -You were having burning and palpitations in your chest -You had an abnormal, fast rhythm of the heart. This is called supraventricular tachycardia (SVT) WHAT WAS DONE FOR YOU WHILE IN THE HOSPITAL: -You were given medications to slow your heart rate down -You were monitored closely on a heart rhythm monitor -You were seen by the electrophysiologists (electrical doctors of the ___ -Your medications were adjusted to help prevent further episodes of SVT WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL: -Please continue taking your medications as prescribed -Please follow-up with your outpatient doctors as ___ Thank you for allowing us to participate your care. We wish you the best of luck! Your ___ Team
Mr. ___ is a pleasant ___ y/o gentleman with a PMH of hypertrophic cardiomyopathy s/p ETOH septal ablation, ulcerative colitis s/p total protocolectomy, and hypertension, who presented with several weeks of palpitations, found to be in supraventricular tachyarrhythmia most likely c/w AVNRT.
113
42
17164417-DS-7
24,903,173
Take your pain medicine as prescribed. ¨ Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨ Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ¨ Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ¨ If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may not resume taking this until you have been seen in follow up by Dr. ___. ¨ You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨ New onset of tremors or seizures. ¨ Any confusion, lethargy or change in mental status. ¨ Any numbness, tingling, weakness in your extremities. ¨ Pain or headache that is continually increasing, or not relieved by pain medication. ¨ New onset of the loss of function, or decrease of function on one whole side of your body.
Mr. ___ was admitted from the emergency department to the surgical intensive care unit on ___ after being adminstered Kcentra and vitamen K. His aspirin and coumadin were held. A trauma evaluation was started which included a dedicated CT SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic surgery was asked to consult regarding. ___, the patient's exam remained stable. Plastic surgery reviewed the CT of the sinus which showed segmental fracture of the left zygomatic arch and possible nondisplaced fracture of the lateral wall of left orbit. Plastics recommended that the patient follow up with them in clinic following discharge from the hospital. He had a repeat NCHCT which showed a stable bleed interval. On ___, patient was stable and transferred to the floor. On ___, the patient remained neurologically stable and was pending a bed to rehab. On ___, patient was stable on examination. Repeat head CT was performed and showed stable ventricular size and improved IVH. He was accepted at rehab and was discharged in stable condition.
226
167
15213209-DS-22
25,710,540
It was a pleasure taking care of you at ___ ___. During your hospitalization, you had surgery to remove unhealthy tissue on your lower extremity. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. LOWER TRANSMETATARSAL AMPUTATION DISCHARGE INSTRUCTIONS ACTIVITY •You should keep your amputation site elevated and straight whenever possible. This will prevent swelling of the stump and maintain flexibility in your joint. •It is very important that you put no weight or pressure on your stump with activity or at rest to allow the wound to heal properly. •You may use the opposite foot for transfers and pivots, if applicable. It will take time to learn to use a walker and learn to transfer into and out of a wheelchair. MEDICATION •Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! •You will likely be prescribed narcotic pain medication on discharge which can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. •You should take Tylenol ___ every 6 hours, as needed for pain. If this is not enough, take your prescription narcotic pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. BATHING/SHOWERING: •You may shower when you feel strong enough but no tub baths or pools until you have permission from your surgeon and the incision is fully healed. •After your shower, gently dry the incision well. Do not rub the area. WOUND CARE: •Please keep the wound clean and dry. It is very important that there is no pressure on the stump. If there is no drainage, you may leave the incision open to air. •Your staples/sutures will remain in for at least 4 weeks. At your followup appointment, we will see if the incision has healed enough to remove the staples. •Before you can be fitted for prosthesis (a man-made limb to replace the limb that was removed) your incision needs to be fully healed. CALL THE OFFICE FOR: ___ •Opening, bleeding or drainage or odor from your stump incision •Redness, swelling or warmth in your stump. •Fever greater than 101 degrees, chills, or worsening incisional/stump pain NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR SURGICAL SITE. IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE STAPLES/SUTURES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT THE WOUND HAS SUFFICIENTLY HEALED.
Patient underwent LLE angiogram with popliteal artery and anterior tibialis artery stent on ___. It was decided to pursue a LLE transmetatarsal amputation and was added on for ___. The patient was NPO prior to ___ procedure, but the case had to bumped to ___ due to limited OR availability. Surgery was rescheduled for ___. Patient received dialysis on the morning of his procedure, which he has getting every 3 days. After induction of general anesthesia for LLE transmetatarsal amputation, anesthesia noticed low blood pressure and ST depressions. At this time, it was decided to hold off on the procedure and consult cardiology. Cardiology stated that the event was most likely secondary to demand ischemia due to no EKG changes post operatively. However, they wanted to assess patients cardiac status through cardiac catheterization. He was added on for ___. Patient was unable to undergo cardiac catheterization and was reschedule for ___. It was on ___ that patient decided he wanted to leave the hospital and come back at another time for the cardiac procedure. This was against medical advice and patient understood. He was advised to continue aspirin and plavix. He was written a script for Augmentin PO for 2 weeks. Patient was contacted by vascular and cardiac surgery for follow up appointments.
548
213
18067322-DS-15
22,235,504
Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted with severe abdominal pain that was most likely due to a small kidney stone, though it was not visualized on CAT scan and UA was negative. Your pain has improved, and as we discussed, you will be discharged with a short course of oxycodone, tylenol and ibuprofen, as well as Reglan and Zofran. Finally, you are given a prescription for a medicine to help the stone pass if it has not already. Please sip fluids to stay hydrated as you recover.
1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with vomitting: Pain was out of proportion to exam, requiring dilaudid PCA for HD 2, however patient eventually felt it may be more anxiety related, was switched to oral oxycodone tylenol motrin. Renal stone is most likely given clinical picture of writhing ___ pain, though exams reviewed with radiology and no evident stone, good ureteral perfusion jets to bladder indicating no osbstruction, no other intraab pathology. Discharged hospital day three with tamsulosin. Tolerating PO. 2. Chronic Stable Asthma - Albuterol 3. ADHD - Currently off all amphetamines (stopped 4 months prior to admit) Full Code Ambulation
96
100
13013759-DS-22
26,057,151
Discharge Instructions Activity · You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · Do not go swimming or submerge yourself in water for five (5) days after your procedure. · You make take a shower. Medications · Resume your normal medications and begin new medications as directed. · It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site · The small bandage over the site was removed. · Keep the site clean with soap and water and dry it carefully. · You may use a band-aid if you wish. What You ___ Experience: · Mild tenderness and bruising at the puncture site (groin). · Soreness in your arms from the intravenous lines. · The medication may make you bleed or bruise easily. · Fatigue is very normal. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the puncture site. · Fever greater than 101.5 degrees Fahrenheit · Constipation · Blood in your stool or urine · Nausea and/or vomiting Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason
Ms ___ is a ___ yo female who presented with a headache. Initial CT at OSH showed a SAH with IVH and she was transferred to ___ for further evaluation. #SAH/IVH from pseudoaneurysm CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA pseudoaneurysm. She was admitted to the Neuro ICU for close neuro monitoring and strict blood pressure control <140. She was taken to angio suite on ___ and underwent pipeline embolization of R ICA pseudoaneurysm. Please see operative report for full details. R groin was angiosealed and she was transported to ICU intubated. She was started on Keppra 1 g Q12H BID for 7 days for seizure ppx and nimodipine 60 mg q4h for 21 days for vasospasm ppx. She was successfully extubated. She was continued on ASA/Brilinta. She remained in ICU for close BP monitoring and vasospasm watch. Head CT ___ showed slight worsening of hydrocephalus but she remained neurologically stable. She had continued nausea and was started on decadron with improvement. She was transferred to the step down unit on ___. She was evaluated by physical therapy ___, who recommended rehab at discharge. On ___, she became very agitated and complained of a headache and had new right ptosis. She underwent STAT CTA brain, which was negative for acute findings. She underwent cerebral angiogram which showed complete resolution of the aneurysm. Physical therapy and occupational therapy were consulted for disposition planning and recommended discharge to rehab. On day of discharge, her pain was well controlled with oral medications. She was tolerating a diet and getting out of bed with assistance. Her vital signs were stable and she was afebrile. She was discharged to rehab in a stable condition. #Hypertension She was started on PO labetalol for blood pressure control, which was titrated and eventually discontinued. #Leukocytosis WBC uptrended and she was afebrile. UA was negative. CXR showed minimal atelectasis and incentive spirometry was encouraged. LENIs were negative for DVT. WBC downtrended to normal. #Diarrhea She had multiple episodes of loose stool. She was negative for C. difficile. Bowel regimen was liberalized to PRN.
410
344
16311983-DS-13
28,630,099
Dear Mr. ___, You were admitted to ___ for worsening leg and abdominal swelling, worsening shortness of breath, and low blood counts. We gave you medications to help you urinate out extra fluid. We were able to get fluid out of your lungs and you no longer requried oxygen to breathe. The fluid in your legs improved. You received blood to elevated your blood count to help your breathing and fatigue. Your blood counts remained stable. Please weigh yourself daily.
___ male with history of CHF, hypertension, and macrocytic anemia of unknoen etiology, admitted with volume overload and dyspnea, concerning for acute diastolic CHF exacerbation, exacerbated by worsening chronic macrocytic anemia. Symptoms improved with diuresis and two blood transfusions. Electrolytes repleted during diuresis, likely worsened in setting of some chronic malnutrition. Discharged to short term rehab with improved edema and on room air. ACTIVE ISSUES # Diastolic heart failure exacerbation CXR, BNP, history and exam suggestive of volume overload secondary to diastolic CHF exacerbation; patient with primarily right-sided heart failure; echo in ___ with LVEF 55%, moderate MR. ___ with IV lasix. Fluid restricted to 2000cc/day. There was a concern for cirrhosis contributing to edema with his low albumin and elevated INR in setting of chronic hepatitis B and EtOH abuse, but RUQ US did not indicate evidence of a cirrhotic liver. Dyspnea is also worsened by concomittant anemia and his severe pulmonary hypertension. Fatigue and shortness of breath improved with RBC transfusions, as below. On ___ he was transitioned from IV furosemide to PO torsemide and was able to maintain diuresis. On ___ his foley catheter was removed and he was able to urinate. He already has outpatient follow-up scheduled in cardiology clinic. # Hyponatremia: Sodium was 119 on admission. Pt has h/o hyponatremia during past hospitalizations, thought to have beer potomania at that time. His current hyponatremia was secondary to hypervolemia in setting of dCHF exacerbation. There could also be a component of chronic, mild hyponatremia in the setting of citalopram use. His Na+ slowly trended up with diuresis. Na+ at discharge was 129. # Macrocytic Anemia: This is a chronic issue for him. Workup to date revealed normal B12, folate, iron studies, ___ only with a few colonic adenomatous polyps in ___, and BM Bx without hypocellularity and no evidence MDS. ___ without signs of active bleeding, stool guiac negative. Likely secondary to chronic EtOH abuse. Received two transfusions of 1U PRBC each for HCT < 21 with improvement in fatigue. HCT stabilized for several days prior to discharge. H/H at discharge was 8.2/24.3 # Alcohol Abuse: Pt has h/o alcohol abuse with prior episode of DT's requiring intubation for airways protection. H/O fatty liver per medical record. Unclear how much he drinks, states that he doesn't drink every day, cannot quantify how much beer, but states that he drinks to take the edge off of his back pain. He received IV thiamine and folate x 5 days, continued on home B12 and MVI. CIWA protocol used, but patient did not score nor receive any benzodiazepines. # Tobacco Abuse He was started on a nicotine patch while hospitalized. # Severe pulmonary hypertension Noted on echo in ___, unclear etiology, may be secondary to chronic hypoxemia from smoking, left-sided valvular disease (MR), or pulmonary arterial hypertension. Would recommend oupatient PFTs and perhaps RHC as outpatient when seeing cardiology. # Diarrhea: Nonbloody, no recent abx use. No recent travel or sick contacts. ___ be malabsorptive or in setting of poor nutrition. C. diff was ordered to be collected but patient did not have diarrhea once admitted. CHRONIC ISSUES # Spinal Stenosis: pt has severe spinal stenosis s/p several surgeries and now physically disabled. He takes oxycontin for his pain and seen at ___ steroid injections, and has h/o opioid abuse in past but not currently abusing it. Continued on home oxycodone. # Proteinuria: documented in past PCP ___. Unclear etiology. Pr/Cr 1.8. Should have outpatient follow-up. # Depression/Anxiety: Continued on citalopram and clonazepam. # Gastritis, GERD: Continued on omeprazole. # Hypertension: Continued on metoprolol and lisinopril TRANSITIONAL ISSUES - Alcohol abuse history - unclear exactly how much he is currently drinking, was on CIWA scale here and highest score was 3 and did not required benzodiazepines; should be followed over the next several days for any signs of withdrawal - Required daily IV magensium during aggressive IV furosemide diuresis, please check Chem-10 within the 48 hours after arrival to rehab (on ___ and replete electrolytes as necessary. He may need daily oral magnesium. -Foley catheter was removed on ___, able to urinate, watch over next day for any signs of urinary retention - Being discharged on 60mg PO torsemide - titrate his diuretic dosing as an outpatient as needed - Recommend outpatient PFTs given severe pulmonary HTN on echocardiogram - Started on 81mg ASA daily given PVD - Full code
79
723
12106911-DS-11
27,943,344
Ms ___ it was a pleasure caring for you during your stay at ___. You were admitted with headache and difficulty with balance. You were found to have multiple brain tumors as well as swelling in the brain. You were started on radiation treatment which you have been tolerating well. We did not find any other areas where the cancer spread. Your steroid dose will be determined by the radiation oncologists. You also have a repeat brain MRI scheduled about one month after you complete radiation. You are discharged to ___ in ___ to continue rehabilitation. You will return to complete radiation this week. ___ at 10:30am. No treatment is scheduled on ___
___ y/o female with history of T4N0M0 Stage IIIA poorly differentiated adenosquamouscarcinoma of the lung s/p right pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now on active surveillance, on enoxaparin since ___ for PE, now presents with headache and gait imbalance found to have multiple brain mets. # Metastatic NSCLC with new CNS mets- MRI shows new enhancing masses within the right frontal, left temporal, and right cerebellar cortices with adjacent vasogenic edema and mass effect, consistent with metastatic disease. Exam with multiple neurologic deficits includiong R facial droop and dysarthria. CT shows significant edema. Pt also w/ ongoing short term memory/cognitive difficulty -Neuro-oncology and radiation oncology consulted. Patient started whole brain radiation ___, plan for total of 10 fractions (currently ___ completed, will complete on ___. - dexamethasone for edema now reduced to 4mg BID, further taper per rad onc. On PPI while on steroids - MRI spine to evalaute for mets in the spine or leptomeningeal disease - none seen. - CT torso to evaluate systemic disease was negative. - she will have follow up brain MRI in ___ Patient did have improvement in coordination and headaches w/ initiation of steroids and WBRT. She was evaluated by physical therapy and is able to ambulate independently however continues to struggle with short term memory, completing tasks/directions. Due to this patient requires ___ supervision for safety. She will be discharged to ___ in ___ for further rehabilitation and possibly long-term care. #Leukocytosis - likely ___ dex, persistently elevated w/o signs systemic infxn. surveillance urine/blood cx NGTD on repeat exams. CXR ___ shows only stable pneumonectomy, clear on L. did improve w/ reduced dex dose. # h/o PE - no evidence of bleeding on head CT or MRI. Able to anticoagulate per neuro-onc -continue home lovenox. # Hypothyroidism - on Levothyroxine
120
292
11427507-DS-23
27,594,123
Dear Ms. ___, You were admitted to the ___ Cardiology Team ___ after you had worsening chest pain. What was done? =============== -You had a cardiac catheterization which showed some narrowing and blockages, but none were suitable to have new stent placement. -We increased your lisinopril dose from 5 mg to 10 mg which may help with your pain. What to do next? ================== -Please follow up with your primary care ___ at 12P) and cardiologist ___ at 2P) for further medication titration as needed. These appointments have been scheduled for you. -We recommend no strict exercise limitations, walking is helpful for your heart, but avoid excessive stress. -Avoid fast food and fried foods as well as red meat. Eat food high in fiber such as fruits and vegetables. We wish you the best! - Your ___ cardiology team
___ year-old woman with diabetes mellitus and known CAD S/P CABG in ___ (LIMALAD, SVG-PDA, SVG-OM/LPL) and post-CABG PCI of SVG-OM who presented with 1.5 weeks of chest squeezing radiation at rest and with exertion to both arms similar to her prior acute coronary syndrome symptoms. # Unstable Angina # Coronary Artery Disease s/p CABG Patient presents with chest pain at rest. She had no biomarker evidence of myocardial infarction. She exercised to ___ METs on a non-imaging stress test without symptoms and initially nondiagnostic 0.5-___epressions which became horizontal during recovery. She was thus referred for coronary and bypass graft angiography which showed native three vessel coronary artery disease with chronic total occlusion of the CX and RCA, unrevascularized native OM1 disease and LPL disease downstream of the SVG (both of these in vessels <2 mm in diameter and thus too small for PCI). No lesions suitable for PCI as native OM1 and grafted LPL <2 mm in diameter. Interventional cardiology recommend ___ medical therapy and reinforcement of secondary preventative measures against CAD and hypertension. Patient was continued on home cardiac medications (ASA, Plavix, metoprolol, atorvastatin and isosorbide mononitrate). Ultimately, lisinopril was increased from 5 mg to 10 mg daily. Metoprolol was not uptitrated due to patients HR (50-60s).
130
208
12600024-DS-22
25,221,898
Dear Ms. ___, It was a pleasure taking care of you Why you were here: -You were in the hospital because you were complaining of jaw pain and swelling from an infection around you tooth -You were not urinating well What we did for you: -You were given antibiotics for the treatment of your infection -The oral surgeons drained a pocket of infection around your tooth -A foley catheter was placed to drain the urine in the bladder What you should do after leaving the hospital: -Call the oral surgery clinic (___ Building at ___ - ___ at EXACTLY 7:00am any day ___ through ___ so you can have a same day clinic appointment to get your teeth removed. -Please continue taking your antibiotic (augmentin) twice a day to be completed for a 7 day course (last dose on ___ -please use the chlorhexadine to rinse your mouth twice a day -Please continue taking all your medicine and follow up with your primary care doctor and dentist We wish you the best, Your ___ team
___ yo F with PMH diabetes and schizophrenia admitted for acute jaw pain/swelling, found to have a periapical abscess in the mandibular anterior vestibule. CT scan revealed no drainable fluid collection in the neck. Patient was started on IV unasyn for oral infection. ___ was consulted who observed a fluctuant lesion at the apex of ___ and performed a beside incision and drainage. Patient received panoramic radiograph of her teeth. The dentistry team recommended that she gets full teeth extraction to be done at outpatient ___ clinic. Patient was transitioned to PO augmentin (last dose on ___. Patient also found to be retaining urine with bladder scan>1000cc of urine. Patient was straight cathed was monitored by bladder scan, found to have increasing PVR and so a foley was placed. Patient to follow up with urologist for urodynamic study. # Dental Infection: Jaw swelling/pain suspicious for periodontal infection. Patient started on IV unasyn. ___ was consulted who observed a fluctuant lesion at the apex of ___ and performed a beside incision and drainage. Patient received panoramic radiograph of her teeth. The dentistry team recommended that she gets full teeth extraction to be done at outpatient ___ clinic. Patient was transitioned to PO augmentin (last dose on ___. Patient's jaw swelling/pain improved and she was able to tolerate soft PO food. #Urinary retention Patient found to have poor urine output while hospitalized. Patient was straight cathed for 1100cc. Patient's urine output was monitored and patient had increasing PVR >500cc, so a foley was placed. Unclear etiology for her urinary retention. Patient on olanzapine, which has anticholinergic effects. UA negative. No evidence of cord compression or peripheral neuropathy. Patient discharged on foley with outpatient urology appointment. # Hypertension: Patient's blood pressure was in the low 100's-110's. Held home chlorthalidone and decreased lisinopril to 20mg. Patient's BP continued to be in relatively low, so she was discharged on 10mg lisinopril to have outpatient followup for blood pressure # OSA: Stable. Patient on CPAP at night # Schizophrenia: Stable. Continued home olanzapine, wellbutrin, sertraline, cogentin, gabapentin # Diabetes: Held metformin. Patient was on insulin sliding scale, but did not require any insulin. # GERD: Continued home omeprazole 20mg BID # COPD: stable. Continued Fluticasone Propionate 110mcg 2 PUFF IH BID, albuterol neb PRN q6h TRANSITIONAL ISSUES ======================= []ensure patient has appointment with ___ (___) to get full teeth extraction (___). Patient needs to call EXACTLY AT 7AM to get appointment same day (___) []f/u jaw pain/swelling []f/u with dentist []held chlorthalidone and decreased lisinopril to 10mg given BP's in the low 100's. f/u blood pressure and titrate meds as needed []foley to remain in place until follow up with urology for urodynamic study for urinary retention. []thyroid gland enlarged on CT scan. Consider thyroid ultrasound Note: Patient at rehab for convalescent stay <30 days. Do not do trial of void for patient. Patient has urology appointment scheduled. #Code Status: full, confirmed #Contact: ___
160
467
13944352-DS-27
28,779,503
Dear ___, You were admitted to the neurology service because of you worsening gait. We restarted your home medications and this improved greatly. You were evaluated by ___ and will be going to acute rehab to work on your gait.
This is an ___ yo woman with PMH significant for multifactorial gait disorder (frontal + parkinsonian features, on Levodopa/Carbidopa for Parkinsonism), AFib, CAD, spinal stenosis s/p lumbar surgery who presents with 3 days of worsened gait freezing, difficulty moving/getting out of bed and slowing of her speech. According to the patient's HCP and friend she had stopped taking her medications at home in a passive suicidal gesture. She has been very clear with her HCP and family that her primary aim is staying in her appartment at home. She does not wish to undergo any life extending treatments. She is amenable to a short stay at acute rehab to maximize her mobility followed by discharge with the plan to remain at home with the aid of palliative services. On presentation her exam was remarkable for Hypophonia and hypomimia. Prominent grasp reflexes bilaterally. Decreased upgaze. Subtle left NLF flattening (baseline). +Generalized whole body bradykinesia. Marked paratonia and rigidity in the trunk and extremities. Weakness L>R. She can only ambulate a couple of steps before retropulsing onto bed, but observed markedly shortened stride length and slowed speed. Her clinical picture was thought likely the result of worsening parkinsonism from medication non-compliance. Her course was complicated by episodes of severe vertigo which is likely BPPV. We has hoped to do an MRI to evaluate for the cause of her vertigo and left sided weakness however the patient any family refused this. The patient's vertigo was treated with meclazine with improvement.
39
247
14242530-DS-13
23,814,694
Mr ___ It was a pleasure taking care of you. As you know you were admitted due to difficulty swallowing which we found was due to irritated tissue. You were given a short course of steroids and medications to control the symptoms. Since you are now eating normally you don't need steroids but can continue the other meds to ensure pain relief. Please be sure to followup with Dr ___ and continue your remaining radiation treatments.
___ ___ with high grade neuroendocrine mediastinal carcinoma (on paclitaxel and RT to lung/esophagus), c/b malignant hemoptysis and compression s/p tracheal stent ___ (now s/p removal ___, DVT (on Xarelto), who presented with worsening odynophagia and dysphagia x 8 days ___ mild mucositis, improved with supportive care and short dexamethasone course, was tolerating normal diet by discharge, has close outpatient f/u in ___ clinic # Dysphagia (solids > liquids) # Odynophagia Pt presented with significant odynophagia/dysphagia. Pt received 4 days empiric fluconazole for ___ esophagitis since he presented w/ neutropenia, though was discontinued given lack of marked improvement and count recovery. ENT performed evaluation and identified mild mucositis. Dr ___ that radiation field did not extend up that high to cause findings. CT showed left sided adenopathy, suggesting that odynophagia/dysphagia are at least somewhat caused by tumoral compression in the neck c/b referred pain from extrinsic compression of the esophagus in the chest. Speech and Swallow team followed during stay, rec'd diet modifications. Patient was given short dexamethasone course which was tapered off by discharge. By time of discharge he was tolerating full diet without issue but had lingering ___ pain, managed with combination of liquid oxycodone and magic mouthwash which he was prescribed on discharge. Pantoprazole continued during stay and prescribed on discharge. Patient is to followup with ENT following completion of his ongoing radiation course. # Metastatic high-grade neuroendocrine carcinoma of the mediastinum # Cancer associated chest pain Diagnosed ___. Completed 4 cycles cisplatin/etoposide/atezolizumab (___), followed by 2 cycles of atezolizumab (last ___. Admitted ___ for small volume hemoptysis w/ rapid progression of disease noted on scan. Started paclitaxel + RT to mediastinum ___. Dr ___ ___ patient during stay, noted that he will receive C2D1 on ___. Pt nearing end of radiation course as discussed above # ___, neutropenia # Acute on chronic anemia Counts improved during stay so was likely ___ temporary BM suppression from recent chemotherapy. Counts to be trended in outpatient setting with further chemotherapy. # Malignant hemoptysis and tracheal compression s/p stenting ___ CT reviewed by IP with possible mild migration. Accordingly, stent removed by IP ___. After removal, patient had mild cough at night which resolved during the day, and CXR was without infiltrate. Pt may have lingering airway irritation from stent removal so abx held, and will need symptoms closely monitored in outpatient setting after discharge # HX of RUE DVT (in s/o PICC), LUE DVT RUE DVT diagnosed ___. LUE DVT diagnosed ___ in setting of holding rivaroxaban for 4 days while awaiting port placement. Patient was continued on rivaroxaban during stay.
75
420
17229222-DS-17
28,260,204
Mr. ___, You were admitted to the hospital with bleeding and confusion. Your confusion cleared quickly with lactulose. You underwent endoscopy that showed non-bleeding esophageal varices, and areas of bleeding in your stomach related to your cirrhosis. You underwent a procedure called APC during your endoscopy to stop the bleeding, and your blood counts stabilized. During your admission, you started the evaluation for liver transplant with laboratory testing and social work consultation. You should follow up with the transplant hepatologist on ___, as previously scheduled, for further evaluation. You also underwent an echocardiogram on admission that showed your aortic stenosis has worsened. You were evaluated by cardiology. You should follow up with your outpatient cardiologist for further management of your aortic stenosis. You may need a special echo called a "trans-esophageal echo" in the future, if you are to be further evaluated for liver transplantion.
___ w/NASH vs. cryptogenic cirrhosis c/b esophageal variceal bleed (___), recurrent encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and anemia who presents to ___ as a transfer from ___ with AMS and GI bleed (Hct 18), found to have hepatic encephalopathy and oozing GAVE. #) Oozing GAVE - Pt has a history of recurrent bleeding from GAVE. An EGD on ___ confirmed the diagnosis, and APC was repeated. The pt required a total of 4 units of pRBCs at ___ this admission, one each on ___ and 1 just prior to d/c on ___. His hct was stable but low at 23.5 on the day of discharge and post-transfusion hct rose to 26.7. The pt needs repeat CBC drawn in 1 week. He was discharged with a Rx for CTX to complete 7 days of SBP prophylaxis given the UGI bleed. If pt continues to have a decline in hematocrit, we suggests a follow up EGD in ___ weeks with possible APC or RFA. He should continue taking PPI 40mg PO daily. #) Encephalopathy - The pt has a history of recurrent encephalopathy after undergoing TIPS. This episode of HE likely was a result of GI bleed. Infectious work-up was negative (CXR clean at OSH. UA neg for infection. No tappable pocket of ascites to r/o SBP). His doctors at ___ considered TIPS reversal given frequent HE admissions, however the hepatology team at ___ recommend against TIPS reversal due to frequent GAVE bleeding, which would likely worsen with TIPS reversal. In addition, RUQ U/S this admission showed increased velocity through TIPS shunt, so it is naturally becoming more stenosed. The pt should continue taking lactulose TID for goal of ___ BMs daily. Ideally he should be on rifaximin as well, but financial restraints prohibit him from taking it. The pt was provided with 1 month of free prescriptions on discharge from ___, but the free pharmacy would not provide rifaximin. #) NASH cirrhosis - c/b esophageal variceal bleed ___, ___, recurrent encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and anemia. Transplant eval had been delayed, per pt's hepatologist at ___, given social stresses with wife currently undergoing w/u for possible breast cancer as well as frequent hospitalizations lately resulting difficulty making it to outpatient appointments. The pt's transplant work-up was initiated during this hospitalization with routine labs, social work consult, and a TTE (see "severe AS" below). Further work-up is being delayed due to severe aortic stenosis. He has follow-up at the transplant ___ clinic at ___. MELD labs were trended and stable this admission. The pt should continue lasix and spironolactone at home dose. #) Severe AS - The pt has a history of aortic valve replacement (bovine, per pt). A TTE was checked this admission due to anasarca. It revealed severe aortic stenosis with a peak gradient of 74 which has rapidly increased since last echo at ___ in the ___. A cardiology consult was obtained and they stated pt "will likely will need aortic valve issue resolved prior to liver transplant. Since he is a poor candidate for redo-AVR, we could consider aortic valvuloplasty as temporary treatment prior to liver transplant or TAVR in the future when he is on waiting list for liver transplant or AS worsens. He is followed by private cardiologist in ___, so he should be followed by his cardiologist as outpatient." ___ was recommended to further evaluate aortic valve prior to any valve intervention. However, since pt had just had APC for GAVE, they recommended holding off on TEE and following up with cards as outpatient. Pt was continued on his home dose diuretics. He was also re-started on nadolol for both cardiac protection and prevention of variceal bleed. Cards recommended aspirin and statin in the future, however benefit of these meds should be weighed against bleeding/hepatic injury risk.
154
652
19787509-DS-6
27,421,515
ACDF: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: • Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. • Rehabilitation/ Physical Therapy: ___ ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. ___ Isometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. • Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. • Cervical Collar / Neck Brace: You have been given a soft collar for comfort. You may remove the collar to take a shower or eat. Limit your motion of your neck while the collar is off. You should wear the collar when walking, especially in public • Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: ___ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ___ At the 2-week visit we will check your incision, take baseline x rays and answer any questions. ___ We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions.
Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Physical therapy and Occupational Therapy was consulted for mobilization OOB to ambulate and functional status. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet.
700
139
15152579-DS-12
25,326,352
Dear Mr. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted because of pain at your elbow and redness/bruising on your right arm. We checked your bloodwork and found you to have an elevated INR (Coumadin level) which has lead to ecchymosis or bleeding within the superficial skin layers. We evaluated your arm with ultrasound and the preliminary read confirmed that there was no hematoma or blood collection that would require further intervention. Also, we repeated your INR which was trending down. After serial examinations of your arm, we feel that the current area of redness is not expanding further. When you return home, it is important that you do not take Coumadin today. Tomorrow, you have an appointment with your PCP, ___, at 3pm for a check-up of your arm and repeat INR level. Dr. ___ will instruct you on further Coumadin dosing. Additionally, please call your cardiologist to arrange an appointment in the next ___ days.
___ year-old male with a PMH of atrial fibrillation on coumadin who presents with right elbow pain and bruising/redness in the setting of supratherapeutic INR, most consistent with extensive ecchymosis. # Ecchymosis/Right arm pain: He presented with large area of ecchymosis covering approximately 40% of right upper extremity, most notably at the medial aspect and antecubital fossa. Area of ecchymosis was relatively stable during course of admission. No drainage, pus or ulcerations consistent with cellulitis. Pt remained afebrile without leukocytosis. Blood cultures were drawn and he did receive Vancomycin IV x1 in the ED. Orthopedic service felt there may be mild hemarthrosis but did not recommend arthrocentesis given elevated INR and likelihood of reaccumulation. Ortho recommended elevation, ice, and full active ROM of elbow. Right upper extremity ultrasound was performed and prelim read was without obvious pseudoanyeurysms or blood collections. US final read pending on discharge. He used tylenol for pain control. ******************* PLEASE NOTE: after patient's discharge, Blood culture ___ bottles) resulted in gram positive rods consistent with bacillus or clostridium species. Thought to be skin or lab contaminant as patient was clinically afebrile, no leukocytosis, did not meet sirs criteria, and there were only ___ blood cultures with this species. Pt's PCP (Dr. ___ alerted by inpatient attending, Dr. ___. Patient will be followed-up day-after-discharge in clinic with Dr. ___. ******************** # Supratherapeutic INR: On coumadin for AFib with CHADS2 =2. His INR was elevated to 5.2 at ___ which decreased to 4.7 in ED and 3.5 morning of discharge with just holding coumadin. His Coumadin was held ___ and ___. He was given specific instructions to follow with his PCP ___ ___ for INR check and further instructions about restarting Coumadin. # AFIB: CHADS2=2, rate control with digoxin. Anticoagulation with coumadin, which was held given supratherapeutic INR. Plan to restart Coumadin on ___ after INR check at outpatient appt. # HTN: stable, he continued home meds # Normocytic Anemia: at baseline, no need for transfusion. # BPH: stable, continued finasteride # Hypercholesterolemia: continued home atorvastatin
175
347
17220099-DS-21
20,230,245
Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why was I admitted to the hospital? - You were dizzy and had difficulty speaking What was done while I was in the hospital? - You had an MRI that showed your cancer was stable - You had a swallow study that showed you are at risk for aspirating What should I do when I get home from the hospital? - Be sure to continue to take your medications as prescribed - Please go to all of your follow-up appointments, including with oncology and the speech and swallow team - If you have headache, nausea, vomiting, new weakness, numbness, tingling, problems speaking, worsening dizziness, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team
___ w/ thalamic glioblastoma c/b hydrocephalus s/p VP shunt, s/p IMRT/TMZ ___, TMZ and Bevacizumab, c/b disease recurrence s/p SRS ___, now on TMZ/Beva q3 mo, started on dex for recent dx of disease progression on ___, who p/w persistent dizziness and now intermittent dysarthria. ACUTE ISSUES # GBM with progressive disease # Dizziness These symptoms have been attributed to disease progression as enhancement on MRI c/w leptomeningeal disease previously. Radiation necrosis is unlikely as she is on Avastin. Was started on dexamethasone recently ___ to determine if she may have any benefit and this helped w/ nausea, but did not help w/ dysarthria nor dizziness. Dizziness is provoked by any movement, dysarthria and dysphagia are worsening from prior admission. MRI as an inpatient showed stable disease. The patient was continued on her home medications and instructed to follow-up as an outpatient to start chemotherapy. # Dysphagia: Symptoms appeared to be worse on this admission. Speech and swallow were consulted and recommended a video swallow, which showed a risk for aspiration. Swallow recommendations are the following: 1. Diet: thin liquids and moist ground solids until chewing improves 2. Medications: whole one at a time with thin liquids 3. Swallowing strategies: -Add a sip of liquid to the bite of food in your mouth if having trouble initiating the swallow -Cough and reswallow after every couple of sips of liquid to clear the airway 4. Oral care: brush teeth ___ times per day and use mouthwash prior to eating/drinking to decrease risk of pneumonia 5. Remain as physically active as possible to decrease risk of pneumonia 6. Consider nutritional supplements (e.g. Ensure, Boost) if chewing and swallowing food is too effortful # HTN: Patient significantly hypertensive. Was started on nifedipine at last admission as was bradycardic with metoprolol. Dose was increased to 20mg q8h with improvement in blood pressures. Goal BP <140/90. # Leukocytosis: Noted to be as high as 26.6 at the time of discharge. The patient was otherwise asymptomatic. Etiology unclear. CHRONIC ISSUES # Headaches: Improved w/ fioricet on last admission. # Dyspnea on Exertion: CTA ruled out PE on recent admission and these symptoms have resolved. TRANSITIONAL ISSUES []goal BP <140/90 []nifedipine increased from 10mg q8 to 20mg q8; converted to total of 60mg nifedipine ER daily []will need continued outpatient speech and swallow evaluation; patient sent with prescription []speech and swallow recommendations: 1. Diet: thin liquids and moist ground solids until chewing improves 2. Medications: whole one at a time with thin liquids 3. Swallowing strategies: -Add a sip of liquid to the bite of food in your mouth if having trouble initiating the swallow -Cough and reswallow after every couple of sips of liquid to clear the airway 4. Oral care: brush teeth ___ times per day and use mouthwash prior to eating/drinking to decrease risk of pneumonia 5. Remain as physically active as possible to decrease risk of pneumonia 6. Consider nutritional supplements (e.g. Ensure, Boost) if chewing and swallowing food is too effortful []should check CBC at next neuro-oncology visit on ___ to ensure leukocytosis is improving #CODE STATUS: Full code, presumed #HCP: Name of health care proxy: ___ ___ number: ___
125
479
10398029-DS-21
20,306,012
Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**
This is a ___ male who had previously underwent an ascending aortic hemiarch replacement back in ___ for an aneurysm. He also had a saphenous vein graft to the posterior descending artery. He presented with shortness of breath and a CT scan was performed and this demonstrated possible aortic intramural thrombus of the ascending aorta. Further workup revealed aortic stenosis. The usual preoperative work up included Dental clearance, carotid US, and Chest CT. ON ___ he was taken to the operating room and underwent the following: 1.Redo sternotomy.2.Coronary artery bypass grafting x2 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery.3. Aortic valve replacement with a 29 mm ___ Ease pericardial tissue valve, model ___, TFX, serial number is ___. 4. Reconstruction of pericardium with CorMatrix. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU for recovery and invasive monitoring. He required inotropy and pressor support to augment his hemodynamics postop. FFP, PRBCs and Protamine were administered for elevated chest tube drainage. He awoke neurologically intact and weaned to extubate. He was started on ___, Lasix. He continued to progress and was transferred to the step down unit for further recovery. Chest tubes remained in due to elevated drainage. Pacing wires were discontinued per protocol without incident. Physical Therapy was consulted for evaluation of strength and mobility. POD# 4 Chest tubes were discontinued per protocol without incident. His rhythm went into Atrial fibrillation and Amiodarone was administered. Anticoagulation was initiated and will be managed by ___ Medical in ___ as discussed with ___. By the time of POD 5 he was ambulating independently, wounds healing, and pain controlled. He was cleared for discharge to home with ___ services. All follow up appointments were advised.
122
308
18979146-DS-23
27,087,881
Thank you for choosing ___ for your care. You were seen in the emergency room by the Acute Care/Trauma Surgery team for a fall that happened a few days before you came in. You were admitted for pain control and was monitored for alcohol withdrawal since you had an elevated blood alcohol level. After evaluation from the Trauma service and Psychiatric service, you are now able to return home for further recovery. Rib Fractures: * Your injury caused 9 - 10th rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus).
Mr. ___ presented to ___ emergency room on ___ after a fall that occurred four days prior to admission. He was evaluated by trauma surgery and admitted for pain control and further evaluation. His hospital course was complicated by agitation secondary to likely alcohol withdrawal. Once evaluated in the ED, he was transferred to the TSICU for observation. Neuro: On admission, he received a rescue dose of phenobarb 2.5mg/kg for acute alcohol withdrawal. His CIWA scales was rated from ___. After 24 hours, he was transferred to the floor for further recovery. On ___ a coded purple was called, and patient required IV Haldol and transfer to the TSICU for management. Psychiatry was consulted and determined that he was acutely delirious. After re evaluation, psychiatry noted much improvement in patient's delirium and noted that patient can be discharged if no further medical needs. Pain was initially managed with a narcotic, but primarily Tylenol. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO, then diet was sequentially advanced as tolerated MSK: Per imaging, he had a chest wall hematoma adjacent to a nondisplaced left ___, and 10th rib fractures. Pain was managed expectantly. A tertiary exam revealed no new injuries. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up is currently as needed, and should follow up with PCP. Instructions with understanding verbalized and agreement with the discharge plan.
318
354
14014890-DS-10
20,149,060
You were admitted to the hospital with abdominal pain. A CT abdomen at an outside hospital raised the possibility of a partial small bowel obstruction and you were transferred here for further workup. We repeated the CT abdomen, this time with oral contrast which can provide more information, and there was no evidence of a small bowel obstruction. There was no evidence of an acute abdominal process to explain your abdominal pain. You have been tolerating a stage III bariatric diet and you are safe to be discharged. Please return to the ___ if you have any recurrent abdominal pain or have any difficulty taking food down. Please also stop taking any NSAIDs, including aleve aspirin or advil. We also drew nutrition las, and you are iron deficient. Please be sure to have close follow up with nutrition labs either by your PCP or ___ nutritionist. We called your PCP to ensure they also know this information. Please also continue to take any medications you were on prior to your arrival EXCEPT for any NSAIDs including aleve or advil; these should be stopped.
Ms. ___ was admitted to the bariatric service with abdominal pain after being transferred from an OSH with a CT read of possible small bowel obstruction. Due to her ___ en y gastric bypass, there was concern of an internal hernia and need for operative intervention. On arrival, she had a nutritional IV fluids given ("banana bag") which consisted of thiamine and Vitamin B12. Stat CBC/chem10 and lactate revealed no etiology of her abdominal pain. She had normal LFTs, lipase, lactate, and white count. She was started on an IV BID PPI and IVF and made NPO. She had a repeat CT abdomen with PO contrast to better evaluate for a small bowel obstruction. There were no abnormal findings on the CT scan. Her diet was advanced to stage III which she tolerated well. Nutrition labs were drawn which revealed iron deficiency. On questioning, she reported not following up with a nutritionist and not being aware of having her vitamin levels drawn by her PCP since her ___ en Y gastric bypass. The importance of having close nutritional follow up due to her altered anatomy was emphasized, including following closely Vitamin B1, B12, iron, vitamin D, and folate. Her primary care physician ___ was also telephoned and a message was with left with his office to communicate these recommendations. She had also been taking NSAIDs in the past and was unaware of their danger with after a gastric bypass, and the need to avoid NSAIDs was also reinforced. On the day of discharge, she was tolerating a stage III bariatric diet. Her pain was well controlled. She was voiding freely. She was ambulating independently without assistance. She will follow up with her PCP in one to two weeks.
187
304
10717448-DS-14
25,638,862
You were admitted to the hospital after a fall and presumed loss of consciousness. We evaluated you for causes of your frequent falls, including arrhythmias, heart attacks, deconditioning, and low blood pressure. Ultimately we were not able to find a single unifying reason for your falls, however a condition called orthostatic hypotension may be contributing, as well as being on multiple sedating medications.
#Found down: Patient with history of falls and dizziness and has been evaluated by Gerontology at ___ for this. Concern was for POTS disease because her HR increased >30 with standing. Has not been worked up for arrhythmia. She is on many medications that can cause hypotension, will however she was hypertensive on admission. She also has a murmur on exam that is known but has not had a recent echo, so one was ordered. It was notable for mild-mod aortic stenosis. EKG was nonischemic and telemetry not notable for any arrhythmias. Orthostatics were normal throughout the admission but the patient felt dizzy with sitting up. Physical and occupational therapy were consulted and recommended rehab. On discharge, carvedilol and aldactone were stopped and her amlodipine and lisinopril were uptitrated, with good control of BPs. #Mild Rhabdomyolysis: No evidence of ___, levels elevated to ~5K on admission. IVF were continued until CK downtrended to normal. #Leukocytosis: likely due to stress reaction. No evidence of infection. Downtrended on recheck. #Chest pain: Had chest pain episode in ED. On arrival to the floor she complained of heart burn. Trop neg x 1. ___ trop 0.02 but could be elevated due to rhabdo. No evidence of ischemia on EKG. Was given Tums and protonix for heartburn.
65
205
17869062-DS-2
24,891,017
You were admitted to the surgery service at ___ for surgical evaluation of your biliary obstruction. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you.
At the time of her admission on ___ the patient was hypotensive and had an elevated WBC to 16 with a left shift. She was therefore transferred to the ICU for further management. She was started on zosyn and given Vitamin K and FFP to reverse her coagulopathy. Due to her hypotension, CT scan was initially post-poned. Upon stabilization of the patient's blood pressure, it was decided to proceed with ERCP on ___. ERCP was unsuccessful due to an obstructing duodenal mass. An NG tube was placed, and three liters of gastric contents were removed from her stomach. At this time, the Hepatobiliary Surgical team was consulted for evaluation. Upon review of CT Abdomen/Pelvis, it was determined that the patient had a potentially operable lesion. The patient was scheduled for an upcoming surgical procedure on ___. For immediate biliary decompression and relief of the associated symptoms and abnormal laboratory values, on ___, the patient underwent percutaneous transhepatic cholangiography with decompression and drain placement. In the days thereafter, the patient was noted to have significant improvement in her TBili laboratory values, and some improvement her jaundiced appearance. Additionally, on ___, the patient had a PICC line placed, and TPN was started. The patient was repleted with intravenous fluids to replace the losses from both her abdominal drain as well as her NG tube. The patient had notable improvement in laboratory values and clinical appearance in this manner, over the following days, leading up to her scheduled operation on ___. On ___, the patient underwent an exploratory laparotomy with biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y, choledochojejunostomy and gastrojejunostomy, 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 NPO with an NG tube, on IV fluids, on a single-day-course of IV zosyn, with a foley catheter, and her PTBD in place, and an epidural for pain control. The patient was hemodynamically stable. On POD#1 (___), she continued to have the epidural for pain control. She therefore continued to have a foley catheter. She required aggressive IV fluid hydration post-operatively, which she responded well to, as gauged by her urine output and vitals, which remained hemodynamically stable and normal throughout. Her TPN was held on this day, and she remained NPO with her NGT n place. On POD#2 (___), her pain remained well-controlled with the epidural. Due to a hematocrit of 23, she was transfused 2 units of Packed Red Blood Cells on this day. Through follow-up of post-transfusion hematocrit, it was determined that she had responded well to this step. She worked on ambulating with Physical Therapy on this day. Her NG tube and foley catheter were maintained, and she remained NPO. TPN was restarted on this day. On POD#3 (___), she continued to have good pain control with the epidural. Her foley catheter was therefore also maintained. Her NGT was clamped on this day, and residuals were checked every four hours. She consequently also remained NPO. She ambulated twice with Physical Therapy. On POD#4 (___), she continued to have good pain control with the epidural. Her foley catheter was also maintained. Her NGT was removed, and she was permitted to have sips of liquids, which she tolerated well. She ambulated with Physical Therapy. On POD#5 (___), the patient's epidural was removed, and she was transitioned to oral pain medications, which she tolerated well. Diet was advanced to clears, in addition to having TPN, which she also tolerated well. She continued to ambulate multiple times per day. The foley catheter was removed, and she voided successfully. On POD#6 (___), the patient's PTBD drain was removed. She was advanced to full liquids, which she tolerated well. She was continued on TPN. She continued to ambulate multiple times daily, with physical therapy. On POD#7 (___), the patient was continued on TPN, and Enlive supplementation was added to her full liquid diet. Her pain was well controlled with oral medications. She continued to ambulate frequently and regularly. On POD#8 (___), per recommendations by Hematology/Oncology, a CT Chest was obtained for staging purposes. She was continued on TPN, but the volume was decreased to half. She continued to have good pain control, tolerating full liquids, and ambulating regularly. On POD#9 (___), she was advanced to a regular diet with Enlive supplementation, and continued on half-volume TPN. She continued to ambulate regularly, and have good pain control. On POD#10 (___), she was maintained on half-volume TPN, regular diet with Enlive supplementation, ambulating regularly, working with ___. 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. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. *********Staples were removed, and steri-strips placed.***** The patient was discharged home without/with services.***** The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.
346
875
11423061-DS-24
24,658,859
Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted after you had a fall, and were vomiting blood. While you were hospitalized, you underwent two head CT scans, both of which did not demonstrate evidence of acute bleed after your falls. Given your history of vomiting blood, you were initially admitted to the ICU. Here you were started on a new medication, called pantoprazole, to treat your GI bleed. You were monitored for evidence of bleeding, which you did not have. You improved, and you were transferred to the normal medicine floor. You undewent an EGD, where the GI doctors used ___ to look into your esophagus, stomach, and first part of your small intestine. During this procedure, it was discoverd that you have erosive gastritis, which is likley the cause of the blood in your vomit. Additionally, you were found to have a large amount of food in your stomach. The GI doctors who did this procedure recommend that you have a repeat EGD in 8 weeks to evaluate for healing, as well as an outpatient gastric emptyng study to evaluate the cause of the food retention in your stomach. Please note that the following changes were made to your medications: 1. Please start taking pantoprazole 40 mg by mouth twice a day Please discuss your medications with your PCP and psychiatrist. It is possible your medications are contributing to your unsteadiness, and you may benefit from having your medications adjusted.
___ y.o male with significant Pmhx of bipolar diorder, depression, osteoarthritis, and DVT/PE s/p IVC filter, on coumadin, who presents from his nursing home s/p mechanical fall on his right side of his head and hemetemesis. # GI Bleed: He reported multiple episodes of non-bloody emesis prior to emesis with frank blood, and the coffee-ground emesis. Additionally, he was found to be guaiac positive on admission. He was admitted to the MICU for close monitoring and observation. There, he was initially started on a PPI drip, and he was evaluated by GI, who recommended inpatient EGD. He was HD stable, his crit was stable, and did not have any additional episodes of vomiting. He was transitioned to IV PPI BID, which he tolerated well. He underwent EGD which showed erosive gastritis and duodenitis, as well as a large amount of food in the stomach. GI recommended repeat EGD in 8 weeks, double dose PPI PO, and an outpatient gastric emptying study. #Reported Dyspnea- He reported dyspnea prior to admission, although this was not an active issue during this hospitalization. He appeared euvolemic on admission with no evidence of wheezing or acute heart failure on exam. No infiltrate on CXR or fevers/chills to suggest pneumonia. Mild pulm edema on CXR better than ___, and stable on room air. He was diuresed with lasix, and restarted on his home regimen. He maintained excellent oxygen saturations throughout this hospitalization. # Lightheadedness: Complained of lightheadedness/dizziness on muptiple days prior to admission. Exact etiology was unclear, but most likely secondary to medication side-effects. There were no focal signs to suggest TIA or CVA, and head CT was normal. He was not orthostatic while on the medicine floor. #Bipolar disease- Stable on this admission. He was maintained on his home regmine of divalproex, doxepin, clonazepam, wellbutrin, paxil and quetiapine. #Hx PE/DVT- In the setting of GI bleed, his home coumadin was held, and he was given 10 mg FFP for reversal, prior to EGD. His INR on discharge was 1.8. #GERD- Well controlled on omeprazole. He denied any abdominal pain or reflux symptoms. In the setting of GIB (see above) he was on PPI drip, and transitioned to IV PPI BID. He was discharged on PO PPI BID, with close GI follow-up.
249
375
18780736-DS-17
23,904,202
Dear Mr. ___, It was a pleasure taking care of ___ during your recent admission to ___ came to use because your creatinine was increased. We gave ___ fluids and your creatinine improved. We also adjusted your diuretic regimen. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish ___ a fast recovery. Sincerely, Your ___ Team
Mr. ___ is a ___ man with history of CLL, thrombocytopenia, pure red cell aplasia, chronic kidney disease, and diastolic congestive heart failure who was admitted for acute on chronic kidney injury secondary to overdiuresis. ================
60
36
10817631-DS-10
25,587,982
Mr. ___, You were admitted to ___ with an infection. We treated you for a respiratory infection, and your symptoms improved. We would like you to complete a 14-day course of antibiotics to help clear this up. Your oncologist would like to see you in clinic on ___.
Mr. ___ is a ___ man with history of CAD s/p CABG, HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on pomalidomide/daratumumab presenting with weakness and fever. #Fever #Sinusitis Patient recently was admitted to BID-M for neutropenic fever with extensive evaluation without source identification. Patient was treated with 10 day course of empiric vancomycin/cefepime. He re-presented with recurrent fever. No clear localizing signs or symptoms of infection other than cough and possible conjunctivitis. CXR was without focal infiltrate. CT chest showed no pneumonia. CT sinus showed possible sinusitis. Patient did have loose stools prior to admission, but they were self-limiting. Infectious disease and oncology were consulted to help advise investigation and management. Patient was treated with empiric broad spectrum antibiotics with IV vancomycin, IV cefepime, and IV metronidazole, then transitioned to PO levofloxacin and flagyl on ___ once it was determined that he likely had viral URI +/- superimposed bacterial conjunctivitis/sinusitis. He remained stable on this regimen and was discharged on levofloxacin and metronidazole to complete a 14-day total course on ___. # Acute metabolic encephalopathy Delirium, febrile effects related to immunotherapy versus infection. Infectious workup and management as above. His encephalopathy resolved with the aforementioned treatment. # Multiple myeloma # Anemia/thrombocytopenia: Currently receiving treatment with daratumumab/pomalidomide. Intention had been to hold pomalidomide, but patient took 2 doses since recent discharge. Held daratumumab/pomalidomide but per Atrius onc. He will see his oncologist Dr. ___ on ___ to discuss resuming therapy. He received 1 U pRBC for symptomatic anemia and Hgb <7. # CAD s/p CABG # Demand ischemia: Patient with mild troponin elevation on admission, likely represents mild demand in setting of acute illness. Patient is asymptomatic and EKG was without acute ischemic changes. His home cardiac medications were resumed. # DMII: Labile blood sugars in setting of recent dexamethasone use. His home medications were resumed # Weakness # Fall Patient with global weakness in setting of febrile illness, labile blood sugars, and multiple myeloma on new immunotherapy regimen. ___ worked with the patient, and his mobility progressed to where they felt he would be safe to return home with home ___. # Conjunctivitis (viral versus bacterial): Patient had scant purulent discharge in left eye in ED and started on erythromycin. He completed 7 days of erythromycin ointment. # Gout: No evidence of acute flare. Mr. ___ was seen and examined on the day of discharge and is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes.
47
407
12658758-DS-28
27,446,862
Dear Ms. ___, You were admitted to ___ because you had pneumonia. During your hospitalization you were transferred to the ICU because you were not breathing well, but this improved with positive airway pressure. You were also treated with antibiotics and responded well. You will be going to a rehab facility after discharge to continue your recovery. In the ICU you were also found to have a new diagnosis of atrial fibrillation, an irregular hearbeat. We started you on 2 medications to prevent clots and stroke. You will also get a call from the cardiology office to schedule an appointment for further management. Please also schedule an appointment with your PCP after you leave rehab. It was a pleasure taking care of you, Your ___ Care Team
Ms. ___ is a ___ woman with history notable for HTN and endometrial cancer with oligometastasis to the left lung status post TAH-BSO in ___ and radiation in ___, presenting with fever to Tmax 100.8 (at home) and dyspnea, sent in by PCP, found to have RML and RLL pneumonia. She was initially treated on the general medicine floor, subsequently transferred to the ICU for hypercarbic respiratory failure. She was never intubated and monitored closely with improvement in respriatory status with continued treatment of pna. She was transferred back to the general medicine floor, where she remained well, breathing comfortably. # Pneumonia: Presented with SOB, hypoxia, and tachypnea. CTA with concern for lower and middle lobe pneumonia superimposed on atelectasis. She was initially treated broadly for HCAP, then transitioned to ceftriaxone and azithromycin for treatment of CAP. On ___, patient was noted to have worsening delirium and increased somnolence, in the setting of sustained tachypnea and hypercarbia. She was transferred to the ICU and started on BiPAP. Hypercarbia resolved and she was considered well enough to transfer to medicine. On the floor she remained afebrile without leukocytosis. She was transitioned to RA and breathing comfortably, sats in the early ___. She completed 8 days of abx (initally vanc/cefepime, narrowed to CTX/azithro) for CAP. Of note, vancomycin was re-started on the afternoon of ___ given blood culture showing GPCs but DC'd later as this was ultimately felt to be a contaminant. # Atrial fibrillation with RVR: Afib with RVR to the 130s was noted incidentally on telemetry in the ED on ___. In the MICU afib with RVR was observed again, and she was started on po diltiazem. Asymptomatic during episodes. She has a CHADS2-vasc of 4 and intermittent afib. She was started on warfarin with lovenox bridge. #Volume overload: Concern for mild diastolic heart dysfunction. CT and CXR with evidence of mild pulmonary edema. Underwent IV and PO diuresis. On discharge, on 1L supplemental O2. O2 requirement most likely thought to be from underlying lung disease from metastatic cancer to lung and subsequent radiation, as well as resolving pneumonia. # Hypertension Continued home nifedipine with holding parameters for SBP<100 or DBP<40. # Hyperlipidemia Continued home lipitor. # Chronic back pain ___ spinal stenosis Continued home gabapentin, but held Tylenol out of concern that tylenol would mask her fevers. Tylenol was restarted upon discharge. # Risk of CAD Aspirin continued this admission.
123
392
17574719-DS-19
26,063,950
Mr. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? - You were admitted to the hospital because you were found to be lethargic. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - You were found to have a urinary tract infection and were treated with antibiotics. - You were found to have low blood pressure which improved after receiving fluids through your IV. - Your mental status improved after starting antibiotics and giving fluids. - Your blood WHAT SHOULD I DO WHEN I GET HOME? - Follow up with your primary care physician - ___ taking antibiotics until ___ We wish you the best! Your ___ Care Team
ASSESSMENT AND PLAN: ___ yo M with history of HTN, HLD, DM, dementia, BPH s/p indwelling foley with recent UTI on cipro presenting with lethargy found to have urosepsis and likely demand ischemia.
108
33
13751863-DS-24
23,659,790
Dear Mr. ___, You were admitted to the hospital after you suffered a fall. You were found to have a patellar fracture of the left knee. Incidentally, you were also found to have progression of your lymphoma. During your hospital stay you underwent radiation and chemotherapy to alleviate the symptoms you were experiencing from the lymphoma. We treated you for a pneumonia seen on your chest X-ray with antibiotics, which you will continue through ___. We monitored your blood sugars closely and you will be discharged with insulin. You may bear weight as tolerated on your injured leg while wearing the brace provided. Please follow up with the appointments listed below.
Mr. ___ is a ___ year old man with recurrent DLBCL, DM1 and cirrhosis who presents after a mechanical fall and is found to have a patellar fracture of the left knee. He incidentally was found to have a 1.6 cm mass in the right temporal area, highly suspicious for malignancy now with evidence of extensive lymphoma progression. ACTIVE ISSUES ============= # HCAP Pneumonia CXR on ___ was suggestive of a RUL pneumonia and given that he had been hospitalized since ___, he was treated for an HCAP with Cefepime and Vancomycin with plan for a 14 day course to end through ___. He did not have fevers and was not symptomatic. His Vancomycin levels were difficult to control, with Vanc trough of 42 on the day prior to discharge (at which point Vancomycin was discontinued) and 25.8 on the day of discharge with evidence ___ (resolved s/p discontinuation of Vanc). Given that he was clinically asympomtatic from a pulmonary status and elevated Vancomycin levels his Vancomycin was discontinued. He will continue to take Cefipime through ___, to complete a 2 week course. # RLE ulcer Patient was admitted with a known RLE ulcer which was evaluated and treated per wound care. However, on ___, given his neutropenia, there was concern for cellulitis and he began treatment with Vancomycin (day ___ with plan for a 14 day course through ___. His Vancomycin levels were difficult to control. His trough was 1.7 on Vancomycin 750 BID and subsequently 42.3 on Vancomycin 1g BID. Given elevated trough, as well as evidence of ___, his Vancomycin was discontinued. His RLE wound was much improved on day of discharge without evidence of infection and his Vancomycin was discontinued as noted without plans to restart. # DLBCL MRI abdomen as well as PET CT showing evidence of progression of disease. He is now s/p palliative chemo with cytoxan/etoposide on ___ and palliative radiation therapy on ___. S/p rituxan on ___. Methadone was converted to TID dosing for pain control (methadone 30mg PO TID) and dilaudid was used for breakthrough pain. He initially required IV dilaudid for pain control and as his pain decreased after chemo/radiation, he was transitioned to PO dilaudid. However, he subsequently endorsed poorly controlled pain with dilaudid ___ PO Q4H PRN and required 0.25 mg IV for breakthrough. He was started on Ativan 0.5 mg PRN pain/agitation which proved to be effective for symptom control. Home dose acyclovir was continued as ppx. # Type I DM Patient has a known history of type I diabetes. He was followed by ___ throughout his hospitalization. He had several issues with both hypoglycemia and hyperglycemia. Ultimately he is discharged on the following regimen: - Lantus 11 units QAM - Humalog sliding scale for goal glucose <300 Breakfast Lunch Dinner Bedtime 71-150 0 0 0 0 151-200 3 3 3 0 ___ 5 5 5 1 301-350 6 6 6 2 351-400 7 7 7 2 - He does have a tendency to fall asleep during his meals and it is thus advised to give him his Humalog after he finishes his meal to prevent hypoglycemia # Hyperbilirubinemia: Initially presented with hyperbilirubinemia, likely related to pRBC transfusion and resolved. # Hyponatremia Patient had hyponatremia to 132 in the setting of hyperglycemia. Most likely a pseudohyponatremia. Resolved with better control of his blood glucose levels. # Thrombocytopenia Patient has baseline thrombocytopenia-acute drop likely due to cirrhosis versus lymphoma versus chemo. There was initial concern for HIT and heparin products were discontinued, however, platelets dropped after stopping heparin products, making HIT less likely. Most likely due to chemo and demonstrated slow improvement throughout his hospitalization. # Anemia Patient anemic at baseline (likely multifactorial) now with acute decrease in Hct, likely due to chemo. Patient was transfused for Hct<21. His blood counts remained stable throughout his hospital stay. # Abdominal pain Likely due to lymphoma, treated with pain regimen as noted above. # Brain mass Incidentally found on Head CT after fall. Better seen with brain MRI. Per radiology, the mass did not appear to look like lymphoma- however it is possible given his extensive disease progression. Unlikely to be meningioma given that it was not seen in ___. He received cyber knife treatment once on ___. # HBV/HCV Cirrhosis Patient has a known history of hepatitis B and hepatitis C. Hepatitis B viral load was negative on this admission. His home dose lamivudine and nadolol were continued during this admission. The patient intermittantly took lactulose but was difficult to maintain complete compliance. # Scrotal swelling Ascities and scrotal swelling malignant versus due to cirrhosis. He was treated with lasix 40mg PO daily; however, swelling with minimal improvement during hospital stay. Will continue on Lasix. On the day prior to discharge he had low urine output, and was bladder scanned for >500 cc (likely largely ___ to narcotic use). He was straight catheterized. He may require intermittent straight catheterization during his rehabilitation stay. # Prolonged QTc QTc 502 on EKG on ___. From reviewing past EKGs, looks as though this has been ongoing. Most likely due to his methadone. QTc was monitored weekly throughout his admission. Qtc 473 on ___. # ___ Was likely in the setting of hyperuricemia. He was started on Allopurinol and his renal function resolved back to baseline. He had another episode ___ in the setting of Vanc trough of 42.3. He was given IVF, Vancomycin discontinued, and his ___ resolved. # Hyperuricemia After receiving chemotherapy, patient noted to have hyperuricemia. Uric acid found to be around 11 and he received rasburicase on ___. He was also maintained on allopurinol ___ PO daily. # L knee patellar fracture s/p Mechanical Fall Patient was evaluated by orthopedic surgery who recommended conservative treatment with immobilization and pain control. Patient worked with physical therapy while hospitalized. He will be discharged with a knee immobilizer. # Hx of substance abuse Patient was admitted on maintenance methadone 90mg PO daily. However, this home dose methadone was transitioned to 30mg PO TID to be used as pain control instead of as maintenance methadone. TRANSITIONAL ISSUES =================== - Patient to follow up with Dr. ___ on ___ - Please continue patient on Lantus and ISS as noted above - Please change wound dressing daily - Patient OK to weight bear as tolerated on left knee with left knee immobilizer - Patient to continue on Cefipime Q12 hours through ___ to complete a 2 week course
111
1,199
17147211-DS-17
21,015,442
Dear ___, You were hospitalized due to symptoms of altered mental status resulting from an INTRAPARENCHYMAL HEMORRHAGE, a condition where there is bleeding found in the brain tissue. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain can result in a variety of symptoms. Brain bleed can have many different causes, including stroke, trauma, medical conditions. We assessed you for medical conditions that might raise your risk of bleeding and stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: 1) Alcoholic cirrhosis (liver disease from alcoholism) with portal hypertension (elevated blood pressure) 2) Diabetes 3) smoking We are NOT changing your medications. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team
Ms. ___ is a ___ year old woman past medical history of alcoholic cirrhosis c/b portal vein HTN, encephalopathy esophageal varices, s/p TIPS ___, T2DM, cervical stenosis with a right frontal intraparenchymal hemorrhage. #Right frontal IPH Mic___ initially presented to ___ ___ after being found on the ground by her daughter confused and less responsive and left sided weakness. She was found to have a right frontal IPH on CTH and was subsequently transferred to ___ for further evaluation. All antiplatelets and anticoagulants were held. In the ___, she transiently required a nicardipine gtt to maintain SBP <150 but this was quickly titrated off. She was given 1 ___ in the ___, and on repeat CBC platelets decreased to 35; another unit of platelets were given for goal platelet count >50. Patient was clinically improving, and admitted to the ___ for Q2H neuro checks for close monitoring given thrombocytopenia. Her platelets were trended Q6H for 24 hours, and she required no further platelet transfusions. CTA H&N negative for stenosis, occlusion, dissection. CTH was repeated ___ and was stable. MRI stable with 2.8 cm hematoma in R frontal lobe, and otherwise negative. Etiology of stroke thought to be secondary to coagulopathy, could also consider hypertensive etiology. We will plan to follow up in stroke neurology clinic for repeat MRI to evaluate for resolution of hemorrhage. #Thrombocytopenia Thought to be secondary to coagulopathy. She received a total of 2U of platelets and required no further transfusions. Discussed case with hematology, who recommended no further workup or intervention. Also discussed with hepatology, who recommended continuing to hold SSRI as these medications can worsen a coagulopathy. #Hypertension She was on a tight BP control, with goal SBP <140. We continued home spironolactone 25 qDaily, and captopril increased from 6.25 TID to 12.5 TID. This medication can be switched to long acting once per day prior to discharge. #Trop 0.03 on admisison Trended down, thought to be secondary to demand. No complaints of chest pain. EKG with no acute findings. #DM A1c 7.9. Patient was put on sliding scale insulin for tight blood sugar control, and this should be continued at rehab. Her home lantus dose was cut by 50%, and this should be increased as needed. #Pulmonary nodules Incidental finding of pulmonary nodules on CTA H&N. "Multiple pulmonary nodules measuring up to 4 mm in the right apex.For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Guidelines for the Management of Pulmonary
233
431
13485675-DS-2
20,482,895
Mr. ___, During this admission you were determined to have a transient ischemic attack and because you are at a high risk of stroke we have started you on aspirin 81 mg daily and atorvastatin 80 mg daily. We are uncertain exactly why you had this event, but to complete our workup we will discharge you with a monitor to look for abnormal rhythms. We will have you follow up in stroke follow up clinic with Dr. ___. Thank you for allowing us to care for you ___ Neurology
___ without significant past medical history admitted with transient right-sided facial droop, speech difficulty, upper extremity weakness, and sensory disturbance, found on CTA at ___ to have left M2 occlusion prior to transfer to ___. Symptoms resolved on arrival to ___, although examination notable for subtle right-sided weakness in the distal upper > proximal lower extremities. MRI brain revealed small left parietal infarcts suggestive of a cardioembolic origin, although no paroxysmal atrial fibrillation noted on telemetry during the admission. Due to intracranial artery stenosis noted on vascular imaging, patient was started on aspirin 81 mg daily and atorvastatin 80 mg daily. TTE revealed a PFO, but there were no DVTs on MRA pelvis ___ US. Patient was discharged with ___ and ___ follow up with Dr. ___. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 123) - () No 5. Intensive statin therapy administered? () Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A
91
407
10961804-DS-10
24,010,761
Dear Ms ___, You were admitted to the ___ after you had worsening shortness of breath. We had to give you IV diuretic medications to help remove the extra fluid from your body and lungs. We found that you were still in an irregular heart rhythm, "atrial fibrillation," and after talking with your Cardiologist Dr ___ decided to perform an electrical cardioversion, which flipped your heart back into a normal sinus rhythm. - Your dry weight is 62.7 kg. - Our hope is that your heart stays in a normal heart rhythm. If you start to feel palpitations you may have atrial fibrillation again, so notify your MD. - You have urine retention. We discussed this with a urologist while you were here, and this is typically followed as an outpatient. You should have follow up with a urologist to figure out why this is happening. It is probably a chronic problem, and there is nothing urgent to do about it. - Please take your medications as below. - Weigh yourself every day, and if you gain or lose more than 3 lbs please notify your doctor. - If you aren't feeling well and have a little bit of fluid buildup again, it is important to call Dr ___ potentially have yourself scheduled for an appointment to be seen. It was a pleasure taking care of you! Zei Gezunt, Refuah Shlaimah, ve'hatzlachah rabah ad me'ah ve'esrim!! Your ___ Cardiology Team
Ms ___ is an ___ with HFpEF, AF, HTN, p/w with progressive SOB, ___ edema found to have CHF exacerbation, s/p IV Lasix diuresis w/improvement in Sx, s/p ___ (___) of AF to sinus rhythm # Acute on chronic HFpEF Pt had gradual progression of Sx over weeks-months, had declined CDAC admission earlier for IV diuresis, found to have volume overload, s/p IV Lasix diuresis. Repeat TTE similar to prior (symmetric LVH, mild AS, mild pulm HTN, EF >65%). After discussion with outpt Cardiologist Dr ___ for ___ of AF to assist with CHF management, increased home Amio to BID but discharging on once a day due to bradycardia in sinus rhythm. Admission weight (69.1 kg 152.34 . D/c weight 62.69 kg (138.2 lbs). Restarted home Losartan as tolerated. DC'd on atorvastatin 10 mg daily, losartan 100mg daily , propranolol 10 mg (also has tremors) BID, Bumetanide 3 mg daily # Paroxysmal AFib vs Flutter Pt has been in persistent AFib vs flutter since at least ___, was initially c/w home Amiodarone + Propranolol. Previous ___ in ___. After discussion w/ outpatient Cardiologist Dr ___ (___) was performed but reverted to Aflutter on ___ and then s/p ___ (___) and returned to sinus rhythm before discharge. Increased home Amiodarone from 200mg qd to 200mg BID during most of her stay but now being discharged on amiodarone 200 mg daily, home rivaroxaban 15 mg daily, propranolol 10 mg BID # Urinary Retention Had multiple PVRs >500cc but continued to urinate 100-200ccs every ___ hours. UA wnl. CTs in two occasions in ___ and ___ showing distended bladder (763 ccs, 528.3 cc) and occupying the space and creating a 4.5 cm hypodense structure posterior to the bladder. A pelvic ultrasound had been recommended at that time, which the patient declined. At this point she should have outpatient urology follow up for consideration of any further workup. A foley catheter was not placed at discharge as she was asymptomatic without UTI ___ at time of discharge. -F/u outpatient if patient wishes to work up # Dysuria and pyuria # Vaginal itching (resolved) Patient completed a 7d course Augmentin for chalazion on day of admission, s/p CTX & fluconazole in ED with c/f UTI vs vaginitis. Started Nystatin w/improvement in Sx. UA w/pyuria, though UCx was neg, no further Abx given #Chest rash: related to pads from ___, improving. CHRONIC ISSUES ============== # Mild Cognitive Impairment: Alert and oriented but with poor short-term memory and attention # Tremor: Pt with baseline tremor, c/w home Propranolol # ?Viral conjunctivitis: per pt, eye drops stopped per outpt Optho, started frequent warm compresses w/improvement in Sx. Gave artificial tears. # HTN: slowly increased Losartan back to home dose, held home amlodipine # CONTACT: HCP: Proxy name: ___ (daughter) Phone: ___ TRANSITIONAL ISSUES =================== [ ] Re-check EKG to determine if she is still in sinus in cardiology f/u in 1w [ ] Patient discharged with ___ of Hearts monitor, please consider adjusting amiodarone dose based on her afib burden. [ ] Stopped home amlodipine during admission due to soft BPs. [ ] Discharge diuretic dose is 3mg Bumex daily [ ] Monitor weights and titrate bumex (dry weight 62.69 kg (138.2 lbs)) [ ] Patient had urine retention, which is likely chronic. She should be seen by urology as an outpatient for further evaluation. Please arrange this. She had a pelvic finding on prior abdominal CT imaging where a mass could not be excluded posterior to the bladder, but refused further follow up. This could be addressed with pelvic ultrasound. [ ] repeat chem 10 panel in ___ days to ensure stable. Cr at discharge 1.2 Discharge weight: 62.69 kg (138.2 lbs) >30 minutes spent on discharge planning/coordination of care
238
605
10312052-DS-19
21,567,940
* You were admitted to the hospital for evaluation of your right pneumothorax and failure to wean from the respirator following your surgery. * You have done well in weaning from the ventilator and breathing on your own and are now ready to return to rehab for more therapy. * You will continue to require tube feedings via your PEG tube and the Speech and Swallow therapist will evaluate you when you are ready to safely swallow food. * Continue to work hard with Physical Therapy to get strong and improve your endurance. * You will need to follow up with Dr. ___ in ___ weeks and the rehab will arrange transportation for you to return to the Thoracic Clinic. * Call ___ with any questions about this hospitalization.
Mr. ___ was evaluated by the Thoracic Surgery service in the Emergency Room and a right pleural pigtail catheter was placed to evacuate his right pneumothorax. He was then admitted to the ___ for vent management as well as management of his pigtail catheter. Most recently at rehab he had been able to tolerate a trach collar during the day and PSV overnight. He felt that his dyspnea improved following placement of the pigtail catheter but on xray, the pneumothorax was the same. There was no air leak from his pigtail catheter. The Pulmonary service was consulted to comment on his fibrotic lung disease which was confirmed on pathology (UIP). After the patient's initial roughly 1-month Prednisone taper, he was not on prolonged steroids. They felt that he didn't have clinical evidence of an ILD flare, and CT imaging did not demonstrate progressive fibrosis or ground glass in a pattern consistent with flaring. However, he did have significant LLL consolidation and mucus plugging; pulmonary hygiene and mucus clearance is key to help with vent weaning. They also felt that his remaining R lung has less parenchymal abnormality than his L lung and his oxygenation would significantly be affected by any pleural process that impairs R lung ventilation. They recommended starting albuterol nebs q6hr with dedicated coughing and airway clearance after, starting start Mucinex ___ mg BID. They will also arrange outpatient pulmonary follow-up for consideration of pirfenidone. Mr. ___ was able to be weaned off the ventilator and has been on a 60% trach collar for the last 72 hours. His pigtail catheter was removed on ___ and he denies any change on his baseline dyspnea. He was evaluated by the Speech and Swallow therapist and cleared for use of a passey muir valve for ___ minute spurts with supervision. His tube feedings were changed to Osmolite 1.5 from Jevity 1.2 due to loose bowel movements. All stool studies have been negative including C diff, banana flakes have been added and the beneprotein has been stopped. Cardiology was also consulted to comment on his PAF with RVR and they recommended titrating up his Metoprolol to 37.5 q 6 hrs, continuing his diltiazem at 60 mg q 6 hrs and if needed for rate control, possibly adding digoxin. Currently with his Metoprolol at 37.5 mg q 6 hrs his rate is better controlled. Anticoagulation was also discussed and deferred given his ___ sore is 1 and prior chest wall hematoma. Mr. ___ is gradually getting stronger and now off the ventilator but still needs more physical therapy as well as SLP before returning home. He was discharged back to rehab on ___ and will follow up with Dr. ___ in 4 weeks.
124
450
13777886-DS-12
23,626,152
MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - Nonweightbearing in the right leg - Range of motion at the right knee as tolerated, in an unlocked ___ brace Physical Therapy: NWB RLE ROMAT in unlocked ___ Treatments Frequency: Dressings may be changed as needed for drainage. No dressings needed if wound is clean and dry. Staples will be removed in ___ weeks at follow up appointment in Ortho trauma clinic.
The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and 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 home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.
193
239
11514055-DS-9
27,231,506
Mr. ___, You were transferred to ___ because of dyspnea. You had an ECHO of your heart that showed decreased function. A second ECHO was done to better evaluate your valve and there was no evidence of infection or clot. A cardiac cath was done and one of your stents was opened up. Medication changes: START lisinopril 10 mg by mouth daily for your heart and blood pressure START metoprolol XL 25 mg by mouth daily for your heart and blood pressure STOP hydrochlorothiazide as you will be on metoprolol XL and lisinopril for your blood pressure Please have INR drawn on ___.
___ year-old-male with a history of CAD s/p CABG in ___, PCI in ___ and ___, AS s/p AVR in ___, atrial fibrillation on coumadin, permanent pacemaker, chronic angina, hypertension, and hyperlipidemia presenting with dyspnea found to have new systolic CHF (EF ___ and aortic valve lesion and new hyponatremia, now s/p POBA to ___. # New-Onset Systolic CHF EF ___: Patient presented with symptoms of new onset heart failure. TTE showed severe regional LV systolic dysfunction (EF ___ with akinesis of the inferior wall, hypokinesis of the lateral and anterior walls with preservation of the septum which appeared to be new. Cardiac cath performed on ___ with successful angioplasty of subtotal occulusion of the left circumflex at the site of the bare metal stent. Otherwise the LIMA to LAD was patient, mid RCA occluded with collateral flow. Patient was diuresed with lasix, discharge weight 76.6kg. He was also started on lisinopril and metoprolol. # Aortic Valve s/p AVR: ___ at OSH showing possibly thrombus or endocarditis of mechanical prosthetic aortic valve. TEE performed on ___ showed no evidence of vegetation or thombus. Further no evidence of endocarditis on exam and blood cultures negative. Patient initially received Vitamin K. He was started on a heparin drip that was continued until INR was therapeutic (>2.5). # Coronary artery disease: Patient has known CAD s/p CABG in ___ ___ to LAD, SVG to RCA (known to be occluded) and SVG to OM (known to be occluded), also BMS to Left circumflex/OM. Patient presented with new wall motion abnormalities on ECHO as described above, EKG without evidence of ischemia, Troponins elevated with flat CK-MB. Cardiac cath performed ___ as above with successful angioplasty of LCx stent. Patient continued on aspirin, ranexa and statin. # Hyponatremia: Patient presented with hypervolemic hyponatremia, sodium of 119 and was asymptomatic. Sodium improved with diuresis to 132. # HLD: Patient continued on simvastatin. Consider rechecking as outpatient.
99
324
19495630-DS-10
28,990,611
You were admitted to the hospital with difficulty breathing and were diagnosed with pneumonia and a COPD exacerbation. You were treated with antibiotics, steroids, and nebulizers with improvement in your breathing. You are being sent home with continuous oxygen, which you should use at all times. MEDICATION CHANGES: - you were started on Albuterol nebulizers and given a prescription for a nebulizer machine - you were started on home oxygen - you should use the Nicotine patch daily - do NOT smoke cigarettes while using oxygen
___ with hx of COPD, tobacco use (ongoing), atrial fibrillation on coumadin, hypercholesterolemia, stage IV CKD presenting with worsening shortness of breath, productive cough of white/yellow phlegm found to have multifocal infiltrates consistent with PNA and COPD exacerbation. . ## Community-acquired pneumonia: Admission CXR showed multifocal infiltrates supportive of pneumonia. He completed 7 days of Levofloxacin symptomatic improvement. Repeat CXR prior to discharge showed significant regression of the infiltrates noted on initial CXR. . ## COPD exacerbation: Symptoms improved with antibiotics as above as well as 5-day course of Prednisone 40mg daily and nebulizers. He was discharged home with rx for a nebulizer machine and Albuterol nebs. He still had mild wheezing on discharge but overall improved. . ## Hypoxemia: Patient is not usually on home oxygen and his normal oxygen saturation is around 93-95% on room air with one recent finding as low as 88% at his cardiologist's office. Here, he initially required 3L NC to maintain sats in the low ___. Despite multiple attempts, he could not be weaned off oxygen completely. He had consistent desaturation to 85-88% on room air with ambulation. Therefore, he was discharged on continuous ___ O2 and set up with ___. Repeat CXR prior to discharge showed improvement of pneumonia and also was not remarkable for volume overload to account for the persistent hypoxemia. . ## Tobacco dependence: He was maintained on a Nicotine patch with good effect. He was told that he cannot smoke now that he is on supplemental oxygen. . The remainder of his medical issues were stable during this admission. .
81
251
12567683-DS-15
27,525,077
Dear Mr. ___, You were admitted to ___ for shortness of breath and new blood clots in your lungs. You were also found to have a pneumonia (lung infection) and a pleural effusion (fluid accumulation in your chest). We treated you with blood thinners to prevent further clots. We also treated you with antibiotics and a procedure, called a thoracentesis, to drain the extra fluid. You were seen by our oncologists, who recommended that you ___ soon for further imaging and staging of your cancer. We are very sorry about this diagnosis. Please do the following once you leave the hospital: - Continue taking the prescribed antibiotics: Augmentin 875 mg every 12 hours, ending on ___, which will treat your pneumonia - Start taking oxycodone 5 mg every 3 hours as you need it for pain control. We have given you enough pills to last one week, before which you will see your primary care physician for ___ - Please also start taking the following medications: 1) Albuterol inhaler with spacer, and guaifenesin as needed for cough, 2) Colace and Senna as needed for constipation - Please continue doing the Lovenox injections (90 mg every 12 hours) to help prevent further blood clots It was a pleasure to participate in your care. We wish you all the best. Sincerely, Your ___ team
___ y/o M with recent diagnosis of lung adenocarcinoma who presented as a transfer from ___ with SOB, found to have bilateral PE's, recurrent malignant right sided pleural effusion, and post-obstructive pneumonia. #Acute pulmonary embolism without cor pulmonale: Patient presented to ___ on ___ with SOB and chest pressure and found to have bilateral subsegmental PE's on imaging. Hypercoaguable state secondary to malignancy. Was transferred to ___ for management and further work-up. On admission to ___, he denied chest pain or dyspnea and his vitals were stable. His cardiac workup was negative with unremarkable EKG and negative troponins. He received heparin on admission and was transitioned to lovenox. Discharged on lovenox 90mg SC q12h to continue indefinitely. #Malignant pleural effusion: On presentation to ___, patient was found to have a right-sided pleural effusion on imaging. Prior to this, he had recently undergone a US-guided thoracentesis on ___ at ___ with 60cc fluid drained. Pleural fluid cytology results were positive for malignant cells. Based on history, was likely a re-accumulated malignant effusion but there was also concern for a parapneumonic effusion given the patient's recent h/o of pneumonia. IP performed a thoracentesis on ___ and 2L were drained from right pleural effusion. Cultures negative at both outside hospital and during this hospitalization. Fluid results were consistent with exudative effusion, cytology confirmed the presence of malignant cells. Patient was weaned from 2L oxygen to RA without issues. A repeat CXR on ___ showed mild right sided pleural effusion, but much improved from admission. Patient was discharged on oxycodone 5mg and an outpatient ___ with IP scheduled for ___. He was counseled on the warning signs which should prompt emergent re-evaluation such as dyspnea, fever, worsening chest pain, hemoptysis. #HCAP: Prior to admission on ___, patient had been treated for CAP at ___ and completed a ___ day course of Augmentin and Azithromycin on ___. He represented to ___ on ___ with productive cough, SOB and fevers/chills. Had CXR and CT torso. CXR showed evidence of postobstructive pneumonitis in the right upper lobe with partial collapse of the right upper lobe. Upon admission to ___, he was started on vancomycin/cefepime given concern for HCAP(start date ___. MRSA, legionella, sputum and blood cultures sent. Sputum culture was not valid and remaining cultures were negative. Legionella was negative. Patient was switched to Augmentin PO on ___ to complete a 2 week course to end ___. He received ipatroprium and albuterol nebs PRN, guaifenesin 600mg BID for management of respiratory sxs, and given a flutter valve. #Pain control: Had significant pain secondary to cancer, pleural effusion, recent procedure. While inpatient his pain management was oxycodone 5 mg mild pain, oxycodone 10 mg moderate pain, dilaudid 0.5 mg IV severe pain. He was discharged on oxycodone 5 mg q3h pain x1 week and bowel regimen with ___ with PCP. #Stage IV lung adenocarcinoma: Recently diagnosed with adenocarcinoma with positive lymph node, invasion of mediastinum and malignant pleural effusion. Cytology was positive for malignancy at ___ and again on this hospitalization. A recent CT chest with contrast demonstrated invasion into mediastinum, vasculature and bronchial tree. CT also showed evidence of adrenal mass with concern for a possible met. Given malignant effusion, patient has stage 4. A bone scan on ___ was negative for bone metastases. The patient has decided to establish care at ___ and has scheduled an outpatient appt on ___. Summary of hospital course will be faxed to ___. Imaging results given to patient in a CD
214
578
14861352-DS-10
24,509,885
Dear Mr. ___, You were hospitalized after your MRI revealed an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. Damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - high cholesterol - high blood pressure We are changing your medications as follows: - starting plavix - stopping aspirin - increasing your atorvastatin dose Because we did not find the cause of your stroke, you will have a cardiac monitor outpatient (called ___ of Hearts). Please call ___ to set this up. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - 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.
Mr. ___ is a ___ year old man man with a history of cerebral palsy and recent cognitive decline who was found to have an incidental acute right occipital stroke on his MRI obtained for cognitive workup. He has no new deficits and is asymptomatic. Etiology is unclear. # Acute Stroke: CTA of the head and neck showed patent vessels and small outpouching of basilar which is likely incidental. He was switched from Plavix 75mg daily from aspirin for secondary prevention. He was monitored on tele for afib. His atorvastatin dose increased from 40mg to 80mg daily. Echo did not reveal cardiac source. A1c was 5.6% and LDL was 107. No etiology of his stroke was found and he was discharged with plan for ___ ___ to monitor for afib. # Hypertension: Lisinopril and chlorthalidone were held to allow for permissive hypertension but were restarted prior to discharge. # Cognitive Decline: continued his B-12 for replacement. He will follow up in neurology clinic for further management.
342
164
17761931-DS-21
23,803,016
Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - Your primary care doctor referred you to the ED for low blood pressures. - You told us you had been experiencing occasional dizziness, weakness in your legs, and leg swelling for quite some time. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had lab work that showed your red blood cells and platelets were lower than normal levels. - You had an ultrasound of your heart (echocardiogram) that showed no change in heart function from prior studies, but did show pulmonary hypertension (increased pressures in your lungs). - You had CT-imaging done of your chest to help determine why you have pulmonary hypertension. - You had CT-imaging of your stomach and pelvis to help figure out why your legs have been swelling over the past year or so. This showed lymph nodes deep in your abdomen that are larger than normal, and will need to be biopsied to get a clear answer as to why. - We monitored your blood pressures, and they were never low. 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. -You will need an Interventional Radiologist (___) guided biopsy of a lymph node. We have asked your PCP to help you arrange this biopsy. -You will need to see a pulmonologist for your new diagnosis of pulmonary hypertension. See below for your appointment scheduling instructions with a pulmonary hypertension specialist. - We held your ___, as well as metoprolol since it may be contributing to your low blood pressures and light-headedness. Speak with your Primary physician about restarting ___ if you are still having difficulty with urinary symptoms. Speak with your cardiologist before restarting metoprolol. - Your cardiology office should call you with a follow-up appointment. Please contact them if you don't hear in the next few days. We wish you the best! Sincerely, Your ___ Team
PATIENT SUMMARY: ================== ___ hx DM2 on insulin, CAD, OSA who was referred to the ED by his primary care physician after outpatient BP readings showed borderline hypotension to 90 systolic, also reporting fatigue and lightheadedness for the last 2 weeks.
336
40
11293234-DS-23
24,089,938
Dear Mr. ___, You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. You had some evidence of inflammation of the bowel on your cat scan and your symptoms improved with antibiotics. You will continue to take flagyl for 3 weeks. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have a midline incision from your prior surgery. We opened a portion of this wound and it will need to be packed with gauze. The rest of the incision is closed with steristrips. Please monitor for worsening signs of infection: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips), these will fall off over time, please do not remove them. Please no baths or swimming until cleared by the surgical team. If you have pain you may take Tylenol as needed. Do not drink alcohol while taking Tylenol. Please do not take more than 3000mg of Tylenol in 24 hours. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities.
Mr. ___ presented to the ED of ___ on ___ for management of small bowel obstruction. He was admitted to the colorectal surgery unit for further management.
312
29
15192547-DS-12
27,929,558
You were admitted to the hospital because you had nausea, vomiting and abdominal pain. This was thought to be related to a urinary tract infection. You were started on antibiotics and you improved and will continue to take antibiotics for another 6 days. You had imaging of your shoulder snd your torso which was unremarkable. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.
BRIEF HOSPITAL COURSE: Tachycardia: Ms ___ presented to the ED with tachycardia. Serial cardiac enzymes were performed, trending down from 0.03 to 0.02. There # Tachycardia: Ms ___ presented with palpitations found to be dehydrated and tachycardic in ED following poor p.o intake with likely demand ischemia with associated mild troponin leak that trended down (0.03 to 0.02) and EKG not suggestive of myocardial infarction. Much improved after IVF. HR wnl, patient remained chest pain free. Her PCP should arrange for an outpatient stress test. She will continue home services, ___ to review that she is taking adequate p.o intake. . Abdominal pain: pt with diffuse abdominal pain initially, with pain resolved on discharge. She had also endorsed associated n/v and found to have UTI. Pain did not appear related to recent surgery and CT abdomen and pelvis did not reveal any acute bowel pathology. She was started empirically on IV ciprofloxacin, switched to nitrofurantoin based on sensitivities from prior urine cultures. A urine culture performed this hospitalization was contaminated and she was treated empirically for UTI with nitrofurantoin for planned 7 day total antibiotic course. . # CKI: pt with Cr from 2.1 from 1.0 in setting of n/v and poor p.o intake leading to dehydration, with ___ likely prerenal in etiology.Cr improved to 1.2 from 2.1 after receiving intravenous fluids. . # s/p L salpingoopherectomy; pathology shows large cyst. Steri strips remained in place per ob/gyn. She will f/u with her gynecologist at ___. . # Recent shoulder surgery: continue home physical therapy. . # Anemia: pt had 8 point HCT drop from 38 to 30.2 in the setting of receiving intravenous fluids. This HCT was believed to be dilutional with subsequent HCT trend showing increase in HCT to 31.8 consistent with this. She should have repeat HCT check on follow up with her PCP.
69
300
15545526-DS-12
22,358,311
Mr. ___, You were admitted due to shortness of breath and cough, you were found to have pneumonia and will continue treatment with your IV antibiotic at home. Your symptoms greatly improved with your antibiotics. You will follow up in clinic as stated below. It was a pleasure taking care of you. Please call with any questions or concerns.
Mr. ___ is a ___ ___ man with high risk MDS and chronic diastolic heart failure recently admitted for several days of hemoptysis and CT showing ? PNA vs. other process found to have a positive AFB smear from ___, who presented to clinic ___ with fever and SOB, s/p ICU transfer for Afib with RVR improved with Dilt/metoprolol, now hemodynamically stable in NSR sputum +klebsiella. #Afib with RVR: Transferred to ICU on ___ for this, now converted to sinus and hemodynamically stable since then. Cardiology following. TTE with no evidence of pericardial effusion. Resumed home metoprolol with holding parameters. #Fever/SOB: Recent admission with chest CT ___ showing LL predominant multifocal consolidations c/f multifocal infection v. vasculitis v. COPD v. pulmonary infarcts. He was treated for HCAP. Sputum sample ___ grew AFB, repeat samples neg now off TB precautions. Beta glucan level also highly elevated on ___. However, most recent B-glucan is negative without a clear therapy. Has had ongoing intermittent productive cough. CT chest ___ shows rapid progression of pulmonary infection. He is growing klebsiella on his sputum cultures which could certainly account for his interval change on imaging and it appears to have been somewhat high grade as is on three different cultures despite therapy. Per pulmonary recs, should obtain chest CT 2 weeks after treatment for klebsiella to evaluate for possible secondary infectious process. If no improvement or significant residual disease per imaging, bronchoscopy would then be indicated. Pulmonary also recommended evaluation for aspiration risk given distribution of disease but this may be difficult to obtain due to TB precautions. -crypto antigen in blood and urine histo negative -ceftazidime (___) then changed to ceftriaxone to complete 14d course ___, off ___ and vanco since ___ -appreciate ID recs-see note AFB unlikely at this point, negative sputums x3 -repeat CT chest 2 weeks after most recent -weekly fungal markers -IgG level 796 on ___ #Acute on chronic diastolic heart failure: BNP on admission was elevated at 4800 and patient was mildly volume overloaded on exam the afternoon of ___, resumed home lasix. CXR ___ shows mild pulmonary edema; however, repeat ___ in the setting of worsening SOB showed progressive pulmonary edema w/ bilateral effusions. Continues on home regimen of lasix 40mg BID and baseline crackles at b/l bases. -Lasix IV x 1 on ___, consider repeat dose if no improvement -telemetry for continuous 02 monitoring -monitoring strict I/Os #Coagulopathy: Likely vit K deficient, received PO vitamin K. Low suspicion for inhibitor but we checked a mixing study since if he did have an inhibitor with worsened hemoptysis treatment would be different. -vitamin K 5mg x 1 on ___ and ___ -f/u mixing study -restarted prophylactic heparin daily dosing and when checking PTT, this should be done peripherally (not from his port) #HR MDS: He has been maintained on dacogen for about a year now, currently on C14 so holding now in the setting of active infection. Exjade on hold while inpatient. -transfuse to maintain hgb > 7, -will need Lasix prn with transfusions #Acute on chronic kidney disease: CKD stage III attributed to HTN and vascular disease. Cr slightly above baseline of 1.4-1.6 though downtrending since admission. Possibly in the setting of volume overload. -Lasix as above -Trend Cr -Avoid nephrotoxins -Hold lisinopril #Hernia: Etiology likely due to previous abdominal surgery in ___ ? incisional-related. No abdominal discomfort or tenderness. We will continue to monitor closely #HTN: -Continue metoprolol with holding parameters -Hold lisinopril given acute on chronic renal failure #CAD: Continue ASA 81 # FEN: No IVF, replete electrolytes, regular diet # Prophylaxis: SQ heparin daily # Access: Port # Communication: ___ (___) # Code: Full (confirmed) # Disposition: home, to complete 1wk course of ceftriaxone outpatient, f/u next week ___ or sooner if issues arise
58
581
14862629-DS-3
26,424,728
Dear Ms ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for abdominal pain and blood in your urine What was done for me while I was in the hospital? - You had some imaging done of your abdomen. It looked like one of the cysts on your kidney had ruptured. - You were given pain medication and closely monitored. What should I do when I leave the hospital? - Continue to take all of your medications as prescribed. - Please obtain bloodwork at ___ prior to your appointment on ___. The order for your labwork has already been placed. Sincerely, Your ___ Care Team
___ hx of polycystic kidney disease on transplant waiting list (listed but inactive until GFR < 20, not on dialysis), currently stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis who presents with flank pain/LLQ pain and hematuria.
127
41
10569306-DS-50
20,719,223
Weigh yourself every morning, call MD if weight goes up more than 3 lbs.
___ year old female with PCKD s/p failed transplant on HD MWF, recurrent fevers due to gram negative bacteremia of unknown source, who presents from dialysis with rigors and temperature to 100.0, without localizing infection. ACTIVE MEDICAL ISSUES: # Elevated temperature: On admission, pt did not meet SIRS criteria and was afebrile however she had report temperature to 100.0 ___s rigors at dialysis. In the past, pt has had two episodes of E. coli bacteremia, and most recently completed a course on ___ of cefazolin for Klebsiella bacteremia. On admission, she had few localizing symptoms other than a cough which is chronic as well as back pain with standing which she reports is also chronic. She denied abdominal pain, n/v/d. No headaches or neck pain to suggest CNS infection. CXR did not show evidence of pneumonia. Blood cultures from ___ at both dialysis and BI were pending, no growth at discharge. CMV viral load was also pending. She was empirically treated with vancomycin (HD protocol) and cefepime. Her antibiotics were stopped as she had no symptoms, remained afebrile with no leukocytosis. Her elevated temperature and malaise may represent viral process rather than overt bacterial infection. Her antibiotics were stopped on the day prior to discharge, and she remained stable. She had an appointment to follow up with her PCP the day after discharge. # HYPERCALCEMIA: Pt noted to have hypercalcemia due to hyperparathyroidism in the past. Her calcium on admission was 11.0. An SPEP was checked (given her back pain and malaise) which is pending at discharge. Her dialysis was also modified as below.
14
264
17989167-DS-21
22,366,186
Dear Mr ___, You were admitted to the ___ after feeling weak and falling at home. You were evaluated by our neurology team, who also did CT and MRI scans of your head, which did not show a stroke. Because you were retaining urine, you were discharged with a foley in place. You have a follow up appointment with Dr. ___ on ___. During hospitalization you had imaging performed which revealed a 1 cm thyroid nodule. Please discuss with Dr. ___ an ultrasound of your thyroid to better characterize the nodule. Please take note of the following: - Please stop taking your Coumadin for 2 days. Your primary care physician, ___, has asked that you restart your Coumadin on ___ at 1 tablet of 5mg and check your INR. Contact Dr ___ with your INR results. - Please follow up with urology to have your foley removed on ___ - Please follow up with your PCP Dr ___ on ___ at 2:30 ___ - Continue all your other home medications as normal It was a pleasure taking care of you at ___. We wish you all the best! - Your ___ care team
___ h/o cardiomyopathy, A-fib, DM and severe mid LAD stenosis s/p cath with DES who presents from PCP with weakness found to have Afib with RVR, AMS during admission. # AMS: On admission patient was A&Ox3 but later became A&Ox1 and agitated. Possible triggers for delirium included urinary retention (patient could not void spontaneously and was discharged with foley), constipation. Workup for CVA including MRI and CT was negative. Workup for infection including renal u/s, cultures, and UA was negative. Renal u/s showed non-obstructing stones. On discharge patient was A&Ox3 but very combative. Questionable component of dementia given history from wife. He may benefit from cognitive testing by Neurology as an outpatient for evaluation of dementia. # BPH with active urinary retention: Bladder scanned on ___ ___ and again had 700+cc urine in bladder. Patient was straight cath'd multiple times for failure to void. A foley was placed and he was discharged with a foley with plan to follow up with urology. # ___: Most likely post-renal in setting of urinary retention, but may have component of prerenal due to poor po intake at home. Creatinine decreased to 1.1 after placement of foley. # Afib on warfarin: Developed rapid rates to 150's in setting of missing evening dose of Metoprolol tartrate. Improved to 100's-110's after receiving PO dose of Metoprolol tartrate 50 mg. INR supratherapeutic at 5.2 (pt had been taking ___ daily). NO evidence of bleeding. Warfarin held again on ___ for INR of 3.6. Per his PCP ___ for patient to re-start warfarin 5 mg daily on ___. # Leukocytosis: Mild elevation of WBC to 11.5. UA negative, renal u/s showed non-obstructing stones. Down-trended to normal without antibiotics. CHRONIC ISSUES: # CAD s/p DES in ___: Continued Aspirin and Plavix, atorvastatin, losartan. # dCHF: Euvolemic, home torsemide held due to ___ but then restarted on d/c. # DM: Metformin held in setting of elevated lactate, restarted on d/c. # H/o gout: Continued home colchicine + probenecid. Transitional Issues =================== -Patient discharged on foley due to failure to void. Needs to followup with urology to discontinue foley. -INR 3.6 on discharge. Warfarin was held on ___ and ___. Patient should restart Warfarin on ___ at 5mg and check his INR at home per recommendation of Dr. ___. -Please follow up 9mm thyroid nodule with thyroid ultrasound. -History obtained from patient's wife and patient's combativeness in hospital concerning for early dementia. Please evaluate with cognitive testing as outpatient with possible referral to cognitive neurology. -Please consider downtitrating tramadol and lorazepam given concern for altered mental status. -Code Status: Full Code (confirmed) -Contact: Name of health care proxy: ___ Relationship: wife Cell phone: ___
186
443
16915421-DS-7
20,186,089
Dear Ms. ___, You were admitted to ___ for evaluation of abdominal pain and you were found to have an incarcerated right inguinal hernia. You were therefore evaluated by the acute care surgery team and offered surgical repair, however you declined surgery during this hospital admission. Risks of delaying surgery were discussed at length, however you have elected to follow up as an outpatient with Dr. ___. You are therefore now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications.
Patient is a ___ year old female with past medical history significant for thyroid cancer s/p thyroidectomy, IBS, diverticulosis, and prior repair of a right inguinal hernia in ___ ___. Patient presented to the emergency department with complaints of abdominal pain and was found to have right incarcerated inguinal hernia on imaging. Therefore acute care surgery was consulted for evaluation and management. The hernia was partially manually reduced at the bedside and she was admitted to the inpatient unit for operative planning. Surgical repair of her incarcerated inguinal hernia with acute care surgery was then offered however the patient declined surgery during current admission. She reported she wishes to have surgery completed by Dr. ___ as an outpatient. Risks of delaying surgery were discussed at length. This included risk of worsening pain and/or bowel incarceration, and need for emergent operation that could require bowel resection. She reported she was accepting of these risks. She was then given the contact information for Dr. ___ clinic to schedule her follow up care. During this hospitalization, the patient voided without difficulty and ambulated early and frequently. The patient was adherent with respiratory toilet 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. She was afebrile and her vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and her pain was well controlled. The patient was discharged home without services. Discharge teaching was completed, and follow up was reviewed with reported understanding and agreement.
299
267
13757970-DS-6
22,877,162
Dear Ms. ___, It was a pleasure caring for you at ___. You presented with bloody diarrhea, which has since stopped. We are still unsure what caused it, but we think it either resulted from an infection in your colon, low blood flow to the colon while you exercised, or inflammation in the colon from another cause. You were given IV fluids and monitored closely. Your blood counts were stable, you are feeling better, are no longer having bloody diarrhea like you were yesterday, and are eating solid food, so we feel that you are ready for discharge. Additionally, the use of ibuprofen can exacerbate (or cause) gastrointestinal bleeding (typically from the stomach). Please use this sparingly and alternate with acetaminophen. Please keep yourself well-hydrated with drinks like gatorade while you continue to have diarrhea and only eat food that you can tolerate. Please review your medications below closely and take them as prescribed. Please keep your follow-up appointment below.
This is a ___ female with minimal PMH who presents with one day of watery diarrhea, BRBPR, and abdominal cramping after running a 5K race, of unclear etiology. # Diarrhea / BRBPR: Pt's symptoms decreased significantly at discharge, with little to no blood in the stool (which remained watery). Very likely lower GI in origin (vomitus was non-bloody). She was hemodynamically stable throughout her admission, and HCT was stable at 37-40. No clear cause at this point, though given absence of prior GI disease, epidemiology, CT scan, conincident nausea/vomiting, and elevated white count, an infectious colitis seems most likely. EHEC and C.Diff neg. Potential culprits could be shigella, salmonella, or campylobacter (cultures pending), though she denies any obvious exposures and absence of fever would be somewhat atypical. Other less likely possibilities include IBD (though she is appropriate age range) or ischemic colitis (she is young, no risk factors - exercise-associated ischemic colitis has been described but is rare and the inflammation in her colon is not at a watershed area). She was given IVF while not taking POs, her nausea was controlled with Zofran, and her diet was advanced to regular. She was told to avoid ibuprofen for the time being given risk of re-bleeding. # Depression / Anxiety: Currently stable. Her home Sertraline was continued. # OCPs: Her home OCP was continued.
157
226
19023440-DS-20
29,815,969
Dear Ms. ___, ___ were admitted to ___ because ___ had a fall at home resulting in a hip fracture. ___ had surgery on ___ without complications. ___ were then transferred to the medicine service because ___ were confused and drowsy. Your labwork showed a high sodium, likely due to your lithium therapy. ___ were given IV fluids and your sodium returned to normal. ___ should continue to drink plenty of water at home to prevent your sodium level from getting too high. ___ also were noted to have high calcium levels, likely due to the effects of lithium on a gland called the parathyroid gland. ___ should follow up with an endocrinologist and general surgeon to discuss management of your calcium levels, which may require surgery. We made the following changes to your medications: -START lovenox injections 30 units once daily (continue until your follow up appointment with orthopedics) -START tylenol ___ every six hours as needed for pain -START oxycodone 2.5-5mg every six hours as needed for pain not relieved by tylenol -START senna, docusate, and bisacodyl to prevent constipation while taking oxycodone We made no other changes to your medications while ___ were in the hospital. Please continue taking your medications as prescribed by your outpatient providers. Please see below for your currently scheduled appointments. If ___ are unable to make an appointment please call and reschedule. It has been a pleasure taking care of ___ at ___ and we wish ___ a speedy recovery. Wound Care: - Keep Incision clean and dry. - ___ can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be full weight bearing on your left leg - ___ should not lift anything greater than 5 pounds. - Elevate left leg to reduce swelling and pain. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - ___ have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. ___ can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If ___ have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room.
Primary Reason for Hospitalization: ___ yo F with nephrogenic DI, breast CA sp mastectomy in ___, admitted with hip fracture sp ORIF on ___. Post-op course complicated with AMS and slurred speech, hypernatremia, hypecalcemia, and pt was transferred to medicine. .
517
41
18003081-DS-40
22,035,704
Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You had bloody vomit WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You had a procedure performed, called an endoscopy, that tried to find a source of the blood. It did not find any single area of concern. - You were monitored closely and did not re-bleed. - You had a seizure in setting of acute illness WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___. We wish you all the best, - Your ___ Care Team
BRIEF HOSPITAL COURSE ===================== ___ Hx ___, severe intellectual disability, recurrent GIBs, unprovoked DVT on rivaroxaban, p/w acute on chronic anemia I/s/o likely UGIB. Patient underwent unrevealing EGD (___) with self-resolution of ongoing bleeding, with course complicated by propofol infiltrate requiring MICU transfer for observation and generalized seizure in setting of acute illness and not receiving home medications TRANSITIONAL ISSUES =================== [] HEART MURMUR: Holosystolic murmur best heard at apex noted on exam, please monitor and consider TTE on outpatient basis. [] ASPIRATION RISK: Patient continues to demonstrate chronic risk of aspiration. Recommend ongoing precautions as well as ongoing discussions with guardian regarding the risks of complications with aspiration [] PPI: Patient should complete a 12 week twice a day PPI course for likely UGIB ACTIVE ISSUES ============= # UGIB He presented with coffee-ground emesis with Hgb 5.5 (baseline ___. EGD ___ was unrevealing. Of note, patient has had extensive GI work up in the past with negative colonoscopy and capsule studies in past. His bleeding self resolved and he was started on lansoprazole 30 BID, and he was discharged with GI follow-up. # Seizure # ___ syndrome Known history ___ Gastaut syndrome. He was continued on felbamate 1400 big + phenytoin 150 bid + levetiracetam 750 bid throughout this admission. He had two breakthrough, generalized seizures during this admission which were treated with IV lorazepam. Neurology was consulted and this was believed to be due to difficulty with medication administration in the ED as well as in the setting of acute illness and no changes were made to his medication regimen. #Aspiration Risk: Patient was evaluated by speech and swallow service and felt to be at baseline swallowing capacity. # Propofol IV infiltration # Arm swelling Midline infiltrated during propofol bolus prior to EGD. He was transferred in the MICU and toxicology was consulted. There were no complications. CHRONIC ISSUES ============== # Hx unprovoked DVT - his home anticoagulation was resumed by the time of discharge after short bridge with heparin gtt to ensure stability after bleed.
134
317
10981725-DS-28
21,250,461
Dear ___, It was a pleasure taking care of you at ___ ___. Why was I in the hospital? - You were having fevers at home What was done while I was in the hospital? - We found that one of your drains was not draining properly - We had the interventional doctors ___ the ___ - You were put back on antibiotics that helped with your fevers What should I do when I get home from the hospital? - Be sure to take all of your medications as prescribed, especially your antibiotics (last day ___ and your immunosuppression drugs - Please go to your follow-up appointments with your primary care doctor, your liver doctor, and the infectious disease doctor - If you have fevers, chills, abdominal pain, yellowing of the skin, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team
Ms. ___ is a ___ year-old woman with history of CAD, hypertension, diabetes mellitus, NASH cirrhosis with DDLT (___) (on cyclosporine and mycophenolate) with aortic conduit complicated by biliary strictures s/p stenting and multiple percutaneous transhepatic biliary drain exchanges with recurrent cholangitis, pseudomonas bacteremia, on suppressive cipro, VRE infections, and left hepatic abscess, who presented with fevers, and elevated ALP concerning for recurrent cholangitis. ACUTE ISSUES #Cholangitis: The patient presented with 1 day of fever & elevated LFTs concerning for recurrent cholangitis. She did not have abdominal pain, however she denies ever abdominal pain with her recurrent cholangitis. Fever occurred while on suppressive cipro. Previous bile cultures grew MDR pseudomonas sensitive only to cipro & aminoglycosides as well as VRE. RUQ U/S revealed persistent perihepatic collection, so likely continued source of infection. The patient's PTBD was uncapped with significant drainage to bag concerning for PTBD dysfunction. She was started on high dose ciprofloxacin and linezolid and ultimately underwent cholangiogram with dilation of biliary stricture and subsequent improved flow. The patient remained afebrile throughout her hospitalization. Her PTBD was capped on ___. Patient did not spike fever overnight, after capping. ID consulted and recommended to complete a 2 week course of cipro 750mg BID and linezolid ___ BID (last day ___, followed by return to ___ 500mg daily for suppression. CHRONIC ISSUES #Idiopathic cirrhosis s/p DDLT: With aortic conduit (___) and stenosis of arterial graft of liver. Patient with multiple complications. Now more stable, though with continued biliary strictures. # Anemia: Patient anemic to 6.9 on ___. Given 1U pRBCs. Likely related to chronic disease/bone marrow suppression given low retic index. Anemia improved appropriately. Now stable in 8s. Iron studies consistent with inflammatory picture (high ferritin, low iron). TRANSITIONAL ISSUES [] Labs on ___: CBC, Chemistries, cyclosporine level. Should be faxed to Dr. ___ ___, Dr. ___ ___. [] discharge antibiotic regimen: ciprofloxacin 750mg q12h, linezolid ___ q12h (last day ___ [] once initial antibiotic regimen is complete, should stay on suppressive ciprofloxacin 500mg daily indefinitely [] follow-up to be scheduled with ___ for PTBD and JP drain management [] discharge hemoglobin: 7.7 [] discharge immunosuppression: Mycophenolate Sodium ___ 360 mg PO BID, CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H # CODE: FULL CODE (presumed) # CONTACT: ___ (sister and HCP), ___
138
368
16759761-DS-26
22,748,003
Dear Mr. ___, It has been a pleasure caring for you at ___. You presented to ___ on ___ with 4 days of cough with blood, abdominal pain, nausea, and fever. Your symptoms were likely due to a viral illness, and this resolved without antibiotics. However, the levels of tacrolimus in your blood were undetectable and your liver tests continued to increase throughout your hospitalization, raising concern for transplant rejection. Therefore, we increased your dose of tacrolimus. We also performed a biopsy of your liver which showed rejection of your liver by your immune system. We gave you additional medicines including steroids to suppress your immune system, however your liver tests remained elevated. You received a second liver biopsy which showed ongoing rejection of your liver. We then added another medicine called ATG (anti-thymocyte globlulin) to further suppress your immune system. After 7 days of therapy with ATG, your liver tests improved. You will need to return to ___ next week for another liver biopsy to make sure that your immune system has stopped rejecting your liver. You will be following up with pulmonology as you have coughed up small amounts of blood and were found to have a nodule in the lung as well as high pressures in the blood vessels of the lung. You will also need an ultrasound of the heart (echocardiogram) to further evaluate this. Your blood sugars have been high so please follow up with your ___ endocrinologist. It has been a pleasure taking care of you, Best wishes, Your ___ Team
Mr. ___ is a ___ with a history of cirrhosis (HCV and EtOH, s/p orthotopic liver transplant ___ with subsequent recurrence of cirrhosis (s/p treatment with simeprevir/sofosbuvir ___, who presented to ___ on ___ with ___ days of cough, hemoptysis, abdominal pain, nausea and fever, found to have subsequent acute liver rejection. # Acute liver transplant rejection: Patient was admitted to ___ on ___ with fevers to 103, ___ days of productive cough, hemoptysis, abdominal pain, nausea, and vomiting of all POs including his immunosuppressive medications. His LFTs were elevated on admission and continued to increase during his hospitalization with peak AST of 144 and peak ALT of 148. His elevated LFTs were concerning for transplant rejection in the setting of decreased tacrolimus level. CT abdomen was concerning for an intraparenchymal process. He then underwent liver biopsy on ___ with confirmed acute liver rejection. Patient was started on high dose steroids for 5 days along with tacrolimus and cellcept, but continued to have elevated LFTs. He underwent repeat liver biopsy on ___ which showed ongoing rejection. He then received 7 days of anti-thymocyte globulin (ATG) for steroid resistant rejection. His LFTs improved with ATG administration to ALT 82 AST 52, and patient was discharged with planned repeat liver biopsy and hepatology follow up. ___: Patient had mild ___ during his admission. His creatinine was elevated to creatinine 1.4 above baseline 1.1-1.2. This stabilized to 1.3 at discharge after fluid administration. His ___ was thought to be secondary to tacrolimus vs hypovolemia. # Diabetes: Patient had difficult hospital course with regard to his glycemic control likely due to steroid administration. He was at times hypoglycemic and hyperglycemic but was not symptomatic. He was managed with his home 70/30 and an insulin sliding scale. His insulin was adjusted per ___ consult recommendations. # Viral syndrome: Presented with ___ days of productive cough, hemoptysis, abdominal pain, nausea, and fever to 103. Likely viral given improvement off antibiotics. Pt had fever of 103 days prior to seeking care and may benefit from prompt evaluation next time he is febrile, given his immunosuppression. Team has counseled patient to seek care immediately with future fevers. He received guaifenisin/dextromethorphan and benzonatate for symptomatic relief of cough. He receieved a CT scan for ongoing mild hemoptysis that showed a small nodule that will need subsequent follow up with pulmonology. # Hyponatremia: Patient had Na+ that was initially downtrending, but resolved with IVF. Patient did not have any associated symptoms. # Medications: You have the following new or adjusted medications: Tacrolimus 3 mg po twice a day Mycophenolate Mofetil 1000mg twice a day Prednisone 20 mg po daily Valganciclovir 450 mg po daily Fluconazole 400 mg po daily Insulin dosing now 24 Units in AM and 26 units in ___
254
458
13743156-DS-11
29,857,174
Dear ___, It was a pleasure participating in your care while you were at ___. You had an episode of unresponsiveness while in your nephrologist's office, which we think was from a vagal response in response to nausea as well as reflective of decreased volume in your vessels. You were monitored on telemetry and we gave you IV fluids. Please schedule ___ in the near future with Dr. ___ your primary care doctor. We wish you the best! Your ___ team
___ with membranous nephropathy and nephrotic syndrome with progressive proteinuria who presents after syncopal episode with concern for pulselessness. # Syncope: By symptoms consistent with vasovagal syncope, borderline orthostatic by vital signs. Received IVF and was monitored on telemetry. Though unlikely, was ruled out for ACS. No tachycardia, pleuritic chest pain, leg swelling or hypoxia to suggest DVT/PE. Felt better day after. Was persistently borderline orthostatic per BP and HR but w/o symptoms, likely due to hypoalbuminemic state resulting in relative intravascular volume depletion. PO intake encouraged upon discharge # Chest pain: Noted upon admission, not pleuritic, unchanged. Acute coronary syndrome ruled out. Resolved by HD 1. Etiology may be muscle soreness/MSK. # Hyponatremia: Improved with more IVF to 134. # Membranous nephropathy/nephrotic syndrome: On prednisone and cyclosporine, recent 24 hr urine with > 6g protein. No significant edema on exam, BPs ok and renal function stable. Continued these medications and associated prophylaxis with atovaquone. # T2DM: Recent HbA1c 7.2%. Glipizide held at last admission, and continued to be held during this admission. Trended FSBG while inpatient as on prednisone, reasonable control achieved on sliding scale alone. Will continue to hold glipizide upon discharge as may potentially be contributing to SIADH/hyponatremia. # Anemia: Mild and stable. Trended while inpatient with no other intervention.
77
209
13653826-DS-4
26,057,824
Dear Ms ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? -You were admitted to the hospital because you were having shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were seen by our lung experts who tried to drain the fluid around your lung. They were unable to drain the fluid unfortunately. We discussed possible surgery to treat this. You decided not to do surgery. We gave you antibiotics to control your lung infection and morphine to help with your shortness of breath. We arranged hospice services so help you spend quality time outside the hospital with family. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Take your medicines as prescribed. Take morphine 30 minutes before you exert yourself for best effect. - You have a follow-up appointment with your oncologist to check on you and make sure your symptoms are under control. If it is too difficult to make it to the office, your oncologist is happy to speak by phone instead. See below for details and phone number. We wish you the best! Sincerely, Your ___ Team
Transitional Issues ==================== []titrate morphine to quell patient's air hunger []titrate Ativan to quell patient's anxiety []titate bowel regimen Summary Statement ================== This is an ___ with h/o Stage IV NSCLC (recently diagnosed), COPD and hyponatremia, admitted for recurrent complex pleural effusion on CT and leukocytosis concerning for pleural infection. The patient's effusion was too viscous to be drained by IP. After the unsuccessful drainage, the patient requested no more interventions or escalations in care. Her symptoms were treated with morphine and Ativan as well as amox/clav to prevent worsening of her likely pleural infection. She was discharged to ___ with hospice and comfort focused care. Active Issues ============== #Left loculated pleural effusion #Leukocytosis The patient presented with a loculated appearing pleural effusion on the left side, leukocytosis to 36,000, and mild hypoxemia requiring 2L O2. She was seen in the emergency department by Interventional Pulmonology who attempted bedside thoracentesis but was unable to extract any fluid due to its viscosity. Given the patient's malignancy as well as significant leukocytosis and fevers, her effusion is likely malignant in nature with possible super-infection. Patient was initially started on empiric vancomycin and cefepime. Treatment options were discussed with the patient and her family, and she decided that she did not want surgical drainage or any further escalations in her care. Palliative Care was consulted. Outpatient hospice services were arranged, and she was switched to p.o. amoxicillin-clavulanate, given p.o. morphine and lorazepam for air hunger and anxiety, and discharged to ___ ___ for ongoing hospice care. #Goals of care During the ___ hospital stay, we had an extensive conversation regarding her goals of care. She noted that she would not want to be intubated or have chest compressions done. She initially thought she would want to be transferred to the ICU for BiPAP but reconsidered and decided that it would not be within her goals of care. We discussed the potential of a VATS surgery which the patient noted she would not be interested in. The patient was seen by the thoracic surgeons and declined any further interventions including thoracentesis. The patient would like her infection treated if possible with po antibiotics. She was treated with po morhine for air hunger and po Ativan for anxiety. #Hyponatremia Patient has a history of chronic hyponatremia with sodium around 130. Serum sodium here on presentation was 130 with serum positives of 265 consistent with hypotonic hyponatremia. Urine electrolytes were not consistent with SIADH. Likely some component of hypovolemia as the patient received IV fluids as well as p.o. intake and sodium stabilized.
190
421
17778496-DS-4
27,597,329
You came to the hospital because you felt fatigued. While you were here you were diagnosed with AML and we started on treatment with ATRA and arsenic. You tolerated the chemotherapy well and your blood cells went up at first and then went down. Also while here you were seen by the colorectal surgeons for a perianal phlegmon. They did not want to do any surgery on it and you were treated with antibiotics. You will continue with antibiotics till Dr. ___ you and tells you that you don't need to take them anymore. If you have a temp of 100.4 please come to the hospital
___ otherwise healthy admitted to the MICU for pancytopenia of unclear etiology and neutropenic fever, found on bone marrow biopsy to have new diagnosis of acute promyelocytic leukemia. # Acute Promyelocytic Leukemia: She presented with pancytopenia and bone marrow biopsy showed hypercellular marrow with 55% neoplastic promyelocytes. FISH study confirmed the diagnosis with the characteristic t(15:17)(q22;q12) translocation. Given leukopenia on presentation, she is classified as low-risk APML and treatment consisted of ATRA with arsenic (added on day 10 of tx). Her WBC went as high as 60 but she never required dexamethasone (she had no symotoms of differentiation syndrome)and never required hydrea. Her counts eventually went down and she became pancytopenic from the chemo. She was discharged still neutropenic but no signs of active infection no fevers (Still on cipro and flagyl) and was advised to all if any fevers # Neutropenic Fever: Fever on presentation, likely secondary to tumor fever or perirectal fistula (described below). Antibiotics initially started were cefepime/Vancomycin. Flagyl and fluconazole were added on ___ given perirectal fistula and antibiotic course was eventually switched to cipro and flagyl while neutropenic. # Perirectal Enterocutaneous Fistula/Diarrhea: One week of anal fissure prior to presentation for which she was using nitroglycerin topical. Onset of diarrhea (cdif negative) as inpatient resulted in pain and development of perirectal fisutula. MRI pelvis showed no abscess. Colorectal did not feel surgery was necessary. Flagyl was added to vanc/cefepime on ___. Her fistula improved with ___ baths and dilaudid for pain control and antibiotcs were switched to cipro and flagyl. # Reaction to Transfusion and IV Contrast: On ___ she developed hypotension and complaints of pain/burning at the IV site, lightheadedness and chills/rigors, during the transfusion of the second of two units of PRBCs. This resolved with steroids, H1/H2 blockers, and fluids. Blood bank did not believe that this is a typical transfusion reaction, specifically no evidence of hemolysis. On ___, she developed respiratory distress and fever to 103 after IV contrast for CT that resolved with steroids, H1/H2 blockers, and fluids. Future transfusions and IV gadolinium contrast infusions went smoothly with premedication (hydrocortisone, tylenol, benadryl).
106
364
19758810-DS-11
23,710,321
Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were having chest pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given medications to treat a heart problem however the origin of the chest pain seemed less likely to be caused by the heart so those were stopped. You were given medications to treat you indigestion and nausea which did help. You were chest pain free on trial off the medications and were doing well with walking around. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team
TRANSITIONAL ISSUES =================== [ ] A1C 7.0. Patient on Invokana only. Patient would benefit from additional oral hypoglycemic to lower A1C further as an outpatient. [ ] Patient started on atorvastatin 40mg daily for ASCVD score >10% (12%). Please monitor for tolerance. [ ] Patient with close cardiology follow-up with Dr ___. Recommend dobutamine stress test to further evaluate cardiac function. BRIEF HOSPITAL COURSE ====================== Ms. ___ is a ___ year old woman with history of AFib, severe asthma, DM, HLD, and iron deficiency anemia who presented with chest pain during IV iron infusion found to have possible ST depressions on EKG, without elevated troponins initially started on heparin gtt. However, patient then described more GI symptoms with indigestion, belching, N/V, and acid reflux relieved with Tums and Zofran. Heparin was discontinued and patient continued to be chest pain free even with ambulation/exertion, making GERD more likely and cardiac pathology less of an acute concern.
133
148
13992480-DS-24
29,272,222
Dear ___ were hospitalized due to symptoms of difficulty talking and right sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - afib - high blood pressure - high cholesterol We are changing your medications as follows: - START Dabigatran Etexilate 150 mg PO BID - STOP coumadin Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If ___ 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 ___ - 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 ___ - 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 ___ with care during this hospitalization.
Transitional Issues: [ ] Pt needs to have a repeat CT chest in 10 weeks to follow up her prior CT findings [ ] Pt is on day 2 of a 7 day course of IV ceftriaxone (started ___ [ ] Pt should continue to undergo speech and swallow evaulation with the hopes of advancing her diet further. [ ] Please monitor the patient for urinary retention with Q-shift bladder scans as this was an issue for the patient early on the her stay. Ms. ___ is an ___ yo woman with PMH significant for afib on coumadin, HLD, depression and hypothyroidism who presented as a code stroke, found to have a left MCA ischemic stroke with aphasia and R sided plegia. The patient had hemorrhagic transformation of the infarct - anticoagulation was held. Etiology of stroke is likely afib although patient was supratherapeutic on coumadin (initial INR 3.3). She underwent a CT of the chest/abd/pelvis to assess for occult malignancy which was negative. She was initially monitored in the neuro ICU and remained stable with slow improvement in her sytmptoms. Her course was complicated by afib with RVR which corrected with increased doses of metoprolol. She diet was advanced very slowly with the help of speech therapy. She was started on Dabigatran on ___ - repeat head CT 48 hours later was stable. HgbA1c 5.7; LDL 153. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? () Yes - (x) No (patient therapeutic on coumadin) 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (x) No (patient therapeutic on coumadin) 4. LDL documented (required for all patients)? (x) Yes (LDL =153) - () No 5. Intensive statin therapy administered? (x) Yes - () No [if LDL >= 100, reason not given: ____ ] (intensive statin therapy = simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL >= 100) 6. Smoking cessation counseling given? () Yes - (x) No [if no, reason: (x) non-smoker - () unable to participate] 7. Stroke education given (written form in the discharge worksheet)? (x) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No [if no, reason not assessed: ____ ] 9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100 or on a statin prior to hospitalization, reason not discharged on statin: ____ ] **10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No [if no, reason not discharge on anticoagulation: ____ ] - () N/A
312
482
11527882-DS-21
23,048,471
Dear Ms. ___, You were admitted to the Acute Care Surgery Service with abdominal pain and found to have inflammation in your appendix. You were counseled on different treatment options and elected for antibiotics. Your pain improved with antibiotics and you are now ready to be discharged home to complete a course of oral antibiotics. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon.
Ms. ___ is a ___ yo F who presents to the Emergency Department with epigastric abdominal pain and underwent outpatient CT scan which was concerning for acute appendicitis. The patient was hemodynamically stable, afebrile, and white blood cell count was 5.1. Discussed options of possible operative intervention versus non-operative management with the patient. Reviewed risks and benefits of both options, and patient decided to pursue non-operative management with antibiotics. On HD2 diet was advanced to regular with good tolerability. Antibiotics were transitioned to oral. 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. Follow up was scheduled to discuss future/interval appendectomy.
259
150
19631414-DS-4
20,088,323
Dear ___ you for coming to the ___. You were in the hospital because of your pain and skin lesions that were concerning for cancer. We performed a biopsy which showed that you have metastatic lung cancer. You started radiation therapy to help with your pain. You will need to follow up with a lung cancer specialist to discuss further treatment options. We started you on oxycontin (long acting oxycodone), oxycodone, tylenol, and a lidocaine patch for pain. You should continue to take ativan and citalopram for anxiety. You were also noticed to need supplemental oxygen when walking around, which is being provided to you. You have been feeling weak throughout the admission, however physical therapy has evaluated you several times and feel that you are safe for discharge. It is important that you continue to drink water and eat food to keep your nutrition status up. . Medication Recommendations: Please START: -Supplemental oxygen at ___ -Oxycontin 30 mg twice daily -Oxycodone ___ tabs) every 4 hours as needed for pain. If you are feeling drowsy or confused, it is possible you are taking too much of this medication. Please avoid this medication until you are feeling back to normal. -Zofran (ondansetron) ___ mg three times per day as needed for nausea -Ibuprofen 600 mg every 8 hours as needed for pain -Acetaminophen 1000 mg every 6 hours for pain -Senna 8.6 mg twice daily as needed for constipation -Docusate 100 mg twice daily for constipation -Milk of magnesia as needed for constipation -Miralax 1 packet daily as needed for constipation -Citalopram 20 mg daily -Propanolol 20 mg every 8 hours It is important you continue to have regular bowel movements as the prescribed pain medications frequently cause constipation in patients. Please take colace daily and senna, miralax and milk of magnesia as needed so that you are having a bowel movement a day. . Please STOP lisinopril.
___ with history of anxiety and hypertension admitted with worsening back pain in setting of concerning lesions on MRI/CT for metastases. Hospital course was notable for diagnosis of metastatic nonsmall cell carcinoma of the lung and radiation therapy to metastatic bone lesions. . #Metastasic nonsmall cell lung cancer: Presented with widely metastatic cancer with lesions in the lung, adrenals, skin as well as diffuse bony disease. FNA of the RUQ subcutaneous nodule demonstrated poorly differentiated non-small cell lung cancer. Hematology oncology was consulted who recommended outpatient oncology follow up which has been scheduled for ___. During this admission, she underwent mapping and palliative XRT to the rib/sternum and L fibula/ilium. MRI of the brain showed mets to the skulls, a meningioma, without intraparenchymal disease. . # Bone Pain: From metastatic disease. She was started on standing oxycontin and acetaminophen as well as prn oxycodone and ibuprofen for pain control. She was additionally given a lidocaine patch for her sternal pain. Her pain medications were titrated until she was no longer requesting all of her prns and was sleeping comfortably through the night. She appeared comfortable on daily examinations and would only say her pain was not well controlled if directly asked. She was discharged on oral and topical pain control and advised to contact her PCP ___ Oncologist should she require adjustments to her home pain medication regimen. . # Hypoxia: On admission, she was noted to be hypoxic, likely related to her baseline decreased lung function (chronic smoker), NSCLC with possible associated atelectesis, and possibly decreased inspiratory volumes ___ sternum and rib pain (bony metastasis). Physical therapy worked with the patient and noted she was 84% on room air when sitting. She was discharged on home oxygen ___ at rest. . # Tachycardia - She had sinus tachycardia on admission. CTA did not show PE. Her tachycardia was believed to be from pain and anxiety, possible hypermetabolic state ___ cancer. She was started on pain control as above and her lisinopril was switched to propanolol TID both for pain control and possibly better control of her anxiety symptoms. . # Social Issues/Depression: The patient and brother are having a very difficult time dealing with her new diagnosis and reduced functional status. The patient has been nervous about being discharged home, but physical therapy felt that she did not require rehab and she has been arranged to have services at home (she will be staying with a family friend). ___, her brother has been staying at a local hotel and they have been resistant to her going there. She lives in ___ but was not interested in having her care in ME. Lastly, Ms. ___ was given the number for psychiatry as she is having a difficult time coping with her diagnosis and speaking to someone or starting on antidepressants may help her. .
300
468
11031369-DS-13
24,937,357
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: - touch down weight bearing on the right lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take enoxaparin 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. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. 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: touch down weight bearing as tolerated on the right lower extremity. no hip precautions. Treatments Frequency: incision may be left open to air.
Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right acetabular fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation, 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. The patient was monitored for withdrawal on a CIWA scale given his history of ethanol use and required no pharmacologic measures for withdrawal and showed no hemodynamic instability secondary to withdrawal. 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 touch down weight bearing in the right lower extremity extremity, and will be discharged on enoxaparin 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.
295
293
15961067-DS-7
27,262,602
Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**
He was admitted on ___ and underwent routine preoperative testing and evaluation. He remained stable and was taken to the operating room on ___. He underwent aortic valve replacement and coronary artery bypass grafting x 3. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated on POD 1. He was weaned from vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He was started on beta blockers, though these were ultimately held. He was initially A-V paced, though eventually the atrial lead stopped sensing and pacing. On ___ he had ___lock, each 7 seconds in duration. He reportedly had loss of consciousness with one of these events. EP was consulted and he underwent PPM placement on ___. He developed delirium following this procedure. Geriatrics was consulted. Olanzapine initiated with good effect. Delirium resolved and olanzapine discontinued. Beta blocker resumed. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged home in good condition with appropriate follow up instructions.
104
235
10147499-DS-9
27,547,361
Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were brought in for increasing confusion and weakness. We believe this was due to a urinary tract infection in addition to the pain medications you were taking. You were started on antibiotics which you will continue to take at hpme. Your pain medication regimen was also modified. You have decided to go home and not back to rehab. Your PCP ___ follow up with you at home this coming week.
___ yo F with a history of HTN, hyperlipidemia and recent C2 decompression with C1-C3 laminectomy/fusion on ___ who was sent in from rehab facility due to altered mental status and was found to have urinary tract infection. # Altered mental status: Patient presented with AMS which resolved by the time of admission. Most likely secondary to urinary tract infection and large doses of narcotics and diazepam following surgery. Patient remained A&Ox3 entire admission. Previously prescribed oxycodone was discontinued and she was transitioned to standing tylenol with as needed tramadol. She will also use ibuprofen as needed on a full stomach. The risk of NSAIDS were discussed with patient but she notes they offer the greatest relief. She was guaiac negative this admission. Hematocrit should be monitored closely while taking this medication. Patient should not take aspirin while taking NSAIDS. #UTI: Urine analysis was strongly suggestive of infection with moderate bacteria and large ___ and nitrites. Urine culture grew pansensitive entercocci. She was treated with a 7 day ___ of amoxacillin for sensitive enterococcus. Infection most likely secondary to foley placements during recent hospitalizations. #Hx of C2 decompression with C1-C3 laminectomy/fusion: Incision appeared clean and without signs of infection. Patient noted extreme discomfort with ___ j collar. She was evaluated by orthopedics who arranged for a new, smaller collar. Patient's pain regimen was modified this admission by holding oxycodone and adding tramadol due to AMS. She will also take ibuprofen as needed (risks and side effects discussed). She will continue to follow up with ortho as an outpatient. Patient deferred going back to a rehab facility and will continue ___ at home. #Weakness: Rehab facility noted weakness prior to admission but patient found to have ___ strength on exam without focal deficits. Neuro evaluated earlier this week without concern. MRI without new findings. #Anemia: Most likely secondary to chronic disease with high ferritin and low TIBC. Guaiac negative this admission. Has been downtrending over the last several admissions and should be monitored going forth. Recommend outpatient hematocrit within the next ___ days to ensure stability.
84
342
13304354-DS-16
29,854,899
•Do not smoke. •No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ___ must wear your brace when out of bed or when sitting. ___ may shower briefly without the collar or back brace; unless ___ have been instructed otherwise. •Take your pain medication as instructed; ___ may find it best if taken in the morning when ___ wake-up for morning stiffness, and before bed for sleeping discomfort. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. •Increase your intake of fluids and fiber, as pain ___ (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Clearance to drive and return to work will be addressed at your post-operative office visit. ***** YOUR PAIN MANAGEMENT PLAN ***** ___ will ___ a 7 day supply of dilaudid 12mg every 4 hours, after this ___ should resume taking your home dose of dilaudid as prescribed by Dr. ___ will ___ a 30 day supply of oxycontin 60mg three times daily. After this ___ should refer to your pain Dr. ___ further pain medication. ___ should continue to take cyclobenzaprine. ___ should follow up with Dr. ___ call his office if ___ have questions about your pain managment.
Patient was admitted to the neurosurgery. Further review of the MRI showed no abscess and Neurosurgery was not concerned for epidural hematoma. A subacute L4 compression fracture was noted and a Aspen quick draw brace was ordered. Patient complained of pain and required IV Dilaudid Q2hrs. Neurology continued to follow. On HD 2, a social work consulted was called for patient coping. Pain services was consulted and recommendations were made after speaking with the ___ pain MD. ___ was curbsided and felt that any steroid recommendations could be made outpatient by the ___ rheumatologist. Neurology signed off. Physical therapy worked with the patient and cleared her for home. Patient refusing discharge until pain management rediscussed. A pain managment was made and agreed upon. On ___ IV dilaudid was discontinued. Her pain was well controlled on oral pain regimen. She was discharged home with instructions for follow and pain managment.
226
150
18853762-DS-43
27,217,540
You were admitted with delirium. You were found to have a urinary tract infection. You were started on linezolid. Given the interaction between linezolid and celexa, your celexa was held. Given your delirium zolpidem was also held. Given your delirum plans were made for you to go to a geriatric psychiatric unit.
A/P: ___ yo W with MMP but no psychiatric hx, sent from ___ at ___ for a change in mental status and resistance to care. This is most like secondary to a UTI.
52
34
13196462-DS-3
28,562,130
You were admitted to the hospital because of nausea, vomiting, and poor appetite, which were most likely due to your chemotherapy. While in the hospital, you also had low blood counts due to your chemotherapy. Because you developed a fever and had evidence of a skin infection around your left eye, we needed to keep you on IV antibiotics for several days. When you leave the hospital you will need a few more days of oral antibiotics to complete the course. You also had low calcium and phosphorus levels, which were most likely due to the zometa you received recently. By the time of discharge, your calcium and phosphorus were stable with you receiving additional supplementation by mouth. While in the hospital you also had discussions with Dr. ___, Dr. ___ Dr. ___ about next steps in your cancer care. You have follow-up scheduled with each of their teams. We have reduced your metoprolol dose from 50 mg to 25 mg daily since your blood pressures were slightly low in the hospital. We also recommend taking your dronabinol twice daily instead of on an as-needed basis.
___ is a ___ year old woman with HTN, non-ischemic CMY (LVEF 45-50% TTE ___, LBBB, and recently diagnosed NSCLC (___) w/ brain mets s/p CK, on ___, prior course c/b afib w/ RVR requiring ICU, subsegmental PE now on enoxaparin, who p/w persistent N/V after her C8 on ___, found to have likely L preseptal cellulitis, neutropenia, hypocalcemia, hypophosphatemia, and mild progression of disease on re-staging scans. # Nausea, Vomiting, Dehydration, Weakness # Pancytopenia / moderate neutropenia # Severe malnutrition Patient presented with nausea, vomiting, and poor PO intake during cycle 8 of chemotherapy. Symptoms improved with supportive treatment, so suspect they were primarily driven by chemotherapy, although likely also has some baseline symptoms from malignancy as well. Low suspicion for pembro-related autoimmune hypophysitis based on cortisol and TSH. By discharge was tolerating regular diet with PRN PO antiemetics. Also changed dronabinol from PRN to scheduled per oncology recommendations, as this has helped with appetite. Seen by nutrition and given suppleents. #Borderline febrile neutropenia #Pancytopenia #Suspected L preseptal cellulitis Developed periorbital erythema and edema within 24 hours prior to arrival on the floor, suspected to be preseptal cellulitis. Exam/history reassuring against orbital involvement. Had temp to 100.5x1 overnight ___ and then developed severe neutropenia ___ with nadir ANC in 300s. ANC >500 since ___. Continued on vanc/cefepime through discharge, and then then transitioned to bactrim/amoxicillin to complete 7 day course from recovery of ANC (___). Periorbital erythema improved rapidly on treatment. # NSCLC - progressive Treatment history as per above, currently cycle 8 of chemotherapy. Unfortunately CT C/A/P and MRI brain notable for mild progression of one cerebellar met and left scalp/bony met, as well as progression of primary with worsening post-obstructive atelectasis. Other disease mostly stable. She has a persistent cough and intermittent headache. As noted above, it is unclear to what degree nausea/vomiting and poor PO intake have been related to her mets vs chemo. Discussed with medical oncology, neurooncology, and radiation oncology during the admission, and Dr. ___ oncology met with patient to discuss goals and future plans. Patient is uncertain whether she will consider any second line chemotherapy. She will be following up closely in oncology, neurooncology, and rad-onc. Steroids were considered for symptoms, but ultimately not given since her symptoms were mostly resolved and since per rad-onc her lack of edema makes steroids less likely to help. # Hypocalcemia: Severe hypocalcemia initially, likely from zometa ___. Initially required IV repletion. Trialed on higher doses of tums 1000 mg PO TID and calcium levels were maintained in the low-normal range. # Hypophosphatemia: Moderate hypophosphatemia likely from zometa, improved with neutraphos. Stopped neutraphos ___, and phos levels remained stable. # Afib/HTN/cardiomyopathy: - continued on home metoprolol (fractionated) and amiodarone; metoprolol intermittently being held for soft BP, so discharged on 25 mg instead of 50 mg # Subsegmental PE: Lovenox continued however the dose was reduced from ___ID to ___ID based on her weight of ~60 kg. # ___: PPI continued # Headaches: overall improved # free T4 elevation TSH lower normal range. Would recheck as outpatient =================================== =================================== TRANSITIONAL ISSUES - needs close monitoring of calcium and phos - has follow-up in neuroonc, rad-onc, and onc - recheck thyroid studies as outpatient =================================== ===================================
186
518
16032226-DS-25
29,410,714
Mr. ___, you presented to us with worsening rash on your legs and worsening mental status due to your kidneys' inability to clear toxins from your blood. We treated these problems by initially giving you a temporary hemodialysis line and performing hemodialysis to clear some toxins. We also had dermatology evaluate your rash and they felt that a biopsy was not indicated at this time. You were also evaluated by the ophthomology team and they stated that your eyes did not have evidence of cholesterol clots. You began to make urine and your creatinine decreased and we determined that you did not need more hemodialysis at the moment. We made the following changes to your medications: Please START Omeprazole 20mg daily while on steroids START Nephrocaps START Miconazole cream, Hyrdocortisone cream rectally, and Mupriocin cream STOP amitriptyline STOP gabapentin STOP levothyroxine CHANGE PhosLo to 1 tab daily CHANGE Prednisone to 10mg daily CONTINUE Warfarin 5mg daily adjust to INR
Mr. ___ is a ___ gentleman with recent admission ___ for post-procedure MSSA bacteremia that was complicated by presumed Nafcillin-induced AIN requiring temporary HD, who re-presented on ___ with renal failure requiring HD, confusion that continued despite HD, and worsened petechial leg rash. During his stay, he underwent hemodialysis. His mental status cleared throughout the admission and he no longer required dialysis and will be followed by nephrology. He was discharged to ___ on the ___. ACTIVE ISSUES #. ___ on CKD: requiring HD but resolving. Presumed to be AIN (though diagnosis not ___ certain and he was a poor candidate for renal biopsy) vs. sequelae of cholesterol emboli (though his cardiac cath was more than a month prior). Never had a very active sediment to suggest RPGN. Opthomology did a dilated fundoscopic exam and did not see cholesterol emboli. Dermatology did not biopsy the skin. On admission, he underwent temporart HD line placement and underwent HD. Line was removed at discharge and patient was to follow up with renal at discharge and Dr. ___. He was discharged on 10mg prednisone with intention to decrease with renal follow up. #. Altered mental status: continued delirium. Very disoriented, intermittently agitated. At first, it seemed likely that this was all related to uremia but per Nephrology he should have cleared by now. No clear infectious etiology to blame (UCx negative ___, BCx from admission negative, CXR ___ negative, C.diff pending). CT head negative for bleed. Did have very suppressed TSH on last hospitalization and he is on Amiodarone, but hyperthyroidism causing delirium is less likely without other systemic manifestations. C.diff negative. B12 and Folate unrevealing. RPR and HIV negative. #. Leukocytosis: no obvious infection. He did complete a course of Vancomycin for MSSA bacteremia, but he had a rising leukocytosis up to 25.9 on ___ so Vanc was restarted from ___ (stopped per ID recs). Prednisone or drug reaction could possibly explain leukocytosis. Resolved to 9 on discharge. Cultures all negative at time of discharge. #. Leg rash: ?vasculitis. Upon prior discharge, the patient had a rash thought to be from Nafcillin-related AIN which appeared to be resolving, but it worsened as an outpatient. Per Dermatology, appearance consistent with vasculitis and he is already on Prednisone for AIN so would not necessarily biopsy. Other etiologies include purpura from platelet dysfunction (Plavix and uremia). Patient was continued on topical Clobetasol per Derm recs but patient was refusing. #. Cool feet: per Vascular, unlikely ischemic. Has non-palpable DPs (but Dopplerable and other pulses palpable), and occasional foot pain. Ulcerations on bilateral dorsum of feet. Per Vascular Surgery, unlikely to be ischemic in origin. #. DM2: on insulin. Exacerbated by steroids and patient eating secret cookies in room. Has had issues with hypoglycemia, much improved with ___ recs. We appreciated ___ recs. #. Hypothyroidism: on replacement. TFTs on last admission showed hyperthyroidism; Synthroid dose is low so this may be due to Amiodarone. Held Synthroid for now -recheck TSH ___ INACTIVE ISSUES #. CAD s/p DES to LAD and distal PDA 1 month ago: stable. Patient was cotinued on ASA, Plavix, Metoprolol, Atorvastatin #. Afib: rate controlled. Held anticoagulation for line placement, but restarted at discharge. Given PFO and afib and prior strokes, is on lifelong Warfarin. We continued Metoprolol, Amiodarone #. CVD: with intermittent facial droop/dysarthria. Concern for prior CVAs based on imaging (multifocal ncephalomalacia, of which a prominent example involves the left temporo-occipital region). Facial droop seems to correlate with times of severe confusion. We continued ASA/Plavix TRANSITIONAL ISSUES CODE STATUS: DNR/DNI EMERGENCY CONTACT: ___ ___ ___ (daughter) ___ -Recheck TSH ___
151
613
11533384-DS-5
25,717,550
Mr. ___, It was a pleasure taking care of you at ___. You were admitted for a pacemaker for atrial fibrillation with tachycardia and bradycardia. Your procedure went smoothly. We started you on a low dose of calcium channel blocker. Please take as directed. Diltiazem 180mg daily. Please also decrease simvastatin to 10mg daily as this interacts with diltiazem.
Mr. ___ is a ___ man with permanent atrial fibrillation with recent syncopal episode and holter showing evidence of tachy-___ syndrome. # Tachy- ___ syndrome: Patient with permanent afib and recent syncopal episode during exertion. Holter monitor showing afib with rates ranging from ___. Admitted to the hospital for RV single lead PPM. Course was unremarkable. Post-op he continues to be in afib with ventricular rates in the 70-80s and intermittent pacing (threshold 50). Diltiazem 180mg daily started to help avoid extreme tachycardia with exertion. He will continue dabigatran for stroke prevention. Keflex for 2 days for prophylaxis. Follow up in device clinic. # Hypercholesterolemia: simvastatin decreased from 20mg to 10mg daily due to interaction with diltiazem. lipids need to be rechecked as outpatient. # Transitional issues: - code status: full code - recheck lipid panel given simvastatin reduced due to interaction with dilt. consider switching to different statin.
59
156
17361720-DS-28
29,292,904
Dear Ms. ___, It was a pleasure treating you at ___! Why was I admitted to the hospital? -You were admitted because you had had diarrhea, and because you were feeling dizzy. -When you were admitted, we also saw that your blood levels were low What was done while I was admitted? -We gave you some fluids to make sure you weren't dehydrated -We made sure your blood level was increasing and that your kidney was functioning well -We gave you diuretics to bring fluid off of your lungs and your legs -We made sure you were able to walk around without falling down What should I do when I go home? -Please continue to follow-up with the ___ clinic to dose your warfarin -Please continue to take iron supplementation for anemia -Please continue to follow a diet that is low in salt -Please weigh yourself every morning and call your doctor if weight goes up more than 3 lbs.
___ yo female with h/o afib s/p cardioversion in ___, CHF with preserved EF, CKD, spinal stenosis presenting with diarrhea of 1 day's duration and lightheadedness, weakness. Afebrile and with stable vital signs, initial evaluation significant for anemia at Hgb 7.6 (baseline ___, mild Cr elevation at 1.9 (baseline 1.5-1.8), and mild pulmonary edema on CXR. She received gentle IV hydration in ED and remained hemodynamically stable. Based on the short time course and relatively benign clinical status, her diarrhea was most consistent with a viral gastroenteritis. Mild ___ was thought to be ___ to volume depletion, while anemia may be related to known thalassemia, iron deficiency, and CKD (no symptoms of bleeding, stool guaiac negative). Received 20 mg IV Lasix for mild volume overload on exam. While admitted the patient was able to take good PO. Hgb came up to 8.1 without transfusion and Cr downtrended to 1.7. Because the patient had no further episodes of diarrhea while admitted and because she was able to ambulate with ___, she was determined to be stable to be discharged. Transitional Issues =============================== [] Please consider repeating CBC, chem to ensure that anemia and Cr continue to be at baseline [] Furosemide and lisinopril were initially held in the setting ___ but were restarted on discharge at regular home doses # CONTACT: sister ___ ___ # CODE: DNR/DNI
146
221
19723067-DS-19
28,283,671
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 to the 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. - 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 aspirin 325mg 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. - 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 THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: weight bearing as tolerated to the left lower extremity 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. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided.
The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left tibia and fibula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left tibial IM nail, 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 without services 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 left lower extremity, and will be discharged on aspirin 325mg daily for 4 weeks 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.
445
264
19217375-DS-12
20,805,131
-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed.
Mr. ___ is a ___ male with a long history of uric acid and calcium oxalate nephrolithiasis. He sought a second opinion from me on ___. I noted that he had approximately 1.5 to 2 cm of left ureteropelvic junction stone and was in acute on chronic renal failure with a creatinine of 3.1 with his last baseline creatinine being 1.9. I urged him to come to our emergency department, and he ultimately presented on ___ to our ED. His creatinine was again noted to be 3.1 with a potassium of 4.8. Plans were made to bring him to the operating room for retrograde pyelography on the right to delineate the anatomy of what appears to be a complex right calyceal diverticulum with stones as well as to place a left ureteral stent and potentially treat his left proximal ureteral stones. He was admitted from the emergency room and prepped for operative intervention. He was taken to the operating room where he underwent cystoscopy, bilateral retrograde pyelograms with interpretation, left ureteroscopy and laser lithotripsy of left ureteral calculi and finally left ureteral stent placement. Foley catheter was placed for urine output monitoring. He was recovered and taken to the PACU and subsequently transferred back to the general surgical floor where he remained overnight. See the detailed operative note for full details. His pain was well controlled on the general surgical floor and on postoperative day one, his foley catheter was removed. After voiding he was discharged home. His post-operative course was unremarkable. Postoperative labs reflected improved creatinine and improvement in his acute kidney injury. He was discharged home with explicit instructions to return for ureteral stent removal and further intervention as necessary.
246
275
15667769-DS-16
21,900,695
Dear ___, ___ were hospitalized on ___ at ___ for your chest pain. During your hospitalization, we did not see any signs of heart attack by your blood work and EKG. While ___ were here, we were concerned about possible slurred speech so ___ got scans of your head and neck to look for a possible stroke. Neurology evaluated ___ had an MRI that showed ___ may have had a small stroke. We have made appointments with your PCP and cardiologist within the next week, so please keep these appointments. In addition, please keep your previously made doctor appointments. Please note that your other home medications have not been changed.
___ with h/o CAD, ischemic cardiomyopathy presents with chest pain. . >> Acute Issues: # Chest pain: This patient has a history of CAD s/p MI in ___. During her hospitalization, she had two sets of negative cardiac enzymes and EKG showed non specific ST changes, unchanged from last EKGs. Due to her negative cardiac enzymes, unchanged EKG, and brevity of symptoms before presentation without recurrence, patient will follow up as an outpatient for catheterization. Patient was discharged on all of her home medications. The cardiology fellow spoke to pt's OP cardiologist who agreed to plan for OP cath. . # Hypotension: The patient's SBPs went into the ___ on arrival to floor. She received 250 cc bolus NS and her SBP responded appropriately (SBPs in 100s-110s). This was most likely due to hypovolemia and antiHTn meds given at BIN before transfer. Through rest of the hospital course, her SBPs remains in the 110s-120s and she remained asymptomatic (no dizziness, lightheadedness). Home metop and lasix were restarted without issue. . # Neuro deficits: On examination of the patient on admission, it was noted that she had dysarthria, facial asymmetry, and mild ptosis. The stroke team was consulted and she received an MRI and MRA head/neck. These images revealed small micro-hemorrhage in the right temporal lobe and subtle focus of slowed diffusion adjacent to the cortex of the right parietal lobe, concerning for a focus of infarction. She got a TTE which showed: Moderate left ventricular dilatation with moderate to severe regional variation c/w multivessel CAD, Normal right ventricular cavity size and systolic function, Right ventricle not well-visualized, Mild mitral and aortic regurgitation, and No cardiac source of embolism identified. She got HbA1c (6.9) and lipid levels drawn (Chol 142, LDL 60). Neurology believes that her dysarthria is readily explained by her penetrating arttery brain lesions and her prior stroke and her long term use of antipsychotics and there is no evidence of recent brain ischemia. Neurology thought anticoagulation may be appropriate for the patient, but deferred to cardiology. Cardiology attending did not feel as though anticoagulation is indicated. >>Chronic Issues # CHF: patient has known ischemic cardiomyopathy, with most recent ECHO showing EF ___ and severe regional left ventricular systolic dysfunction with global hypokinesis and akinesis of the septum, apex, distal two thirds of the inferior wall. She presented with a proBNP 3707, but lower than her baseline of >4000. Patient's lungs clear, however patient does have elevated JVP. Her heart failure medications were held for a day due to hypotension, but were resumed during the hospital course and she maintained hemodynamic stability. # DM: The patient's glucose was monitored qAHCS and she was put on an ISS. Her HbA1C was 6.9. She was discharged on her home diabetic medications. >>Transitional issues: - Patient will go to rehab on DC for ___ and OT - needs to follow up with cardiologist to plan for outpatient cath - She should follow up with psychiatrist (or PCP if she does not have a psychiatrist) to discuss her antipsychotic medications and doses. Neuro recommends that she decrease her antipsychotic meds as it may be exacerbating her neuro symptoms. - Please consider restarting lisinopril as an outpt if BPs will tolerate
113
527
16788215-DS-8
25,220,000
___ was admitted to the hospital because she had two seizures. She underwent EEG in the hospital which did not show any ongoing seizures. She had no further clinical seizures and her mental status returned to baseline. We did not find any trigger for her breakthrough seizures - there was no sign of infection or electrolyte abnormalities. A discussion with her outpatient epileptologist was held and no changes were made to her anti-epileptic medications. We are waiting for the results of a blood test to monitor the level of her Zonegran to make sure her dose is at the therapeutic level.
___ was admitted to the Neurology floor in stable condition. A workup for infectious etiologies was negative. A zonisamide level was sent and is pending. She underwent extended routine EEG monitoring with no evidene of seizure activity. Her mental status returned to baseline. After consultation with Dr. ___ AED regimen was left unchanged and she will continue zonisamide 700 mg monotherapy. She was discharged to the care of her parents to return to her group home.
101
76
11855455-DS-23
21,762,700
Dear Mr. ___, Thank you for allowing us to take part in your care! WHY WERE YOU ADMITTED: - You were having chest pain and we wanted to figure out why. WHAT HAPPENED IN THE HOSPITAL: - We did bloodwork and a CAT scan, and everything was normal. - We think your chest pain was related to cocaine use. WHAT SHOULD YOU DO AFTER LEAVING: - Follow-up with your doctors as ___. - Take your medications as prescribed. - Please stop using IV drugs, as you have already had multiple heart infections related to drug use. - If you notice severe chest pain, shortness of breath, or headache, please return to the hospital. Thank you for allowing us to take part in your care! your ___ team
___ with h/o IVDU and recurrent endocarditis involving bioprosthetic mitral valve, presenting with intermittent central chest pain, fatigue, and malaise after recent heavy cocaine use. Currently pain free and hemodynamically stable.
114
32
13870141-DS-20
21,099,410
Dear Mr. ___, It was a privilege caring for you at ___. You were admitted because you were found on the ground in your apartment. You underwent imaging of your neck and head which did not reveal any fractures. You sustained an injury to your neck "whiplash" which caused swelling at the back of your throat, which made it difficult to swallow. You were kept in a soft collar neck brace for your comfort and should follow up with orthopedics (Dr. ___ in ___ weeks. While the swelling continues to improve, it will remain difficult to swallow. Your diet will be initially restricted to consistencies which decreases the risk that food and drink inappropriately pass down your windpipe instead of your esophagus. While you are having difficulty swallowing, your medications are given crushed in applesauce. Unfortunately your tolcapone cannot be crushed, so while you are unable to take this, we are doubling your dosage of sinemet to prevent worsening ___ symptoms. Once you are able to swallow better again your medications should be changed back to the previous doses. We wish you and your wife a speedy recovery. Best, Your ___ team
___ PMHx hypothyroidism, ___ disorder (Dx ___, and recent falls who presented after been having been found down in his apartment for up to 36 hours. Noted to have mild rhabodomyolysis and C1-C4 prevertebral edema due to cervical trauma without evidence of fracture or ligamenetal injury.
192
46
15083239-DS-8
24,386,191
You were admitted to the hospital with pelvic pain and kidney failure. Your pain was better controlled by adjusting your pain medications and by addressing constipation. You were also found to have kidney failure which was due to obstruction from prostate cancer; this was managed with tubes placed in the back to drain each kidney. Your kidney function improved. . Please see below for your medications. . The urology doctors also ___ and replaced your suprapubic catheter. You were started on a medication for potential bladder spasms. . You will continue to be followed closely by Hospice of ___ ___ when you return home.
# Renal failure- due to post-renal obstruction ___ tumor invasion of bladder wall. Discussed with patient and wife prior to obtaining ultrasound. IVF overnight did not improve creatinine. ___ consulted for bilateral nephrostomy tube placement to relieve obstruction as a palliative procedure to extend his quality of life. Attempt was made to internalize the tubes, but ___ unable to do so, so external tubes with collection bags were means of decompression. His hospice nurse has experience caring for patients with percutaneous nephrostomy tubes, and should they cause discomfort at home, they can be removed. Following placement, creatinine improved from 4.6 to 1.1 on the day of discharge. ++ Nephrostomy tube care, wash with ___ saline and ___ hydrogen peroxide and cover with dressing daily. Flush with ___ NS if bloody or clogged. ++ suprapubic tube care-wash with ___ saline and ___ hydrogen peroxide and cover with dressing daily. Flush with 30cc saline if bloody or clogged. # Advanced pancreatic cancer-the patient wishes to pursue only palliative therapy. Symptoms were well controlled with morphine 5 mg IV Q3H PRN. With input from palliative care, regimen was converted to MS ___ 30 mg BID and MSIR ___ Q3hrs. However, this regimen again proved challenging as pt would go from periods of confusion to severe pain. Therefore, the patient was converted to a fentanyl patch at 25mcg q72hrs and continued to use MSIR for breakthrough pain. AT a dose of ___ Q3hrs prn. Difficulty balance as pt often with pain using 15mg and somewhat confused/sedated with 30mg. Pt should get 30mg MS ___ ___. Can trial ___ at intervals during the day, depending on symptoms. Could also uptitrate fentanyl patch. Pyridium was discontinued given significant anti-cholinergic effect that was likely exacerbating constipation. However, the urology team felt that pt was having bladder spasms and pt was started on oxybutynin therapy TID with good effect and improvement in spasms. # Fever- treated at home with levofloxacin for empiric UTI coverage. Ceftriaxone continued initially on admission. Initial urine culture from chronic suprapubic catheter was indeterminate, repeat cultures from each nephrostomy tube were negative. However, pt with another low grade temperature on ___ and culture was sent from suprapubic tube which showed mixed flora. Antibiotics were discontinued. . # Constipation- pt given an aggressive bowel regimen, with enemas, which relieved constipation. . #anemia/thrombocytosis, leukocytosis-felt to be related to above process. No signs of C.diff, or PNA. # HTN- continued amlodipine . # FEN- IVF, replete lytes, regular diet # Contact- patient, wife ___ ___ # Code- DNR/DNI . Transitional care 1.continue titration of pain medication prn. Pt currently on 25mcg fentanyl patch and MSIR ___ Q3hrs pain. Occasionally 15mg works, occasionally needs 30mg. Would give 30mg ___. 30mg occasionally too sedating. Could also uptitrate fentanyl patch prn.
101
458
18259787-DS-22
25,591,637
Mr. ___, You were admitted to ___ due to headache, vomiting. On brain imaging, we found that the bleed in your known stroke from previous admission was stable, but the swelling around this brain bleed was increased. This swelling can increase up to 3 weeks after initial brain bleed, therefore we felt your symptoms were caused by the expected increase in the swelling around the known bleed. As your headache and vomiting improved soon after presentation, we did not have to give you medications to lower pressure in the brain. We also found that you had a Urinary tract infection, therefore we started you an antibiotic to treat this. [ ] Please take amoxicillin by mouth till ___ for urine infection. [ ] continue other medications as prescribed. You were seen by our physical therapist who recommendation continuation of rehabilitation. You were discharged to rehab on ___. It was a pleasure taking care of you, Sincerely ___ Neurology Team
HOSPITAL COURSE: ___ man with past medical history of HTN, HLD, poorly controlled DM, CAD, and recent admission for right ICA and MCA occlusion s/p TPA, ICA stent placement, and thrombectomy with TICI3 reperfusion with ___ hemorrhagic transformation who presented as a transfer from ___ for severe headache, nausea and vomiting. At ___, neurological exam stable. On imaging, no new hemorrhage but had increased ___ edema around the known old hemorrhage. Patient was observed and had spontaneous resolution of symptoms with stable neurological exam. He was found to have Enterococcus UTI, treated initially with IV Ceftriaxone, then narrowed to IV ampicillin and discharged to Rehab on oral amoxicillin. ======================================= ## Headache, known Right MCA stroke with hemorrhagic transformation: On arrival to ___, patient reported that he had mild headache over the past few days. It became worse day before admission & improved with Tylenol. He then vomited once. He had no complaints when evaluated in the ED, specially no headache. On initial presentation, his exam was largely stable from most recent documented discharge physical exam with stable left hemiparesis, dysarthria, left facial droop. New findings on initial exam were decreased sensation to light touch and pinprick in the left side of his face in the V2 and V3 distribution, in addition to decreased light touch and pinprick in his left upper extremity compared to the right upper extremity. On repeat exam in ED, his sensory exam was noted to be symmetric without any difficulty to light touch, exam was thus essentially unchanged from discharge exam after previous hospitalization: VSS. Awake & alert. ___ seem intact. + flattening of L NLF. No field cut. + pronation of L UE. L hemiparesis (___) w/ increased tone. L sided hyperreflexia. Sensations intact. CT head showed stable left basal ganglia hemorrhagic transformation with increased surrounding hypodensity ___ edema) resulting in increased effacement of the R lateral ventricle and 1-2 mm midline shift. CTA showed patent R ICA stent; scattered calcifications in the ICAs, and narrowing of R ___. He was thus admitted for observation due to increased ICP due to increased ___ edema. Given resolution of symptoms and stable exam, hyperosmolar therapy was not given. He remained stable during the hospitalization. Overall exam is largely stable from most recent documented discharge physical exam with stable left hemiparesis, dysarthria, left facial droop. We continued aspirin (81 mg) and Plavix given his ICA stent. Repeat ___ evaluation was done, and ___ rehab was recommended, therefore patient was discharged to ___ rehab on ___. [ ] continue aspirin 81 mg and Plavix [ ] continue atorvastatin 80 mg ##Enterococcus UTI: He was found to have Enterococcus UTI, treated initially with IV Ceftriaxone (___), then narrowed to IV ampicillin (___) and discharged to Rehab on oral amoxicillin 500 mg TID till ___ (for a total 7 day course). ============================================
151
463
15793371-DS-13
22,384,894
Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You came to ___ with concern that you had Tuberculosis. After we took 3 sputum samples, it was determined that you do NOT have Tuberculosis in your lungs. You will continue to need anti-biotics for your spine infection. You will be treated with oral antibiotics for your spine infection for another 30 days. You should follow-up with Dr. ___) for weekly blood work while taking this ___ antibiotics.
___ pmHx HIV, HCV, IVDA who recently was discharged with epidural abscess who p/w concern for Tb and with ___ rash ?drug related # AFB+ Abscess Cx: Patient with growth of AFB on abscess that previously was known positive for MRSA. Patient was admitted from rehab for r/o Tb. - 3 induced sputums with AFB sputum was smear negative on gram stain - Dr. ___ with ID will f/u State lab to return speciation and contact patient # MRSA Abscess: Patient on extended course of Vancomycin s/p multiple drainages of epidural abscess. Derm consulted, felt rash was due to Vanco and this was stopped. Daptomycin was started at the recommendation of ID. She declined the opportunity to go to rehab for continued abx with Daptomycin, so PICC line was removed give hx of IVDU and pt was d/c with 4 weeks of linezolid ___ PO BID. She will f/u with Dr. ___ in ___ for weekly CBC, CMP, ESR, CRP and LFTs. She will also f/u at ___ in ___ clinic in 4 weeks. # Transaminitis: LFTs slightly elevated, trending up. Risk for hepatitis due to IVDA as well as known Hep C. Could be due to medications. Hep B surface antigen was negative. # Normocytic Anemia: Hct 33 on admission, stable at this level during last admission. Iron studies normal. # HIV: Low CD4 count measured here thought to be secondary to acute illness (171 on ___. ID did not feel prophylactic bactrim was indicated at that time. CD4 ___. She was contniued on home truvada and raltegravir.
84
260
19517966-DS-14
26,332,025
You were admitted to ___ for abdominal pain from ___ ___ in ___. You got an endoscopy which showed an ulcer and a fistula between two parts of your stomach. You were also found to have a bacteria called h. pylori in your blood. You will need to be on 4 medications for this for 14 days. Take your last dose of bismuth, metronidazole and doxycycline on ___. You continue the omeprazole after that date if it help with your symptoms. You should follow up with your PCP after your discharge from ___. . Medication changes see next page .
This is a ___ yo F with a PMHx of gastric by pass, idiopathic intermittent abdominal pain who initially p/t ___ for a clonidine and alcohol overdose, course c/b self limiting bradycardia and hypotension, transferred to ___ for psychiatric treatment now transferred to ___ for further evaluation of about 5 days of RUQ abdominal pain with prior normal imaging and labs, found to have h. pylori with an anastomotic ulcer and a gastro-gastric fistula . # Gastro-gastric fistula The patient was evaluated by the ___ surgery team and they recommended a GI evaluation for further work up. The patient got an EGD on ___ which showed a marginal ulcer at the g-j anastomosis and a gastro-gastric fistula which was not amenable to endoscopic therapy due to the size of the fistula. The patient was also found to have h. pylori serology. These findings were discussed with the ___ surgery team and they felt as though a trial of medical therapy was appropriate with follow up as an outpatient in ___ weeks. The patient was agreeable to this and will follow up initially at ___, although her surgery was done else where. . # marginal ulcer in the setting of h. pylori positive serology A component of the patients pain is also likely due to her ulcer found on EGD. The patients h/o overdose, alcohol use and h/o gastric bypass puts her at risk for ulcers and fistulas. The patients h. pylori serology also came back positive. Her Hgb was stable during this hospitalization. She will be treated with quadruple therapy for this with omeprazole 20 BID, bismuth 525 QID, metronidazole 250 QID and doxycycline 100 Q12H for 14 day course (start date is ___ ending ___. This is a non-conventional regimen due to the patients allergies to pcn and biaxin (rash) and unavailability of tetracycline at ___. This issues was discussed with both pharmacy and ID and they agreed with this regimen. The patients abdominal pain associated with both her ulcer and fistula were an ongoing problem in house but did improved and she was able to tolerate a bariatric diet. She was initially on Dilaudid IV and was eventually transitioned to oxycodone. Given the patient has issues with alcohol in past, narcotics should attempt to be weaned off as her symptoms resolve. The patient had times when she appears very comfortable and other times where she is in tears. Her pain has been relatively well controlled for the past several days on Carafate 1 g QID, oxycodone 15 Q3H prn and tylenol ___ Q8H standing. Tramadol can also be considered as the patient is attempting to come off narcotics. There is a small risk of serotonin syndrome with her current medication regimen, but pharmacy indicated that this is not a contra-indication to using this medication. . # SVT with episode of symptoms in house The patient has a known h/o SVT and has had a prior evaluation by a Cardiologist who suggested a possible ablation in the future. Anxiety related to pain and her condition seemed to drive the onset of SVT (which appeared to be AVNRT by EKG). Her symptoms terminated with vagal maneuvers. The patient was attempted to be started on metoprolol 12.5 BID, but she had borderline bradycardia, so this was deferred. She should follow up with a Cardiologist as an outpatient. Serial cardiac enzymes were negative following this episode. . # Anxiety/Depression with recent suicide attempt with clonidine and alcohol The patient has a history in the past of suicide attempts and alcohol abuse. The patient denies active SI or HI while in house here. She was followed by psychiatry and had a 1:1 sitter for the duration of her stay. She had mood lability and was often tearful during medical evaluations, specifically about her deceased husband. Much of her anxiety was in regards to having her pain treated. . # Transitional Issues [] follow up with Bariatric Surgery at ___ in ___ weeks for further management of her gastro-gastric fistula and consideration of surgical management [] complete her 14 day course of antibiotics for her h. pylori positive ulcer and follow up with her PCP and confirm eradication with a urea breath test, fecal antigen test, or upper endoscopy performed four weeks or more after completion of therapy [] follow up with Cardiology regarding further management of her SVT [] further management and outpatient Psyc services per inpatient Psyc at ___ .
104
749
14446098-DS-23
24,908,383
Dear Ms. ___, You were admitted to the hospital for shortness of breath. You were found to have the flu that is causing your difficulty breathing. You also had mild heart failure from the flu. You should continue to take the oseltamivir (Tamiflu) for flu treatment until ___. Please follow-up with your transplant doctors next week as they will need to check your labs again. They also recommend you take 3.5 mg twice a day of your tacrolimus. Please continue to take your furosemide (Lasix) as previously prescribed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Take care. Your ___ Team
Ms. ___ is a ___ with PMH significant for LRRT ___ and recent diagnosis of humoral rejection s/p IVIG and rituximab who presented with dyspnea, cough, wheezing, and hypoxemia. BNP was elevated to 11,000 and patient had evidence of mild fluid overload on exam. Additionally, she tested positive for influenza A. She was diuresed with IV lasix, ultimately with a lasix ggt at 5mg/hr. She was also started on oseltamivir 30mg q12h for treatment of influenza and duonebs. Her respiratory status improved significantly and she was stable on room air on the day of discharge with ambulatory sat in 92-94% range. Her tacro level was at 4.8, so her tacro was increased from 2g q12h to 3.5g BID. She was discharged on her home dose of diuretics with plan to continue Tamiflu 30mg q12 for 5 day course to end on ___. She will need repeat labs drawn on ___ at her follow-up appointment with transplant nephrology. #Acute on chronic HFpEF (EF 65-70%) #Acute hypoxic respiratory failure ___ influenza A infection BNP was elevated at admission to 11k, likely acute on chronic diastolic HF ___ influenza infection. She was diuresed with Lasix intravenous bolus and placed on a Lasix ggt at 5mg/hr. Her respiratory status improved and she was transitioned back to Lasix 40mg PO BID. She was also found to have influenza A infection that was likely contributing to acute hypoxic respiratory failure. Patient was placed on Tamiflu 30mg q12h (renal dosing) and she had duonebs standing. Her respiratory status improved significantly and she was stable on room air after requiring 3L O2 at admission. Ambulatory O2 sat ranged from 92-94% on the day of discharge. Will be discharged on albuterol inhaler. 5 day course of Tamiflu will end on ___ (renally dosed to 30mg q12h) -preload: lasix 40mg BID -NHBK: c/w carvedilol -afterload: c/w hydralazine
101
302
17425699-DS-17
29,775,166
Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having severe abdominal pain, nausea, and vomiting. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had lab tests and imaging that showed that you had inflammation of the gallbladder (cholecystitis) that was causing your symptoms. - The Interventional Radiology team performed a percutaneous cholecystostomy (tube placement in the gallbladder to drain bile). - Tests showed that there was an infection with E. coli in the gallbladder. - You were treated with antibiotics and your pain and nausea and fevers improved. You received IV fluids for rehydration and then slowly restarted eating and drinking. - You were seen by the Cardiology and Surgery teams, who recommended that you get a cholecystectomy (gall bladder removal) in the future after your acute infection resolves. - You worked with Physical Therapy who recommended that you go to ___ rehab to regain your strength before returning home. 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. - You are going to need to continue your antibiotics until you have your gallbladder surgery. - You will need to keep the gallbladder drain in place until your follow-up appointment with the surgery team. You will have help draining this at rehab. - Please discuss with your cardiologist and their team about timing of stopping your Plavix prior to surgery. We wish you the best! Sincerely, Your ___ Team
P - Patient summary statement for admission =========================================== ___ with PMH of HLD, CAD s/p CABG and multiple PCI, GERD, HTN, DM presenting with RUQ abdominal pain, nausea, and vomiting. A - Acute medical/surgical issues addressed =========================================== # Acute cholecystitis Patient presented with acute onset progressive RUQ pain, fevers, and leukocytosis consistent with acute cholecystitis. Initially tachycardic to HR 110s but otherwise HDS and reassuringly, LFTs and lipase wnl. ___ performed percutaneous cholecystostomy on ___. She was kept NPO, received IVF resuscitation and IV morphine and acetaminophen for pain control, and was initially treated with Unasyn. Bile culture from cholecystostomy grew E. coli resistant to ampicillin and intermediate resistance to Unasyn. ___ MRCP demonstrated acute gangrenous cholecystitis without choledocolithiasis. New perihepatic ascites was noted on MRCP, however ___ tube study did not show definite evidence of leak. Afebrile since the morning of ___, when she was switched from Unasyn to Zosyn. Clinically improved on conservative management with decreased pain (last dose of morphine on ___ am) and improvement in leukocytosis and tachycardia. On day of discharge she was tolerating full PO diet without issue and she was transitioned from Zosyn to Bactrim on ___ with plan to continue Bactrim until cholecystectomy. Surgery (ACS) evaluated patient and recommended continuing conservative management followed by cholecystectomy as outpatient after acute infection is cleared. Physical Therapy evaluated patient and recommended ___ rehab. # CAD Pt has an extensive history of CAD with chronic stable angina s/p CABG in ___, and most recently DES to PL in ___. Positive cardiac stress test (___). Patient follows with Dr. ___ was evaluated in the ED by Cardiology. She has chronic exertional angina but reassuringly EKG with no interval change and trop negative this admission. At last appointment with Dr. ___ was discussion regarding possible diagnostic angiogram if symptoms worsened. Exertion at level of ___ METS brings on typical angina. Cardiology was consulted when surgical intervention during this admission was being considered, recommended holding clopidogrel for 3 days prior to cholecystectomy if warranted. Home clopidogrel 75mg QD was initially while surgical intervention during this admission was considered, then restarted on ___ as clinical status improved. Continued home ASA, simvastatin, fractionated home metoprolol. Home Lasix was held ___ infection and relative hypotension. # IDDM On home Humalog ___ 95 units SC daily. While NPO she was given 50U Lantus qhs with HISS. C - Chronic issues pertinent to admission =========================================== #HTN Continued home metoprolol tartrate 25mg Q6H (fractionated). Home isosorbide mononitrate and lasix held in setting of infection and SBPs ___. #HLD Continued home simvastatin 5mg po daily. #GERD Continued home ranitidine 300mg po daily. #Vitamin D Deficiency On home 50,000 ergocalciferol q2 weeks. #Chronic Pain #Diffuse Osteoarthritis Continued home tramadol 50mg po TID. Continued gabapentin 300mg po am and afternoon and gabapentin 900mg po qhs. Vitamin D supplementation as above. Home Vicodin held while patient received morphine. #Asthma #Allergic Rhinitis Continued albuterol inhalers prn and home cetirizine. #Depression Continued venlafaxine 150mg po daily T - Transitional Issues =========================================== [] Plan for cholecystectomy after acute infection: We will continue antibiotic treatment with Bactrim (sensitive on bile culture) until patient follows up with surgery in clinic. Per surgery team, will arrange follow-up in ___ weeks and likely plan for surgery in ___ weeks. Percutaneous cholecystostomy tube management per surgery team. [] Clarify plan with Cardiology regarding how long to hold Plavix prior to cholecystectomy. Patient has follow-up appointment on ___ during which a plan should be made detailing went to stop Plavix prior to surgery. [] F/u BP and electrolytes in 1 week: home isosorbide mononitrate, Lasix 20mg QD and potassium repletion 20mEq QD held this admission in setting of infection and SBPs ___ restart as tolerated. [] F/u blood glucose levels, insulin regimen: on home Humalog ___ 95 units SC daily, has been getting 50U glargine QHS during this admission while mostly NPO. FSBGs mostly in 100s-200s, but had a BG of 409 the morning of discharge after having breakfast. Would recommend uptitrating towards home dose prn as PO intake increases. [] Consider changing to high intensity statin if able given significant cardiovascular disease. #CODE: Full, confirmed #CONTACT: ___ (husband) ___
266
663
16846688-DS-14
23,370,796
Mr. ___, You were admitted after sustaining a fall secondary to the visual deficits from the mass in your brain. You underwent work-up including a CTA, Audiogram, Speech and Swallow, and Ophthalmology evaluation. We are transferring you to Dr. ___ at ___ for further care.
Mr. ___ was admitted to neurosurgery service after a fall with large cystic cerebellopontine angle mass. #CPA mass He was started on Decadron for cerebral edema. He underwent CTA for operative planning. Ophthalmology evaluated patient and findings were consistent with bilateral ___ nerve compression, causing his diplopia. Given the mass location, Dr. ___ ___ transfer to ___, Dr. ___. Patient and HCP were updated and in agreement. An Audiogram was done on ___ prior to transfer to ___. #Dysphagia SLP evaluated patient and he was found to have intermittent aspiration with thin liquids. He was put on nectar thick diet.
44
99
19023118-DS-11
25,046,338
Mrs. ___, ___ were admitted to ___ due to a recurrent small bowel obstruction. Due to your history of multiple prior surgeries as well as your other comorbidies, we initially attempted to treat your small bowel obstruction with bowel rest and a nasogastric tube. ___ were started on total parental nutrition to maintain your caloric intake. Ultimately, ___ did undergo an exploratory laparotomy with Dr. ___ did have several adhesive bands that he did release to resolve your obstruction. ___ will need to follow-up in clinic with him. Incision Care: *Please call your doctor or nurse practitioner if ___ have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. ___ may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If ___ have staples, they will be removed at your follow-up appointment. *If ___ have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. General Discharge Instructions: 1. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. 2. Avoid lifting weights greater than ___ lbs or lifting that requires ___ to strain until ___ follow-up with your surgeon, who will instruct ___ further regarding activity restrictions. 3. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 4. ___ may take your prescribed pain medication for moderate to severe pain. ___ may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 5. Take prescription pain medications for pain not relieved by tylenol. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication if ___ are experiencing constipation. ___ may use a different over-the-counter stool softener if ___ wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. ___ may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); ___ should continue drinking fluids, ___ may take stool softeners, and should eat foods that are high in fiber. 8. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please call your doctor or nurse practitioner or return to the nearest ER if ___ experience the following: ___ experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If ___ are vomiting and cannot keep down fluids or your medications. ___ 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 a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. ___ have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern ___. It was a pleasure taking care of ___ here in the hospital and we wish ___ a speedy recovery.
The patient presented to the ___ ED on ___, two days out from prior discharge due to intermittent chronic abdominal pain, cramping and increaing nausea. An NG tube was placed and CT abdomen/pelvis showed high grade small bowel obstruction. She was subsequently admitted to the ___ surgery service and treated intially with bowel rest, NG tube and TPN. Given her reoccurrance and the fact she was not showing signs of improvement she ultimately underwent an exploratory laparotomy with Dr. ___. GI: She was made NPO and IV fluids were initiated. Nausea was treated with IV ondasetron and ativan. Due to poor nutritional status a PICC line was placed and patient was placed on TPN. Her diet was advanced as her bowel function returned slowly until she was placed on a regular diet on POD10, which she tolerated well. She was tolerating a regular diet at discharge on POD11, passing flatus and stool. CV: Vital signs were routinely monitored and the patient remained hemodynamically stable Pulm: There were no respiratory issues. Extubated after surgery without issues. Neuro: Pain was controlled with IV morphine and acetaminophen. She was transitioned to PO medications upon d/c. GU: Foley ___ was placed upon admission for urinary output monitoring and discontinued; the patient returned to straight caths for neurogenic bladder which she had been preforming at home. She did have a urine analysis and urine culture performed as there was residue seen on the foley cathater tubing, but no urinary tract infection was found to be treated. PPX: The patient received subq heparin and wore SCDs. --------------------
556
255
17517983-DS-105
23,411,823
Dear Ms. ___, It was a pleasure taking care of you during your admission to ___. You were admitted for abdominal pain, hyperglycemia, and hypertension. You with treated with insulin drip, labetolol drip, and dialysis. Your sugars improved although they remained difficult to control. Your abdominal pain improved and you were able to tolerated liquids and food. During this hospitalization, you also met with a pain specialist who recommended you discuss a referral to the pain clinic with your PCP. You met with interventional radiology who will schedule you for a port catheter placement as outpatient. The port placement will help give you long-term access for the frequent blood draws you require. Please continue taking your home medication regimen and follow up with your outpatient dialysis center, your endocrinologist, and your PCP. Sincerely, Your team at ___
Ms. ___ is a ___ woman with a history of poorly controlled T1DM, ESRD on HD, and gastroparesis who presented with hemoptemesis, nausea, vomiting, and abdominal pain found to have elevated blood sugars in and acidosis, most consistent with HHS.
134
41
16014771-DS-37
23,356,223
Dear Ms. ___, It was a pleasure being able to participate in your medical care during your stay at the ___. You came to the hospital because of your headache and chest pain. We performed several tests of your heart and there were no major signs of a heart attack. We also performed a CT scan of your head that was normal and did NOT show a stroke. You had an episode of chest pain while in the hospital and we repeated tests of your heart, which again did not show a heart attack. Because you continued to have chest pain while you were in the hospital, we contacted the cardiology team and they performed a cardiac catheterization, which is a procedure to look at your heart vessels. They did not see any changes compared to the last examination of your heart vessels. We continued your home medications, which we would like you to continue as prescribed. Thank you for letting us participate in your care. Please follow-up with your cardiologist as indicated below. We wish you all the best, Your ___ Care Team
Ms. ___ is a ___ year old woman with multiple cardiovascular risk factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p stent with prior MI in ___, CVAs x2 including left occipital stroke in ___, lung CA s/p chemotherapy and surgery, atypical chest pain, who presents with headache and chest pain found to have a normal EKG and negative troponins. # Chest pain: Given her normal EKG, negative troponins, and history of atypical CP with a negative workup, and reproducible chest pain on palpation, an acute coronary process was considered unlikely during her presentation. We started her on naproxen, continued her home aspirin, and continued to monitor her clinically. However, she complained of chest pain on hospital day one and had a negative EKG and negative troponins. Cardiology was consulted and recommended cardiac catheterization. The cardiac catheterization was unchanged from her prior evaluation and a cardiac etiology for her chest pain was felt to be unlikely. # Headache: She had a CT head that showed no acute intracranial abnormality. We continued her home Oxycodone-Acetaminophen (5mg-325mg) ___ and avoided IV opioids after she had transient opioid-induced delirium. Her headache had resolved prior to discharge. # Opioid-induced transient delirium: During her hospitalization, she had an episode of pin-point pupils, slurred speech, somnolence, decreased respiratory rate to ___ breathes per minute, and dry mouth which was likely secondary to receiving oxycodone and IV morphine. She was hemodynamically stable, satting well on room air, and mentating during the episode and was without focal neurological signs with unchanged baseline weakness in her right upper and right lower extremity. She was back to her baseline within 30 minutes of the episode. We held IV pain medications and she did not have any similar episodes before she was discharged. # H/o stent and CVA: We continued her home clopidogrel. # Cardiovascular risk factors: We continued her home aspirin and atorvastatin. # GERD: We continued her home pantoprazole. # Hypothyroidism: We continued her home levothyroxine. # Chronic back pain: We continued her home gabapentin 600mg and oxycodone-acetaminophen. # Insomnia: We held her home TraZODone 150 mg and gave her trazodone 50mg PRN instead. We held her home melatonin. # Allergies: We held her home hydrOXYzine and cetirizine. # ?Asthma: We held her ProAir HFA (albuterol sulfate). # Vitamins: We continued her home multivitamins, cyanocobalamin, and held her home fish Oil. # CODE STATUS: Full (confirmed) # CONTACT: ___ (sister, HCP) ___ TRANSITIONAL ISSUES [] Follow-up with cardiologist Dr. ___. Consider starting low-dose beta blocker (ie. Lopressor 12.5mg BID) if her blood pressures allow.
179
412
11050647-DS-14
21,265,607
Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because your liver was damaged from drinking alcohol again WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were continued on steroids to help you recover. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors ___ below) - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight increases by more than 3 pounds - Please maintain a low salt diet and monitor your fluid intake - Seek medical attention if you have new or concerning symptoms or you develop - Please continue to work towards sobriety ****MEDICATIONS**** You will need to continue taking prednisone 40mg for 28 days (last day on ___. We are working on getting you an appointment at that point with Dr. ___ further evaluation. It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team
Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH cirrhosis c/b ascites, varices, and HE, and recent admission for alcoholic hepatitis who presented as a transfer w/ concern for PVT but was found not to have PVT by MRI and found to have worsening alcoholic hepatitis.
214
49
15137016-DS-20
21,354,934
Dear Mr. ___, It was a pleasure caring for you at ___. WHY WERE YOU ADMITTED? - You had back pain and were found to have abnormal lung findings on chest CT. WHAT HAPPENED THIS ADMISSION? - You were seen by the lung doctors and ___. You received a procedure called a percutaneous ("through the skin") lung biopsy. WHAT SHOULD YOU DO ON DISCHARGE? - Take your medicines as prescribed. - Go to your follow up appointments as scheduled. We wish you the best, Your ___ team
Mr. ___ is a ___ with no significant past medical history who presented to OSH with pleuritic back pain, found to have abnormalities with lung mass on CTA chest, transferred to ___ for further workup, ultimately underwent lung biopsy for suspected malignancy vs infection. #Left lower lobe peripheral lung mass #Pleuritic back pain Patient presented with back pain increased with inspiration. CTA performed at ___ showed a left lower lobe peripheral lung mass with surrounding ground-glass opacity. Differential included bronchoalveolar carcinoma, fungal infection, atypical bacterial infection. No family history of lung cancers at young age. He does smoke marijuana on a daily basis. He was treated initially with CTX/azithromycin which was stopped at ___. Pulmonary and ___ were consulted. Patient underwent CT guided percutaneous lung biopsy targeting the left lower lobe mass on ___ after multidisciplinary discussions. CXR after the procedure showed no pneumothorax. His pathology and other results will be followed by the pulmonary team, followup to be arranged after discharge. He should have an appointment within the next 4 weeks. # Sinus Tachycardia He had sinus tach in 100s to 110s intermittently. CTA did not show any PE. Likely there was an element of pain and anxiety contributing. He received 25 mg Hydroxyzine with a calming effect. # Normocytic anemia Hb 12.8 on HD 3, possibly in setting of receiving IVF, would recheck as an outpatient. TRANSITIONAL ISSUES: ================== [] f/u biopsy micro and path
87
233
15636557-DS-14
24,563,720
Dear Ms. ___, You came to the hospital because you were having symptoms of vision loss in your right eye with flashing patterns and lights. We saw that you cannot see well out of the right side of your vision. On MRI we see that you have an MS flare, which is affecting the part of your brain that processes vision. We have started you on a course of steroids to treat the flare. You have received three doses here and you will complete the course as an outpatient. Your MS ___, is aware of the plan. We have given you his clinic number. You should call to set up an appointment soon to discuss your options for long term treatment to reduce your risk of flares. He has prescribed vitamin D for you in the past. We recommend that you take this as it is helpful for people with multiple sclerosis. Unfortunately, it is not safe for you to drive right now. You cannot see out of the right half of your vision. We have given you a note for work to let them know that you cannot drive for now. It will take some time for the steroids to take effect. You will need to be evaluated by Dr. ___ to be cleared to drive again. It was a pleasure taking care of you. Sincerely - ___ Neurology Team
___ presented with one week of right-sided visual artifacts and difficulty seeing on the right. She was found to have a right homonymous hemianopsia. MRI brain showed multifocal FLAIR hyperintensities with contrast enhancement, consistent with an acute MS flare. She was treated with IV methylprednisolone. She received three doses as an inpatient and will complete two doses as home infusion. She will follow up with her outpatient neurologist to start long term MS therapy. Her course was otherwise notable for headache which responded to tramadol and mildly elevated blood sugars while on prednisone. Her home medications for headache, depression and anxiety were continued. She was discharged with a peripheral IV in place for the purpose of her home IV infusions.
226
118
15798647-DS-3
23,119,190
Dear Mr. ___, It was a pleasure taking care of you during your hopsitalization. You were admitted in order to treat an infection of your blood. We believe that the infection was caused by a blockage of your bile system in your liver. We replaced these biliary drains and gave you antibiotics to treat the bacteria in the blood stream and you felt better by time of discharge. We wish you all the best. Sincerely, Your ___ team
Mr. ___ is a ___ year old gentleman with a history of adenocarcinoma of unknown primary causing biliary obstruction now s/p biliary drain placement x2 during his prior admission, who is admitted to the MICU with septic shock secondary to cholangitis/infected bilomas. # Septic shock: Cholangitis vs infected bilomas. Biliary obstruction likely caused by adenocarcinoma. Patient presented with hypotension requiring pressors, tachycardia, leukocytosis, and fever. He was found to have new bilomas on CT imaging. Recent blood cultures from ___ revealed VRE in ___ bottles. Blood Cx at ___ grew pseudomonas sensitive to zosyn. Given linezolid and zosyn (first dose ___. Pressures improved with IVF, pt required pressors only briefly during ___ procedure for replacement of billiary drains (see bellow). #Billiary Obstruction: Secondary to adenocarcinoma. Billiary drains placed, found to be clogged, replaced on ___. During procedure, SBP was in the ___, patient responded to brief administration of phenylephrine. Did not require pressors on floor after procedure. LFTs downtrending. #Adenocarcinoma: Based on path markers is not of colon or lung origin. Mass causing biliary obstruction with increased total bilirubin. He will be seen for follow up in Liver Tumor MDC on ___ by hepatology, medical oncology, and interventional radioloty where consideration will be given to systemic chemotherapy. # Anemia: Normocytic anemia. Patient recieved 1u pRBC with appropriate response. Hemolysis labs negative. Iron studies consistant with anemia of chronic disease. TRANSITIONAL ISSUES - Continue linezold/zosyn for at least 2 week course (day 1: ___ - ___ for VRE bacteremia and pseudomonas bacteremia - Please obtain weekly CBC/differential with BUN/creatinine while patient is on linezolid - Please obtain infectious disease input regarding course of antibiotics - Call ___ rehab ___ to follow up blood cultures with VRE & ___, MD ___ - Patient was discharged with 2 biliary drains drained to gravity. Please let interventional radiology know if patient has any pain, tenderness, redness, or unusual discharge at the drain or around the drain site.
76
316
17693798-DS-54
21,188,787
Dear Ms. ___, You were admitted to ___ for abdominal pain and diarrhea. While you were here your kidney function was found to be worsened, likely because you were not eating or drinking very much while also having diarrhea. This improved with IV fluid, encouraging you to drink more, and medications to improve the diarrhea. You were started on a medicaton called tincture of opium which has improved your diarrhea. You should continue this medication until you speak with Dr. ___. We evaluated the swelling of your neck, which was not caused by a problem with your blood vessels. An ultrasound was performed which did not show enlarged lymph nodes but instead an odd fat distribution. You can follow up with Dr. ___ this. Please return to the hospital if you discover you cannot tolerate eating or drinking or your diarrhea severely worsens from your baseline.
___ female with a hx of crohns disease and collagenous colitis s/p colectomy, ___ syndrome s/p stenting to ___, depression who presents with acute on chronic abdominal pain, diarrhea, and swelling of left face with MRV not showing signs of ___ syndrome. #Diarrhea/abdominal pain: Acute on chronic for last 4 weeks. Has baseline malabsorption/diarrhea secondary to collagenous colitis and colectomy. Given that patient has had ___ BMs daily, this appears more likely to be part of chronic diarrhea state ___ to colectomy rather than crohn's flare. Stool studies as noted below pending. Patient was previously prescribed tincture of opium, however she had not started it. She was started on tincture of opium and did well as a result. Once she started on ___, she did not have issues with ___ (despite being NPO and not receiving IVF for ~20 hours for her imaging study). She has follow up appointment with ___ in ___ who has been following her for her chronic abdominal pain and diarrhea. #Soft tissue swelling: Patient presented with worsening neck and supraclavicular swelling which was concerning for ___ syndrome given that patient has hx of subclavian stenosis s/p stent. MRV did not reveal vascular source of neck swelling and plethora, this was originally thought to be ___ lymph node enlargement so an ultrasound was performed which only showed prominent subcutaneous fat. ___ Syndrome: First dx in ___ and has been difficult to manage. Thought to be ___ to frequent central line placement. In ___ a stent was placed in ___ but quickly clotted but revascularized following in-stent balooon angioplasty. ___ has been well controlled this then. However, INR has proven difficult to control given frequent diarrhea, poor intestinal absoprtion, poor diet, and alcohol use. Target INR 2.5-3.5 given history of recurrent thromboembolic disease. On PE, pt does have L>R facial swelling which she says is consistent with previous IJ clots, however MRV was unrevealing. Started Lovenox on ___ to bridge INR (see below for anticoagulation) -warfarin 12mg PO daily with follow up with ___ clinic -after compromising with patient, will bridge INR with 1.5mg/kg lovenox until INR>2, then may discontinue ___: Patient presented with Cr 2.5 from baseline 1. Most likely prerenal from poor po intake and recent exacerbation of diarrhea. Patient was resuscitated with IVF and started on ___ as noted above. Patient was encouraged to take PO liquids and did well. #Depression: Pt has long standing depression. While denies SI, has made overtures that she would consider hurting herself. -continue with SSRI -patient should follow up with her PCP regarding her depression
147
433
15024110-DS-21
26,569,618
Dear Mr. ___, You came to the hospital at ___ because you were feeling unwell and had low blood sugar. You were found to have a mass in the middle of your brain, called a pituitary macroadenoma. You were seen by neurosurgery, who recommended an outpatient follow up along with ENT (ear nose and throat surgeons) follow-up with discussion for possible surgery. Because this tumor presses on and damages areas that release certain hormones, you required replacement hormones and will need to continue these when you leave. See the rest of your paperwork for these changes. You should follow up with endocrinology after you leave the hospital. **You will need to have your labs checked on ___ before your endocrinology appointment. Please go to ___, these labs are ordered for you** When you initially came to the hospital, your INR (warfarin level) was very high. We stopped this and put you on an injection blood thinner until your level normalized. You were discharged on warfarin again and will need to follow up VERY CLOSELY with your primary care doctor to ensure that this level does not get high again. High INRs can result in severe bleeding!! You will need your INR checked ONCE A WEEK at the ___ ___ above ___. We adjusted your insulin because one of your new medications, hydrocortisone, can make your sugars higher than normal. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team
BRIEF SUMMARY ============= Mr. ___ is a ___ with history of atrial fibrillation on Coumadin (chads2 4), HFpEF (LVEF 63% ___, hypertension, and T2DM who presented with weakness in setting of hypoglycemia, subsequently found to have new pituitary mass concerning for a pituitary macroadenoma. # Expansile sellar mass concerning for pituitary macroadenoma: Initially presented to ED with weakness and hypoglycemia. He was noted to be lethargic upon presentation, and a CT head showed a 3.5x1.3 cm hyperdensity in the sella eroding into the sphenoid sinus. Neurosurgery was consulted, and felt that there was no need for inpatient surgical intervention, currently no focal neurologic findings. ENT was consulted, and will coordinate with neurosurgery for surgical management as an outpatient. He was discharged to follow up as above. # Supratherapeutic INR: INR >13 on admission, unclear etiology. ___ be due to inapprpropriate med administration in the setting of confusion. He received vitamin K and Kcentra in the ED, with normalization of his INR given concern for bleeding into the suprasellar mass. His warfarin was held, and once cleared by neurosurgery was transitioned to ___ to bridge and restarted on warfarin. He was discharged on his prior dose of warfarin with strict instructions to follow up for INR checks and with his PCP. # Hypocortisolemia: # subacute confusion: Patient with a few weeks of new confusion, may be related to neuroendocrine deficit secondary to mass. Endocrine was consulted and recommended sending testing for the HPA axis. He was found to have low testosterone and low AM cortisol. IGF-1 and ACTH were normal. He was started on hydrocortisone 20 mg QAM and 10 mg QPM with improvement in mental status. Low testosterone level was not treated. # Hypoglycemia: Patient with report of hypoglycemia when EMS arrived. No hypoglycemia in house. His glargine initially at 16 units BID, then increased to 18 units BID but he had borderline low blood sugars so this was reduced back to 16u BID at discharge.
245
320
18531371-DS-11
27,014,747
Dear ___, ___ were hospitalized due to symptoms of left sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We saw on MRI that ___ had a small stroke (not a TIA) that caused your weakness. This was most likely caused by small vessel disease, which is from high blood pressure, diabetes, high cholesterol. We stopped your aspirin, started Plavix, which is similar to aspirin, and increased your atorvastatin to decrease your risk of stroke in the future. ___ will have physical therapy at home per physical therapy recommendations. Stroke can have many different causes, so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: high blood pressure diabetes atherosclerosis of your blood vessels high cholesterol We are changing your medications as follows: stop aspirin start Plavix (clopidogrel) 75 mg daily increase atorvastatin to 80 mg nightly Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If ___ 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 ___ - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team
___ woman with a history of HTN and DM presented with acute onset left-sided weakness and slurred speech that lasted for 2 hours before resolving spontaneously prior to presentation to the hospital. She was admitted to the stroke service. CT head showed hypodensity in the right basal ganglia. MRI brain w/o contrast confirmed small acute infarct in the right putamen and as well as the body of the right caudate nucleus. Her stroke was most likely secondary to small vessel disease given the location and her risk factors. We did consider this a failure of ASA. Her home aspirin was stopped, and she was started on Plavix 75 mg daily. She had mild weakness on the L side in an upper motor neuron pattern distribution. ___ assessed and felt that she was able to be discharged home with home ___. She passed her swallow evaluation. TTE not done as this was felt to be small vessel etiology. Her stroke risk factors include the following: 1) DM: A1c 5.5% 2) intra and extra cranial calcifications noted on CTA 3) Hyperlipidemia: LDL 173, started on atoravastatin 80 # CKD--Cr 1.4 on admission, 1.2 on discharge (baseline). TRANSITIONAL ISSUES stroke - follow up in stroke clinic in ___ months. Stopped aspirin, started Plavix 75 mg daily this admission. Increased atorvastatin to 80 mg qhs. DM - continue glycemic control HTN - continue blood pressure control Consider outpatient Echo Home ___ TSH pending at the time of discharge
358
238
16371478-DS-5
21,304,150
You were admitted to the hospital after a Right Sided Colectomy for surgical management of your Colon Cancer. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have a long vertical incision on your abdomen that is closed with dermabond. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. ___ Dr. ___. You may gradually increase your activity as tolerated but clear heavy exercise with Dr. ___ Dr. ___. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. You may also take Ibuprofen as prescribed for pain. Please take this medication with food to protect your stomach. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck!
Mr. ___ was initially admitted to the ___ medical service from the emergency department: ___ y/o M with h/o remote duodenal ulcer, presents with abdominal pain, BRBPR x2 months, CT showing cecal and terminal ileum inflammation. # Colon Mass: Presented with RLQ abdominal pain and BRBPR. Per discussion with outpatient GI doctor, he has colonoscopic evidence of a large apple-core mass in the ascending colon. Biopsies were taken of this lesion, which were consistent with a poorly-differentiated colon primary. CT showed evidence of thickening and inflammation in this region. Colorectal surgery recommended resection of this lesion, especially in the setting of anemia. # Anemia: Baseline Hct appears to be in the mid 40's as of ___, but on admission it was down to 32, and continued to drift down during his time on medicine. Given the presence of a large colon mass, this is the likely source of blood loss. The patient was transferred to the colorectal surgery inpatient surgery pre-operativly. His CEA was 21. Right open colectomy was preformed on ___. The patient tolerated this procedure well and recovered on ___ 5. Post-operative day one, the patient was given intrvenous pain medications and fluids. All post-operative laboratory values were stable. He ambulated without issue with god pain control. Clear liquids were tolerated well. The foley catheter was removed at midnight. The patient was able to voisd without issue on post-operative day two. In the late morning of ___ day two, the patient reported passing flatus. His diet was advanced to regular which was tolerated well. All pain medications were transitioned to pills. The patient was requiring minimal narcotic medications. On the morning of post-operative day three, the patient was stable and tolerated breakfast. He continued to pass flatus. He was meeting all discharge criteria and was discharged home in the care of his supportive wife. All follow-up instructions were given to the patient. The pateint had access to a ___ inerpreter throughout his hospitalization however, he understands ___ well.
611
329
12964119-DS-29
21,442,888
Ms. ___, You were admitted to the antepartum service for nausea, vomiting, and abdominal pain. You were observed in the hospital for several days. Because you were unable to tolerate sufficient amount of nutrition, you were started on tube feeds. You received tube feeding for about a week, and subsequently you were able to tolerate some oral intake. You were not able to tolerate full amounts of normal nutrition, however we felt it would be helpful for you to trial being at home to see if that would help with your oral intake. Thus the tube was removed and we made a plan for close outpatient ___. As you recover from this acute episode of worsened nausea, it is important to take small sips and small bites of bland food when feeling nauseous. The most important thing is to stay hydrated, and you can do this by taking small sips of water or gatorade. The following medications are very helpful for nausea and vomiting of pregnancy: *Zofran (can take 3 times daily) *Pyridoxine (can take 4 times daily) *Doxylamine (to be taken at night) *Zantac (twice daily) In addition, while in the hospital, we addressed the following issues: 1. Adrenal insuffiency: While you were in the hospital you received stress dose steroids for your adrenal insufficiency. The endocrinology team felt it was safe for you to go home on the regular dose. If you start feeling sick again and cannot tolerate oral medication, you can take an intramuscular injection of hydrocortisone. You have been prescribed hydrocortisone in order to do this. Please ___ with Dr. ___, as detailed in the ___ instructions. 2. Chronic narcotic use: Regarding your narcotic use, you were continued on a fentanyl patch. You also took dilaudid when you were able to tolerate oral pills. We have given you a fentanyl patch, and you should ___ with your primary care doctor in order to obtain more patches in the future, as well as more narcotics to treat your chronic pain. 3. Ativan use: In addition, for you ativan has been helpful in the past. We have provided you with a short course of this to help get you through this period of nausea. This is not a medication we recommend to use chronically, however, it is reasonable to use in pregnancy intermittently. While taking narcotics, do not drive or drink alcohol. For your prenatal care, we have arranged for you to ___ in the ___ Clinic, which meets on ___ afternoons. Please see ___ information for the date and time of your clinic. Your first visit in clinic will be this ___ morning to ___ on your weight and diet. Please keep a log of your food you take at home.
Patient is a ___ year old G6P3 who was admitted to the hospital on ___ given persistent nausea in early pregnancy. Her hospital course was notable for several other issues below: 1. Persistent nausea/abdominal pain: On admission patient had reported a 10 pound weight loss over several weeks, as well as vomiting at home. Initial diagnostic evaluation was negative for concerning etiologies of nausea/pain. She had a negative ultrasound for adnexal pathology, normal white blood count making appendicitis or other infectious etiologies unlikely, and a normal urinalysis making kidney stones or urinary tract infection unlikely. Her nausea was felt to be consistent with a combination of nausea of pregnancy and long-standing nausea. In the hospital, she was initially managed with oral zofran and fluids and intermittently was able to tolerate oral intake. Her pain was managed with her normal doses of narcotics (see problem below). By hospital day 4, however she was unable to tolerate oral intake due to nausea and abdominal pain induced by nausea. She requested IV ativan use in order to eat and received a few doses of this with good ability to eat. Additional services were consulted to evaluate alternative reasons for the patient's persistent nausea. Endocrinology was consulted due to history of adrenal insufficiency, and while her steroid dose was increased to stress dosages, this did not improve her ability to take oral intake. Psychiatry was also consulted, due to history of somatization disorder, and her presentation was felt to be consistent with this. There was no intrinsically medical reason identified for persistent nausea. Because she was able to tolerate some oral intake, she was switched to oral ativan which she initially declined. She declined all other oral medications, despite demonstrated ability to tolerate oral intake and requested IV ativan in exchange for eating. This request was not met, and patient unable to consistently provide herself with nutrition for another 2 days, although she was able to take oral ativan and dilaudid. Per recommendation from hospital nutritionist, decision was made to proceed with enteral feeding through a feeding tube. Thus, on hospital day 7 (___), a Dobhoff tube was placed in a two step fashion in the patient's stomach. Appropriate location was confirmed with a chest x-ray and enteral feeding was started. The patient was able to tolerate enteral feeding without any vomiting, and she was passing gas and having bowel movements. Plan was made to proceed with enteral feeding as an outpatient, however given patient's insurance, outpatient tube feeding was not possible. On hospital day 10, tube feedings were cycled overnight, which patient tolerated well, and attempts were made for patient to eat and drink around the tube. Patient did overall well with this on hospital days ___. Tube feeding was decreased on hospital day 14, and plan was made to stop tube feeding on hospital day ___ (___) with plan for removal on ___. However, patient reported being unable to eat and she had lost 3 kg over ___ days by hospital day 16 (___) and thus tube feeding was restarted. On hospital day 17, team decided that tube feeding was counter-productive to goals of care for patient (to go home). Since patient had demonstrated ability to eat, and tube was felt to be limiting ability to eat, plan was made with patient approval for trial of feeding without feeding tube. The feeding tube was thus removed. On hospital day 17, patient able to eat and drink and thus decision was made for trial of home with close outpatient ___. Of note, she was discharged on a week's worth of oral ativan (7 days x three times daily), as well as zofran, doxylamine, pepcid, and vitamin b6 to optimize ability to tolerate oral feeding. Of note, ativan is not a standard anti-emetic in pregnancy, and thus this medication was provided for initial optimization, but it was made clear to patient this would not be a continuing medication provided by obstetric service in pregnancy.
443
659
12058674-DS-10
22,598,778
Ms ___, It was a pleasure participating in your care while your were admitted to ___. You were admitted because there was a blockage in your intestine that was causing you to become very ill. In speaking with your power of attorney it was decided that the focus of your care would be on making you comfortable. You were given medications to help with this and will be returning to your nursing home facility. You should stop all medications with the exception of the following: -Roxicet ___ mg/5 mL Solution: ___ mL PO every 2hr as needed for pain -ZOFRAN ODT 4 mg Tablet, Rapid Dissolve, One 1 Tab, Rapid Dissolve by mouth every four hours as needed for nausea. -lorazepam 0.5 mg Tablet every four hours as needed for agitation, under your tongue. Going forward, the goal should be focused on your comfort and further hospitalizations should be avoided in an effort to keep you comfortable.
PRIMARY REASON FOR ADMISSION ___ F with severe dementia who presents with emesis with CT showing SBO, pt is admitted for for medical management of SBO, acute renal failure, hyperkalemia, leukocytosis. After discussion with patient's power of attorney, pt was made comfort measures only. . # Small bowel obstruction: Patient was admitted with emesis. CT scan demonstrated SBO with at least 2 transition points likely ___ internal hernia with a closed loop. Initially NG tube was placed and patient was evaluated by surgery regarding possible intervention. In discussion with the patients HCP/power of attorney the decision was made not to persue surgical intervention. She was latter made comfort measurues only the the NG tube was removed. She was symptomatically managed with PRN morphine, zofran and ativan. . #Leukocytosis: Pt was notes to have a leukocytosis on admission with a predominance of neutrophils. Differential includes: urinary vs GI source. CXR also concerning for a possible pneumonia. The patient was covered broadly for gram neg, gram pos, anaerobes in ED with vanco and zosyn. Antibioitic were discontinued when care was transitioned to comfort measures. . #Severe Sepsis: On admission met patient was tachycardic with a leukocytosis, likely source being urinary or GI, meeting criteria for sepsis. Lactate 2.1 (>2.0) suggesting severe sepsis. MAP>60 therefore patient did not meet criteria for septic shock. As above the patient was initially started on antibiotics as well as IVF these were discontinued. . #Hypernatremia: Na 147, pt is 1.8 L free water deficit. Likely from poor access to water. . # ARF: Initialy Cr 3.6. Likey pre-renal in setting of sepsis, emesis, SBO, poor access to water and hydration. ATN also considered, possibly preceeded by a pre-renal state. Given 3 L in the ED. Acute renal failure likely explains hyperkalemia. . #Hyperkalemia: K 6.5, confirmed on green top. Likely from ARF. EKG with no peaked T waves, narrow QRS, no EKG signs of hyperkalemia right now. However, pt not able to take kayexelate since she has SBO and not able to excrete K through bowel movements. K will likely increase and cause arrtyhmias. Power of attorney is aware, he wants patient to be CMO, he explained that he does not want any dialysis. . # ? Lung mass: Patient noted to have possible RUL mass on CXR concerning for malignancy. CT was recommended for further evaluation. However this was not done given patients poor prognosis from other active medical issues. . #Comfort Measures Only: Patient's power of attorney requests that patient be CMO. Wants goal of care to focus on comfort only. He does not want any surgeries, no tubes, no HD. Given patients rising K, she is at risk for arrythmias. Also at risk for hypotension in the setting of possible sepsis. Pt unfortunately not able to verbalize any pain or discomfort. She was given PRN morphine for pain. All vitals and lab draws were held. In dsicussion with the power of attorny the decision was made to transition her to hospice care at her home facility. . TRANSITIONAL ISSUES - As above patient should be treated with comfort measures only - Patient will receive hospice care at her home facility
173
542
15789056-DS-4
21,574,798
Dear Ms. ___, You were admitted to ___ for shortness of breath due to extra fluid in the lungs after your recent Rituximab dose. You improved with several dose of a diuretic by IV. While here, you developed new left-sided weakness concerning for possible stroke. You are being transferred to the Neurologic service at the ___ for further evaluation and management. Your vascular surgeon will also be seeing you at the ___. It was a pleasure caring for you.
This is a ___ with CLL, secondary ITP on prednisone and recently started on Rituxan, HTN, HL, carotid artery stenosis, likely CAD s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w CAD and increased LVEDP, who presents with dyspnea on exertion consistent with pulmonary edema. Course complicated by acute-left sided weakness and neglect concerning for CVA vs. TIA. Active Problems - # Dyspnea on exertion and # Acute hypoxic respiratory failure, likely due to # Pulmonary edema with bilateral pleural effusions, likely due to # Acute diastolic CHF: Her story is fairly consistent with acute diastolic CHF, with recent admission where she received fluids initially but also had NSTEMI and TTE showing some LV overload (BNP at that time was quite elevated as well). She has history of fluid overload requiring diuresis in context of platelet transfusion. Last admission she was discharged only on home HCTZ, which may have been inadequate to maintain euvolemia. Prednisone also likely contributed to fluid retention, and recently she received her Rituxan infusion ___, after which she began developing shortness of breath. During her hospitalization, she received a total of 100 mg IV Lasix (doses of 40 mg, 40 mg, and finally 20 mg IV on ___ with improvement in her symptoms. She is no longer requiring additional O2. Goal is to continue gentle diuresis with aim of -500cc/24 hours. Her oncologist is aware that she will likely need Lasix with her next Rituximab infusion. # Acute left-sided weakness and left gaze neglect - occurred the morning of ___, along with noted dysarthria. Upon assessment by the neurology team, her symptoms had resolved but upon reassessment several hours later, her symptoms recurred (see discharge exam) raising concern for a flow-limiting lesion, especially in light of her carotid artery stenosis on the right. Her symptoms resolved with laying flat and improvement of her SBPs to the 140s (she has been otherwise in the 100s-120s). Neurology recommends an MRI here along with vascular surgery consult to discuss CEA, however patient and her family prefer to transfer to the ___ as her vascular surgeon is there. Therefore no studies were performed here prior to transfer, except for a lipid profile (at goal), hemoglobin A1C (at goal), and TSH (wnl). She was on ASA every other day due to her ITP; after discussion with her oncologist, she was changed to daily aspirin. She is on a statin. # CLL, ITP - followed by Dr. ___. Recently admitted in ___ with steroid-resistant ITP, so was started on Rituximab for a planned 4 doses over 4 weeks. Her Rituximab will be held this week per her oncologist given acute medical issues. She will need Lasix with future infusions as noted above. Her baseline WBC is in the low ___ platelets in the ___ is good for her. She is on prednisone 20 mg daily for her ITP. # CAD, recent NSTEMI type 2 - during recent admission in ___, she sustained a type II NSTEMI (no EKG changes, peak Troponin at OSH 1.5) felt to be in the setting of hypotension from dehydration due to norovirus. TTE showed WMA c/w underlying CAD and preserved systolic function. Her troponins trended down and then back up here to 0.28, likely from fluid overload. She had no EKG changes or symptoms. She is on aspirin, BB, and ACE-I (latter two which may need to be held to allow for permissive hypertension given concern for CVA). # Sinus tachycardia - HR in the ___ here, likely related to hypoxia and volume overload. Improved to ___ prior to d/c with improvement of hypovolemia. # GERD - on PPI. Patient is full code. HCP: ___ Relationship: Daughter Phone number: ___
83
628
14835486-DS-31
23,895,432
Dear Ms. ___, You came to the hospital because you felt unwell and had a fever. At the hospital, it was determined you had a urinary tract infection. Our doctors started ___ on IV antibiotics, and later switched you to oral antibiotics. Please stop your antibiotics on the evening of ___. during your hospital stay, you started to feel better, and we discharged you back to your nursing home.
Mrs. ___ is a ___ year old woman with neurogenic bladder complicated by multiple urinary tract infections presenting with fever, mental status change, increased urinary urgency with leukocytes and white blood cells on urinalysis. Given patient's history of chronic UTIs and the clinical presentation the most likely diagnosis is UTI. # UTI: Patient has a history of recurrent UTI's in setting of neurogenic bladder, and comes in with fever, dysuria and grossly positive U/A. On admission she was empirically started on vancomycin and zosyn for UTI after review of her prior culture date. Given microbiological history, and patients allergy to linezolid, she was transitioned to daptomycin for gram positive and meropenem for gram negative coverage ___. In house, Ms ___ symptomatically improved. Urine culture taken before abx administration on ___ showed fecal contamination, so patient was empirically narrowed to ciprofloxacin based on her prior urinary tract infection of Morganella morganii sensitive to Ciprofloxacin. Patient was monitored for a an additional 48hrs on ciprofloxacin alone to assure she remained afebrile and symptom free. On ciprofloxacin she continued to feel improved, mentoring at baseline and was d/ced back to rehab on ___ with plan to discontinue antibiotics on the evening of ___. # Frontal maxillary sinus tenderness: Nasal exam unconcerning for acute bacterial sinusitis (no purulent dischagre or focal tenderness but rather B/L frontal sinus tenderness). Of note, patient is on guaifenesine at nursing home for "nasal congestion". It appears patient has been using afrin off and on, making rebound congestion possbility. She was trialed on fluticasone with good response. # Constipation: home constipation regimen: bisacodyl pr, fleet enema prn, milk of magnesium, senna. will continue. One time episode emesis ___ concerning for possible obstruction though patient passing gas. She had a BM ___ without issue. # Hx HIT: No heparin products used in house. Use fondaparinoux.
68
306
11233477-DS-8
21,789,333
Discharge Instructions Brain Hemorrhage without Surgery Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may have difficulty paying attention, concentrating, and remembering new information. •Emotional and/or behavioral difficulties are common. •Feeling more tired, restlessness, irritability, and mood swings are also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason
#IPH with cerebral edema The patient was admitted from the emergency department to the neuro intensive care unit where she was started on Mannitol therapy. A bolus of Decadron was given but then shortly after discontinued. She was started on Keppra for seizure prophylaxis. A CTA was performed which demonstrated a stable large left frontal intraparenchymal hemorrhage with edema. There was no evidence of vascular abnormalities. An MRI was also ordered due to concerns for an underlying lesion given the location, size, and morphology of the bleed which was negative to underlying lesion with recommendations to repeat in 6 weeks. She remained stable and was transferred to ___ on ___ where the mannitol was weaned to off. Neurology was consulted who recommended follow-up in the stroke neurology clinic with repeat MRI to re-evaluate for underlying lesion and follow-up in ___ clinic if needed after discharge. Patient was evaluated by ___ and OT who recommended rehab. She remained neurologically stable and was transferred to the neuro floor. Her electrolytes were repleted PRN and she was given a small fluid bolus for slightly elevated BUN with improvement. #Hypertension Patient's home atenolol 25mg was switched to metoprolol tartrate 12.5mg BID. In order to maintain SBP goal <160 the dose was increased to metoprolol tartrate 25mg BID. The patient tolerated this well and blood pressure was maintained at goal.
411
226
11064934-DS-4
24,224,193
Discharge Instructions: Call your neurosurgeon’s office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate – but start slowly and increase at your own pace. - Do not operate any motorized vehicle while you are taking narcotic medications. For migraine: -Please continue taking your home migraine medication as instructed. For temporomandibular joint dysfunction, we recommend the following: - Soft diet for two weeks - Ibuprofen up to 800mg three times daily for 1 week - Massage of jaw muscles three times daily - Follow up with dentist or oral surgeon
Ms. ___ was admitted to the Neurosurgical Service for further evaluation of left ear fullness, headache, & dizziness on ___ s/p left posterior fossa craniotomy for TGN. The patient's pain was well controlled with Tylenol and oxycodone. Head CT was reported to show no acute intracranial findings, but was notable for fluid in the mastoid. Her CRP on admission was 11.2. ENT service was consulted for concern of possible CSF leak or mastoiditis. Imaging was reviewed and felt to represent fluid in the mastoid with no evidence of bony destruction or coalescent mastoiditis. Recommendations were made to obtain MRI and pursue treatment of other possible contributing factors including migraines and TMJ. An MRI Head was performed on ___ which showed postoperative changes s/p posterior fossa craniectomy and left mastoid effusion. The hospital course was otherwise remarkable. The patient remained afebrile and neurologically intact. She continues to have left sided head pressure and ear fullness with decreased hearing on the left. Based on the imaging and overall clinical picture, decision was made to discharge the patient home on a steroid taper, with instructions to follow up closely with ENT (Dr. ___ and neurosurgery (Dr. ___. A thorough discussion was had with the patient regarding the expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient expressed readiness for discharge.
148
233
18399227-DS-7
24,050,352
Dear Ms. ___, It was a pleasure to care for you. You were hospitalized due to your symptoms of nausea, vomiting, and abdominal pain. A CT scan showed inflammation of your large intestine. Based on the sigmoidoscopy (looking at your large intestine with a camera), we believe you have ischemic colitis, which is inflammation of your large intestine due to decreased blood supply, which may have been caused by a drop in blood pressure during your recent surgery. Please drink plenty of fluids to stay well hydrated, avoid NSAIDs (such as Advil/ibuprofen and Aleve/naproxen) and continue a low residue diet. If you are concerned about dehydration, you can use pedialyte for hydration. Please follow up with GI for a colonoscopy to evaluate healing of the large intestine.
___ with history of HTN and vasovagal syncope as well as prior constipation and N/V following prior non-abdominal surgeries who presents with constipation, N/V, and abdominal pain following L thumb surgery on ___, found to have pancolitis on CT and findings consistent with ischemic colitis on sigmoidoscopy. #Ischemic colitis: Pt with symptoms of N/V, constipation, abdominal pain, and poor po. Pt was given 1 dose metronidazole in ED. CT shows pancolitis with sparing of distal colon and sigmoid. Inflammatory markers elevated. Underwent sigmoidoscopy with findings consistent with ischemic colitis; with biopsies taken. Possibly due to hypotension during recent surgery. Pt symptoms improved during admission, and leukocytosis resolved. Pain was treated with tylenol; opiates avoided due to potential to slow bowel transit. Pt was treated with bowel regimen for constipation; per GI stimulating laxatives were avoided. Pt was placed on low residue diet and was tolerating po prior to discharge. Amlodipine was discontinued given desire to avoid further hypotension, with goal SBP>120. Pt to avoid NSAIDs, continue low residue diet, use colace and miralax prn constipation; po hydration encouraged. Will follow up with GI in ___ week for full colonoscopy. #HTN: Given ischemic colitis, goal SBP >120. Amlodipine was discontinued. Home lisinopril and metoprolol were continued. Also remained on asprin 325mg. ___, likely pre-renal: Recent baseline creatinine 0.8-1.0. Creatinine elevated at 1.2 on admission. Likely prerenal in setting of poor po, BUN:cr >20. Creatinine returned to baseline after IV fluids. #Hyponatremia: Possibly hypovolemic hyponatremia in setting of poor po intake. Improved following IVF. #HLD: Continued on pravastatin. #Overactive bladder: Home oxybutynin was held during admission given potential effect on constipation; was restarted at discharge.
126
269
12298542-DS-16
25,743,442
Mr. ___, it was a pleasure taking care of you here at ___. You were admitted to the hospital because you were having a heart attack (myocardial infarction). A cardiac catheterization was performed and a stent was placed to open up the corononary artery that was blocked. It is VERY important that you take Aspirin and Prasugrel every day. These medications help keep the stent open. Do NOT stop taking these medications without talking to your cardiologist first. You were also started on several other medications to help decrease your risk of having another heart attack. The following changes were made to your medications: - STOP lovastatin - START Atorvastatin 80mg daily at bedtime - START Metoprolol Succinate (Toprol XL) 25mg Daily - START Lisinopril 2.5mg Daily - START Prasugrel 10mg Daily - START Aspirin 325mg Daily You should continue all of your other meds as you were previously
Mr. ___ is a ___ yo M with a history of hyperlipidemia, but no known history of CAD who presented with ongoing substernal chest pain found to have elevated cardiac biomarkers and ECG showing ST depressions in V2-V4 concerning for posterior STEMI (vs. anterior ischemia), now s/p coronary angiography with bare metal stent deployment in OM1. # STEMI/CAD: Patient presented with posterior STEMI (peak CKMB 89) found to have occlusion in OM branch now s/p BMS placement. Patient also found to have 2 vessel CAD that was not intervened on. ___ had 40% stenosis in distal segment, and LAD had adjacent ostial and proximal 70-80% stenosis. Patient's risk factors for CAD include hyperlipidemia and family history. Echocardiogram showed some focal areas of hypokinesis but overall EF relatively preserved at 50-55% with no clinical evidence of heart failure. - Patient should have an Imaging Stress Test in ___ weeks as outpatient to evaluate if the residual LAD disease is significant and warrants further intervention. He was scheduled to follow-up with ___ in cardiology at ___. - Started on prasugrel for at least one month (ideal 12 months) - Started ASA 325 mg - Changed home lovastatin to atorvastatin 80 mg - Started Metoprolol Succinate 25 mg Daily for post-MI secondary prophylaxis - Started Lisinopril 2.5mg, this can be uptitrated as an outpatient as BP tolerates - Patient was given information and contact numbers for cardiac rehabilitation programs near him.
141
231
11223240-DS-22
27,709,930
You were admitted to the surgery service at ___ for observation after you incarcerated incisional hernia was reduced in ED. You are now safe to return home to complete your recovery with the following instructions: Please return in ED if you will have severe abdominal pain, obstipation, severe nausea with emesis. Please wear abdominal binder for comfort. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you.
The patient with history of incisional hernia was admitted to the General Surgical Service for evaluation of severe abdominal pain. In ED patient was found to have incarcerated hernia, which was manually reduced. After patient's hernia was reduced, patient's diet was advanced to regular and was well tolerated. On HD 2, patient underwent abdominal US as part of pre-operative evaluation. Ultrasound revealed small volume ascites without evidence of varices. Patient continue to tolerated regular diet, he was able to move his bowels, and he denied abdominal pain. Patient was discharged home in stable condition. Prior his discharge, he was scheduled to see his Hepatologis for pre-op evaluation. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.
207
157