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17288685-DS-26 | 20,331,087 | Dear Ms. ___,
You were admitted to ___
because you had positive blood cultures from your previous
admission. We found that the bacteria in the blood culture was
likely just a contaminant and did not need to be treated with
antibiotics.
You were having muscle cramping so we checked labs which showed
that you had some injury to your muscle cells called
rhabdomyolysis. Because of the rhabdomyolysis you received IV
fluid hydration and your labs have normalized.
You also had a viral gastroenteritis causing you to have
diarrhea. However, this improved with IV fluids as well.
You also developed shortness of breath. You had chest x-rays
which showed that you may have had some fluid in your lungs so
we gave you some medication to get rid of the extra fluid. Your
breathing has now improved and is back to normal.
You also developed some foot pain which we think is due to your
nerve tissue in your legs so you were started on a new pain
medication.
Please ___ with your outpatient providers as instructed
tomorrow.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you very much for allowing us to participate in your care.
All best wishes for your recovery.
Sincerely,
Your ___ medical team | ___ ___ speaking woman with a history of CAD, sCHF (EF
40-45%), CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p
colectomy with ileostomy referred for blood cx drawn ___ with
corynebacterium vs. proprionobacterium, admitted for
hyperkalemia and an episode of vomiting/leg cramps in ED with
continued nausea/vomiting, found to have a CK of 35,000 possibly
related to statin therapy.
#POSITIVE BLOOD CULTURE: The patient was called back after prior
admission for GPR's in single cx c/w propionobacterium or
corynebacterium growing 6 days after culture was drawn. Given
that the patient has no prosthetic valves or devices (only stent
from CABG in ___, was afebrile, and had a normal WBC, it was
thought that this was very likely a skin contaminant. Patient
did have vomiting in the ED and on the floor, however this was
determined to be a viral gastroenteritis. Repeat blood cultures
from ___ were negative.
#RHABDOMYOLYSIS. Patient reported L thigh cramping on admission.
CK 35,000 on admission w/ h/o admissions to ___ in ___ and ___
with similar elevations. At these times it seemed to be linked
to her fibrate/statin therapy, and this was the working
diagnosis on this admission as well. This also explains her
elevated AST/LDH as well as her admission hyperkalemia (also in
the setting of ___. Her hyperkalemia was normalized w/
insulin/gluc/calcium and Kayexalate. Pravastatin was promptly
discontinued, and aggressive IV hydration was begun. When the
patient became hypoxic in the setting of CKD and high volume
load, fluids were d/c'd. By this time, her CK had trended below
3,000, so this was deemed safe.
#HYPOXIA. Likely V/Q mismatch ___ pulmonary edema in the setting
of fluids for rhabdomyolsis. No signs of PNA, no suspicion for
PE, and given CHF and CKD, as well as clinical exam, edema was a
sufficient explanation for the hypoxia. The patient was
relatively refractory to to diuresis and the clinical exam was
never c/f significant volume overload, so other etiologies,
including interstitial disease or a clinically significant
decline in cardiac functionm, were entertained. A CT scan
demonstrated only ground-glass opacities c/f pulm edema, and the
patient's O2 sats improved to baseline prior to discharge.
#ADENOVIRUS GASTROENTERITIS. Patient was recently admitted prior
to this admission for vomiting which resolved that admission and
was thought ___ a viral gastroenteritis. On this admission,
initially thought to be related to rhabdomyolysis and resultant
lyte abnormalities, but viral cultures returned positive for
adenovirus. Remaining stool cx/O+P negative. Norovirus negative.
#PYURIA, BACTERIURIA. In the setting of a fever to ___, a UA
and urine cultures were sent. Pt remained asymptomatic. She was
briefly started on ciprofloxacin, but this was discontinued
given lack of symptoms and absence of recurrent fevers.
#FOOT PAIN. A few days prior to discharge, Ms. ___ began
complaining of b/l burning foot pain. Given her history of
diabetes and the quality of the pain, it was thought that this
was consistent with diabetic neuropathy. Started low dose
gabapentin with symptomatic improvement.
#VAGINAL PRURITUS. A few days prior to discharge, Ms. ___
complained of vaginal pruritus w/o dysuria, hematuria, or
reported discharge. A pelvic exam demonstrated white cervical
discharge concerning for candidiasis. She was treated with a
dose of fluconazole.
#DM2: Fingersticks on this admission were 100s to 200s, so we
continued her 30mg humalog ___ qam and qpm plus sliding scale.
#HTN: On amlodipine, metoprolol, hydralazine. BPs were 140s-160s
this admission, outpt recommendation had been to increase
amlodipine to 10mg so we did uptitrate this med. She remained
asymptomatic - no headache, no chest pain, vision changes -
during this admission.
#CHRONIC ANEMIA: Ms. ___ has a chronic normocytic anemia,
with Hgb ___, concerning for anemia of chronic disease. Epo
levels were elevated.
#CKD IV/V: Patient w/ recently placed left fistula. She
continued her phosphate binder, sodium bicarbonate (increased to
1300mg TID on this admission) and vitamin D. Her Cr did rise
with diuresis in the setting of her pulmonary edema and was 3.7
on discharge, but this is in keeping with previous values in her
chart over the past year.
#CAD: Patient was noted to have a lipemic specimen on admission
labs. Triglycerides were found to be ~700. Unfortunately, she
needed to d/c her statin due to the rhabdomyolsis and had had a
previous similar reaction to fenofibrate. We continued her home
aspirin, started fish oil, and scheduled her for follow up in
Cardiology clinic where she will be evaluated for other
lipid-lowering treatments.
#HFrEF. Per patient, she suffers from baseline SOB when climbing
stairs, does not walk a lot, and spends most of her day in bed.
We continued her home metoprolol, Imdur, and hydralazine. | 210 | 762 |
19265652-DS-29 | 21,370,940 | You came in with nausea, vomiting, headaches and blurry vision.
We think that this may have been due to at least in part a
buildup of toxins from your progressive kidney failure. You
were started on dialysis and had some improvement in your
symptoms, although not full resolution. During the admission in
addition to starting dialysis we also adjusted the medications
for your blood pressure and diabetes, and you underwent a
procedure for your right eye. Because of your aunt's illness you
left against medical advice on ___, with a plan to return
shortly thereafter. It is of utmost importance that you follow
the instructions to keep your dialysis catheter clean while you
are out of the hospital. We have also provided prescriptions for
the medications that you do not have and a list of changes to
your medications that we have made. At this point your blood
pressure remains poorly controlled, and so it will be important
for your medical team to keep working on this when you return.
It will also be important for you to return for further
dialysis. Upon your return our medical team will also discuss
further with the eye doctors the future plans for your eye
treatments.
For your insulin our diabetes team has recommended 9 units of
long acting per day, as well as 5 units of short acting with
each meal plus the sliding scale. You can take 5 units at night
if you have a late meal, but if not then you can just use the
sliding scale. Similarly if you do not eat at other meal times
you can just use the sliding scale alone. | Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy and
likely gastroparesis who presented with nausea/vomiting,
headaches and blurry vision, ultimately started on HD but with
persistently erratic BPs. Left AMA due to family emergency, but
plans to return to care within ___ hours.
# N/V ___ suspected diabetic gastroparesis
# Malnutrition
Pt with multiple admissions for these symptoms and now presented
with the same. Previously thought to be gastroparesis vs.
cannabis-hyperemesis syndrome but given worsening renal
function, may also represent component of uremia. Symptoms
remained poorly controlled despite aggressive medical therapy
with multiple antiemetics including reglan, as well as HD to
address possibility of uremia. Discharged back on prior home
regimen of reglan, although this can be titrated further when he
returns to care. Would attempt to miminize his overall pill
burden as this is a likely contributing factor.
# ESRD now on HD
Patient with rapid progression of renal failure in recent
months. Worsening renal failure attributed to diabetic
nephropathy and renal vascular disease. Due to concern for
uremia he was started on HD during the admission. He underwent 4
HD sessions. He was started on sevelamer and nephrocaps. As
noted above he left AMA on ___. Fortunately he does have an
outpatient HD spot for next week, so after he returns to care
and other medical issues are optimized, he has an HD spot and
transportation to and from his HD center. As of yet no permanent
access plans. He was given careful instructions for care of his
line while outside of the hospital. Upon his representation
would contact ___ regarding outpatient HD
plans.
# Bilateral proliferative diabetic and hypertensive retinopathy
# Bilateral traction retinal detachment with vitreous hemorrhage
# Severe vision loss R>L
Pt reports progressive blurry vision over the last 2 weeks.
Ophtho was consulted and felt symptoms could be consistent with
resolving vitreous hemorrhage. Seen by retinal team on ___iagnosed with severe diabetic retinopathy and he underwent
panretinal photocoagulation in the R eye. Per ophtho note plan
had also been for photocoagulation of L eye, followed by
bilateral vitrectomies as outpatient. Patient left before these
plans could be confirmed, so would recommend touching base with
Dr. ___ patient ___. Patient very distressed by
his vision loss and motivated to pursue ophtho interventions.
# HTN
Patient with history of poorly controlled hypertension,
presented with SBPs in 200s, which was felt to be related to
pain, vomiting, and medication nonadherence. He was changed from
labetalol to carvedilol for increased adherence and restarted on
losartan, as well as his nifedipine and clonidine patch. Home
hydralazine was held. Initially it appeared his HTN was better
controlled, but in the days prior to discharge his BPs
fluctuated from 120s-210s, often higher in the morning and lower
in the afternoon and evening. He received intermittent
hydralazine PRN. His BP will need to be better controlled before
a safe discharge, particularly considering the immediate risk of
worsening retinopathy and vision loss. Would also consider
inpatient secondary hypertension work-up given his erratic BPs.
# IDDM:
A1C 7.9% ___. Glucose control has been very labile in the past.
___ was consulted and titrated insulin through the admission.
His insulin management was complicated by GI symptoms and poor
PO intake. Toward the end of the admission he was typically
eating minimal food through the day until the evening/night,
when he would eat one or two large meals. His insulin was
adjusted accordingly, and his glucose levels were relatively
well controlled, but only in the setting of relatively poor
nutrition. Upon discharge from his re-admission will need to
determine safe plan for insulin at home given his vision loss.
He has had some help recently from family but does not expect
this long term and wishes to inquire about additional help he
can get at home through his insurance (this was not addressed
prior to his leaving AMA). Of note his current regimen is 9
units lantus daily plus 5 units humalog for meal coverage four
times daily if eating (breakfast, lunch, dinner, second dinner),
plus sliding scale. This dosing was overall reduced from his
prior, which likely related to renal failure and also poor PO
intake.
# Anemia
Hb: 7.0 on admission, has recently been in the 7___s. No e/o
bleeding, likely ___ renal disease. Dropped to 6.7 on ___ s/p
1U pRBC with adequate response. Has not received ESA yet due to
poorly controlled HTN.
#Leukocytosis
WBC normal most of admission but rose just prior to his AMA
discharge. No localizing findings or fevers to suggest an
infection. Will need further work-up if still present when
patient returns to care.
#Circumstance of AMA discharge
Patient's aunt fell ill and patient left on short notice to see
her, but plans to return to ED within ___ hours. No
alternative plans were devised to avoid this. Patient also left
from the last admission for personal reasons with a plan to
return, which he followed through with. He is very concerned
about his vision and also recognizes that HD is critical at this
point and that he needs to return to address these and other
issues. Therefore there was no significant question of his
capacity and overall it seemed likely he would return as
planned.
=======================================
TRANSITIONAL ISSUES:
[ ] continue to titrate nausea regimen for suspected
gastroparesis
[ ] Discuss future access plans/?vein mapping with renal team
[ ] touch base with ___ about HD plans
[ ] touch base with Dr. ___ ophtho plans
[ ] Needs plan for insulin management given vision loss
[ ] Titrate BP regimen and consider secondary work-up
[ ] Continued titration of insulin regimen
[ ] recheck CBC and consider infectious work-up if rising
leukocytosis
[ ] consider hep B immunization as outpatient
[ ] discuss with case management potential home care options
given patient's vision loss
=======================================
>30 minutes in patient care and coordination of discharge | 276 | 962 |
11440070-DS-19 | 21,821,719 | Dear Mr. ___,
You were admitted to the ED at ___ after sustaining a fall.
You had an x-ray and a CT scan which showed you to have several
right rib fractures and a small right lung injury. You had a CT
of your spine and head which showed no acute injuries. You were
admitted to the Acute Care Surgery team for pain control and
respiratory monitoring. You are now medically cleared to be
discharged to home. Please note the following discharge
instructions:
* Your injury caused right 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).
Pain regimen:
___ - ___
- Take Oxycontin 20mg in the AM
- Take Oxycontin 10mg in the ___
- Dilaudid 2mg every 3 to 6hrs as needed for pain (for 5 days
from discharge)
- After complete your Dilaudid regimen, you can take Tylenol OR
Advil for pain. You can by them over the counter.
- Baclofen 10mg three times a day (for eleven days after
discharge)
___ - ___
- Take Oxycontin 10 mg - one in the morning and one in the
afternoon | Mr. ___ is a ___ year old M adm s/p fall ___ feet from rope
swing. +head strike, +LOC. Pt was admitted ___ and found to have
R sided rib fractures and R small pneumothorax s/p CT placement.
Chest tube now discharged showing a small apical pneumothorax,
constant over the course of two days s/p CT removal.
Patient main issues during this hospitalization involved:
1. Pain: Patient had a significant amount of pain when he was
lying in bed, but no pain when standing or sitting. Several
attempts of medication/doses were attempted in order to improve
his pain. On HD 6 he was discharge home. By the time of
discharge his pain had improved with a combination of Oxycontin,
Dilaudid, Tylenol, Lidocaine patch and Baclofen. Patient was
discharge home with the following pain meds regimen:
- Oxycontin 20 mg am x 4 days
- Oxycontin 10mg am x 4 days -> Then pt instructed to take
Oxycontin 10mg am/pm for a week.
- Dilaudid 2mg Q3-6h PRN for 5 days. Then pt instructed to take
either OTC tylenol or Advil
- Baclofen 10mg TID for 11 days
- Lidocaine patch
2. R side pneumothorax:
Patient had a chest tube placed as he was noted to have a slight
increase of his right side pneumothorax. His chest tube was
initially put on suction with successful improvement of his
pneumothorax. After his chest tube was removed patient was
noticed to have a small apical pneumothorax, that was closely
observed the next couple of days. His pneumothorax was small and
stable and we felt it was safe to discharge patient home w close
follow up.
On HD 6 patient was discharge home. On discharge he was
tolerating a regular diet, pain was under better control w PO
pain meds, we was ambulating w/o difficult, his chest tube
incision was c/d. Patient will follow up with us in clinic in
the next couple of weeks. Dr. ___ patient to
follow up with oour Nurse ___ in a week but
unfortunately she does not have any availability in the next
couple of weeks. | 411 | 344 |
12928031-DS-19 | 28,293,501 | Dear ___,
___ came to the hospital because ___ lost consciousness. While
___ were here ___ had a part of your pacemaker replaced. ___
also received too much of your Tikosyn which caused your heart
to stop briefly and ___ were shocked back to a normal rhythm.
___ were brought to the ICU for monitoring and were taken off
the Tikosyn. Your metoprolol was increased to control your
atrial fibrillation. ___ should also make sure your blood levels
of the coumadin are monitored closely; your INR was elevated at
discharge. A visiting nurse will be coming to your home to check
your levels.
Please follow up with your PCP and your cardiologist. It was a
pleasure taking care of ___!
-Your ___ Team | ___ y/o woman with hx of CAD s/p PCI, Afib, sick sinus syndrome
s/p PPM, MV replacement, and severe TR c/b cardiac ascites
presented with syncopal event. Etiology of her syncope is
unclear; her pacemaker was interrogated and did not show any
arrhythmias at home. It was found that the pacemaker had a low
battery, so she went for generator change with metronic sensia
dual chamber on ___. They tried to place a new RV lead but she
had subclavian vein stenosis that prohibited new lead placement.
Her hospital course c/b torsades leading to vfib cardiac arrest
s/p x1 shock w/ROSC. The torsades was due to long QTC ___
medication error with extra dosing of her dofetilide. She was
transferred to the ICU for close monitoring. Her dofetilide was
held and she was started on metoprolol 50mg BID to control her
atrial fibrillation. Echo showed stable cardiac function. Her
INR was elevated at discharge to 4.7; she will have ___ monitor
her INR closely after discharge. | 126 | 167 |
12892298-DS-14 | 24,832,990 | INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand 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:
- Non-weightbearing right upper extremity, light activities of
daily living only (hair brushing, tooth brushing, etc)
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Hand Surgeon, Dr. ___. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Non-weight bearing right upper extremity, minimal activities of
daily living
ROM OK at elbow and shoulder, OK for digit ROM
Splint to remain in place until clinic f/u, keep clean and dry
Patient to maintain functional mobility
Treatments Frequency:
Keep splint clean and dry
Cover with a plastic bag to shower
Splint to remain on until clinic followup
No dressing care needed | The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have an open right distal radius fracture as well as radial
ulnar joint dislocation and was admitted to the hand surgery
service. The patient was taken to the operating room on ___
for irrigation and debridement of the right wrist as well as
operative 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 OT who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right upper extremity. 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. | 588 | 261 |
19636128-DS-23 | 22,697,287 | Dear Ms. ___,
You came here with abdominal pain and were found to have a bowel
obstruction on imaging. You were taken to the OR where you
underwent an enteroenterostomy. A J-tube was placed to ensure
you are getting adequate nutrition.
You hospitalization was complicated by 2 falls. Initial imaging
demonstrated a brain bleed but repeat imaging was stable so
neurosurgery did not feel operative management was appropriate.
We do think your brain bleed did lead to low sodium levels in
the hospital (a condition called SIADH). We anticipate that your
sodium level will improve with time.
In the meantime please restrict your fluid intake by mouth to
less than 1L. The rehab facility will check your sodium levels
as well.
You should follow up with Dr. ___ our surgery clinic
in ___ weeks. You can reach his office at ___ to set
up an appointment. | Ms. ___ ___ yo F with hx of total gastrectomy with RNY
esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy
(since removed) ___ for T2aN0 gastric adenoCA who presented
on ___ to ___ ED for acute epigastric pain. CT A/P was
obtained which revealed dilated small bowel thought to be
consistent with afferent loop obstruction. Acute care surgery
was consequently consulted in the ED. Patient was admitted under
ACS on ___ for further evaluation and management.
Overnight ___ patient fell unwitnessed while getting out of
bed, striking head. Non-contrast HCT revealed small left sided
subarachnoid and parafalcine subdural hemorrhage. She was
evaluated by neurosurgery who did not recommend operative
management. The patient had a repeat fall with head strike
without associated changes on imaging later in her hospital
course. She fortunately did not sustain any ongoing neurologic
deficits from either fall.
On ___ patient underwent uncomplicated ___
enteroenterostomy and placement of jejunostomy with EBL of 20
mL. She was noted to be stable in the PACU s/p 1 unit pRBC. She
was ___ transferred to the floor. On discharge her tube feeds
were at goal and she tolerating a (small) clear liquid PO diet.
On ___ the renal team was consulted for progressive
hyponatremia that initially developed on ___. They felt this was likely SIADH in the setting of
subarachnoid hemorrhage and recommended fluid restriction and
appropriate workup, with expectation of improvement as
intracranial hemorrhage improves. The endocrine service was also
consulted and after workup were in agreement this was likely
SIADH. They agreed with the renal team's recommendation to
restrict PO intake to <1L and to continue trending her sodiums
at her rehab facility. There is no place for salt tabs or
vaptans at this time. | 144 | 285 |
18482037-DS-9 | 20,282,048 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- Your primary care doctor got labs that showed your liver
function tests were elevated
What was done while I was in the hospital?
- Your Keppra was switched to a different anti-seizure
medication called lacosamide
- Your antibiotic was switched from meropenem to a different one
called daptomycin
- Your labs showed that the liver function tests began to go
down relatively quickly
What should I do when I get home from the hospital?
- Be sure to continue to take your home medications, especially
your lacosamide and daptomycin as prescribed
- If you have fevers, chills, a seizure, confusion, dizziness,
new rash, abdominal pain, changes in your skin color, or
generally feel unwell, please call your doctor or go to the
emergency room
Sincerely,
Your ___ Treatment Team | SUMMARY STATEMENT
Mr. ___ is a ___ with PMHx of childhood asthma and
multiple B/L ear infections s/p tympanostomy tubes, right upper
molar infection s/p extraction, and a recent hospitalization
(___) for GAS meningitis/bacteremia (right mastoiditis s/p
multiple surgical interventions for source control) c/b seizures
and then DRESS/DILI, who presents with worsening of previously
down-trending LFTs.
ACUTE ISSUES
#Acute liver injury: Concern for reactivation of DRESS syndrome
vs. drug-induced liver injury, which can relapse even weeks
after in the setting of discontinuation of culprit drug. Unsure
which drug was original offending agent, however prior
vancomycin, meropenem, and Keppra are all possibilities. Given
elevated LFTs, Keppra and meropenem were initially held. The
patient's LFTs rapidly began to downtrend. Neurology was
consulted and recommended switching patient to lacosamide for
seizure prophylaxis. ID was consulted and recommended switching
patient to daptomycin for brain abscess. The patient was
continued on prednisone, as well as his home calcium and
famotidine.
#H/O GAS meningitis and temporal abscess: Patient was scheduled
for head MRI and ID follow up in the coming week. No recurrence
of any symptoms and no fevers. Patient had been taking IV
meropenem at home as instructed. Last dose 4PM on ___. The
patient was switched to daptomycin without side effects. Repeat
MRI brain showed interval decrease in size of the abscess.
#Seizures: Initially held Keppra, before switching to lacosamide
for seizure prophylaxis.
#Leukocytosis: Approximately stable since last admission. Likely
from steroids vs. DRESS. No infectious signs or symptoms.
TRANSITIONAL ISSUES
[]New medications: IV Daptomycin 650mg q24h (at least until ID
follow up on ___ lacosamide 100 bid (at least until neuro
follow up ___
[]ID working on re-scheduling outpatient appointment and repeat
brain MRI
[]Patient continued on previously documented prednisone taper
(see discharge medications)
[]Consider re-sending LFTs at upcoming dermatology appointment
[]OPAT labs: weekly CK, CBC, BUN/Cr
#CODE: FULL CODE (presumed)
#CONTACT: Father ___ ___ | 139 | 298 |
11279141-DS-19 | 26,252,480 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency as long as the
stent is in place.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated | Ms. ___ was admitted from the ED on ___ with low grade
fevers to 101.3. She was started on broad coverage with
vancomycin and Zosyn. Repeat CT scan was obtained with delayed
cuts showing no extravasation of contrast from the collecting
system, but a moderate sized stone causing upper pole
hydronephrosis of the right kidney. As before, the right
ureteral stent was quite low and was not draining the upper
pole.
The decision was made to exchange and reposition the ureteral
stent and she was added on for cystoscopy and ureteral stent
exchange, which was performed on ___. A glidewire was
advanced past the stone into the upper pole and a new ___ Fr x 28
cm stent placed over a wire. Retrograde pyelogram showed the
collecting system was intact with trace to no extravasation of
contrast.
The patient did well postoperatively and remained afebrile
throughout her hospital stay aside from the initial night of
admission. Her ___ drain was removed on HD 3 (POD 1) and she was
discharged home later the same day in good condition. She was
given a 10 day course of PO ciprofloxacin and
amoxicillin/clavulante and instructed to make an appointment
with ___ in ___ weeks, and to call the office in two
days to follow up her culture results. She will return for an
interval discussion with Dr. ___ further management
of the stent and stone. | 272 | 230 |
16929344-DS-18 | 23,979,299 | Dear Ms. ___,
You were admitted to ___ with elevated liver tests and
swelling in the abdomen. You also had a cough and were found to
have a pneumonia.
To treat the ascites, a paracentesis was done that removed 3
liters from your abdomen. You were given diuretics to help
remove the fluid.
A liver biopsy was done to assess how your liver is doing. It
showed inflammation. You were given an increased dose of
azathioprine that you need to take every day. You were also
given steroids to help treat inflammation. It is very important
that you avoid all types of alcohol, including with cooking,
going forward.
You had a cough for one week before coming into the hospital.
Chest CT was done and showed that you have a pneumonia. You had
one fever in the hospital. You were treated with antibiotics and
your symptoms improved. You should keep taking the medication
called Levoquin for a total of two weeks. Your last day of
antibiotics is ___.
If you experience fevers, chills, swelling in the abdomen,
vomiting blood, black or bloody stools, shortness of breath, or
worsening cough, please call your doctor or return to the
emergency department.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Liver Team | ___ year old woman with PMHx Primary biliary cirrhosis and
autoimmune hepatitis referred to ER for workup of increasing
bilirubin and abdominal distension concerning for progression of
autoimmune hepatitis vs. PBC/cirrhosis progression. Ascites was
found on ultrasound and large volume paracentesis was performed
with no evidence of SBP. Transjugular liver biopsy was performed
showing inflammation consistent with autoimmune hepatitis and
toxic metabolic injury. Her course was complicated by pneumonia
with fever for which she was treated for community acquired
pneumonia.
# Primary Billiary Cirrhosis: Child B, MELD 21 on admission.
History of varices s/p banding. Decompensated by jaundice,
ascites and varices with INR, bilirubin above baseline with
unclear etiology. Per history, the patient had been taking
azathioprine 75mg daily but only 15 days per month. A
transjugular liver biopsy with ___ on ___ pathology showing
inflammation consistent with autoimmune hepatitis and toxic
metabolic injury. MRCP showed ascites and varices without liver
mass. She was continued on ursodiol. Azathioprine was increased
to 125mg daily. Prednisone was started for autoimmune hepatitis
at 40mg on ___ with concurrent bactrim prophylaxis and
calcium/vitamin d supplementation. Her ascites was managed with
3L removed by paracentesis with ___ on ___. When renal function
stabilized she was restarted on furosemide 20mg, spironolactone
50mg. She was given furosemide 40mg IV for diuresis during her
stay due to lower extremity edema and then transitioned back to
home dosing of oral furosemide. There was no evidence of SBP 118
WBC on diagnostic para ___. She was continued on nadolol.
# Pneumonia, suspected community acquired bacterial: Most likely
due to pulmonary etiology from CAP/Bronchitis. CXR showed
possible consolidation in LLL. Chest ct showed bronchial wall
thickening and opacities that may reflect pneumonia. She was
started on levoquin ___ and spiked fever to 101. She was
switched to ceftriaxone and azithromycin ___ with no further
fevers. Urine legionella antigen negative. CMV VL was negative.
EBV VL, mycoplasma antibodies, quantiferon gold pending at the
time of discharge. Ceftriaxone/azithromycin transitioned to
levoquin on ___ for a planned two week course to complete
___.
# ___: Recent baseline Cr 0.6. Presented with ___ to 0.9 with
hyponatremia with a history of recent flu like illness with GI
component. Alternatively, she has signs of worsening cirrhotic
physiology with worsening abdominal distention now with
improving creatinine s/p 62.5g albumin. Feurea: 3.5%, FeNa 0.42%
suggestive of pre-renal etiology. Restarted Furosemide and
spironolactone without renal impairment.
TRANSITIONAL ISSUES
=============
#NEW MEDICATIONS
- Vitamin D ___ UNIT PO 1X/WEEK (TH) for total of 12 weeks.
- Levofloxacin 750 mg PO DAILY (LAST DOSE ___
- PredniSONE 40 mg PO DAILY
- Sulfameth/Trimethoprim SS 1 TAB PO DAILY
- Calcium Carbonate 500 mg PO BID
#CHANGED MEDICATIONS
- AzaTHIOprine 125 mg PO/NG DAILY
- Ursodiol 500 mg PO BID
#STOPPED MEDICATIONS
- Alendronate Sodium 70 mg PO QSAT
- Budesonide 6 mg PO DAILY (patient was not taking) - please
avoid in the future as it puts patient at risk for thrombosis
- Ocaliva (obeticholic acid) 5 mg oral DAILY (patient was not
taking)
- Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
[ ] Added prednisone and increased dose of azathioprine for
autoimmune hepatitis. Monitor for response on prednisone and
increased dose of azathioprine. MELD 18 on day of discharge. If
not improving, then discuss liver transplant (workup started
inpatient)
[ ] Continue prednisone course for autoimmune hepatitis with
Bactrim prophylaxis
[ ] Labs for transplant workup were ordered while inpatient
[ ] She asked about the possibility of live donor as well
[ ] Multiple side-branch IPMN will require follow up imaging
[ ] Follow up chest CT to document resolution of opacities after
treatment with antibiotics
[ ] Optimize diuretics to balance relative hypotension and
worsening ascites. Low blood pressures prevented increasing
dosing while inpatient.
[ ] Continue ergocalciferol 50,000 units weekly for total of 12
weeks for low vitamin D. Switch to ___ units daily after
completion of weekly doses
[ ] Alendronate stopped because it puts her at risk for
esophagitis and bleeding from esophageal varices. Please ensure
Endocrinology follow up to discuss alternative medications
[ ] Ensure she is taking in no alcohol, including with cooking
[ ] Follow up repeat quantiferon gold as first was
indeterminate. If repeat is indeterminate will need further
workup.
# CODE: Full code, confirmed
# CONTACT: ___ (boyfriend) ___
# DISCHARGE WEIGHT: 69.13 kg | 213 | 707 |
16325240-DS-16 | 26,817,777 | 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:
- You have completed your 2 week course of Lovenox for
anticoagulation.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- TDWB RLE in ___ unlocked
- NWB LUE in splint
Physical Therapy:
- TDWB RLE in ___ knee brace
- NWB LUE in splint
Treatments Frequency:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on left hand until follow up appointment
unless otherwise instructed
- Do NOT get splint wet | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open midshaft femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right femur I7D and ORIF, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor.
Musculoskeletal: Prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE. Throughout the hospitalization,
patient worked with physical therapy, who determined that
discharge to home with home ___ was most appropriate. His left
upper extremity remains NWB in a splint post-op. Two week
post-op films were obtained on ___ and staples were removed.
Neuro: Post-operatively, patient's pain was controlled by
dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood for acute
blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD ___, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. He will follow up in 4 weeks post-discharge, as
his two week follow up was done while he was in house. The
patient completed his two week course of chemical DVT
prophylaxis. All questions were answered prior to discharge and
the patient expressed readiness for discharge. | 215 | 389 |
14451001-DS-16 | 25,646,103 | Dear Mr. ___,
You were admitted to the hospital for work-up of your liver
disease and due to concern on your recent MRI that you could
have a clot in the IVC vein. You had an ultrasound performed,
which showed no evidence of clot, and your MRI images were
reviewed by our radiologists who felt that there was no clear
evidence of clot in the IVC vein.
While in the hospital, you were given a blood transfusion in
order to treat your anemia. You also had an endoscopy which
showed no esophageal varices (distended veins, which are a
complication of cirrhosis), but did show irritation of the
esophagus, for which you were started on omeprazole to protect
your esophageal lining.
After discharge, please continue to eat a low-sodium diet as you
discussed with the nutritionist. Also be sure to follow up with
your regular providers (details below). | Mr. ___ is a ___ with history of Wilms Tumor s/p
chemo/XRT and nephrectomy at age ___, recently diagnosed HCV
genotype 1, and chronic EtOH use, referred to ___ for
evaluation of new cirrhosis and possible IVC occlusion seen on
outpatient MRI.
# Cirrhosis: Newly diagnosed, likely secondary to HCV and
alcohol use. MELD score 10 based on age and admission labs.
Outside MRI report initially concerning for ___ but hepatic
lesions are not classic for ___ on our review of images here. No
history of hepatic encephalopathy. We initiated diuresis with
furosemide. Nutrition was consulted for education regarding low
sodium diet. A 2L fluid restriction was placed. He had a
screening endoscopy which revealed no varices but was notable
for esophagitis, for which PPI was started.
# Ascites: New onset ascites, no history of paracentesis. This
was evaluated with ultrasound but no readily accessible fluid
pocket was seen, so paracentesis was deferred. There was low
suspicion for SBP in the absence of SIRS/sepsis physiology or
abdominal pain.
# Hepatitis C: Genotype 1, untreated. Will follow-up outpatient
records. ___ need to consider treatment in the future.
# Coagulopathy: INR 1.4 on admission, no known source of
bleeding but had Hgb 6.5 in the setting of untreated hepatitis
C. Plt 158. We administered Heparin SC given platelet count was
in the normal range.
# Anemia: Hct slowly downtrending since ___. He is symptomatic
with fatigue and decreased exercise tolerance. Hct 22.0 (Hgb
6.5) on admission, and macrocytic (MCV 114), likely etiologies
include ETOH toxicity vs HCV marrow suppression vs nutritional
deficiency. He was transfused 1 unit pRBCs and tolerated this
well with appropriate increase in post-transfusion hematocrit.
# Hypothyroidism: Continued home levothyroxine.
# Asthma: Continued home albuterol inhaler. | 144 | 284 |
14616329-DS-17 | 24,798,434 | Dear Mr. ___,
What happened while you were in the hospital?
- You came to the hospital because of fevers and feeling unwell.
What happened while you were here?
- You were treated for a pneumonia.
- Your heart arrhythmia, ventricular tachycardia, became worse
after your quinidine was held.
- You were then started on a new medication, mexiletine, for
your arrhythmia. You did not have any more arrhythmia once this
medication was started.
What should you do when you leave the hospital?
- You should continue to take all of your medications as
prescribed.
- You were started on two new medications: Mexiletine 150 mg PO
Q8H (to be taken three times per day), torsemide 5 mg daily.
- Your metoprolol was increased from 25 mg a day to 50 mg a day
- You should STOP taking quinidine
- Please weigh yourself every day and call your cardiologist if
your weight increases by three or more pounds
- Please follow up with your doctor ___- we have
scheduled you with Dr. ___ Dr. ___.
It was a pleasure taking care of you.
Best,
Your ___ Team | Mr. ___ is an ___ yo male with history of atrial fibrillation
on rivaroxaban, CVA, VT s/p ICD placement, prolonged QT recently
initiated on quinidine, non-ischemic cardiomyopathy (EF 45% -->
___, and hypertension with recent admission for Strep bovis
bacteremia s/p 6 wks CTX who presented to ___ on ___ with
fevers and hypotension initially treated in the ICU and then
transferred to the cardiology service with course c/b VT.
#Ventricular tachycardia
Patient ___ a complex history: Initial episode in ___. S/p
secondary prevention single chamber ICD. Recurrence in ___
w/MMVT that required ATP started on amiodarone 200 mg daily,
which was increased to 400 mg daily. Amio was later weaned due
to concern for a/e. Admitted in ___ with MMVT and EP applied
programmed ventricular stimulation via ICD with resolution of VT
and he was started on amiodarone IV, which was later d/c due to
previous intolerance. Underwent VT ablation on ___
readmitted with bacteremia and he was started on dofetaline,
however, his QTc was markedly prolonged on this regimen and so
it was discontinued. In follow up, he was started on quinidine
as his QT appeared shorter.
During this admission, the quinidine was held after QTC was
noted to be >500. After discontinuation of quinidine, the pt was
noted to have significant burden of VT while in the ICU. EP was
consulted. The patient was started on a lidocaine drip and then
transitioned to mexiletine 150 mg PO q 8 hours. His QTC remained
at 400 ms and he had no more episodes of VT.
#Heart failure with reduced ejection fraction
Patient ___ a history of non-ischemic cardiomyopathy with
reduced EF of 40-45%. Repeat echo during this admission
demonstrated worsening of EF ___. Unclear if this new
reduction is related to acute illness given fever and
hypotension upon admission vs. worsening burden of VT. Because
of his hypotension, his losartan and eplerenone was initially
held. This was restarted after his blood pressures improved. He
was given one dose of 40 mg IV Lasix on ___ given his increased
weight (we believe dry weight is 145-150 pounds) and elevated
proBNP. His metoprolol succinate was increased from 25 mg to 50
mg daily. Torsemide 5 mg was added upon discharge. Because of
reduced EF and symptoms, bIV pacer should be considered as an
outpatient.
#Hypotension/fevers
#Community acquired pneumonia
Pt presented with fever and hypotension concerning for sepsis.
Because of recent strep bovis bacteremia, ID was consulted.
Blood and urine cultures were without growth. Echo was without
vegetation. CXR was w/o consolidation although pt noted cough
upon admission. He was initially treated with vancomycin and
ceftriaxone for CAP, which was changed to ceftriaxone and
doxycycline to complete a five day course. With fluid
resuscitation and antibiotics, patient's symptoms improved and
he remained HDS.
#Thrombocytopenia
Pt was noted to have thrombocytopenia upon admission. No heparin
exposure. With treatment of sepsis, platelets increased and were
143 upon discharge.
#Severe MR
___ been evaluated for mitral clip in the past and sx not
thought to be related to severe MR. ___ consider re evaluation
for mitral clip as an outpatient.
#Atrial fibrillation with history of CVA
Patient was continued on home rivaroxaban and metoprolol
succinate was increased to 50 mg daily.
#Psych
Continued home lorazepam and mirtazapine
**TRANSITIONAL ISSUES** | 175 | 533 |
16365542-DS-23 | 20,349,202 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the Hospital because you were coughing and having
trouble breathing. This is likey due to your heart not pumping
as well, and your bronchiectasis acting up. It is also possible
that you had a pneumonia and a condition called hypersensitivity
pneumonitis.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We tested your blood and sputum for infection. You received
antibiotics to treat a possible pneumonia. You also received IV
diuretics to help your heart pump better and to get rid of the
excess fluid in your legs and lungs. You received chest ___ to
help loosen up the phlegm in your chest.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs.
- Please clean your musical instruments (such as bag pipes)
regularly.
- Please continue airway clearance at home with acapella 10
breaths at least twice daily.
We wish you the best!
Sincerely,
Your ___ care team | ATIENT SUMMARY
=====================
___ with history of CLL/SLL with pulmonary parenchymal
involvement diagnosed in ___ s/p chemotherapy (last in ___
c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA,
bronchiectasis, chronic systolic heart failure (LVEF 40-45% in
___, and atrial fibrillation on rivaroxaban (TIA while on
warfarin) who presents with subacute progressively worsening
cough and SOB and new hypoxia.
============= | 203 | 56 |
10922882-DS-19 | 25,861,315 | Dear Mr. ___:
-What happened on this hospital stay:
You were admitted to ___ with swelling in your legs and
difficulty breathing. Your repeat echo did not show any
concerning fluid around the heart. It did show some changes in
the heart that can be seen with long term high blood pressure.
You also had positive blood cultures that grew bacteria. You
were treated with vancomycin. Ultimatley your blood did grow a
specific bacteria called staph epidermidis which is a common
contaminant from the skin. To be sure that you were not growing
any dangerous bacteria we checked blood cultures on you after we
had stopped antibiotics to ensure that you were not growing
anything else. These cultures were pending on your discharge.
You were given medications to help get fluid off and to treat
your blood infection. You also had heart imaging to make sure
that it was pumping properly and not infected.
-When you leave the hospital is very important that you:
See your regular doctor tomorrow to have them follow up on your
blood cultures to ensure that they are negative.
It is very important that you come to the hospital if you have
any symptoms such as fever or chills, chest pain, cough or
anything that you are concerned about.
When you leave please weigh yourself daily and call your doctor
if your weight increases >3 lbs.
It is also important to take your medications as prescribed.
It was a pleasure to care for you,
Your ___ Team | Key Information for Outpatient ___ with a history of
recent babesiosis infection, HFpEF, HTN, HLD, and T2DM, who
presented initially with dyspnea on exertion, and is transferred
from ___ for "pre-tamponade," with repeat TTE showing no
significant effusion and no tamponade, but clinically he is
significantly volume overloaded. Later in the course of his
hospital stay he was found to have 2 out of 4 blood cultures
that were positive for gram-positive cocci in pairs that
ultimately speciated to staph epidermidis. ID was consulted and
they felt that as long as he had no growth off of vancomycin for
48 hours, the suspicion for a true infection was low. Blood
cultures 48 hours after antibiotic discontinuation remain
negative.
#HFpEF exacerbation: Presented with history of orthopnea and ___
edema that started at end of his recent hospitalization. This
was most likely multifactorial: diastolic dysfunction in setting
of HTN, volume resuscuitation and renal failure as well as
hypoalbuminemia at last hospitalization. TTE was notable for
normal systolic function with Grade II (moderate) left
ventricular diastolic dysfunction. His BP was significantly
elevated on admission here which may have been exacerbating his
diastolic heart failure. Renal failure resolved by this
admission. He was diuresed with boluses of 20 IV Lasix with
improvement and transitioned to po Lasix 20 mg on discharge due
to continued bilateral lower extremity edema. For his
hypertensive heart disease, amlodipine was added to his
Lisinopril regimen
#GPCs on blood cultures x2, suspected contaminant: ___ blood
cultures returned positive for staph epidermidis, but patient
clinically well (no fever or leukocytosis). He was started on
Vancomycin, but this was stopped after 48 hours per ID
recommendations, and daily cultures monitored for clearance
(several remain pending on day of discharge). His TTE was
re-evaluated by cardiology and they did not see any
vegetations. He was discharged with a plan to see PCP the day
after discharge to follow-up on these blood cultures and obtain
new cultures; if cultures from ___ days after stopping ABx
remain negative, then this is most likely a contaminant.
#Albuminuria: Patient had a alb/cr. ratio in the 4000s range.
This is severe proteinuria. He has a history of diabetes on
insulin at home so this could be secondary to diabetic
nephropathy. We think this was most likely secondary to his
underlying diabetic nephropathy and he will see nephrology on
discharge for further follow-up
___: Patient developed mild pre-renal ___ after aggressive
diuresis. Creatinine returned to baseline of 1.2 on discharge
after holding IV diuresis
#History of elevated ___: At OSH had elevated ___ 1:1280,
speckled pattern. Rheumatology was consulted and recommended to
repeat the ___. His overall picture did not fit for a distinct
rheumatologic disease and they did not recommend further
follow-up | 245 | 451 |
11835748-DS-10 | 22,190,737 | Dear Mr ___,
It was a pleasure to take care of you at ___
___. You were admitted with acute weakness,
clumsiness and trouble speaking. After extensive laboratory and
radiology workup, it was determined that the cause of your
symptoms was a stroke. The stroke was caused by risk factors
that include high blood pressure, tobacco abuse and elevated
cholesterol. We did tests to look at your heart which did not
show acute abnormalities, but it is important that you follow up
with your primary care and cardiology appointments. After you
are discharged, please continue taking aspirin and atorvastatin
for your stroke, as well as a few medications for your high
blood pressure. | Mr. ___ was admitted to the neuroICU after receiving ___
dose tPA (by weight). This was terminated abruptly, after it was
learnt that the original onset of his symptoms was well before
the first related time of 2PM. He remained hemodynamically
stable in the ICU and follow up neuroimaging did not show any
hemorrhage in his brain. His examination was significant for
profound weakness of the right arm, with gradually improving
weakness of the right leg.
- He was followed closely by physical therapy throughout his
stay who judged him to be a good candidate for acute
rehabilitation. At the time of discharge, his physical
examination was notable for right arm plegia, slight pyramidal
weakness of the right leg, and right facial weakness.
- His cholesterol returned elevated and so he was started on a
statin. He was also continued on an aspirin, and his BP control
required three agents.
- He was counseled by our nutritionist about the importance of
healthy food choices.
- His EKG showed profound elevations of the ST-segment
consistent with a J-point elevation. He never had chest pain or
chest discomfort. Echo showed LVH, and so he will follow up with
cardiology in 6 weeks.
- He was quite tearful at the initial presentation, and his
motivation and participation was rather poor at times. He was
agreeable to starting on a low dose of fluoxetine, with the
goals that improving his mood may assist with his overall
recovery. His family visited him on numerous occasions during
his stay.
TRANSITIONAL ISSUES:
- We apologize that we were unable to set up his follow up
appointments prior to discharge, but they will be set up. We
will contact his rehabilitation facility directly to ensure that
those are communicated.
- HCTZ may need to be uptitrated as needed to control his BPs
- Would continue to encourage smoking cessation. While on the
floor, he did not require nicotine supplementation | 117 | 321 |
11282860-DS-22 | 29,134,879 | 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.
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.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
The medication may make you bleed or bruise easily.
Fatigue is very normal.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure. | On ___, the patient was admitted to from the ED for a SDH.
He was neurologically intact and his blood pressure was
agressively controlled in the ICU. He was given a unit of
platelets for aspirin use.
On ___, the patient was neurologically stable. He was
transferred to the step down unit. CTA imaging did not show any
abnormalities.
On ___, the patient underwent diagnostic cerebral
angiography which did not show any evidence of vascular
lesions/abnormalities. He remained stable neurologically.
ON ___, the patient was stable neurologically. Repeat CT
imaging was stble. He ambulated in the halls without any
difficulty, tolerated a PO diet and was able to void. He was
discharged to home in stable condition with follow up
instructions. | 377 | 126 |
18529479-DS-14 | 22,967,419 | 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 RLE
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 daily for 4 weeks
WOUND CARE:
- Do not get your external fixator device wet.
- Monitor pin sites for severe pain, redness or drainage.
- Keep the pin site area clean. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for application of an external fixation device, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the RLE extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 161 | 256 |
15112986-DS-22 | 21,240,160 | Dear Mr. ___,
You were admitted to ___ with chest pain and trouble
breathing.
You had a stress test which showed that you have some blockages
in the blood vessels in your heart, but they are similar to the
ones you've had before. You were started on more medications to
prevent chest pain from the blockages.
You also were seen by the lung doctors for ___ that were
found in your lungs. You will see them in the pulmonology clinic
to decide if you need a biopsy of these lesions.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history of CAD,
hypertension, diabetes, CKD on HD MWF, presented with back pain
radiating to his chest associated with shortness of breath. | 112 | 29 |
15861013-DS-8 | 27,141,101 | Dear Mr. ___,
You were admitted for workup of your atypical chest pain. During
your visit, you were consulted by nephrology and your creatinine
(which is a surrogate marker for your kidney function improved).
The renal doctors feel ___ your kidneys have improved because
you were slightly dehydrated.
You have been experiencing a lot of heartburn and upset stomach
lately. For this reason, we performed an upper GI endoscopy.
This showed gastritis or irritation of your stomach. The GI
doctors also performed a biopsy. For this reason you should
follow up with them. They will mail you the results of the
biopsy in ___ weeks. If you do not hear from them within 3
weeks, please call the office of Dr. ___ to enquire about the
biopsy results.
We also wanted to make sure that your pain was not caused by
your heart. Your exercise stress test was normal. In addition,
your cardiac enzymes were normal. Also, we evaluated your heart
with an echocardiogram. It showed that your heart was somewhat
enlarged. It also showed that your heart was pumping bloody
normally without any valve or motion abnormalities. For this
reason, we can safely say that you have not recently had a heart
attack. However, you should try to maintain a healthy diet,
regular exercise, and close follow up with your physicians.
Please resume your normal home medications. We made the
following changes to your medications.
1. START: Please take lasix 20mg once a day
2. START: Please take omeprazole 40mg once a day
3. STOP: Indocin.
If you experience any of the danger symptoms listed below please
call Dr. ___ consider coming in to the emergency
department. | ___ year old male with morbid obesity (BMI 48), DMII, CAD ___
years s/p inferior wall myocardial infarction, OSA on bipap,
gout, who presents with acute on chronic renal injury, atypical
chest pain, cramps, and dyspepsia for workup of his various
sequalae.
1. Rule out acute coronary syndrome:
This is a patient with multiple risk factors for UA/NSTEMI. He
reported constant cramping throughout his body. This crampy
sensation would sometimes be in his legs and other times it
would be substernal. This pain "crampy" in nature and would go
away in ___ seconds. It was not related to exertion and there
were no known factors which would alleviate or exacerbate this
condition. Given his TIMI risk score of 3 which represents a 13%
risk at 14 days of: all-cause mortality, new or recurrent MI, or
severe recurrent ischemia requiring urgent revascularization, he
was ruled out for ACS.
-Serial EKG were performed. His EKGs were unchanged from prior
and there were no signs myocardial ischemia on EKG.
-He had two negative troponins.
- He was further evaluated with an treadmill EKG which did not
show EKG changes concerning for ischemia, nor did it reproduce
any angina.
-His TTE showed cardiomegaly with normal to mildly depressed
ejection fraction. There were no signs of any focal wall
motion/valvular anomalies.
Given that there were no dynamic EKG changes, with a negative
exercise stress, and a normal echo, with negative cardiac
enzymes suggests that his chest cramping was not ischemic in
nature.
2. Acute on chronic renal failure:
The patient presented with a serum creatinine of 2.4. Of note
this was unchanged since his previous admission approximately 10
days ago. As part of his work-up, we held his lasix, got a
urinalysis, urine electrolytes, renal ultrasound, and formal
renal consultation.
-By holding the patients lasix his creatinine dropped from 2.3
to 1.6 over the course of two days.
-His renal ultrasound showed no pathology or signs of
obstruction. (However, it did show a diffusely fatty liver
incidentally).
-Renal consult suggested that his acute kidney injury was
pre-renal in nature and suggested having the patient continue to
hold his ACE-I and only take 20mg of lasix once a day instead of
BID.
-He was discharged with lasix 20mg once a day and follow up with
outpatient nephrology.
3.Dyspepsia:
The patient complained heartburn, nausea, feeling like he was
"throwing up in his mouth," and dysphagia for solids but not
liquids.
-We stopped his indocin which we felt might be causing
irritation of the gastric mucosa.
-We also started the patient on a proton pump inhibitor.
-GI was consulted an a EGD was performed which showed gastritis.
A biopsy was taken for further evaluation.
-In addition he was tested for h-pylori. THIS RESULT IS STILL
PENDING******
-He has follow up with Dr. ___ as an outpatient.
4. Type 2 DM: While inpatient, we put Mr. ___ on a ___
sliding scale and stopped his metformin secondary to his poor
kidney function. As his renal function improved, Dr. ___
that the patient would be safe to resume taking his metformin
and ___ as an outpatient. | 277 | 515 |
11818505-DS-5 | 25,929,657 | Ms. ___,
You were admitted for your hip and flank pain. You were found
not to have a urinary tract infection. For your hip pain, you
were evaluated by physical therapy.
Thank you for allowing us to participate in your care
___ care team | Pt is a ___ with history notable for seronegative arthritis,
hypertension, diabetes here for severe flank pain x 1 week and
oliguria/increased urinary frequency with CTU negative for
hydronephrosis or stone concerning, no radiographic evidence for
pyelonephritis. UA was negative, UCx without growth on
discharge.
#Flank pain: GU vs MSK etiology. Patient has been afebrile,
without leukocytosis, and questionable urinalysis given
contaminant in ED urine sample and outside clinic UA with trace
leuks s/p 6 days of cipro. Urinary symptoms point towards GU
etiology although imaging is negative. However, pt does have
history of seronegative arthritis and has required pred and mtx
for pain control. Given that the flank pain radiates down
buttocks and upper thighs it was felt her pain was likely MSK.
CRP elevated at 7. We treated pain with 1 dose oxycodone 5 mg,
patient slept well and on morning of discharge was no longer in
pain. On day of discharge, patient denied hip pain, flank pain
or difficult urinating.
#hyponatremia: notable new hyponatremia to 127, has been low as
131 on prior check given ___ for celecoxib however pt does
endorse somewhat low po intake today, urine lytes suggest
possible SIADH etiology. Pt given IVF in ED and appears to have
worsened. On morning of discharge, Na+ 132 that improved after
pain control and PO intake.
To follow the hyponateremia, patient is scheduled for repeat
Chem10 on ___ with her PCP.
#seronegative arthritis: controlled outpatient with pred5 mg and
methotrexate injections
#hypertension: restarted lisinopril upon discharge. will hold
for now given possibility of infection although vitals stable
#diabetes: restarted metforming 1000mg
#anxiety: continued clonazepam 0.5 prn
#nutrition: continued iron sulfate, magnesium oxide, vitamin E,
vitamin D, fish oil capsules
======================
Transitional Issues
=======================
- Should she remain on meclizine
- F/u hyponateremia, ensure sodium is stable
- close follow up with rheumatology, primary care
- DNR/DNI (confirmed) | 43 | 304 |
13769908-DS-20 | 27,172,986 | Dear Ms. ___,
You were hospitalized due to symptoms of headache, blurry
vision, and right upper extremity numbness resulting from an
ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. Smoking
2. Hypertension
Please start taking Atorvastatin 40mg every evening. Please also
start taking Lovenox 80mg subcutaneously every day while also
taking Warfarin 5mg daily for blood thinner therapy. You may
stop taking Lovenox when INR (level used to check for efficacy
of Warfarin) is between 2 and 3 for 24 hours. Due to starting to
take Coumadin, please stop taking Aspirin at this time.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below. Please call ___ to arrange to have
a repeat ultrasound of your L arm 1 month following discharge to
determine if previously seen blood clot has improved. Please
call ___ to arrange for follow up in ___ to
discuss findings of this ultrasound.
Please see your primary care doctor, ___, on ___ at
3pm at ___ follow up and to
have your INR checked while you are being initiated on Coumadin.
Please obtain labwork provided in form as outpatient at Lab
Services here at ___. Please follow up in ___ in
___ (phone number: ___ in near future to follow up
these labs to evaluate for propensity to form blood clots.
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
Please make sure you follow-up with the Cardiology Department to
receive Kings of Hearts. You will also require a Cardiology
procedure called "TEE" in which will be scheduled for you and
the department will reach out to you.
Sincerely,
Your ___ Neurology/Neurosurgery Team | ___ yo female patient admitted to Neurosurgery for further work
up after presenting with LUE paresthesias and blurred vision.
Head CT showed right occipital edema concerning for underlying
lesion.
#Brain lesion/Acute ischemic stroke
Brain MRI with and without contrast was done. This showed a
non-enhancing lesion concerning for possible PCA infarct.
Neurology and Neurooncology were consulted and MRS was ordered,
stroke workup ongoing. Patient was started on Atorvastatin per
neurology recommendations. TTE was unremarkable. CTA showed
patency of the major intracranial vasculature without stenosis,
occlusion, or aneurysm and patency of the bilateral carotid
arteries and vertebral arteries, without internal carotid artery
stenosis by NASCET criteria. MRS ___ suggested evolving
infarction in the distribution of the right posterior cerebral
artery rather than an underlying malignancy. Neurology was
notified and cleared the patient for discharge with follow-up as
outpatient including an appointment with Dr. ___
___ monitor, and TEE. Her home Aspirin 81mg was resumed on
___. Signs and symptoms of stroke were reviewed with the patient
and her family with a ___ interpreter present in the room
prior to discharge. Due to blood clot found in brachial artery,
her Aspirin was stopped and she was transitioned to Lovenox
bridge to Coumadin. All questions and concerns regarding imaging
results and follow-up plan were answered with the interpreter at
this time.
#Pyelonephritis/Leukocytosis
On admission the patient was noted to have Leukocytosis of 23.
She was afebrile and urinalysis was negative. CT torso for
metastatic work up showed left pyelonephritis. Urine culture
was ordered and Cipro was started after Urine Cx was obtained.
MERIT service consulted for evaluation however given that the
patient is afebrile and UA negative, recommend following up on
urine culture. On ___, urine culture resulted as negative,
Cipro discontinued. Patient was monitored closely and denied
back pain, urinary symptoms, fevers, chills with ___
interpreter present. She was advised to follow-up with her PCP
after discharge.
#Occlusive thrombus in the left brachial artery:
A LUE ultrasound was done for complaints of general pain in the
left bicep/tricep area. The ultrasound showed occlusive thrombus
in the left brachial artery. Vascular surgery was consulted and
recommended CTA torso including the LUE to evaluate for causes
of thrombus such as aortic plaque. The CTA torso showed new
wedge shaped lesion in R kidney suggestive of infarct and some
atherosclerosis but no clear source. She was started on Lovenox
and Warfarin as noted above. Due to concern for hypercoagulable
state, associated labs were sent with other arranged to be
collected as outpatient. She was directed to follow up with
Hematology as outpatient to review lab results. She is ordered
for repeat LUE US in 1 month and follow up in ___. | 452 | 451 |
14294356-DS-12 | 22,671,714 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for shortness of breath. We
found that you had heart failure and an irregular condition
called atrial fibrillation.
The testing that we did made us concerned that you had a heart
condition called amyloidosis. We did a biopsy that confirmed the
diagnosis of amyloidosis. We have sent the tissue to a
specialized lab to determine exactly what kind of amyloidosis it
is, since that will determine treatment.
We treated your heart failure symptoms with diuretics and you
urinated out your extra fluid. We are discharging you home on
your home furosemide.
In terms of the atrial fibrillation, you could not undergo
cardioversion since you had a blood clot in your heart. Instead,
now we are treating the blood clot with a medication called
Coumadin (warfarin). You need to follow-up with our
___ CLinic for management of your Coumadin dose. For
now, you also need to inject yourself with Lovenox twice a day
until the Coumadin levels are appropriate.
Your cardiologist here, Dr. ___ like to see you in his
clinic for further management of your heart failure and
amyloidosis. We have made an appointment for you, information is
below. Please weigh yourself every morning and record your
weights, and bring them to the clinic.
On behalf of your medical team, take care.
-___ medical team. | A/P: ___ with no recent PMH, referred by PCP for management of
CHF and A-fib with RVR after pt stopped outpatient therapy.
Volume overloaded on exam, EF ___, severe LVH, low E'.
Concern for infiltrative cardiomyopathy.
#Dyspnea on exertion/CHF/Cardiac amyloidosis: The patient's
findings are most consistent with congestive heart failure. On
admission, the patient had crackles, pitting edema, elevated
JVD, positive Kussmaul sign, and S3 on exam. A chest xray showed
mild pulmonary edema. ProBNP 4281. The patient had no chest pain
to suggest an acute etiology, and EKG and troponins did not
suggest ACS. A TTE on ___ showed an EF ___, severe LVH,
low E', with findings suspicious for infiltrative
cardiomyopathy. Our heme-onc team was consulted, and serum and
urine labs for infiltrative disease (SPEP, UPEP, uric acid, LDH,
wuantitative immunoglobulins, iron studies, beta 2
microglobulin) were unremarkable. A cardiac MRI was done ___
that showed nulling consistent with amyloid deposition. A right
heart cath/left heart cath was done with biopsies ___.
Biopsies were positive for amyloid deposition. Samples were sent
to an outside lab for mass spec typing. In addition, the right
heart cath/left heart cath showed 2 vessel disease, elevated RH
and LH filling pressures, and elevated PASP. No intervention was
done for the coronary disease. With regards to treatment of the
patient's CHF, he was aggressively diuresed and discharged on PO
lasix 20mg. We also started aspirin and high-intensity
atorvastatin for his newly-diagnosed CAD. Metoprolol started at
his recent outpatient visit was continued. His blood pressure
was controlled with lisinopil 2.5mg, and he was discharged on
the same medication. The patient's symptoms improved
dramatically and he was ready for discharge on ___. A
follow-up appointment was made in the heart failure clinic. We
are awaiting the results of his amyloid typing.
#Afib with RVR: diagnosed at recent outpatient appointment, had
on admission in the setting of not tolerating metoprolol
prescribed by PCP. The patient's RVR was initially controlled in
the ED with diltiazem. During the admission his rate was
controlled with metoprolol, with a goal rate in the 80___s-90's.
We did not want the rate to be slower because of the patient's
infiltrative cardiomyopathy. A TTE with cardioversion was
planned. On ___, the TTE showed clot in left atrial
appendage, so no cardioversion was performed. The patient's
CHADS2 score is 3 (CHF, HTN, DM). The patient was anticoagulated
with a heparin drip as an inpatient, and he was switched to
warfarin with a lovenox bridge prior to discharge. The patient
was discharged with lovenox training and a follow-up appointment
in the ___ clinic for warfain management.
#DM: This is a new diagnosis for the patient, with A1C 6.8% at
recent PCP ___. We controlled his glucose with diet only and
his fingersticks were well-controlled. The patient was seen by a
dietician during this admission.
#Creatinine elevation on admission: The patient's creatinine was
1.3 on admission. The patient's baseline is unknown. The
etiology of this presumed bump was unclear. Chemistries were
trended and Cr quickly dropped to 0.9, and was stable at
0.9-1.0.
# Transaminitis: The patinet had a mild transaminitis on
admission. The etiolog was unclear. A RUQ ultrasound on ___
showed unremarkable liver and bile ducts. On repeat labs the
transaminases improved slightly, but alk phos remained elevated
at 245.
***Transitional Issues***
[ ] Dry weight 66.7 kg
[ ] Continued monitoring of INR and warfarin dose (started
___
[ ] follow-up final tissue biopsy for specific amyloid type,
refer to specialist as appropriate
[ ] continued management of diuretics, monitor electrolyte
levels.
[ ] will need stress test as outpatient | 225 | 592 |
15738458-DS-4 | 20,525,771 | Have a friend/family member check your incision daily for
signs of infection.
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, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion 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.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. | Patient presented to ___ and was admitted to the ___
care unit for close neurological monitoring and care. Plan was
made that he would undergo surgery on ___ for evacuation of
his right subdural hematoma. Initially upon admission he was
intoxicated and unable to provide informed cosnent for surgery
and a repeat CT head was stable. On ___ he was awake alert and
oriented x 3, understood his current condition, and was able to
provide informed consent for surgery. he was taken to the
oeprating for for evacuation of his right subdural hematoma via
right sided craniotomy. he toerlated the procedure well was
extubated in teh oeprating room and transferred to the ICU
post-operatively for further monitoring and care. He underwent a
post-operative CT head that showed decreased right subdural
hematoma with decrease in midline shift. He remained stable
overngiht into ___ and on mornign rounds he was noted to have
increased somnolence and difficulty with teh date. A CT scan of
the head was done which showed increased blood products and
increased midline shift. He was closely monitored following this
but given a change in neurologic status, returned to the
operating room for a re-evacuation of the subdural hematoma on
the right. He remained intubated s/p the procedure and returned
to the ICU for close monitoring.
On ___, the patient's examination waxed and waned overnight.
The subgaleal drain output was 40cc since the OR and the
Subdural drain output was 35cc since the OR. The patient was
actively withdrawing from alcohol and was requiring additional
doses of Ativan per CIWA scale.
On ___, the patient remained intubated as he was withdrawing
and requiring increased benzodiazpines. He received a
Phenobarbitol bolus for withdrawal symptoms. The subdural drain
and subgaleal drains remained in place for continued drainage.
Antibiotic coverage continued as the drains remained in place.
The non-contrast head CT shows a stable bleed with slight
improvement in midline shift and pneumocephalus.
On ___, the subgaleal drain was removed and 2 staples were
placed for closure. He continued with intermittent fevers. The
sputum gram stain showed gram positive rods; the culture remains
pending at this time. He continues to receive Phenobarbitol for
etoh withdrawal. The non-contrast head CT obtained today showed
stable post op changes and subdural drain in place with stable
fluid collection. Subgaleal drain removed, 2 staples placed at
drain site. Temp, sputum gram stain shows 1+ GPRs, pending
culture. Receiving Phenobarb bolus for etoh withdrawal.
On ___, he remained intubated and received phenobarbitol
boluses for his withdrawl. Head CT was performed and was stable.
His subdural drain was removed, two staples were placed.
On ___, a non-contrast head CT was performed and was stable. He
was extubated. His CDiff culture was positive and he was started
Flagyl 500mg PO TID.
On ___, Mr. ___ underwent a bedside speech & swallow
evaluation which he passed.
On ___, the patient was neurologically and hemodynamically
intact and was stable for floor transfer, but due to his
Phenobarbital taper he remained in the ICU for close monitoring.
___, the patient remained neurologically and hemodynamically
stable and was trasfered to the floor in stable condition. His
staples were removed, incision healing well.
On ___ he was walking with ___ and did well. later in the day he
fell OOB, did not strike head and did not require imaging or
workup. He was awaiting placement. Later int eh evenign he
reported difficulty urinating with a burning sensation. A UA was
sent which was not overtly concerning for UTI. HE remaiend
stable into ___. He was screened and accepted to the ___
for rehab. Plans were made for discharge, he was given
instructions for followup, and all questions were answered. | 186 | 615 |
18566607-DS-15 | 23,241,601 | Dear Mr. ___,
You came to the hospital because you were having increased
difficulty breathing and increased pain in your legs in the
setting of feeling like you were having an allergic reaction to
your medications. In the midst of stopping your medications for
blood pressure and heart failure, we found that you were
experiencing a heart failure exacerbation where your heart was
not as able to pump fluid around the body causing some of it to
back up into your lungs. We treated your heart failure by
giving you a medication called lasix to help take the extra
fluid off of your lungs. While in the hospital, you developed a
cough which we treated with an antibiotic called azithromycin
with improvement in your cough. In terms of your joint pain, it
appeared that you were having a gout flare, which we treated
with a steroid and allopurinol, a medicine to decrease the uric
acid buildup in your body. This helped improve your gout. We
also suspect that you developed musculoskeletal pain from
deconditioning during your hospital stay. This pain improved
with Tylenol and working with physical therapy.
We recommend that you take a medications called beta-blockers
(e.g. carvedilol or labetolol), or other medications, to help
control your blood pressure and to optimize your heart function.
Unfortunately, however, you refused to take these medications
while you were with us. We recommend continuing to address this
with your cardiologist and your primary care doctor as we think
this would benefit you in the long term.
We Recommend:
- Weigh yourself every morning right after you urinate, call
your doctor if your weight goes up more than 3 lbs.
- Take your medications every day as prescribed. You can see a
list of these medications below. You should bring this list with
you to your next doctor's appointment.
- Work with physical therapy to regain strength and range of
motion as this will improve your pain and mobility.
- Follow up as below
It was a pleasure caring for you at ___. We are glad that you
are feeling better.
Take care,
Your ___ Cardiology Team | ___ yo male with HTN, dCHF (EF >55% ___, recurrent MRSA
infections, TURP, CKD stage 3, h/o L leg split-thickness skin
graft and chronic LLE lymphedema and pannus edema who presents
with heart failure exacerbation in the setting of medication
nonadherence and increased LLE pain consistent with gout flare.
# dCHF exacerbation
Presenting with orthopnea in the setting of medication
nonadherence, BNP 1243 and CXR with pulmonary edema indicating
CHF exacerbation. No pulmonary infiltrate to suggest PNA and no
increased cough to suggest Asthma/COPD exacerbation on admit.
Ruled out amyloidosis as FreeKap 46.4, FreeLam 44.2, Fr K/L
1.05. HA1c 5.9%. Diuresed with goal net negative ___ L daily.
Home Torsemide 80 daily. Received multiple IV boluses for 100mg
lasix followed by several days of a 10cc/hr Lasix drip with
significant UOP. Held two days in the setting ___ on CKD.
Switched ___ to Torsemide 40 daily with new even UOP/weight. On
home O2 of ___. In terms of optimizing antihypertensives, we
would prefer that he take carvedilol to improve cardiac
function, but Mr. ___ believes that he is allergic so is
refusing to take carvedilol. Consider further discussion
outpatient. BPs have been stable on maximum amlodipine 10mg
daily. Discharged on 40mg torsemide PO daily.
# ___ on CKD stage 3: Baseline 1.5-1.7. Creatinine 1.4 on admit
> up to 2.5 ___ > down to 1.8 ___. ___ likely secondary to
overdiuresis given FeUrea 20; unremarkable renal ultrasound, and
higher dose of losartan. Improved with holding PO Torsemide and
losartan (and with avoiding the significant amounts of ibuprofen
that patient takes at home). Restarted torsemide ___ with
continued improvement in creatinine down to 1.8.
# Leg and back pain
H/o of gout; likely also with radiculopathy and msk pain.
Completed a course of steroids for his gout without significant
improvement in pain, though also on Lasix drip which will
exacerbate gout further. States that ibuprofen is the only thing
that cures his pain; however, given his cardiac and renal
function, he should not be on NSAIDs, which has been discussed
with the patient at length. Encouraged to participate in
Physical therapy as this would help improve radiculopathy or
arthritis. Started on gabapentin and lidocaine patch. Started on
1gm acetaminophen PO q6hours with significant improvement in
pain. Also attributes improvement to cyclobenzaprine. Will
switch to acetaminophen to 650 q6hrs prn outpatient. Will
continue cyclobenzaprine and lidocaine patch PRN for pain. B12
WNL; waiting for Methylmalonic acid lab for neuropathy workup.
Consider further workup outpatient.
# Gout
acute gout flare in the setting of diuresis; currently in a
hyperuremic state (Uric acid level 11.8). Pt takes 800 mg of
ibuprofen TID at home; advised to stop dt CAD and CKD. Pt states
they have confirmed gout by arthrocentesis, but no results in
OMR. Appreciate rheum rec for methylpred taper and allopurinol.
Completed methylpred taper 60 ___ & ___ > decreased by 10mg
per day until completion on ___. Started allopurinol ___
daily ___ and will continue outpatient.
#HTN: BP to 170s on admit > well controlled on amlodipine 10mg
while inpatient. For cardiac function, would prefer that patient
is on carvedilol or losartan; however, he states that he is
allergic. Patient also refused labetolol as he only wants to be
on one antihyprtensive. While not the ideal regimen for his
heart failure, his BPs are stable on amlodipine 10mg daily.
continuing home amlodipine 10mg tablet daily.
# Adjustment reaction; Personality disorder (schitotypal vs
narcissistic); Autism spectrum disorder
Patient with concrete thinking and limited health literacy
leading to fear of medications and medical care. For example:
believes that ibuprofen and "15 cherries" will cure his gout.
Also with some paranoia about health and people coming into his
home. Appreciate psych recs to focus on immediate needs with
patient and to communicate concrete and concise informant about
treatment plan
# Leukocytosis: Leukocytosis now resolved. WBC increased in the
setting of acute gout flare. Patient believes that he is having
an allergic reaction to the medications we are giving him;
however, no signs of systemic allergic reaction on exam. In
terms of infectious workup, Blood cultures with NGTD. Started on
ceft/vanc ___ for presumed LLE cellulitis initially; however
appears more like chronic venous stasis with lymphedema and
gout, so ceft/vanc stopped ___. With some cough productive of
green/yellow phlegm ___ with sinus congestion. CXR difficult to
assess, but no clear infiltrate. Suspected bronchitis. Completed
5 day course of Azithromycin. Blood cultures with NGTD. Cough
and leukocytosis resolved on discharge.
# Rash face/chest and Aphthous oral ulcers; Patient concerned
about allergic reaction. Evaluated by dermatology and count only
to have contact dermatitis and aphthous oral ulcers. ___ seek
allergy testing outpatient. Derm recommendations below; however,
patient did not feel better with creams or ace bandage
wrappings. HSV culture preliminary negative.
- Face rash: 2.5% hydrocortisone BID PRN
- Truck rash: triamcinolone 0.1% cream BID PRN
- Pruritis: fexofenadine 60mg BID
- Lower extremities: aquafor TID > kerlex and ace bandages
- LLE ulcer eschar: collagenase and xeroform
- Aphthous ulcers: HSV culture, viscous lidocaine
- Nose irritation: nasal saline QID PRN
#Moderate Aortic Stenosis
Peak velocity 4.4, Mean gradient 45. Likely complicating HF
exacerbation. Outpatient follow up with Dr. ___.
#CAD
H/o ?NSTEMI without intervention. Continue clopidogrel 75 mg
(Asa allergy). Discussed need to avoid NSAIDs given CAD and CKD.
#Asthma/OSA
Has both restrictive and obstructive PFTs from ___. Pt has some
inspiratory or expiratory wheezes on exam after lungs cleared
from pulmonary edema, unlikely to have exacerbation though
required home albuterol at times throughout hospitalization.
Continue 2 puffs alb 4x daily PRN; continued nebs PRN.
___ Edema
chronic venous stasis and lymphedema with acute gout flare.
Treatment with Lasix as above with improvement. Derm
recommendations to treat LEs and Panus with aquafor TID > kerlex
and ace bandages, but patient felt that this increased his pain. | 351 | 955 |
19300890-DS-16 | 29,378,615 | Dear Dr. ___,
___ was a pleasure taking care of you. You were admitted because
of severe nausea, vomiting, and abdominal pain. You were given
IV fluids and Zofran for your nausea. Your GI symptoms improved
and you were stable for discharge. You can take Tylenol for your
abdominal pain. Please follow up with your PCP and your
gastroenterologist. You also complained of urinary burning. We
have a urine culture and gonorrhea and chlamydia testing pending
at discharge and will call you with the results. Please be sure
to engage in safe sexual practices, wearing a condom every time
you engage in sexual activity to protect you from sexually
transmitted infections.
We wish you the best,
Your ___ team | Mr. ___ is a ___ year old gentleman hx of malrotation of gut
s/p surgical intervention presents with nausea, vomiting,
abdominal pain x1 week. CT scan negative for any acute process.
Pt initially had leukocytosis w/ left shift, and WBCs in the UA.
Pt was tested for HIV, GC/chlamydia, which are pending on
discharge. Pt was given IV fluids and Zofran with resolution of
symptoms. Pt tolerated full PO diet and his symptoms improved,
and he was stable for discharge home.
#Abdominal Pain/Nausea/Vomiting
No clear source for patient's GI symptoms. Possible that patient
has cyclic vomiting syndrome given patient has chronic hx of
nausea/vomiting and has been symptom free for several months,
and pt also has hx of migraines which is associated with ___.
Also suspect patient may have some sort of gastroparesis given
hx of slow motility on gastric emptying study, possibly related
to his hx of malrotation. With history of marijuana use, was
intrigued at the possibility of cannabis hyperemesis syndrome.
However, pt does not endorse any behavioral shower relief and pt
stopped using marijuana for 5 days now without resolution of
symptoms. Given normal CT scan unchanged from before, no concern
for bowel obstruction, IBD, or acute process. Does not appear to
be infectious gastroenteritis given only 1 episode of diarrhea.
No acute electrolyte abnormalities is reassuring.
Pt with leukocytosis w/ left shift on admission and WBCs in the
UA. Pt endorses high risk sexual activity and at risk for STI,
which could have precipitated his GI symptoms. Pt was tested for
HIV, GC/chlamydia, which are pending on discharge. Pt was given
IV fluids and Zofran with resolution of symptoms. Pt tolerated
full PO diet and his symptoms improved, and he was stable for
discharge home. Consider gastric emptying study to assess for
motility issues
#High risk sexual activity
Pt was tested for HIV, GC/chlamydia, which are pending on
discharge. Patient was encouraged to engage in safe sex practice
TRANSITIONAL ISSUES
============================
-f/u patient's GI symptoms. Consider getting a gastric emptying
study to assess for motility issues.
-f/u Urine GC/chlamydia. Treat if positive
-f/u HIV ab test
-encourage safe sex practice
#Code Status: Full Code
#Emergency Contact/HCP: ___ (Father) ___, ___
(Mother) ___ | 117 | 356 |
17032321-DS-8 | 27,370,066 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your left foot
infection. You were given IV antibiotics while here. You are
being discharged home on oral antibiotics with the following
instructions:
ACTIVITY:
There are restrictions on activity. Please try to stay off the
Left Foot as much as possible. When ambulating wear the surgical
shoe provided and keep weight off the front of your Left foot.
You should keep this site elevated when ever possible (above the
level of the heart!)
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient was admitted to the podiatric surgery service from
the ED on ___ for a Left foot infection. On admission, she
was started on broad spectrum antibiotics and monitored for
improvement.
The patient remained afebrile with stable vital signs. Her WBC
count normalized. Her pain was well controlled oral pain
medication on a PRN basis. The patient remained stable from
both a cardiovascular and pulmonary standpoint. She was placed
on clindamycin and ciprofloxacin while hospitalized and
discharged with oral antibiotics. Her intake and output were
closely monitored and noted to be adequtae. The patient refused
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged.
The patient was subsequently discharged to home on HD3 with plan
for her to go to the OR on ___ for outpatient surgery.
The planned procedure is a partial Left Hallux amputation. The
patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 411 | 156 |
16327789-DS-18 | 23,188,372 | Dear Mr. ___,
You were transferred to ___ on ___ after suffering a
fall. You were experiencing head and facial injuries. you will
need to follow up with the plastic surgery and ENT team as out
patient clinic in the following dates listing down.
You are now medically cleared to be discharged to home. Please
note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ was admitted to the ICU after his fall of ___ feet
because his imaging findings included pneumocephalus as well as
multiple facial fractures, for which neurosurgery, plastic
surgery, and ENT were consulted.
N: There was a concern for possible CSF leak, and he required
q1h neuro checks. A CTA was obtained on HD2 that did not show
any signs of bleeding, and he was AOx3 and neuro intact
throughout his entire hospitalization. He was originally kept
flat for 48 hours, and then sat up to assess for CSF leak. none
was identified and he was allowed to space out his neuro checks.
Repeat CT head 48 hours after admission showed improved
pneumocephalus, and there continued to be no signs of a leak.
The following day his neuro checks were spaced out and he
continued to be neuro intact, so he was transferred to the
floor.
CV: no issues with his blood pressure throughout his hospital
stay.
P:
GI: | 262 | 160 |
16256607-DS-11 | 20,363,148 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted after a fall and found to have
a recurrent urinary tract infection. We did not find any
concerning underlying cause of your fall such as a heart
arrhythmia, and suspect your fall was related to general muscle
weakness. Your fall resulted in a small bleed in your head for
which our neurosurgeons were consulted and recommended no
intervention. However, your Plavix was discontinued as this can
worsen current bleeding and causes increased risk of future
bleeding.
Also while you were here you were noted to be retaining urine
and a foley catheter was placed. This can attempted to be
removed at your living facility.
Please continue to take all medications as prescribed.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with the past medical
history and findings noted above who presents after an
unwitnessed fall.
# Unwitnessed Fall
# Forehead hematoma
Fall unwitnessed (found lying on the floor in her room) but
bruise on forehead suggests headstrike. Pt does not recall the
event. CT head/neck with no intracranial abnormality. While
patient with history of 4:1 flutter, ECGs at baseline with HRs
in ___ and no documented events on tele > 48h. Cardiac enzymes
negative. No murmur on exam nor history of DOE to raise concern
for valvulopathy-mediated syncope. Noted to have borderline low
BPs so home amlodipine discontinued. Collateral obtained from
nursing staff at ___ and story seems consistent with mechanical
fall as patient noted to be impulsive with poor situational
awareness. Recommend continued rehab and fall precautions on
return. Unclear if UTI (see below) contributed in fall risk.
# SAH:
CT scan with very small SAH without mass effect or focal neuro
symptoms. She was evaluated by neurosurgery who concluded that
there was no need for intervention or follow up imaging. Plavix
was held and should not be given for at least two weeks.
However, given risk of recurrent falls, decision made to hold
indefinitely. Physician at ___ agrees.
#UTI
#Urinary retention:
UA on admission with pyuria with WBCs greater than assay. UCx
growing mixed flora. Treated with CFTX. Subsequently found to be
retaining urine and thus bladder placed. She was unable to
undergo CIC due to agitation with this, so foley left in place.
Given contaminated initial UCx, repeat obtained. UA with
significant reduction in pyuria indication response to CFTX so
she was transitioned to PO cefpodoxime to complete a seven day
course through ___. She will need a voiding trial at ___ with
PVRs closely monitored to determine need for CIC versus chronic
foley if not voiding spontaneously.
#Aflutter 4:1 block on ECG and tele with HRs stable in ___.
No documented bradycardia/tachycardia or other arrhythmia.
Continued BB. Patient not on anticoagulation and this was not
started in setting of SAH, however, given history of repeated
falls, likely risks > benefits.
# Hypertension:
Borderline low BPs noted. Imdur and amlodipine held. BB
continued.
# Subacute cognitive decline:
Per discussion with ___ staff, patient with intermittent
confusion and cognitive decline over past month since arrival.
Likely had been declining even longer. Consistent with
progressive dementia.
# Type II diabetes:
Diet controlled. No issues.
#Carotid stenosis:
Continued on statin but. Last U/S in ___ with only mild
stenosis. Plavix discontinued in setting of SAH, with plan to
not resume per discussion with PCP at ___.
# Hypothyroidism. - continued synthroid 88 mcg
# Neuropathy - continued gabapentin.
TRANSITIONAL ISSUES:
===================
[] Discharged with indwelling foley. Recommend voiding trial
with monitoring of PVRs. ___ require CIC if not spontaneously
voiding.
[] Recommend NOT resuming Plavix due to high fall risk.
> 30 mins spent planning discharge | 136 | 477 |
17864807-DS-10 | 25,057,835 | Dear ___,
___ were admitted to the hospital with increased pain in your
hips. ___ were evaluated by the spinal surgeons who felt this
was not related to your recent spine surgery. ___ were also
evaluated by our rheumatologists who thought your symptoms were
due to inflammation in your bursa of your hips. ___ received
steroid injections to improve your pain with good effect. Your
pain is much improved!
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if ___ develop a
worsening or recurrence of the same symptoms that originally
brought ___ to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern ___.
It was a pleasure taking care of ___!
Your ___ Care Team | Mrs. ___ is a ___ woman with history
of PMR (on chronic prednisone), hypothyroidism, fibromyalgia,
chronic abdominal pain with dyspepsia, and spinal stenosis s/p
recent lumbar laminectomy and posterior spinal fusion on ___ by
Dr. ___, admitted with bilateral hip pain thought to be from
trochanteric bursisitis, superimposed on her postoperative
pains, with inability to ambulate.
# Bilateral hip pain
# Trochanteric Bursitis
# Inability to ambulate: Patient evaluated by spine in the ED
who felt that there was low concern for infection given clean
appearance of surgical site and for lack of neurologic symptoms.
They recommended against imaging at that time. There was
initially concern for a flare of PMR based on elevated CRP and
patient was started on higher dose steroids. However,
rheumatology consult felt symptoms were more consistent with
bilateral trochanteric bursitis. Steroids were returned to
___ dosing and patient underwent bilateral trochanteric
bursitis injection. With treatment, her symptoms improved
significantly and she was able to walk to the chair with
assistance from nursing.
# Spinal Stenosis, s/p
# Recent lumbar laminectomy and posterior spinal fusion:
Orthopedics saw in ED, low concern for infection given
appearance of surgical site and for lack of neuro symptoms.
Recommended against imaging. Patient remained without concerning
neurologic features for the duration of her hospital course.
Strength was ___ in bilateral lower extremities throughout on
discharge. Per discussion with Dr. ___ surgeon),
aspirin 81mg was started at discharge to prevent clotting and SC
heparin stopped. Please continue for 1 month post-operatively.
# Thrombocytosis
# Elevated CRP:
Patient admitted with elevated CRP and thrombocytosis (950)
which may have been related to recent spinal surgery.
Thrombocytosis improved over course of admission suggesting
resolving process.
# Hyperkalemia: Serum potassium was initially elevated to 5.6.
There was a large discrepancy between plasma and serum potassium
which was suspected due to pseudohyperkalemia in the setting of
thrombocytosis (>900).
# Polypharmacy: Patient on high doses of narcotic pain meds,
benzodiazepines and muscle relaxants concerning given patient's
age. Discussed extensively with patient who is amenable to
weaning her medications as her post-operative course improves.
Please work with patient to wean narcotic pain medications as
able given ongoing improvement in her pain post-operatively. | 127 | 360 |
18458383-DS-15 | 25,731,024 | You were admitted with swelling and infection of your scrotum.
You received antibiotics and improved. A foley catheter was
placed, and will need to remain in place until you follow up
with Urology. Please try to keep your scrotum
elevated/supported as much as possible.
It is important that you use BiPAP every night to help treat
your sleep apnea.
You were also noted to have a rash in your low back that may be
shingles, but is no longer infectious.
Please see below for your follow up appointments and
medications. | ___ h/o morbid obesity, obesity hypoventillation on chronic 02,
not compliant with nocturnal bipap, diastolic CHF, current
resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis. He does not have
___ gangrene or evidence of necrotizing soft tissue
infection. His obesity, poor skin hygeine, likely diastolic CHF
and pulmonary hypertension, and limited mobility all lead to
accumulation of scrotal edema.
# Scrotal cellulitis: he received: local skin care, scrotal
elevation, IV vancomycin and IV ceftriaxone to cover strep and
MRSA organisms (and some GNR coverage). Urology followed.
Patient did well and was transitioned to Keflex and Bactrim to
end on ___.
He has an inverted penis and Foley catheter will need to remain
in place until a voiding trial is performed at ___. Please
see below for wound care recs. Emphasis is placed on skin care
in the scrotal/inguinal region, and the urethral meatus should
be cleaned daily. The patient is encouraged to walk at least
three times daily. While in the bed or chair, the scrotum
should be elevated to help limit the amount of edema. Tramadol
was used for pain control.
# Chronic hypercarbic respiratory acidosis with metabolic
alkalsosis due to obesity hypoventilation and likely OSA
--SNF notes document non-compliance with nocturnal bipap. He
remained on nocturnal Bipap and 02 titrated to keep sats >88,
below 98%. It is imperative that he continue to receive BiPAP
nightly.
# Diastolic CHF, chronic and pulm hypertension: suspected
--continued PO lasix 100mg weight stable
# Low back rash- resolving dermatitis vs. resolving shingles.
No new lesions, all crusted over. Outside window of benefit
with antiretrovirals, and asymptomatic. Need to continue to
monitor skin for new lesions (no other rash, only in right S2
dermatome in the right gluteal cleft). If new lesions develop,
would consider valacyclovir 1000 mg TID.
# HTN: amlodipine
# Diabetes: continue lantus and SS insulin, held glimiperide and
metformin, and restarted metformin at discharge.
#Hyperlipidemia: simvastatin
#anxiety/depression: fluoxetine
Heparin SC
diabetic diet
Full code | 90 | 334 |
19245341-DS-4 | 22,318,342 | Dear Ms. ___,
You were admitted to ___ for surgery to drain an abscess in
your mouth. You have recovered well and are now ready for
discharge home. Please follow the instructions provided to you
by the Oral and Maxillofacial Surgeons to ensure a speedy
recovery:
ACTIVITY:
-You may resume your normal activity.
MEDS:
-You may resume your normal medications.
-You are being provided with a prescription for a 10 day course
of Augmentin. as well as pain medication.
-You may take a stool softener (such as Colace) or a laxative
(such as Senna) as needed for constipation while taking narcotic
pain medicine.
FOLLOW-UP:
-Follow up with OMFS as scheduled.
RETURN TO ED or call the office for:
-worsening pain not controlled by medication
-fever >101.5
-worsening swelling of the face
-erythema of the wound or purulent drainage
-difficulty breathing
-any other reason that concerns you
Thank you for allowing us to participate in your medical care.
Sincerely,
Your ___ Surgery Team | Ms. ___ presented to ___ ED on ___ with Ludwig's
angina. She was intubated in the ED for respiratory distress and
secretions. She was taken emergently to the operating room on
___ by OMFS. Please see OP Note for more details regarding
the procedure. Patient was kept intubated for 1 days and was
successfully extubated on POD1. She was kept on Unasyn until
___ when she was transitioned to PO Augmentin.
___ drains were removed on ___. She was discharged home
on ___. At the time of discharge, she was tolerating a
regular diet, ambulating independently, voiding spontaneously,
and pain was well-controlled with oral medications. She was
discharged with instructions to follow up in clinic with ___
next ___. | 157 | 121 |
19950352-DS-18 | 27,931,909 | Dear Ms. ___,
You were admitted to ___ because of weakness and difficulty
breathing. We didn't find any signs of infection. We talked
about doing an MRI of your head but you declined. You then
developed some pain on your forehead and we found a rash there,
consistent with shingles and started you on an antiviral.
We asked the ophthalmology doctor ___ doctor) to evaluate you
because of the shingles and she noted that there was an
abnormality on the back of your eye. It's unclear if this is
something that has been there before or something new. It could
potentially be related to your cancer or an infection. It is
very important for you to see your eye doctor within ___ week of
leaving the hospital.
When you get home, continue your medications.
It was a pleasure caring for you, and we wish you the best.
Sincerely,
Your ___ Oncology Team | ___ is a ___ year-old woman with extensive stage small
cell lung cancer on carboplatin and etoposide with concurrent
radiation who presented from Radiation Oncology with weakness
and dyspnea, most likely I/s/o chemoradiation, subsequently
found to have Herpes Zoster.
# Herpes Zoster
While inpatient, developed pain of L forehead, and subsequent
vesicles in V1 distribution. Slight redness and pruritis of
chest and back. ID & Derm consulted and felt these represented
radiation changes and not disseminated zoster. Started
valacyclovir for planned 14 day course given immunosuppression
(through ___. Consulted ophthalmology for evaluation given V1
distribution and complaint of fuzzy vision in L eye; no evidence
of zoster retinitis, and normal visual acuity, however noted
incidental lesion as below.
# Subretinal Lesion
___ disk-diameter subretinal lesion noted at 5 o'clock next to L
optic nerve during ophthalmologic evaluation which was thought
consistent with choroidal metastasis v. granuloma v. other
inflammatory lesion. Recommended neuroimaging if possible with
thin orbital cuts with contrast; however, given patient is
declining recommended follow-up with Atrius ophthalmology within
1 week of discharge with OCT, visual field and ultrasound.
# Weakness
# Debility
# Tremor
Presented with weakness I/s/o chemoradiation. Infectious
findings negative apart from VZV as above. Intention tremor
noted which has been present for some time. TSH & cortisol
normal. Patient declined all CNS imaging. Evaluated by ___ and
deemed to be below baseline, but likely primarily due to
fatigue; recommended home with home ___ but patient declined home
services.
CHRONIC ISSUES
==============
# COPD
Dyspnea likely due to known COPD. Improved with standing duonebs
and continuation of home inhalers.
# Extensive-Stage SCLC
Followed by Dr. ___ at ___. Currently on treatment break after
3 cycles and conclusion of radiation; will repeat PET in 1
month.
>30 min were spent in discharge coordination and counseling
TRANSITIONAL ISSUES
===================
[ ] Needs ophthalmology f/u within 1 week of discharge to
evaluate heaped-up lesion near L optic disk.
[ ] Should continue valacyclovir for 14 day total course
(through ___ | 146 | 313 |
19292638-DS-16 | 20,437,029 | You were admitted for management of a pneumothorax and
associated pleural effusion with pigtail chest tube placement
and pain control optimization. Both conditions resolved and the
chest tube was removed prior to discharge. Please follow the
below directions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to our trauma surgery service after
being transferred from an outside hospital for management of a
right pneumothorax s/p assault. CXR also showed associated right
pleural effusion. She had a pigtail catheter placed in the
emergency room that was then replaced the following day when it
was noted to have migrated into an incorrect position on chest
X-ray. Subsequently, daily chest radiographs showed resolution
of her pneumothorax, so her chest tube was transitioned from
suction to water seal. However, her chest tube output remained
high, suggesting persistent pleural effusion so her chest tube
was kept to water seal until this output decreased to
<100cc/day, when the chest tube was pulled and post-pull X-ray
showed no recurrent pneumothorax. Her respiratory status
remained stable throughout her stay and her pain control regimen
was optimized prior to discharge. allowing for adequate
respiratory effort with use of incentive spirometry. She was
discharged home in stable condition. | 331 | 159 |
17850903-DS-22 | 23,773,675 | Dear Ms. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted because you were feeling weak and tired, likely due to
multiple factors, including low red blood cell count, urinary
tract infection, and deconditioning after your recent fall.
Although you have a low red blood cell count at baseline due to
your myeloproliferative disorder, there was some concern that
you were bleeding slowly from your gastrointestinal tract. You
were evaluated by the gastrointestinal doctors, who suggested a
study of your large intestine (colonoscopy). Colonoscopy did not
show any active bleeding, and you also underwent a second study
(video capsule endoscopy), the results of which are pending at
discharge. In anticipation of colonoscopy, your warfarin was
held, and you received another blood thinning medication
(heparin) while your INR (a measure of your blood's clotting
ability) was low. Following colonoscopy, your warfarin was
resumed, and you were starting on another blood thinning
medication (enoxaparin), which you will need to continue for a
few days until directed otherwise by your primary care doctor.
You also completed treatment for urinary tract infection. You
were evaluated by the physical therapists, who felt that you
were safe to go home without rehabilitation services.
The following changes were made to your medications:
- Please STOP nitrofurantoin since you have completed your
antibiotic course for urinary tract infection.
- Please CONTINUE warfarin 5mg daily and enoxaparin 80mg ONCE A
DAY unless directed otherwise by your primary care doctor. You
will be able to stop enoxaparin injections once your INR (a
measure of your blood's clotting ability) falls into an
appropriate range. | Ms. ___ is a ___ with history of myeloproliferative disorder,
cerebrovascular accident x2 (___), esophageal varices
complicated by remote gastrointestinal bleed with splenorenal
shunt status post splenectomy, and L1 fracture (___) who
presented with subjective weakness. | 271 | 36 |
16631460-DS-10 | 22,444,437 | Dear ___,
You were admitted to the antepartum unit for treatment of
influenza. You were started on oseltamivir (Tamiflu) for
treatment as well as Tylenol for fever reduction. You were given
IV fluids for rehydration. Your strep test is still pending. At
this time, you are safe for discharge to home.
Please follow these instructions:
- Complete your course of Tamiflu for a total of 5 days.
- You may take acetaminophen 500-1000mg every 6 hours for pain
- You maybe take guaifenesin 10mL (200mg) every four hours as
needed for cough
Monitor for the following danger signs:
- headache that is not responsive to medication
- abdominal pain
- increased swelling in your legs
- vision changes
- Worsening, painful or regular contractions
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Nausea/vomiting
- Fever, chills
- Decreased fetal movement
- Other concerns | Ms. ___ is a ___ year old G1 with a history of mild
intermittent asthma who was admitted with flu like symptoms and
a positive influenza A culture on ___.
Regarding her influenza A, she presented to triage for history
of three days of fevers and cough. Her Tmax was 103 at home. Her
last febrile episode was 101.2 (___). A WBC returned as
7.4 with 83% neutrophilic left shift. A UA showed large
Leukocytes and ketones and a urine culture was obtained. She had
a rapid flu test which returned positive for Influenza A. A
chest xray was obtained, which returned negative. She received a
IV hydration via a initial 2 liter fluid bolus and was continued
on IV fluids until tolerating PO. She was given acetaminophen 1g
Q6H for fevers and pain and started on Tamiflu 75mg BID for a
planned 5 day course.
She did not continue the azithromycin. In the evening of ___,
patient was tolerating a regular diet. She had normal bladder
and bowel function.
The patient remained afebrile throughout the end of the day on
___ and ___, but did continue to have tachycardia to the
130s. An ECG showed sinus tachycardia on ___. Her tachycardia
improved to the low 100s on ___ with improved po and IV
hydration.
She had good fetal movement and no signs or symptoms of preterm
labor. Her fetal heart tracing was reassuring throughout her
hospital stay.
By hospital day 3, patient was tolerating a regular diet,
ambulating and voiding without issue. She had a sore throat so a
throat swab was sent.This was negative for strep. She was
discharged to home with close follow up on hospital day #3. | 166 | 278 |
19881444-DS-11 | 29,133,463 | stop smoking as we discussed.
Keep your follow up appointments
take medications as prescribed | AECOPD, likely due to viral URI. Flu neg. Stable. Improved
rapidly with nebs, abx, and prednisone. Ambulatory sats normal
on room air, felt much better by HD 3, evaluated by ___ and felt
safe for home no services from a mobility standpoint.
Encouraged smoking cessation repeatedly to pt. Gave nicoderm
patch
Hx mult cancers, ? in remission, due for surveillance in onc f/u
___. No acute issues on this front evident during this
hospitalization
Chronic back pain on high dose opiates: cont ms contin. We do
not have fentora. Discussed with pharmacy, who recommended
dilaudid po ___ mg q 3 h prn pain while hospitalized, which
worked well for pain control without sedation | 13 | 118 |
13347956-DS-17 | 20,291,607 | Dear Ms. ___,
You were admitted to ___ on
___ for evaluation of possible seizures. You were
placed on long term monitoring by EEG. Your EEG did not show any
seizure activity during these episodes of slurred speech or
dizziness. You also had a consult by the spine specialists in
regards to cervical and lumbar spinal canal stenosis. At this
time there is no recommendation for surgical intervention. You
should follow up in the spine clinic as instructed (their number
is below).
You should begin to taper off your Keppra and Trileptal as per
the instructions given to you by Dr. ___.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay. | ___ h/o HTN, HL, recurrent falls p/w similar episodes of
recurrent falls with leg stiffening, being "propelled forwards",
and occasionally mild slurring of speech without any impairment
of consciousness.
[] Falls - The patient has signs of myelopathy on examination
with weakness and brisk reflexes but no significant sensory
changes. She has cervical spinal canal stenosis on MRI. This is
most consistent with cervical spondylosis with myelopathy. She
was treated with a soft cervical collar. A spine consult was
obtained and there was no recommendation for surgical
intervention. She will follow up in the ___ further
management.
[] ? Seizures - She was monitored on 24h cvEEG monitoring and
had several typical events without any EEG correlate. She was
advised to taper off her Keppra and Trileptal slowly and to
follow up in the epilepsy clinic for further management.
Physical therapy and occupational therapy evaluated the patient
while admitted and cleared her for discharge home with
outpatient ___. | 133 | 156 |
11834767-DS-21 | 22,725,811 | Dear Ms. ___,
You were admitted because you had an episode of fever, chills,
and body aches. We started you on antibiotics given concern for
infection. Since you have been here you have had no further
episodes of fever, which is reassuring. Your blood cultures have
not grown any bacteria and your urine did not reveal a source of
infection. Your chest Xray was normal. We monitored you for 24
hours after discontinuing the antibiotics and you did very well.
We feel that you are safe for discharge home today. However,
please return as soon as possible if you do have another episode
of fever as it will be important to pursue further investigation
regarding the cause.
Thank you for allowing us to be a part of your care,
Your ___ team | Ms. ___ is a ___ year old woman with a history of
multiple myeloma diagnosed ___ currently undergoing
radiation therapy for L5 plasmacytoma presenting with chief
complaint of fever, chills, and body aches.
Fever: Ms. ___ presented with a fever to 101.2 on the
morning of admission though had no subsequent fevers. The
etiology of her fevers is unclear without localizing source on
history or physical exam. She was afebrile throughout her
hospitalization. She was initially started on Vancomycin and
Cefipime for neutropenic fever. Antibiotics were discontinued on
hospital day #2. She was monitored for 24 hours after
discontinuation of antibiotics without recurrence of fever. She
was not neutropenic during her hospital stay. Urine culture was
negative. Blood cultures revealed no growth. CMV DNA was
negative though EBV and HHV6 results were pending on discharge.
She was counseled on the importance of returning to the hospital
if her fever returns and she expressed understanding.
Plasmacytoma and back/leg pain: Ms. ___ is currently
undergoing radiation therapy for L5 plasmacytoma causing nerve
root compression with palliative radiotherapy to L4-S1. She has
not yet started chemotherapy due to personal hesitation and
anxiety. She received 2 radiation treatments during her hospital
stay and is scheduled for her last fraction on ___. She
ambulated without difficulty during her hospital stay without
change in lower extremity strength, no bowel or bladder
incontinence, and denied lower extremity pain. She will continue
with radiotherapy to L4-S1 as noted above. She will follow up
with Heme/Onc in clinic to further discuss systemic therapy on
___.
Rash: Ms. ___ presented with isolated 1-2 mm
erythematous non-confluent, non-pruritic macules on her cheeks
bilaterally on hospital day #3. Possibly viral vs drug related,
and improved prior to discharge.
FEN: Regular diet, gluten free
Prophylaxis:
DVT prophylaxis with heparin- patient refused heparin during her
hospital stay. Ambulated daily.
Pain: Oxycodone PRN. Avoided Tylenol to assess for fevers.
Bowel regimen: Senna and Colace | 130 | 319 |
12448633-DS-20 | 29,759,775 | It was a pleasure taking care of you at ___.
You were admitted from home with shortness of breath. This was
caused by accumulation of fluid in your lungs, which happened
because you were not taking one of your medicines as prescribed
(Lasix). You were treated with BIPAP and medicines to remove
extra fluid. Your weight at discharge is 102 pounds - this
should be considered your "dry weight" (that is, weight without
any excess fluid in your body). Your kidney function declined
briefly because of your heart failure, but it was improving at
discharge.
It is EXTREMELY important that you take all of your medicines
every day to help your heart pump effectively and avoid another
hospitalization from heart failure.
Please weigh yourself every morning, call Dr. ___ weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Thank you for allowing us to participate in your care. | Ms. ___ is an ___ with CAD and known 3VD s/p recent
hospitalization ___ for STEMI who presents with dyspnea,
pulmonary edema and 2 lb weight gain suggestive of decompensated
heart failure. | 157 | 32 |
14778421-DS-28 | 25,006,393 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You had increased swelling in your legs
- Your kidney tests were a little bit elevated
What was done while I was in the hospital?
- You were started on a diuretic (water pill) to remove the
extra fluid in your legs
- Your labs were monitored
What should I do when I get home from the hospital?
- Continue to take all of your medications as prescribed,
including your water pill
- Please have your labs checked in 1 week to ensure that your
kidney tests are stable
- Make sure to go to all of your follow-up appointments
- If you have fevers, chills, worsening swelling in your legs or
belly, or generally feel unwell, please call your doctor or go
to the emergency room
Sincerely,
Your ___ Treatment Team | Mr. ___ is a ___ year old man with past medical history of
T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney
transplantation in ___, repeated skin cancers related to
immune
suppression, hx of Hep C (undetectable vital load in ___, HTN,
who came to the ED with weight gain, swelling over face and
legs.
ACTIVE ISSUES
=============
# Weight gain
# Bilateral lower extremities edema
# Pulmonary congestion on CXR
Patient presented with reported weight gain of ___ lbs over 5
days along with new bilateral lower extremity edema. Patient
reassuringly asymptomatic with no dyspnea or chest pain. BNP
elevated to 3200 with negative troponin. No evidence of
cirrhosis on CT A/P. Patient received 40 IV Lasix in the ED with
some improvement in ___ edema. Echocardiogram performed with
normal systolic function, notably with enlarged left atrial and
mildly elevated pulmonary artery systolic pressure to 27. Given
hemodynamic stability, and reassuring volume exam with only mild
edema of lower extremities, patient started on oral diuretic of
torsemide.
# ESRD s/p SCD kidney transplantation in ___:
# ___ on CKD:
Cr. 1.8 on admission, up from baseline of 1.3-1.5. Renal
transplant U/S demonstrated moderate hydronephrosis stable from
prior with patent transplant vasculature. Of note, patient
underwent renal biopsy on ___, which demonstrates diabetic
nephropathy with nodular glomerulosclerosis. UA demonstrated
proteinuria with Pr/Cr ratio of 1.6. Creatinine improved to 1.6
and then on repeat 1.8, which notably in setting of
supratherapeutic tacrolimus.
# Anemia
Hgb 9.0, on repeat 9.5. MCV wnl. Iron studies with low serum
iron, but otherwise unremarkable. Baseline appears to be ___.
Stool guaiac was negative. Last colonoscopy in our system ___.
Due for repeat. Started on PO iron.
# Incidental lung finding:
3 mm pulmonary nodule of the right lower lobe, for which no
dedicated CT follow-up is recommended. RECOMMENDATION(S): For
incidentally detected single solid pulmonary nodule smaller than
6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk
patient. | 140 | 327 |
11294985-DS-3 | 23,197,348 | You came to the hospital because you had chest pain. You were
transferred from ___ because were felt to be having a
heart attack. You had a catheterization which showed a complete
obstruction of one the arteries that feed your heart. The
cardiologists unplugged the blockage and put in a drug-eluting
___. You were started on 2 very important medications to
prevent any obstructions within your ___: full dose aspirin,
and clopidogrel [plavix]. You need must take these medications
every day. You were also started on:
- atorvastatin, which lowers cholesterol and prevents
progression of coronary artery disease
- lisinopril, which helps protect the structure of the heart and
lowers blood pressure
- metoprolol, which lowers heart rate and blood pressure and
decreases the stress on the heart. | Mr. ___ is a ___ with a PMHx of BPH who was transferred
from ___ with chest pain found to have NSTEMI.
# NSTEMI
Patient with presentation c/w late NSTEMI with positive cardiac
enzymes without ST elevations. He was maintained on heparin gtt.
Mild persistent chest pain, evaluated by cards in ___ and
underwent LCH on ___. He was found to have extensive thrombus
in LCX and underwent thrombectomy, balloon dilatation and
placement of ___. He was maintained on metoprolol,
atorvastatin and lisinopril, plavix and full dose aspirin.
# PUMP: TTE showed depressed EF 50-55%. No clinical signs of
heart failure; pt remained euvolemic.
# RHYTHM: NSR on Telemetry
# BPH: Con't Terazosin and finasteride | 125 | 111 |
14927306-DS-25 | 29,906,090 | Dear Ms. ___,
You were admitted because you had the flu and an infection in
your lungs. We treated you with medications for this. You should
continue taking your antibiotic (levofloxacin) until ___ for
your pneumonia.
We also found your heart rhythm to be going fast so we have
given you a heart monitor that you should use when you leave the
hospital. Your cardiologist will follow up on these results.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
It was a pleasure taking care of you,
Sincerely your ___ Team | ___ with history of CKD on dialysis, CAD, seizures, and HFpEF
who presented with respiratory distress and was found to have
multifocal pneumonia and influenza, with likely new onset AF in
the setting of infection.
#Influenza/Pnemonia: Patient was treated with a 5 day course of
Tamiflu (___) and started on coverage for HCAP with an 8
day course of levofloxacin 500 mg q48h (end ___. Patient
required ___ O2 and improvement in her symptoms and oxygen
status was noted with treatment.
#Atrial fibrillation- Patient was noted to have intermittent
episodes of Afib during this hospitalization, with no prior
diagnosis previously. Patient was started on carvedilol 12.5 mg
BID given patient's hypertension. Regarding anticoagulation,
patient's cardiologist was contacted and recommended deferring
anticoagulation given likely provoked AF in the setting of acute
illness and the fact that patient is already of dual
antiplatelet therapy. Patient was discharged with ___ of
hearts monitor at discharge with plans to follow-up with Dr.
___.
# TTE performed ___ showed: Symmetric LVH with normal global
and regional biventricular systolic function. Moderate to severe
mitral regurgitation. Moderate to severe tricuspid
regurgitation. At least moderate pulmonary hypertnesion.
#HTN- Patient was found to be persistently hypertensive so her
dose of imdur was increased to 60 mg daily. Patient was also
started on carvedilol 12.5 mg BID. Discharge BP: 124/64.
# CKD Stage 4- Patient received HD on MWF.
# Diastolic CHF (EF ~60%): Patient with no e/o heart failure
clinically. BNP likely
elevated in setting of CKD. Patient's isosorbide mononitrate was
increased to 60 mg daily. Patient was also started on carvedilol
12.5 mg BID as above.
# CAD/HLD with history of bypass ___ years ago. Patient was
continued on home doses of atorvastatin, plavix, aspirin. Imdur
increased to 60 mg daily. Carvedilol was added as above.
# Seizure history: Patient has a history of seizures during
times of infection per patient's daughter that manifest as
rhythmic jerking of the arms and legs. No evidence of these
seizures during this admission. Patient was continued on keppra
500 mg BID and keppra 500 mg tablet ___ after each HD session.
# Glaucoma- Patient was continued on latanoprost 0.005 % drops
(ophthalmic)
# GERD- Continued famotidine 20 mg q24h
# Depression- Continued celexa 20 mg daily | 97 | 373 |
13181224-DS-44 | 26,946,488 | Dear Mr. ___,
You were admitted to ___ from ___ to ___ after having a
seizure at your rehab center,
WHY WAS I ADMITTED?
====================
- You were admitted because you had a seizure. We investigated
the cause and found that your calcium levels were critically
low.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
=============================================
- We gave you IV calcium to get your levels back to an
acceptable range.
- We gave you vitamin D, which helps to keep your calcium levels
up.
- You were seen by neurology, who did not feel as though there
were any other reasons for your seizure.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
=============================================
- Follow up with your doctors as listed below.
- Take all of your medications as prescribed.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Transitional Issues
====================
[ ] Furosemide and potassium supplementation - held in the
setting of ___, hypocalcemia. Can be restarted on an outpatient
basis
[ ] Seizure precautions - given history of seizure patient
should not drive (per state laws), operate heavy machinery, bath
alone, swim, or climb ladders for 6 months or until cleared by
his primary care physician.
[ ] Transaminitis - attributed to amiodarone, though should be
followed up in the future to ensure stabilization
[ ] Alcohol use - evidence of alcohol use even since his liver
transplant. Alcohol use counseling should be considered in the
outpatient setting.
[ ] Electrolyte abnormalities - calcium, magnesium, and vitamin
D should be check periodically to ensure they are within
adequate levels and repleted prn.
[ ] Please check CMP on ___ and replete as indicated
[ ] Is on warfarin for atrial fibrillation. Was changed from
rivaroxaban on his last hospitalization ___ discharge) to
warfarin. Unclear based on notes the reasoning for the
transition. Will continue warfarin but should be evaluated by
PCP or cardiology regarding restarting rivaroxaban.
[ ] On discharge from rehab, please connect patient to ___
___ clinic. Per ___ clinic, cannot establish care with
their services until after discharge from rehab.
[ ] New medications: thiamine 100mg daily, folic acid 1mg daily,
vitamin D 2000IU daily
___ year old male with CAD s/p multiple stents and recent 3v CABG
___, EtOH cirrhosis s/p OLT in ___ on tacrolimus, atrial
fibrillation on warfarin, HFrEF, CKD, IDDM, and PAD presented
from rehab center with new onset tonic-clonic seizure x1 and
severe hypocalcemia secondary to vitamin D deficiency.
# Seizure
Patient presented from rehab center after sustaining a
tonic-clonic seizure. A work up, including head CT, was
negative. The patient was noted to be severely hypocalcemic,
which is thought to have precipitated his seizures. Neurology
was consulted, who felt that the hypocalcemia was sufficient to
explain the seizures and recommended against EEG and
anti-epileptic medications. Mr. ___ did not suffer any further
seizures after the initial episode.
# Severe hypocalcemia
Presented to OSH with calcium reportedly 5.1. A thorough work up
revealed vitamin D deficiency as well as hypomagnesemia, which
were felt to be the causes of his hypocalcemia. Notably, PTH was
within normal range. Calcium, vitamin D, and magnesium were all
repleted to appropriate levels, and the patient was started on
PO repletion for discharge.
# AMS
The patient suffered from altered mental status throughout his
hospital course, remarkable for waxing and waning features and
altered sleep-wake cycle most indicative of hospital-acquired
delirium. Other causes of AMS were also entertained, most
notably ___'s encephalopathy and hepatic encephalopathy in
the setting of his extensive alcohol abuse history. Ultimately,
it was felt that his presentation was not consistent with
___'s encephalopathy (no nystagmus or evidence of
cerebellar dysfunction) or hepatic encephalopathy (no
asterixis). However, given relatively low impact of vitamin
supplementation and risk of Wernicke's, started patient on
thiamine supplementation per neurology recommendation.
# Alcohol use
Patient had varying reports of the last time he had alcohol, but
collateral acquired from his brother indicated that the patient
had been drinking significant amounts of alcohol since 6 months
after his liver transplant in ___. Given his history of alcohol
use, he was started on MVI, thiamine, and folate.
# ___ on CKD
Patient's baseline Cr appeared to be around 1.0-1.1, but his Cr
was lower on admission. It uptrended on ___ to 1.4, which was
thoguht to be secondary to hypovolemia given patient his was
significantly net
negative based on I/Os. His Cr returned to his presentation
levels with increased fluid intake and kidney function remained
stable for the remainder of his hospital stay. Of note, his home
Lasix was held in the setting of his ___ and should be resumed
on an outpatient basis.
# Transaminitis
# OLT ___
Mildly elevated AST/ALT to the ___ on admission. Patient was
started on amiodarone on previous hospitalization in ___ for
atrial fibrillation, which was the suspected etiology of his
transaminitis. On exam, the patient had a nontender RUQ and no
evidence of
cholestasis on labs. His tacrolimus levels were monitored, and
no dose adjustments were necessary to keep within goal ___ per
hepatology).
Chronic/Stable Medical Issues
==============================
# Atrial fibrillation
- Continued amiodarone
- Continued warfarin
# CAD s/p stenting, 3v CABG
- Continued ASA 81mg
- Continued atorvastatin 80mg daily
- Continued imdur 30mg daily
# HFrEF
EF 22% ___ in setting of hospitalization for CABG
- Held Lasix 20mg daily given hypocalcemia, ___
- Continued lisinopril 10mg
- Continued metoprolol succinate 25mg daily
# IDDM
- Continued home regimen of lantus and Humalog SSI
# PAD s/p stenting
- Continued ASA, statin | 141 | 743 |
13643569-DS-7 | 21,199,887 | You were admitted with a blood clot to your lungs. You were
seen by the hematology and vascular medicine teams. We have
stopped your rivaroxaban and have started enoxaparin (Lovenox).
It is very important that you take this medication as prescribed
twice daily and follow up with your hematologist as scheduled | ___ woman with h/o PE at 7 wks gestation (___), IVC
clot 2 wks post-partum s/p catheter-directed thrombolysis and
IVC filter s/p removal, and submassive PE in ___ who
presented to the emergency department for evaluation of pleurtic
chest pain, found to have recurrent bilateral pulmonary embolism
with right heart strain despite rivaroxaban.
# Acute submassive PE:
# Chronic VTE:
The patient has a history of recurrent VTE and presents with a
recurrent PE despite AC with rivaroxaban. She denies missing any
doses. She follows with hematology who in their last note wrote:
"Pt has a history of peripartum PE/IVC thrombus without
identified contributing hypercoaguable syndrome (negative APL
abs, AT antigen repeatedly normal). Her IVC filter was removed
___. She was treated with 6 mo therapeutic AC (warfarin ->
Xarelto) then transitioned to ppx ASA 81mg daily on which she
developed a LLL segmental PE (neg trop, BNP) and normal TTE.
During that hospitalization, she underwent a repeat CTA chest 5
days after the diagnostic study which revealed no change in her
exam. She was started on rivaroxaban 20 mg twice daily" She was
transitioned to once daily rivaroxaban. At that time (___)
hematology recommended lifelong anticoagulation. They noted "She
does not have Antithrombin deficiency nor any identified
hypercoagulability syndrome, though it is clear that she remains
at high risk of recurrent thrombosis. Her APLS testing is
negative, so she is safe to be anticoagulated with rivaroxaban."
She missed her most resent hematology follow-up appointment in
___ of this year.
- TTE reviewed, re-assuring
- LENIs negative
- Appreciate Hematology and MASCOT consult recommendations
- Placed on Lovenox ___ q12. ___ cont on DC and have patient
follow up with Dr. ___
- ___ repeat anticardiolipin and B2 glycoprotein testing -
PENDING on DC
- Hold home Rivaroxiban.
- Pain control with acetaminophen 1000mg PO Q6H PRN.
- Avoid NSAIDS for now if possible
# Migraine Headaches:
-Monitor | 54 | 313 |
19011264-DS-7 | 24,058,380 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
Why was I here?
-You were here because you had nausea, confusion, and abdominal
pain.
What was done while I was here?
-You were found to have inflammation of your colon on a CT scan
- this is called "diverticulitis".
-You were treated with antibiotics. These were switched to oral
once you were feeling up to taking oral meds.
What should I do when I go home?
-You should continue taking your antibiotics for a total of 14
days. The last day will be ___.
-You should continue taking all of your other medications as
directed on this paperwork.
We wish you the best!
Sincerely,
Your ___ Medicine Team | ___ is a ___ yo woman with a history of ESRD due to
lithium toxicity s/p LRRT ___ years ago on azathioprine,
prednisone, and tacrolimus, baseline creatinine ~0.9, IBS with
chronic diarrhea, OSA on CPAP, anemia, HTN, severe bipolar
disorder, presenting with nausea (no vomiting), RLQ/vague
abdominal pain, and diarrhea for the past week, with one day of
confusion/delirium, found to have acute uncomplicated
diverticulosis on CTU, which was successfully managed medically.
# Acute uncomplicated diverticulitis
# Nausea / abdominal pain
# Toxic Metabolic Encephalopathy
Patient presented with nausea, abdominal pain, and 1 day of
confusion. CTU in the ED showed acute uncomplicated
diverticulitis, which would explain symptoms. Renal was
consulted regarding her immunosuppressive medications and
recommended continuation of her regimen as she was relatively
stable and not septic. She was started on IV cipro and PO
flagyl, and was advanced to PO cipro on ___. She was initially
NPO, but by ___ she was tolerating some clears, and her diet
was advanced thereafter. By the day of discharge she was feeling
like herself and was able to walk with her walker. By ___ she
is tolerating diet well.
Per ___ evaluation, she will need rehab, anticipate this will be
less than 30 day stay.
# ___ - Resolved.
# ESRD s/p LRRT in ___
Patient w/ ___ to 1.3 from baseline 0.9. Likely pre-renal in the
setting of dehydration/ diverticulosis as above. S/p 2L NS in ED
and MIVF overnight ___ ___ resolved. Urine Cx negative.
Tacro level 8.5 on ___, dose was decreased to 2mg bid (from
home dose of 4mg BID), level was 10.2 on ___, thus dose was
dropped to 1mg. Recheck of level on ___ was 6.7. Tacro level
likely elevated in the setting of diarrhea. Continued other home
meds: prednisone 5mg daily, and azathioprine 75mg daily. Recheck
on ___ tacro level was 4.7, and she is being discharged, so
final discharge dose will be 2mg BID.
*IMPORTANT* She will need tacro level checked on ___
and fax the labwork to ___.
# Tertiary hyperparathyroidism
# Hypercalcemia
Known history, followed by endocrine. She is on alendronate
weekly (was not dosed while inpt). Continued cinacalcet. Held
cholecalciferol.
# Diarrhea
# IBS
Per patient, daughter, and medical records review, diarrhea
appears to be chronic ISO IBS.
C. diff was checked and was negative. (has history of infection
in ___ and was checked again in ___, was negative). Imodium
was given for sx relief.
# Severe bipolar disorder
Continued divalproex, lamotrigine, aripiprazole, venlafaxine. Of
note, her med doses were incorrectly recoded on her
pre-admission med list. The doses were adjusted and corrected on
___ by our pharmacy team.
# HTN
She was briefly on metoprolol after she was stabilized from an
infectious standpoint, however it was discovered that her home
medication list was incorrect, thus this was discontinued.
# OSA
Uses CPAP and 2L O2 at night. These were continued inpt.
__________________________________ | 113 | 485 |
15686619-DS-17 | 20,085,750 | Dear Ms. ___,
You were admitted to the gynecology service for treatment of
your cellulitis and abscess. A drain was placed in the fluid
collection and you were started on antibiotics. You have
recovered well and the team believes you are ready to be
discharged home. Please call Dr. ___ office with any
questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Cellulitis/Abscess:
* You were discharged home with a drain in place. A visiting
nurse ___ come to your home to help you take care of the drain
and monitor its output. The nurse will be in contact with the
interventional radiologist on when to have it removed.
* Please take all your antibiotics as directed. You will
continue with the daptomycin infusions, which your visiting
nurse ___ help with.
* You will also be scheduled for an MRI on ___. If your
drain is still in place then, please call ___ between
8AM & 6PM to reschedule the MRI
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the Gynecology service
for pelvic subcutaneous fluid collection concerning for abscess
vs. seroma. CT scan showed "1. A lower anterior abdominal wall
peripherally enhancing fluid collection containing locules of
air is decreased in size from prior, currently measuring up to
9.6 cm, compared with 14.2 cm previously, however is again
concerning for infected seroma/abscess. This would be amenable
to percutaneous drainage if desired. 2. A 2.7 cm left adrenal
lesion is not significantly changed from prior, however is again
incompletely characterized. Recommend correlation with prior
imaging if available, or outpatient MRI/CT adrenal for further
characterization if no prior imaging is available. 3. Hepatic
steatosis." She was initially continued on her home antibiotics,
IV daptomycin and oral doxycycline. She was given IV dilaudid
and tylenol for pain. She remained afebrile with normal vital
signs, and labs initially demonstrated a mild leukocytosis of
12.5. She underwent ___ drainage of the pelvic
subcutaneous fluid collection, during which 60cc of cloudy fluid
was drained and a pigtail catheter was placed for continuous
drainage. Fluid gram stain was negative, with sparse
enterococcus growth, and fluid creatinine were normal, no
anaerobes or acid-fast bacilli were seen. She was seen by the
Infectious Disease team who recommended transitioning to IV
flagyl and ceftazapime, with continuation of her IV daptomycin.
She experienced some urinary urgency, and had a UA which was
normal, and UCx negative. She was given pyridium for her
symptoms. For her type 2 diabetes, her home metformin and
glipizide were held, and she was placed on an insulin sliding
scale and her blood glucose was closely monitored. For her
bipolar disorder, and COPD/asthma, she was continue on her home
medications.
From ___, she continued to improve clinically. Drain
output was 50cc daily. She continued to have no leukocytosis and
no bandemia. She remained afebrile. Her abdominal exam was also
noted to improve with decreasing erythema and induration.
On ___, her CBC was noted to have an HCT drop from 35.6 to
28.6. Her exam was benign with stable VS, low suspicion for
active intraabdominal bleeding. HCT was repeated 6 hours later
and was stable at 36.2. Her drain output also decreased to 30cc.
Due to her clinical improvement, per ID team she was continued
on Daptomycin and transitioned to PO flagyl and levaquin through
___. CRP, CK, ESR were all drawn for daptomycin monitoring
which were all normal. EKG was also obtained which did not show
any evidence of QTc prolongation. She was also restarted on her
home metformin and glipizide. Her ___ remained stable between
130-200.
By ___, she had improved clinically and was discharged to
home in stable condition with home nursing set up for IV ABX
infusion as well as drain care and outpatient follow-up as
scheduled. | 308 | 465 |
16041820-DS-16 | 28,078,958 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY YOU WERE ADMITTED:
-Your biopsy showed diffuse large B-cell lymphoma (DLBCL) and
you were admitted to have labs checked and staging workup
WHAT HAPPENED IN THE HOSPITAL:
-You had an echocardiogram of your heart which showed good
cardiac function
-Your drain from the surgery was removed
-You received chemotherapy for your DLBCL, and tolerated it very
well. Your nodules shrunk in size.
WHAT YOU SHOULD DO AT HOME:
-Continue taking allopurinol ___ daily for 1 week after you
are discharged
-Please return to clinic on ___ to receive your neulasta
-Please keep all of your appointments below
-Take all your medications as indicated
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team | Ms. ___ is a ___ woman w/ prior lymphoma in ___
treated w/ 6 cycles CHOP found to have DLBCL admitted for
staging and determination of treatment.
#DLBCL, germinal center type: R supraclavicular mass removed by
plastic surgery with pathology showing follicular lymphoma w/
transformation to DLBCL. Cytogenetics positive for IGH/BCL2 and
rearrangement of BCL6, negative for MYC. Several nodules on R
neck, R axilla, nape of neck, and lower back. Underwent CT
head/neck/torso for staging which showed subcutaneous nodules in
neck, chest, abdomen. Also had TTE given plan for anthracycline
therapy with EPOCH-R which showed no cardiomyopathy (LVEF >55%).
Started on allopurinol to prevent tumor lysis given uric acid
7.8. The patient completed EPOCH-R (5 day cycle), tolerated well
with minimal nausea, and resulting shrinkage of subcutaneous
nodules. Patient to return to clinic on ___ for neulasta, and
again on ___ w/ Dr ___ further management of DLBCL.
#Lower extremity Edema:
#Weight gain: Patient w/ 10 lb increase in weight and
development of lower extremity edema iso prednisone as well as
IV hydration for chemotherapy. Gentle IV diuresis in house with
some improvement. Patient weight on discharge 165.8 (dry weight
157.7). The patient's volume status is expected to improve once
discharged as she will no longer be receiving IVF or pred and
given her good kidney function. Patient to have close follow up
for further management.
#INSOMNIA: Likely iso pred and anxiety. Improved w/
diphenhydramine + ramelteon + lorazepam PRN. | 124 | 241 |
14390025-DS-24 | 23,211,900 | Dear Mr. ___,
You are being discharged to ___ house to receive comfort
measures and to pass comfortably. | Mr. ___ is an ___ year-old male with a history of pancreatitis
c/b pseudocyst and multiple debridements, insulin-dependent DM,
CAD s/p RCA stent, carotid artery stenosis s/p CEA, PAD s/p
stent, HTN, prior alcohol use, recurrent C diff, and lymphocytic
colitis who was admitted to the hospital with vomiting and
abdominal pain. Upon admission, the patient was made NPO, given
intravenous fluids and underwent imaging. A cat scan of the
abdomen/pelvis was obtained which showed portal venous gas and
pneumatosis in the duodenum and jejunum concerning for bowel
necrosis.
Based on these findings, he was taken to the operating room
where he underwent an ex-lap, small bowel resection, and SMA
stenting on ___. After the surgery he was admitted to the
intensive care unit for monitoring. During his stay, he
received blood products (RBCs and FFP) and returned to the
operating room on ___ for primary re-anastomosis and closure of
fascia. He was extubated on ___. On ___, the patient had a
sodium of 151, and was started on D5W and TPN without sodium.
He was transferred to the surgical floor on ___. However, he
returned to the ICU soon after when he was reported to have a
sodium of 158. He continued on D5W and started on an insulin
drip for an elevated blood sugar. Once his hypernatremia
improved, he was transferred back to the surgical floor.
Neurosurgery was consulted for management of his T12 wedge
fracture and recommended a TLSO brace on side of bed for use
when he is out of bed to chair. ___ was consulted for enteral
access and a GJ tube was placed. The G tube was kept to gravity,
and tube feeds were initiated via the J tube. Plavix was started
on ___ for mesenteric stent patency once enteral access was
established.
The patient again returned to the intensive care unit on ___
after he had an acute desaturation event with hematemesis,
concerning for aspiration and possible upper GI bleed. He was
started on broad spectrum antibiotics for presumed aspiration
pneumonia based on his respiratory status, chest xray, and
significant leukocytosis to 30. He initially required
non-rebreather but was weaned to high flow nasal cannula and
eventually to regular nasal cannula. He underwent a CT torso to
evaluate for other infectious sources, which revealed an
anterior abdominal wall collection concerning for abscess. A
drain was placed into the collection by ___ on ___. While in the
ICU, he developed dark red stools and similar output from his G
tube. His hematocrit slowly dropped and he required
transfusions. GI was consulted and recommended a BID IV PPI and
upper endoscopy. Endoscopy was referred, as his hematocrit
eventually stabilized. During his ICU stay, code status was
discussed with the patient's wife, and he was transitioned to
DNR/DNI. The patient was deemed stable for transfer to the
surgical floor on ___.
While on the surgical floor, the patient experienced episodes of
emesis and there was concern for aspiration. Tube feeds were
held and a bowel regimen was given which resulted in a large
bowel movement. He received Lasix for diuresis. His wound vac
was changed and the wound continued to heal well. A family
meeting was held with the surgical team and palliative care and
the decision was made to make the patient's care comfort
measures only. Vitals signs were stopped, diet as tolerated,
and medications provided for pain relief, agitation, and nausea.
He was discharged to ___ to continue providing comfort
care | 17 | 588 |
14170666-DS-19 | 21,859,246 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with a rash on your feet. You were seen
by the dermatologists who think that this rash is from contact
dermatitis with an infection. You were treated with topical
creams and with antibiotics. Please follow up with dermatology
after discharge. You have been prescribed a strong pain
medication to take if you have severe pain ___ your feet. This
medication can cause sleepiness and constipation. Please use
this medication (oxycodone) as little as possible. You should
continue taking antibiotic Augmentin until ___.
While you were hospitalized, you were also noted to have high
thyroid hormone levels. You were seen by the endocrinologists
who discussed options for treatment. You have elected
radioactive iodine treatment. You are scheduled for a thyroid
uptake scan on ___ at 10 AM, and ___ at 10 AM (this is
a two day scan). Please do not eat anything after midnight
prior to this scan. Please do not consume ANY seafood, seaweed,
sushi, or kelp prior to this test. After the test, you will
follow-up with your Endocrinologist on ___ as below.
You have been started on medication atenolol to help control
heart rate, blood pressure and tremor which are side-effects of
high thyroid levels.
You are being sent home with home nursing and home physical
therapy support. They will meet you at your house to start the
services.
We wish you the best ___ your recovery!
-- Your medical team
RASH and WOUND INSTRUCTIONS:
- Apply mupirocin to open areas on the top of the feet. Keep
covered with xeroform (rather than dry gauze) to reduce pain
with
dressing changes.
- Apply COPIOUS Triamcinolone 0.1% ointment twice daily to rash
on
trunk and extremities for up to 2 weeks (started
___. DO NOT apply the OPEN AREAS on dorsal feet
but can apply to all other
itchy areas).
- Apply hydrocortisone 2.5% ointment twice daily to rash on face
and
neck for up to 2 weeks
- Apply ***COPIOUS moisturizer (E.g. Vaseline or Eucerin cream)
to the extremities twice daily | SUMMARY:
___ yo F PMHx ___, stage IA serous endometrial adenocarcinoma
s/p abdominal hysterectomy, b/l salpingoopherectomy, adjuvant
chemo and brachytherapy (completed ___, DM2, HTN and eczema
who presents with b/l ___ rash, most likely caused by exuberant
contact dermatitis with MSSA superinfection and subsequent skin
breakdown with associated id reaction on the body ___ the setting
of diffuse xerosis. Hospital course complicated by symptomatic
hyperthyroidism, started on beta blockade with improvement. | 351 | 70 |
15056444-DS-11 | 26,633,895 | Ms. ___,
You were admitted with a severe headache. A work-up for brain
mass, bleed, or infection was negative. Most likely, you were
having one of your chronic headaches that was worse than usual.
Many of your symptoms that you described are consistent with
migraines. We have made an appointment with the ___ Headache
___ further evaluation, please find the details below.
You were not taking medications at the time of admission and
have not been discharged on new medications. For headaches in
the future, you can use acetaminophen (Tylenol) or an NSAID like
ibuprofen (Motrin) or naproxen (Aleve). Sometimes caffeine helps
to relieve headaches. You can also consider an over-the-counter
migraine reliever which contains either acetaminophen or
ibuprofen with caffeine. Please do not take more than ___
(___) of acetaminophen daily, regardless of whether in a
migraine reliever or on its own.
Appointment have been made on your behalf with the ___
Headache Center and a new PCP at ___. Please
find the details below.
It was a pleasure participating in your care, thank you for
choosing ___! | The patient is a ___ without significant past medical history
who presented to the ED with viral symptoms and headache, s/p LP
with no striking findings on CSF, admitted for symptom control
and concern for aseptic meningitis.
.
#Headache
Patient with headache for past 5 days with viral symptoms
including sore throat, nausea, subjective fever and chills, and
body aches. Viral symptoms largely resolved. Patient reported
that headache was similar in quality to usual headaches (same
location, nausea, mild photophobia), with the only difference
being persistent pain and difficulty falling asleep because of
the pain. In ED, patient afebrile, without meningeal signs, no
bleed on CTH, and CSF with minimal WBC count (possibly accounted
for by RBC ___ traumatic tap), normal protein and glucose. CBC
without leukocytosis. Neuro exam completely non-focal. Current
symptoms seemed most consistent with patient's usual chronic
headache vs. headache ___ viral syndrome vs. rebound headache
from analgesic use. Bacterial meningitis was unlikely given lack
of white cells in CSF. Headaches could still be result of viral
meningitis, though still would expect a larger presence of white
cells. Aseptic meningitis from NSAIDS was possible. History did
not support venous thrombosis given lack of family or personal
history of clot, no OCP use, and no history of smoking.
Positional exacerbation of symptoms could be consistent with
ICP, possibly idiopathic intracranial hypertension given
obesity/overweight, but no concurrent use of tetracyclines,
vitamin A, or OCPs, and no visual symptoms. Unfortunately,
opening pressure of LP not recorded by ED. By the time the
patient reached the floor, her headache was a ___. She was
given some fiorcet for pain relief and offered ondansetron for
nausea. On hospital day #2, the headache had completely
resolved. The patient was encouraged to seek follow-up with her
PCP and request ___ referral to the ___ Headache Center. Final
CSF cultures are negative.
.
TRANSITIONAL ISSUES
#Patient sexually active, and given vague viral symptoms (sore
throat, myalgias, fever, headache), acute HIV syndrome could not
be ruled-out. Patient should obtain HIV testing as an outpatient
in ___ weeks.
#Patient should consider further evaluation of chronic headaches
as a component of her symptoms might be rebound headaches in the
setting of frequent analgesic use. | 175 | 361 |
12020379-DS-17 | 25,044,056 | You were treated at ___ for a
left long/middle finger infection and then developed a right
lung pneumonia according to a chest xray.
. | The patient was initially evaluated at ___ where
blood cx were obtained and he was given IV Unasyn. An xray of
the hand was negative for foreign
bodies and the pt was transferred to ___ for further
evaluation. The patient was admitted to the plastic surgery
service on ___ with a diagnosis of Suppurative tenosynovitis
of flexor sheath, left long finger. Patient was taken to the
operating room and underwent Incision and drainage, flexor
sheath, left long
finger, where immediate expression of pus was observed. The area
was irrigated and a second incision was made at the volar
surface. Patient tolerated the procedure without difficulty and
was transferred to the PACU, then the floor in stable condition.
Please see operative report for full details. Pt was
subsequently put on Vancomycin and Unasyn. Cultures are growing
mixed flora but predominantly with S. aureus. A blood cx from
the OSH is noted to be positive for a Streptococcus spp per
report.
Infectious disease was consulted to assist in determining the
antibiotic regimen necessary and appropriate to treat his
infection. A TTE was also done to r/o endocarditis and was
found to be negative. They recommended treatment for the
flexor tenosynovitis, bacteremia as well as a newly diagnosed
RUL pneumonia. He was sent home on a 2 week regimen of
nafcillin as well as a 5 day course of levaqin to treat the
pneumonia.
Neuro: The patient received po dilaudid with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on ___, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. All questions were answered, and patient has
appropriate follow-up care. | 23 | 369 |
13625109-DS-17 | 24,622,331 | Dear Mr. ___,
You were admitted to ___ with a small amount of blood in the
area of your prior stroke. Your neurologic exam was improved
from when you were last admitted. Your lovenox was held for 1
day and then restarted. In consultation with your cardiologist
and your oncologist, you will start on apixaban instead of
lovenox. You will start this medication tonight. You will
follow-up with your oncologist, cardiologist and stroke
neurologists as an outpatient.
Please follow up with your oncologist regarding the findings on
your Chest CT that was done during this admission.
It was a pleasure taking care of you,
Your ___ Neurologists | Mr. ___ was admitted to the neurology service on ___ as
a transfer from an outside hospital ED for intraparenchymal
hemorrhage as noted in the HPI. Lovenox was held initially.
#NEUROLOGY
Neurologically, his exam was noted to be unchanged from prior
admission and remained stable. NCHCT was repeated and showed no
changes, with known small SAH with small SDH extension. Given
that hemorrhage was unchanged from prior, and he is at high risk
for stroke ___ afib and/or hypercoagulability due to pancreatic
cancer, lovenox was restarted. Repeat NCHCT 1 day later showed
no changes in the size of hemorrhage. Upon speaking with the
family, there had been plan of switching from lovenox to
apixaban as outpatient, given high cost of lovenox. We discussed
that there is no evidence for apixaban to treat
hypercoagulability from pancreatic cancer, but given likely poor
compliance with lovenox (patient resistant to two injections per
day) in addition to high cost, after conversation with PCP and
cardiologist, Mr. ___ was switched to apixaban 5mg BID (no
need for renal dosing given normal renal function on discharge
see below but surveillance of renal function and adjustment
accordingly is necessary).
#RENAL
His creatinine was elevated on admission to 1.6 (confirmed poor
PO intake in ___ days prior to admission), likely pre-renal and
downtrended to 1.1 upon discharge with IVF and good PO intake.
#PSYCH/SOCIAL
As in HPI, sister had sent patient in for question of suicidal
ideation. Patient was in good spirits here and denied suicidal
ideation. He was seen by social work given concern for poor
situation at home. Patient expressed that he felt safe going
home with his sister, and his sister agreed to take him home. He
was offered an alternative (rehab) but he declined.
#HEME/ONC
Patient was scheduled for a CT torso with contrast as
outpatient, which was done as inpatient on the day of discharge
per family request. Results to be followed up upon by Dr.
___ wanted these images, final read pending at time
of discharge.
#TRANSITIONAL ISSUES
[ ] CT torso results | 107 | 331 |
13674587-DS-14 | 24,810,777 | Dear Mr. ___,
You were admitted to the hospital due an incidental
pneumoperitoneum on CXR and CT scan (air into your abdominal
cavity). The reason for this finding is unkown. This usually
happens after an abdominal procedure when air enter the
abdominal cavity during the procedure or if you have a bowel
perforation.
Therefore it was reasonable to admit your to the hospital for
observation despite the fact that you are asymptomatic (without
any symptoms).
You were closely monitored daily with labs and vitais signs. As
you continue to be stable we felt you could be discharge home
with close follow up with your PCP. There was no signs of bowel
perforation on your CT image, your clinical presentation is
stable therefore no surgical intervention was recommended.
We would like that you follow-up with your PCP/or Rheumatology
(Dr. ___ in order to revise your home medication. You
might need to decrease the amount of prednisone as this
medication can thin your bowel wall and predispose you to an air
leak inside your belly. We spoked with your Rheumatology team
yesterday about this and they would like to see you back in
clinic to revise your home medication dose. Dr. ___ who is
currently prescribing your prednisone will be better able to
acces the risk/benefits to decrease this medication.
We alwo hold off your warfarin during your hospital stay as your
INR level was higher than recommended during your first
day(3.4). At discharge your INR level was 2.5 which is within
the desired range. Please follow-up with your PCP to have the
dose readjusted if necessary.
You should have a repeated CT in the next couple of months (if
still asymptomatic) to monitor interval change. Please have your
PCP schedule this for you.
You will be discharged home with a two weeks ___ of
antibiotic. These medications can help control the bacteria that
usually grows inside your gastrointestinal tract. You do not
have evidence of an infection but we would like to make sure
that if the air is coming from the bowel, that any bacteria that
might have spilled into your belly is contained.
It was a pleasure taking care of you during this
hospitalization.
Your ___ team | ___ M on 60 mg of prednisone daily presents with incidental free
air seen on CXR. Subsequent CT scan w/ pneumoperitoneum, R colon
pneumatosis. Patient is completely asymptomatic, hemodynamically
stable, and non-tender on exam. The patient was admitted to the
Acute Care Surgery service for observation. He was started on IV
antibiotics, kept nothing by mouth, given IV fluids, and
monitored closely with serial abdominal exams.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and had no pain.
The patient was discharged home without services. The patient
was discharged with a prescription to complete a 2-week course
of antibiotics for a suspected GI source of the
pneumoperitoneum. The patient had follow-up scheduled with his
cardiologist, rheumatologiost, and in the ___ clinic. He was
instructed on danger signs to watch for when home. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 365 | 226 |
15295974-DS-15 | 29,683,758 | Dear Ms. ___,
You were admitted to ___ with headaches, fevers, chills, and
muscle aches. You underwent a spinal tap in the ED which was
quite reassuring- you do not have meningitis. We suspect that
you had a very mean viral infection that led to a migraine and
muscle spasms. We treated you effectively with medicine and you
felt better.
The following changes were made to your medications:
1. START CYCLOBENZAPRINE 10mg every 8 hours as needed for muscle
spasms
2. RESUME EXEDRINE for your migraines
You can also use ibuprofen or naproxen for neck/back pain
Please be sure to take your HAART therapy every single day due
to your elevating viral load!!
It was a pleasure taking care of you, Ms. ___ | Ms. ___ is a ___ with a history of HIV/AIDS and previous
cryptococcal meningitis here with HA, fevrs, chills, myalgias
and arthralgias that was probably due to acute viral syndrome
with superimposed migraine. | 119 | 33 |
14422685-DS-9 | 26,135,770 | Mr. ___,
You were hospitalized because of nausea, vomiting, shortness of
breath. Likely you had a viral illness of your GI tract.
However, you were diagnosed with a new diagnosis of "heart
failure" this admission. This means you have a weak heart. As
part of the evaluation of this diagnosis you underwent a
"catherization" which reveal a lot of heart disease. In order to
fix this, you need heart surgery.
Please DO NOT take your Plavix from now on. You aspirin dose has
been changed to 81mg from 325mg
You are scheduled for heart surgery (called a "CABG") on ___.
Stop your metformin on ___.
Stop your lisinopril on ___.
Please weight yourself every day, and call the cardiology office
in order to see if you need a diuretic (a medication to remove
the extra fluid). If you feel short of breath or notice leg
swelling you should also call.
Please follow the directions in the book the surgeons gave you
before the surgery.
It was a pleasure taking care of you at ___,
We wish you well
Your Team at ___ | Mr. ___ is a ___ year old man with a PMHx significant for
severe vascular diseae & hypertension presented with 4 days of
___ and epigastric pain, inability to tolerate PO.
# Acute systolic heart failure. New diagnosis. Fluid
resuscitated in ED with 1L NS and this caused acute onset of
shortness of breath and pulmonary edema. CXR showed pulmonary
vascular congestion, and BNP obtained was 7k. Admitted to heart
failure service for new diagnosis of CHF. Echo on admission
showed EF of 30% to 35%. Initially diuresed well with boluses of
20 IV Lasix, maintained euvolemia without maintenance diuretic.
Work up revealed 3vessel coronary artery disease. Cardiac
surgery evaluated and recommended CABG. Vascular surgery
approved discontinuation of Plavix given recent stent.
# ___ ABDOMINAL PAIN: History of renal infarct that presented
similarly in ___. CT abdomen/pelvis unrevealing for etiology
of abdominal pain. Etiology thought to be likely viral
gastroenteritis. Improved considerably and was taking full POs
by the time of discharge.
# Proteinuria: patient has urine Pr/Cr ratio 5.4. Renal
consulted and recommended etiology was likely diabetic
nephropathy. Bp med changes included uptitration of ACE. No
renal biopsy required.
CHRONIC ISSUES
# DIABTES MELLITUS: Hb A1c 8.6%.
# PERIPHERAL ARTERIAL DISEASE: maintained on home dose Asa 325.
Plavix stopped ahead of CABG.
TRANSITIONAL ISSUES
-------------------
WEIGHT ON ADMISSION : 71.6 kgs
WEIGHT ON DISCHARGE: 70.9 kg
DISCHARGE CR:0.8
# 3 VESSEL CORONARY ARTERY DISEASE: Patient scheduled for
outpatient CABG on ___. Stop metformin on ___. Stop lisinopril
on ___.
# NEW DIAGNOSIS OF HEART FAILURE: Likely ischemic in nature,
full evaluation otherwise negative. Patient NOT started on
maintenance diuretic. Discharged with ACEi, carvedilol, ASA,
high dose statin
# MED CHANGES:
Aspirin decreased from 325 to 81
Lisinopril increased to 40mg daily
Clopidogrel discontinued
Hydrochlorthiazide discontinued
Labetolol discontinued
# Consider Hep A/B vaccination | 177 | 312 |
11130122-DS-7 | 28,567,008 | Dear Mr. ___,
You are leaving the hospital against medical advice.
Why was I here?
-You had chest pain
What was done for me while I was here?
-You had a cardiac perfusion study that showed you have poor
flow through one of your coronary arteries
-We started you on medications to lower your risk of having a
heart attack
-We recommended that you have a Cardiac catheterization done on
___. You left before this procedure was done.
What should I do when I go home?
-Take your medications as prescribed.
-Make appointments to see your primary care provider and ___
cardiologist when you leave.
We wish you the best in the future.
Sincerely,
Your ___ Care Team | Patient is leaving against medical advice. Risks of leaving the
hospital prematurely, including severe disability and death,
were discussed with the patient.
Mr. ___ is a ___ year old man with history of asthma,
depression/anxiety, active tobacco smoking who presents with
acute onset chest pain with exertion.
=============
ACTIVE ISSUES
=============
# Unstable angina:
Patient presents with new onset left-sided chest pain occurring
with exertion. Presentation is concerning for evolving coronary
artery disease, unstable angina given new onset chest pain. CAD
risk factors: active tobacco smoking with longstanding history,
hypertension. ECG notable for RBBB, inferior TWIs, and
anterolateral STDs (all new since prior tracing ___. Troponins
NEG x3. Exercise stress was transitioned to pharmacologic
stress, perfusion study shows a mild perfusion defect involving
the LAD territory.
-not taking medications at home
-started on:
heparin gtt (d/c'd ___
aspirin 81 mg PO daily
atorvastatin 80 mg PO daily
metoprolol succinate XL 50 mg PO qHS
-plan was for TTE, cardiac catheterization but patient not
willing to stay over the weekend and therefore leaving AMA
# Microscopic hematuria:
Patient has a reported history of lithotripsy. Patient should
have subsequent urine studies with possible CTU/urine
cytology/cystoscopy as an outpatient given his significant
history of smoking.
# Elevated blood pressure:
Currently normotensive, though with report of elevated BP at
urgent care.
- Consider initiation of ACE-I if persistently hypertensive
===================
TRANSITIONAL ISSUES
===================
[] continue aspirin 81 mg PO daily
[] continue atorvastatin 80 mg PO qPM
[] continue metoprolol succinate XL 50 mg PO daily
[] monitor BP as an outpatient, if persistently hypertensive,
consider starting ACEi
[] consider TTE-- recommended while inpatient, however patient
left AMA before this could be done.
[] consider cardiac catheterization-- recommended while
inpatient, however patient left AMA before this could be done.
[] consider HgbA1c, lipid panel to assess for additional cardiac
risk factors
[] repeat urine studies. Consider CTU/urine cytology/cystoscopy
if persistent microhematuria given smoking history | 110 | 299 |
10419066-DS-4 | 23,312,315 | You were admitted with abdominal pain, nausea, vomiting and
abnormal liver function tests. You underwent imaging of the
biliary tree with MRCP that shows possible blockage at the
distal common bile duct. You have been evaluated by the ERCP
and have been advanced a diet without any recurrent symptoms.
The liver function tests are rapidly improving and the ERCP/GI
team will be reviewing all your information at the
multidisciplinary conference tomorrow evening. They will be
contacting you in the following days to help coordinate a follow
up procedure to further evaluate this finding.
You should continue on a low fat diet and monitor for any
recurrent symptoms of abdominal pain, nausea, vomiting or
fevers. Please returns for urgent evaluation if these occur.
We have been holding your Lisinopril due to mild dehydration on
admission. Please do not restart it until you are seen by your
primary care physician.
Best wishes from your team at ___ | ___ y/o F with PMHx of chronic Hep B, H pylori s/p treatment and
s/p laparoscopic CCY in ___ who presents with abdominal pain
with N/V, dilated biliary tree on imaging and
elevated/obstructive LFTs. MRCP shows change in caliber of
distal CBD though no obvious stones. Symptoms and lab
abnormalities resolved without intervention and pt has close
follow up planned with ERCP team for procedure. | 164 | 68 |
18606928-DS-19 | 21,838,827 | Mr. ___,
You were admitted to the ___ Department of Colorectal Surgery
for a small bowel obstruction. You received a nasogastric tube,
which allowed your intestines to decompress, until your bowel
function returned. Once your bowel function returned, your tube
was removed. You were then progressed from sips to clear liquids
to a regular diet at the time of discharge. Now that you are
tolerating oral medication and food, you may now return home for
the remainder of your recovery. Please pay close attention to
your discharge instructions.
*Medications*
Please continue to take all medications as prescribed.
*Diet*
You may continue to eat a regular diet as tolerated.
*Abdominal Pain/Danger Signs*
If you notice any return of abdominal pain combined with nausea
and vomiting or any of the "Danger Signs" listed below, please
discontinue eating food and call your physician or go to your
nearest emergency department for prompt evaluation.
Good luck with the remainder of your recovery. We wish you the
best. | Patient was admitted to ___ Department of Surgery from the
Emergency Department. His brief hospital course is as listed.
Neuro: Patient's mental status was monitored regularly per floor
protocol. He received IV acetaminophen for pain relief. Once
tolerating oral foods and medication, he was transitioned to
oral acetaminophen.
Cardio: Patient's heart rate and blood pressures were monitored
routinely per floor protocol. He continued his home lisinopril,
amlodipine, and HCTZ. No acute issues were addressed during this
hospitalization.
Pulmonary: Patient's respiratory rate and oxygen saturation were
monitored regularly during his hospitalization. No acute issues
were addressed during this hospitalization.
GI/FEN/GU: Given patient's suspected SBO, patient received a NGT
in the ED. He was given IV fluids for hydration. Patient's
electrolytes were monitored routinely and repleted as
appropriate. Once patient had return of bowel function and his
NGT output decreased, his NGT was removed. Patient was started
on regular diet without incident prior to discharge home. His
urinary output was monitored to ensure adequate peripheral
perfusion. Patient continued his home mesalamine and
pantoprazole.
Heme: Patient's hematocrit was monitored to rule out concern for
bleeding. He continued his home aspirin.
ID: Patient's fever curve and WBC count was trended. Patient was
afebrile throughout hospitalization. Patient was given IV flagyl
and cipro until he could tolerate oral medications. He was
discharged home to continue a 7 day course of antibiotics.
PPX: Patient was given subcutaneous heparin for DVT prophylaxis.
Once patient was tolerating oral medication and nutrition, he
was discharged home with appropriate prescriptions. He will
return to service on ___ for surgery. | 155 | 252 |
13098632-DS-15 | 28,928,507 | Dear ___
___ were admitted after a fall that caused ___ to have left leg
pain and inability to walk because of the pain. Imaging of your
head / left hip / pelvis did not show any acute injury from your
recent fall. We gave ___ tylenol to control your pain, and ___
worked with ___ to improve your ambulation, which ___ did.
.
It is very important that ___ try to drink more water by mouth,
because ___ were lightheaded when ___ came to the hospital
because ___ were not drinking enough water.
.
___ also are having pain from your shingles on your left leg.
___ can take tylenol for this pain. | Assessment and Plan:
___ with PMH DM, afib on coumadin, CKD presents after poor PO
intake and sustaining fall at ___ with subsequent hip pain s/p
negative CT head / neck / pelvis but failed to ambulate safely
so admitted for placement.
# Hypovolemia: Pt presented orthostatic and was bolused one time
each day of admission. Pt's wife reports that he is no longer
drinking fluids, only drinking tea. "He dislikes the taste of
water". Furosemide was held during hospitalization and will be
held on discharge due to poor PO intake and admission with
orthostasis.
# Left leg weakness / pain: Pt presented with profound left leg
weakness, and while he never c/o pain, he actually would jolt
upright when his left hip was externally rotated. He was given
standing PO tylenol, and encouraged to work daily with ___,
during which he improved on his weight bearing and ambulation.
Initially team considered obtained MRI left hip to assess for
muscle transection or nerve damage from fall, however, since pt
was spontaneously improving with ___, determined that pt was
actually not weak but limited by pain.
no e/o of left pelvis fx, no paresthesias or pain currently,
weak mostly in hip adn knee. Weakness worse after fall. Dorsal
column neuropathy may be related to unsteadiness. currently
unsteady but able to bare weight
- check B12, CK
- ___ c/s
# Mechanical fall: Pt reports walking through a door and there
not being a step, so he fell. He denies LOC. He fell on his left
side, and extensive CT imaging of left hip / pelvis/ head / neck
are not concerning for fracture. Pt also has h/o of carotid
hypersensitivity, but based on hx this is unlikely as pt reports
losing balance after stepping through a door.
# Shingles: Pt presents with paninful lesions behind left leg
without e/o vescicles. Since the time course of shingles is
unknown, team did not feel that acyclovir or other antiviral
would change duration of lesions or alter likelihood of
postherpetic neuralgia.
# DOE: Pt initially complained of dyspnea on exertion, which was
thought to be ___ to pulm htn possibly with a component of COPD
given smoking hx. Pt was never wheezing or poorly moving air or
clinically with rales on exam. He was also never hypoxic or SOB
when working with ___.
# Afib on coumadin: CHADS 3. Pt was continued on atenolol 25mg
PO qd and was continued on warfarin 4mg PO qd.
# CKD: (baseline 1.7-1.9) Pt was given IVF for orthostasis on
admission and Cr downtrended to 1.5
# DM: not on insulin at home, but has been on humalog ISS during
hospitalizations
# Anemia: baseline hct 32. Stable
# BPH: Pt was continued on home doxazosin 4 mg tablet.
# CHF EF 54%: Held furosemide for poor PO intake, and will hold
on discharge pending clinical improvement and PO intake. Was
taking furosemide 20 mg tablet.
# B12 Def ___ gastrectomy: B12 was > ___.
# Code: Full (discussed with patient)
# Communication: Patient
# Emergency Contact: Ms. ___ ___
TRANSITION ISSUES
# consider resuming furosemide as was stopped on admission ___
orthostasis
# Pt does not c/o pain, so do not rely on his hx to tell ___ msk
pain | 109 | 531 |
19948103-DS-2 | 21,009,849 | Dear ___,
It has been a pleasure taking care of you in the hospital. You
were admitted for fevers, nausea, and vomiting. You had a workup
and were found to have EBV mono (EBV is a common virus that
causes mono) and the flu. You were treated with intravenous
fluids and anti-emetics. You had hepatitis which means
inflammation of the liver from the virus. You were seen by
infectious disease doctors and ___ team as well. You
continued to improve. It is important you not play contact
sports for 3 months so you dont get a splenic rupture because
you have an enlarged spleen from the mono. You were also started
on tamiflu for the flu. | ___ yo M w/ no significant PMH who presents with fevers, n/v,
splenomegaly, transaminitis, elev direct bili and is EBV IgM pos
and influenza A positive.
#EBV Mononucleosis, Transaminitis: He initially presented with
GI symotoms (nausea and vomitting) most likely related to
hepatitis but over hosp course dev pharyngitisn exam with
enlarged tonsils. EBV IgM positive with ___, smear with
atypical lymphs. CMV Ab neg. Pt had transaminitis (AST ALT
300s), elev bili (up to 3), splenomegaly and also had low grade
DIC (slightly elevated INR and PTT) all related to EBV. Initial
concern for autoimmune hemoltic anemia in setting of low hapto
and elev LDH and elev bili (though direct higher than indirect)
and coombs and agglutinin were somewhat inconclusive and most
likely there was a low grade hemolytic anemia. EBV can cause an
autoimmune hemolytic anemia (anti-i). Ferritin in the 2000s
making HLH (EBV can cause HLH) unlikely. Heme/onc and ID
involved in his care. He was given zofran, IVF as supportive
measures. He was told to avoid contact sports bc of splenomegaly
and risk of splenic rupture.
#Influenza A:
He was started on tamiflu day ___ w/ plan to treat for 5 d
#Coagulopathy, Diseminated Intravascular Coagulation, Hemolysis:
slightly elev INR and PTT but stable, this was likely a low
grade DIC (elev D dimer, FDP, though fibrinogen normal) combined
w/ acute hepatitis. Hematology was consulted. He never required
transfusions | 115 | 234 |
15400120-DS-7 | 21,381,787 | Dear Ms. ___,
You were admitted to ___ with difficulty writing and concern
for stroke. You had a CT and MRI which did not show any stroke
but your story is concerning for a possible transient ischemic
attack or TIA. You were started on aspirin. You had an
ultrasound of your heart which did not show any evidence of
clot. You will need a wear a heart monitor to look for evidence
of atrial fibrillation which may have caused your symptoms.
Please call ___ and ask to be transferred to the
cardiology Holter monitor lab. Then you can pick up the ___ of
Hearts monitor at the hospital. You will follow-up with Dr.
___ at the appointment scheduled below.
It was a pleasure taking care of you,
Your ___ Neurologists | Ms. ___ is a ___ y/o F with a PMHx of HLD, depression, and
rheumatoid arthritis on Prednisone who presented to ___ ED
after sudden onset of difficulty writing and visual disturbance
which resolved after 1 hour concerning for possible TIA.
# Possible TIA: Ms. ___ reported symptoms that her hand
wasn't doing what she wanted it to do but no focal weakness or
difficulty with anything else besides writing a check. She also
had difficulty remembering the details surrounding the event.
Given these symptoms and the pecuiliar story, she was worked up
for a possible TIA. Stroke risk factors include: HbA1c 6.5 and
cholesterol panel as follows: HDL 67, LDL 91 and triglycerides
132. She had CTA and MRI which showed patent vasculature and no
evidence of stroke. She was started on aspirin 81mg. She had a
TTE which did now show any thrombus. Tele showed NSR. She was
discharged with plans to record her heart rhythm with ___ of
Hearts monitor. It is not clear that this episode was a TIA but
given her risk factors and possible prior TIA in the past, she
should continue on aspirin and be followed closely for further
symptoms.
# Memory impairment: The only finding on exam was poor recall,
specifically poor retrieval. She was able to register and store
3 objects. Vitamin B12 and folate were sent but were pending on
discharge. TSH was normal. She will need ongoing neurology
follow-up for this issue.
# Depression: Patient was continuted on Escitalopram Oxalate 20
mg PO/NG DAILY
# Hyperlipidemia: Patient was continued on Atorvastatin 10 mg
PO/NG QPM
# Rheumatoid arthritis: Patient was continued on PredniSONE 15
mg PO/NG DAILY
Transitional issues:
- endorsed memory problems and had difficulty with memory
retrival on exam, not storage. Will need ongoing work-up
- f/u ___ of hearts data
- f/u vitamin b12, folate levels
- will need diabetes treatment: HbA1c 6.5
- repeat UA, had trace protein and 3 rbcs
- f/u final read of mRI
- may need thyroid ultrasound, had bilateral thyroid nodules on
CTA (TSH 0.67)
- HCP: ___ (partner) ___
- Code: presumed FULL | 130 | 349 |
19019550-DS-2 | 23,183,035 | You were admitted for episodes of unresponsiveness. You
underwent an extensive neurologic, autonomic and cardiologic
workup. Your MRI of the brain was normal. Your EEG was normal
during the events, so seizures are very unlikely. Cardiology
diagnosed you with inappropriate sinus tachycardia syndrome, and
treated you with nadolol (a beta blocker) which helped your
heart rate stay under control. You should be able to return to
your regular activities, but increase your level of exertion
slowly and stop if you experience symptoms of racing heart,
palpitations, or any other abnormal symptoms. | NEURO:
Ms. ___ was admitted to Neurology Service after having an
event of unresponsiveness during tilt table testing that was
concerning for seizure. She monitored on continuous video EEG
for 48 hours. Several of her medications (amitriptyline,
florinef, mestinon, metoprolol) were stopped in order to better
evaluate her baseline function and capture events. She did have
3 typical events in the first 24 hours of admission. These
occurred while on the commode, and began with the usual
tachycardia and palpitations, followed by rising tingling
sensation up the neck and shortness of breath, slowly losing the
ability voice though at first able to understand, then no longer
able to speak or understand, and finally LOC. She would remain
unresponsive to sternal rub or nailbed pressure, despite normal
blood pressure, after she had been laid supine, and this would
persist for 5 minutes. After this she would awaken and appear
back to baseline, no post-ictal period. EEG was normal during
all of these events. However, EKG leads of the EEG did capture
intermittently elevated heart rate to 140-160s alternating with
normal rate during the episodes.
Autonomics was consulted in order to rule out primary
dysautonomia. The autonomics testing done just prior to
admission had revealed only inappropriate tachycardia, with no
other evidence of systemic primary dysautonomia and stable BP
during her testing and event. THe autonomics team recommded MRI
brain with thin cuts through brainstem, this showed
They also recommended urine catecholamines and 5-HIAA which were
pending at the time of discharge. She will follow up with
autonomics division in 2 weeks.
She does not need to restart mestinon/florinef/etc, because she
does not have orthostatic hypotension (only tachycardia).
Topamax was also stopped because of concern for worsening her
symptoms, and also it was ineffective for migraine prophylaxis
for her. SHe was started on nadolol as recommended by cardiology
(see below) and we will also try this for migraine ppx. | 91 | 316 |
13777829-DS-17 | 21,064,064 | Dear Ms. ___:
You were admitted to ___ for shortness of breath. We found
that the fluid in your right lung had built up again. You were
seen by the Interventional Pulmonology team, who did a procedure
to drain the fluid. You had some episodes of confusion while
you were here, so you were seen by the neurology team, who
thought these might be due to seizures and started you on a new
medicine to prevent seizures.
If you feel short of breath again, you should go to the
emergency room.
Here is the dosing schedule for this new seizure medicine,
lamotrigine:
___: 50 mg once daily
___: 50 mg twice a day
___: 50 mg in the AM, 100 mg at night
___: 100 mg twice daily
You should follow up with your neurologist about dosing after
this point.
If you have a new rash, call your doctor immediately.
It was a pleasure taking care of you!
Your ___ Team | In brief this is a ___ yr old female who has a hx of Afib on
Apixaban, hypertension, recent admission for fall w/ traumatic
SDH & SAH, recent admission for a ___ complicated by rib
fractures and right sided hemorrhagic pleural effusion, now
presenting with SOB and found to have recurrent right pleural
effusion. | 153 | 54 |
11267787-DS-19 | 24,850,604 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You had an infection of your toe bone.
WHAT HAPPENED IN THE HOSPITAL?
Your toe was removed. You received antibiotics for the infection
in your toe.
WHAT SHOULD YOU DO AT HOME?
-Please take your three antibiotics as prescribed for an
additional five weeks
--Vancomycin twice daily through your PICC line
--Ciprofloxacin twice daily by mouth
--Metronidazole three times daily by mouth
-Please follow-up with OPAT weekly
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | ___ female with history of DM2, remote DVT/PE, on
lifetime AC, admitted for subacute cellulitis/osteomyelitis of
right third toe s/p uncomplicated amputation. | 90 | 22 |
19974576-DS-13 | 24,449,283 | Dear Ms ___,
**WHY DID YOU COME TO THE HOSPITAL?**
-You came to the hospital with belly pain
**WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?**
-We took a picture of your belly (CT scan) and it showed that
you have a small blockage in your bowels and growing size of
your cancer
-We placed a tube through your nose in your belly to help with
your bloating, nausea and pain
**WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?**
-You will be going home with hospice care. You and your family
will receive help from nurses.
-___ have an appointment with your oncologist at ___ on
___ (see below for more details).
It was a pleasure taking care of you.
Your ___ Team | ___ with metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary not currently receiving treatment
who presented with abdominal pain, abdominal distension, emesis
found to have partial small bowel obstruction.
Patient had CT scan upon admission that showed increased primary
and metastatic tumor burden as well as a partial bowel
obstruction. Surgery was consulted and recommended no surgical
intervention. NGT was placed to intermittent suction with
minimal output. NGT placed to gravity and pt had nausea and
abdominal pain. NGT was then placed back on to suction with
relief of symptoms. NGT was to gravity prior to discharge and
patient's pain was stable.
Imaging noteable for worsening of patient's malignancy. Pt has
been out of the country (___) for nearly a year and has
received some medical treatment there (antibiotics per her
family). Patient reported that she would not want chemotherapy
or surgery. Palliative care was consulted and met with the
patient. After an extensive goals of care discussion, pt was
made DNR/DNI and is going home with hospice services.
**TRANSITIONAL ISSUES**
-Patient was discharged with "Hospice comfort kit contents"-
acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl
10 mg suppository, haloperidol 5 mg/1 ml oral solution,
lorazepam 5 mg/1ml oral solution, senna-s
-Also wrote script for fentanyl patch if needed
-Please maintain patient's comfort
-MOLST form was signed on ___. DNR/DNI, do not hospitalize | 114 | 218 |
17652541-DS-19 | 26,094,721 | Ms. ___, it was a pleasure caring for ___ at ___
___. ___ were seen here for a fall that ___ had at your
nursing home. In the ER, x-rays showed a compression fracture of
one of your spine bones called T12. ___ were fitted for a brace
to help with back pain. It is recommended that ___ wear this
until ___ see orthopedics in clinic in 2 weeks.
We wish ___ well! | ASSESSMENT AND PLAN: Ms. ___ is an ___ year old woman with
mixed vascular-Alzheimer's dementia, chronic hepatitis C, and
osteoporosis who presents today from her locked dementia unit
for an unwitnessed fall and was found to have T12 compression
fracture and minor leg laceration.
#) FALL: Although unwitnessed, suspect mechanical fall given
vision difficulties and history of distal sensory
polyneuropathy. Lower suspicion for cardiac etiology. Her ECG
showed no ischemic changes. Urinalysis and toxicology screen
were unimpressive. She needs supervision when out of bed. She
sustained a minor left tibial laceration that required sutures.
These will either fall out spontaneously or can be removed in 1
week, whichever is sooner.
#) T12 COMPRESSION FRACTURE: Unclear chronicity. Radiology
thought "acute" but patient's daughter reports she has an old
vertebral compression fracture (films from ___
___ in ___. Per Spine surgery, activity is as
tolerated since this is not an unstable fracture. She was fitted
for ___ brace and should wear this when out of bed if
tolerated. She needs to follow up in clinic with Dr. ___ in 2
weeks.
#) OSTEOPOROSIS: Patient has a history of osteoporosis and
hypovitaminosis D. She She is not on a bisphosphonate. Unclear
of last DEXA. Consider starting calcium and vitamin D. Consider
discontinuing PPI if possible since it impairs both vitamin D
and calcium absorption (Am J Med. ___.
#) ALZHEIMER'S & VASCULAR DEMENTIA: Continued memantine and
galantamine.
#) CHRONIC HEPATITIS C: Has chronically elevated transaminases.
Untreated. No history of cirrhosis or evidence of synthetic
dysfunction by coagulation studies.
TRANSITIONAL ISSUES
-------------------
[]Sutures may be removed from left tibial laceration in ___
days
[]2mm left upper lobe nodule discovered incidentally on trauma
CT T-spine. There was no specific follow up recommended for this
nodule. | 73 | 287 |
10095139-DS-10 | 25,266,690 | You were admitted to the Acute Care Surgery service with
abdominal pain, and were found to have a partial small bowel
obstruction. You were treated with bowel rest and pain
medications, and are now ready to return to home. Please follow
the instructions below:
-You are being given a prescription for narcotic pain
medication. Do not drive or drink alcohol if taking narcotic
pain medication.
-No strenuous exercise or heavy lifting for at least two weeks.
-Resume all of your home medications unless advised otherwise.
-If you do not already have an appointment scheduled, call the
APS office at ___ to make an appointment in ___ days.
-Call the ___ clinic if you have any questions.
-Call the ___ clinic or go to the nearest emergency room if you
have fevers > ___ F, abdominal pain, or for anything else that
is troubling you. | The patient was admitted to the Acute Care Surgery Service on
___ with a partial small bowel obstruction. The patient was
transferred to the hospital floor for further care. The hospital
course was uneventful and the patient was discharged to home. | 141 | 43 |
13986211-DS-3 | 24,562,790 | You were admitted with inflammation in your pancreas
(pancreatitis) and significant liver injury. You were diagnosed
with cirrhosis of the liver. You had an ERCP to look at the
bile ducts and had some bleeding from this. You were also
diagnosed with a pneumonia and will need to complete a course of
antibiotics.
It is very important that you avoid any future alcohol. Please
follow up with your PCP as scheduled. We recommend referral to
a GI doctor to monitor your liver and pancreas and to consider
removal of the gallbladder. IF you wish to see Dr. ___ at
___, please call the number below.
You will need to return for another ERCP in 4 weeks. | ___ history of TBI complicated by seizure disorder, psoriatic
arthritis on humira, active EtOH abuse, history of EtOH
pancreatitis and T2DM who has alcoholic hepatitis on suspected
alcoholic cirrhosis and necrotizing pancreatitis(alcohol vs
gallstone). Course complicated by ERCP with post sphincterotomy
bleed requiring metal stent and ___ embolization.
# Acute blood loss Anemia
# UGIB - post-sphincterotomy bleed, s/p GDA embolization on ___,
stabilized
# Acute Necrotizing pancreatitis - initially thought to be
gallstone pancreatitis for which he underwent ERCP with
sphincterotomy on ___, but now appears to be most likely
alcoholic pancreatitis. He is clinically improved and tolerating
diet with supportive care
-- outpatient ERCP/ACS followup, repeat ERCP in 4 weeks
-- He can follow up with GI closer to home post PCP follow up
# Decompensated alcoholic cirrhosis - new diagnosis, hepatology
following, appreciate recs. After initial concern about EtOH
hepatitis and rising ___ score he stabilized without need
for steroids.
--monitored nutrition, advanced diet to high-protein low-fat
diet per liver recs may need NGT if not meeting caloric targets,
but appears to be doing so now
--For his cirrhosis he needs outpatient follow up. For
pancreatitis ? CCY although alcohol favored over gallstone
pancreatitis.
#Sinus tachycardia #Fever #Hypoxia #Multifocal Pneumonia -
Initially now concern for infection though given concurrent
hypoxia and low grade fever, CTA chest performed showing PNA, no
PE. Placed on Vanco/CTX, narrowed to ceftriaxone and he will be
discharged on a 3d course of levofloxacin.
#ETOH abuse/withdrawal
Long history of ETOH abuse and recent admission for withdrawal
with possible withdrawal seizure treated with CIWA protocol. s/p
phenobarb loading and rescue dose in the ED.
- completed phenobarb protocol/taper | 122 | 266 |
15422889-DS-2 | 20,397,507 | You were transferred from another hospital for further
evaluation of colon mass with suspicion for possible liver
metastasis. You had a colonoscopy that also confirmed suspicion
for colon cancer, however the biopsy is PENDING at the time of
discharge. You will need evaluation by a surgeon, which your
family has arranged at ___. In addition, you will need
to follow up with an oncologist. Your family has suggested
following up at ___ after biospy results. Please be sure to see
your PCP and these specialists to help in determining the next
steps in your care. You may need a biopsy of the liver lesions
as well.
Your symptoms improved during admission and you were able to
tolerate a regular diet. | This is a ___ yo M with a PMHx colonic polyps s/p multiple
removals all of which were benign in the past per report,
gastric overgrowth c/b UGI ulcer s/p ___ year of antibiotics who
p/w 1 week of abdominal pain progressive to bloody stools with a
CT scan from OSH that showed a narrowing in the ascending colon
with cecal dilation and mild stranding without free air on CXR,
normal lactate.
.
# Ascending colonic adenocarcinoma with Hematochezia. Etiology
suspected was colonic adenocarcinoma given radiographic
appearance. Other considerations could include lymphoma vs.
adenoma. Colonscopy was performed on ___ confirming
suspicion of colonic adenocarcinoma. Biopsy was taken during
admission and returned POSITIVE for adenocarcinoma just after pt
discharge. Pt's laboratories remained normal and his diet was
successfully advanced without complication. Pt reported normal
BM prior to ___. There was no evidence of any GI bleeding during
admission. CT scan at ___ raised concern for hepatic metastasis.
See below. Pt and family wished to undergo colorectal surgical
evaluation at ___. Pt's family arranged for this
appointment which reportedly occurred ___ at 2Pm. In
addition, pt's family wished to investigate which oncologist to
follow up with, preferring to f/u at ___. Pt and family
were provided with contact information to set up an appointment
at ___ or ___ if desired.
SOcial work was consulted during admission.
-Attempting to call pt's 2 listed telephone numbers after
discharge to relay the pathology results. Left message for the
patient to return my call. In addition, called over to PCP's
office but the office was closed for the day.
.
# hypodensities in liver-per family report this had been noticed
in the past. This was noted on OSH CT imaging. Liver function,
per laboratory testing appeared intact. DDx includes cysts vs.
metastasis. Pt may require a liver biopsy in the outpatient
setting to confirm metastatic disease. Pt wished to follow up at
___ and ___. Pt will f/u with PCP for ongoing care as well.
CEA was elevated. AFP WNL.
.
# HTN-continued ACEI
.
# HLD-continued statin
. | 120 | 333 |
16007214-DS-44 | 21,522,348 | Dear Mr. ___,
You were admitted to ___ for chest pain. You were having
intermittent chest pain for many weeks, but the pain was worse
in the 2 days prior to your admission. You were also having leg
pain from your prior accident. You were worked up for acute
myocardial infarction or other cardiovascular events, and EKG,
cardiac enzymes, and continuous monitoring all failed to show
any evidence of a cardiac etiology of your chest pain. Your
discomfort is most likely due to musculoskeletal pain, which you
have also had in the past.
Please continue your home medications; no new medications were
prescribed for you. Please follow up with your primary care
physician, ___ as instructed below, for further management
of your leg and chest pain.
Please continue to weigh yourself every morning, and call your
doctor if your weight goes up more than 3 lbs. | Mr. ___ is a ___ with CABGx3 (___), anterior MI (___),
ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off
coumadin ___ noncompliance), chronic chest and R leg pain, and
multiple prior ED visits and admissions for syncope and/or chest
pain, now presenting with chest pain. | 143 | 48 |
14593900-DS-10 | 28,474,798 | Dear Mr. ___,
You were hospitalized due to symptoms of right hand and face
numbness and 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.
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:
- atrial fibrillation
- high cholesterol
- high blood pressure
We are changing your medications as follows:
- start lovenox injections and take until your INR is ___
- HOLD aspirin while taking lovenox (you can restart this once
you stop lovenox)
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
Please get your INR checked in 2 days, ___. | ___ w/ Afib, CAD s/p 4x CABG, HLD, HTN, and previous stroke in
___ and TIA in ___ who presented with 10 minutes of right face
and arm numbness and weakness, found to have a small ischemic
stroke. He was just restarted on Coumadin 2 days ago and his INR
was subtherapeutic. He will be bridged with lovenox until his
INR is ___. While taking lovenox, his aspirin is being held, but
can be restarted once the lovenox is stopped. | 189 | 81 |
10213765-DS-4 | 28,522,861 | You were admitted to ___ after falling 30 feet through a
skylight. You sustained multiple injuries, including a liver
laceration, pelvic fracture, and rib fracture. You were taken to
the operating room and had your pelvis fixed by the Orthopedic
team. You have worked with Physical Therapy and Occupational
Therapy, and you are cleared for discharge home to continue your
recovery. Please note the following discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Rib Fractures:
* Your injury caused one rib fracture which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment. | The patient is a healthy ___ male who by report fell 30
feet through a sky light with GCS 15. He was brought to the
emergency department by med flight was concern for pelvic or hip
fracture. He complains of abdominal pain. Fast exam is negative.
CT demonstrates pneumothorax and right 7th rib fracture, lung
contusions. Imaging also reveal the patient has a left
compression pelvic fracture, and Orthopedic Surgery was
consulted. The patient was currently stable with a patent
airway and pain well controlled. Head CT and cervical spine CT
negative. CT abdomen demonstrates grade 2 liver laceration and
small splenic injury. Patient was admitted to ___ for further
management of injuries and serial hematocrits.
HD2 the patient was taken to the operating room with Orthopedics
for open reduction, internal fixation anterior pelvic ring and
posterior pelvic ring injury with 7.3 mm screws. The patient
tolerated the procedure well and remained hemodynamically
stable. On POD1 the patient was transferred to the floor.
Hematocrits remained stable. Pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient worked with Physical Therapy and
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with crutches, voiding without assistance, and
pain was well controlled. He was cleared by Physical Therapy
for home with outpatient ___. The patient was discharged home
without services. The patient and his family received discharge
teaching, including lovenox teaching with the use of an
interpreter, and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He had
follow-up scheduled with the ___ clinic and with Orthopedics.
.. | 668 | 326 |
11052273-DS-24 | 26,744,273 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. As you know, you originally went to the
hospital due to shortness of breath, and you were found to have
an abnormally fast rhythm. You were started on oral medications
and then underwent a procedure to have the abnormal rhythm
fixed. Also, you were started on a blood thinner to reduce the
risk of a blood clot due to the abnormal way the heart squeezes.
In addition, you were found to have excess fluid in your system,
and you were given intravenous medication to help you urinate
out more fluid.
Please see the attached sheets for changes to your home
medication regimen. Please notify your doctor immediately if
you notice any blood in your stool, or if you have dark black or
tarry stools. Also notify your doctor if you notice any other
abnormal bleeding such as nosebleeds or blood in your urine.
Continue Lovenox at home until you are told to stop taking it.
Apply over-the-counter Lotrimin to groin for skin irritation as
necessary.
We wish you the very best in the recovery process. | ___ with PMH HTN, COPD, and DMII p/w DOE of one day's duration
found to have new diagnosis of atrial flutter with e/o pulm
edema on CXR, now s/p ablation and diuresis.
ACTIVE DIAGNOSES
# Atrial flutter: Pt has severe COPD as well as diastolic heart
failure and UTI on admission, so these may be contributors to
atrial flutter. Hyperthyroidism was ruled out with normal TSH.
TTE showed new right ventricular cavity dilation, free wall
hypokinesis and pulmonary artery hypertension which were
concerning for acute PE, but V/Q scan showed low probability of
PE.
She was initially rate controlled with diltiazem and metoprolol.
Spontaneously converted to sinus rhythm just prior to TEE, so
TEE was cancelled prior to flutter ablation ___. Metoprolol
was continued post-procedure and diltiazem was stopped.
Management of diastolic heart failure exacerbation and UTI as
described below.
Anticoagulation was initially held given patient's history of GI
bleeding, but with a CHADS score of 4 she was started on
warfarin, bridging initially with heparin IV (TTE results were
concerning for possible PE, but V/Q scan was low probability for
PE so heparin gtt was changed to a-fib protocol). Heparin gtt
was replaced by Lovenox upon discharge. Anticoagulation should
be continued for at least one month post-ablation.
# Diastolic heart failure exacerbation: LVEF >/= 65% on TTE this
admission, consistent with diastolic dysfunction. Patient was
treated with IV furosemide with good response. Weight on
discharge was 100.2kg, with no crackles on exam. She was
returned to her home dose of torsemide 5mg daily upon discharge.
Check chemistry panel ___ for monitoring s/p treatment for
diastolic heart failure exacerbation.
# UTI: s/p three-day course of ciprofloxacin for Klebsiella UTI.
# Anemia: Pt has h/o iron deficiency anemia and GI bleeding (see
below). Hct was 34.3 on admission. Hct reached a minimum of
28.8 but was 30.5 on repeat check the same afternoon. Hct was
30.4 on day of discharge. Rectal exam produced no gross blood
and no gross stool (see below).
# Right groin irritation: skin of right inguinal region had
initially erythematous patch with gray film after ablation
procedure, which improved on post-procedure day 2. There was no
hematoma or bruit. Topical nystatin or Lotrimin was recommended
as necessary.
CHRONIC DIAGNOSES
# h/o GI bleeding: She had no evidence of active bleeding,
including no bowel movements for several days. Rectal exam ___
produced no gross stool or gross blood; guaiac was difficult to
interpret in the absence of a true sample but the glove was
guaiac negative. Attempted to advance bowel regimen on day of
discharge as pt had not produced any stool for sampling and
rectal exam had produced no significant sample, but pt declined
aggressive bowel regimen. Hct was stable this hospitalization
as described above. Continued omeprazole. Outpatient
colonoscopy ___.
# HTN: continued metoprolol as above.
# DM2: held metformin in house and replaced with sliding scale
insulin. Resumed home diabetes regimen upon discharge.
# Hypercholesterolemia: continued simvastatin.
# COPD: FEV1 of 42% of predicted in ___ (most recent
spirometry), reduced DLCO on outpatient testing with evidence of
emphysematous disease, outpt spirometry also shows restrictive
features thought secondary to obesity. Continued spiriva,
albuterol. Added ipratropium while hospitalized. Goal O2 sat
upper ___ - low ___. On day of discharge, O2 saturation went
down to 87-88% with ambulation while working with ___. Pt was
asymptomatic. Further monitoring/management as outpatient is
advised.
TRANSITIONAL ISSUES
*Check INR on ___ and titrate warfarin
accordingly. Stop Lovenox once INR >2.0. Warfarin can be stopped
1 month after ablation.
*Check chemistry panel ___ for monitoring s/p treatment for
diastolic heart failure exacerbation.
*O2 saturation went down to 87-88% with ambulation while working
with ___. Pt was asymptomatic. She has h/o COPD so slight
desaturation might be reasonable in her case. Further
monitoring/management as outpatient is advised.
*Colonoscopy on ___ | 192 | 649 |
12786165-DS-20 | 27,843,338 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
NWB RLE
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
Physical Therapy:
NWB to injured extremity
Treatments Frequency:
Please perform pin care with xeroform and dry sterile gauze to
pin sites qd | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right pilon fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for application of external fixator for R pilon fracture,
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 on ___ to Dr.
___ with anticipated ORIF following. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. | 211 | 244 |
13844565-DS-8 | 23,305,291 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted to the hospital because you were feeling
short of breath and were found to have multiple blood clots in
your lungs.
What was done for me while I was in the hospital?
- In the hospital, you were given oxygen to help you breathe
more easily and were started on an intravenous blood thinner
called heparin to treat your blood clots.
- You were then transitioned to two blood thinners called
warfarin (a pill) and lovenox (an injection), which you will
continue to take after you leave the hospital. Ultimately, you
will only take warfarin to treat your blood clots, but your INR
(a lab that is checked to monitor warfarin levels in the blood)
was not in the recommended range prior to discharge, so you will
continue lovenox until your INR is in the target range (___).
Your primary care doctor ___ follow your INR levels and advise
you on how much warfarin you should take each day.
What should I do when I leave the hospital?
- Please go to your follow up appointments as scheduled (see
below for appointment information). Most of them already have a
specific date & time set. If there is no specific time
specified, and you do not hear from their office in ___ business
days, please contact the office to schedule an appointment.
- Please take 5mg of warfarin the evening of ___.
- It is VERY important that you have your labs (INR) drawn the
morning of ___. Your labwork results will be faxed to your
primary care doctor, and she will let you know how much warfarin
to take on ___ (and thereafter).
- Please monitor for new/or worsening symptoms including, but
not limited to, shortness of breath and chest pain. If you do
not feel like you are getting better or have any other concerns,
please call your doctor to discuss or return to the emergency
room.
It was a privilege caring for you, and we wish you well!
Sincerely,
Your ___ Care Team | PATIENT SUMMARY:
___ hx of obesity, provoked DVT/PE in ___ and recent T2-T4
laminectomy for spinal stenosis (___) who initially
prsented with dyspnea, found to have submassive PE, s/p heparin
gtt, then transitioned to warfarin (on ___ bridge), with
subtherapeutic INR on discharge. | 350 | 43 |
19861211-DS-22 | 22,502,881 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- fall at home
- fever
What was done for you in the hospital:
- you were treated for severe infection using IV antibiotics
- you were transfused blood products while your blood counts
were low following your latest cycle of chemotherapy
- you were given heart medications and blood thinners to treat
atrial fibrillation
- you underwent an MRI of your brain that showed evidence of
strokes, possibly due to your atrial fibrillation
- you underwent repeat CT scans of your chest and abdomen to
assess for progression of your lymphoma, these demonstrated that
your lymphoma is stable
What you should do after you leave the hospital:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your oncologist to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your oncologist to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | SUMMARY:
___ man with PMHx notable for myelodysplastic syndrome
and relapsed high-grade ___ lymphoma with Burkitt-like
features, most recently on R-EPOCH (___), as well as HFrEF
(LVEF 31%) and ischemic cardiomyopathy, and recent admission for
MSSA bacteremia now re-admitted for mechanical fall with course
complicated by neutropenic fever / sepsis, rapid a-fib, acute
in-hospital delirium, and acute cardioembolic CVAs. | 245 | 59 |
16233687-DS-21 | 24,035,807 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
====================================
- You had a bleed into your right thigh/pelvis, likely because
of being on warfarin.
- You also had a pneumonia.
- You had difficulty breathing because of a thyroid mass found
to be cancer.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
======================================
- You were initially admitted to the intensive care unit, where
you received multiple blood transfusions. Your bleeding stopped
on its own.
- You were seen by the lung (interventional pulmonary) doctors
and the ___ doctors for your ___. The tube used for the
tracheostomy was changed while you were in the hospital.
- You were also seen by the endocrinology/thyroid team, and you
had a biopsy of your thyroid/goiter.
- Unfortunately, the biopsy showed something called anaplastic
thyroid cancer.
- You were seen by our oncology (cancer) team, and they told you
and your family that this is a very aggressive disease.
- You were restarted on anticoagulation/blood thinning
medication (called heparin) because of the clots you have in
your neck and lungs. However, you started to bleed from your
trachea and previously bled into your urine as well.
- Decision was made to NOT give you blood thinners, because the
risk of bleeding currently outweighs the risk of forming new
clots.
- After many discussions with the oncology team, you will be
transferred to ___ for additional evaluation and
treatment
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
===========================================
- Continue to take medication as prescribed.
- Continue to follow up with your team of doctors.
We wish you all the best.
Warmly,
Your ___ Care Team | Ms. ___ is a ___ year old woman with hypothyroidism, goiter
since ___, sensorineural hearing loss, morbid obesity and
recent admission ___ for tracheal obstruction and right
vocal cord paralysis secondary to enlarged goiter requiring
tracheostomy, with course complicated by diagnosis of PE/RIJ
DVT/R subclavian DVT discharged on warfarin, who was admitted
___ from her LTACH with hemorrhagic shock from right
iliopsoas/thigh hematoma and HCAP. Her course has been
complicated by pericardial effusion, volume overload, various
clots and bleeding episodes, and diagnosis of anaplastic thyroid
cancer.
Her intermittent desaturation, bloody secretions and air hunger
reflect her thyroid cancer invasion into trachea. Although
radiation therapy in combination with BRAF/MEK inhibitor has not
been fully studied and patient may not be able to tolerate full
course of radiation this would appear to be best trial of
palliation.
#Anaplastic thyroid cancer
Patient has had a goiter for ___ years, and before ___ had
no
full workup per patient and daughter. She presented acutely
___ with
compressive symptoms causing tracheal compression. At that time,
biopsy showed fibrosis and was unrevealing for malignancy.
However, during this hospitalization endocrinology was formally
consulted and repeat biopsy was done; biopsy showed papillary
carcinoma that degenerated into anaplastic cancer. Oncology was
consulted and followed the patient. Radiation oncology was
consulted and said that the risks of radiation outweighed the
benefits. She was BRAF mutation positive and there was
discussion regarding palliative Tafinlar and Mekinist for which
insurance authorization is pending. Palliative care was also
involved in her care and symptom management as below. Transfer
to ___ for additional evaluation
including the role of palliative radiation.
#Acute on chronic respiratory failure secondary to tracheal
obstruction secondary to goiter s/p trach
#Anxiety
#Subjective dyspnea
#Tachypnea
Patient expresses a significant amount of anxiety over trach and
secretions, and often expresses discomfort. She was taken for
two bronchoscopies with IP during this hospitalization, which
showed mass and granulation tissue distal to the trach. Trach
was extended past this on ___, but is temporary as mass is
aggressive and will continue to grow. For symptom management
palliative care was consulted. She was started on standing
klonipin for anxiety control, with Ativan for breakthrough. She
was given duonebs, mucomyst and saline nebulizers with some
improvement in comfort. Morphine 1mg IV q8hrs was also started
for refractory air hunger.
#Hemorrhagic shock
#Right iliopsoas hematoma
#Left bicep hematoma
#Hematuria
#Bloody tracheal secretions
Patient was admitted from her rehab with hemorrhagic shock from
right iliopsoas/pelvic bleed in the setting of being discharged
on warfarin for a RIJ thrombus and PE. She required two ICU
transfers early in her hospital course, with CTAs that did not
show active extravasation or anything intervenable. Heparin gtt
and warfarin were held. She was supported with blood
transfusions, and stabilized. However, throughout her course
whenever challenged with heparin, she developed multiple
bleeding issues: hematuria, left biceps hematoma, and bloody
tracheal secretions from friable mass/granulation tissue.
Decision was made to hold anticoagulation after discussion of
risks/benefits with patient and family.
#Right IJ thrombus
#Left cephalic vein thrombus
#PE
Patient at risk for clots in the setting of malignancy and also
in the setting of compression from goiter. As above, heparin was
trialed multiple times, with bleeding each time.
#HAP
The patient had known tracheal compression s/p trach in setting
of enlarged thyroid. On admission there was also concern for
hospital acquired pneumonia, but breathing also worsened in
setting of acute bleed. She was placed on mechanical ventilation
in the ED for tachypnea, then weaned to pressure support in the
ICU, then to trach mask with appropriate oxygenation. Her CXR
was suggestive of PNA, so she was treated with Zosyn and
vancomycin. Vancomycin was discontinued with MRSA negative swab
and zosyn course completed.
#Pericardial Effusion
Likely malignant. Patient had a small pericardial effusion noted
on ___ prior to this admission. She was found to have fluid
around her pericardium on chest imaging, so TTE was obtained on
___. This showed a moderate pericardial effusion with RV
collapse, consistent with hypovolemia vs tamponade physiology.
Cardiology and cardiac surgery were consulted, who recommended a
repeat TTE. On ___, this showed interval improvement in both
the side of the effusion and lessened RV collapsed. CT surgery
and cardiology recommended no further intervention at this time.
Repeat ___ showed stable effusion.
#Toxic Metabolic Encephalopathy
The patient was supposedly unresponsive with intermittent
twitching at ___ during her entire stay since her
recent discharge ___. CT head with no evidence of intracranial
bleed or abnormality. Neurology was consulted, who recommended
an EEG, which was free from seizure activity and MRI was
considered, however was unable to be performed due to plates in
the patient's arms. Other differentials included thyroid
dysfunction, hypercarbia, electrolyte derangements, and
infection UTI vs PNA. Ultimately, she improved with Zosyn and
vancomycin, while also correcting her anemia which suggested
that her encephalopathy was likely due to infection and toxic
metabolic encephalopathy.
#Vitamin D deficiency
#Hypocalcemia
#Hypothyroidism
Concern that compression from goiter causing hypoparathyroidism
vs surgical disruption of parathyroid glands. Endocrinology
followed her during her course, and she was vitamin D loaded and
then resumed on 1000U daily. Calcium was repleted with feeds and
IV. Levothyroxine was continued at home dosing.
#severe protein calorie malnutrition
Patient had an NGT for feeding at last discharge. She had a PEG
placed during this hospitalization.
#Sinus Tachycardia
At last hospitalization ___ patient was started on
metoprolol for sinus tachycardia. However, sinus tachycardia was
likely compensatory in the setting of PE, malignancy,
respiratory discomfort and anemia. Metoprolol was weaned off.
#Goals of care
The patient experienced a lot of emotional and physical
discomfort during her hospitalization even prior to diagnosis of
anaplastic thyroid cancer. At the time of diagnosis, the
aggressiveness of this cancer was explained and patient and
daughter were very clear that they wanted to seek treatment and
be full code. | 271 | 955 |
14549065-DS-16 | 28,436,790 | Dear ___,
It was a pleasure caring for you at ___
___. You were hospitalized for difficulty breathing
due to fluid surrounding your lungs called pleural effusions.
More than a liter was drained from the right side. The tunneled
pleural catheter on the left side drained well after your
interventional pulmonologist instilled a medication to dissolve
adhesions. We treated a skin infection around the catheter
insertion site too. Please continue two antibiotics as
prescribed. See the attached medication reconciliation for
details. As you know, the effusions are due to aortic stenosis,
so we hoped to assess your candidacy for a transcatheter aortic
valve replacement (TAVR) while you were here. In the end, we
postponed the pre-TAVR coronary angiogram due to your kidney
function. The structural heart team will revisit the possibility
of a TAVR when you follow-up with them in clinic. We increased
your torsemide to 40 mg daily to slow the accumulation of fluid
until then. You previously took three 10-milligram pills. You
should take four 10-milligram pills now. If you prefer, you can
take two 10-milligram pills twice per day as discussed. This
might lessen your hand cramping. We wish you all the best.
Sincerely,
Your ___ care team | ___ female with chronic bilateral pleural effusions due
to severe aortic stenosis/moderate mitral regurgitation, has a
left-sided tunneled pleural catheter in that regard, referred
for (1) acute on chronic dyspnea on exertion and (2) recurrent
tunneled pleural catheter site cellulitis.
#Acute on chronic dyspnea on exertion due to chronic bilateral
pleural effusions. She underwent thoracentesis for interval
enlargement of the right-sided effusion. Simultaneously, the
intrapleural fibrinolytics instilled via her left-sided tunneled
pleural catheter on the morning she was referred had a delayed
effect, finally draining well here. She was more comfortable and
her ambulatory oxygen saturation was likewise high ninety-range
without supplemental oxygen requirement thereafter. A bedside
ultrasound on the day of discharge was also reassuring. Her TPC
was capped in that regard. Her studies were still consistent
with a transudate. We increased her torsemide to 40 mg daily to
slow the rate of re-accumulation but this is not a long-term
durable solution hence expedite TAVR assessment. Her weight and
NT-pro-BNP at discharge are 125 pounds and 5831, respectively.
#Severe aortic stenosis/moderate mitral regurgitation. She did
not have decompensated heart failure but her valvular disease is
decidedly the cause of her effusions. She was referred to our
structural heart team for TAVR so hoped to expedite that process
this hospitalization; however, renal insufficiency precluded an
elective pre-TAVR coronary angiogram after all. She will have a
low-contrast pre-TAVR CTA after discharge instead. Routine
ultrasound of the aorta and branches was performed. She is
robust for her age and high-risk for re-hospitalization until
the cause of her effusions is addressed so remains a reasonable
candidate for TAVR. She and her family are not opposed to it
either.
#Tunneled pleural catheter site cellulitis. The erythema
receded, and her pleural studies were not consistent with a
secondary infection of the pleural space, so converted
vancomycin to doxycycline/cephalexin. It was once purulent, and
she has been hospitalized for intravenous antibiotics in the
past, so favor both MRSA and Streptococcus spp. coverage.
CHRONIC/STABLE ISSUES
#Paroxysmal atrial fibrillation. She is in normal sinus rhythm
and rate controlled with diltiazem. There are no foreseeable
interventions so resumed warfarin for a CHA2DS2-VASc of 4.
#Stage III/IV chronic kidney disease. Attributed to hypertensive
nephropathy and renovascular disease. Her creatinine of ___ is
in keeping with her trend in the last year.
___ esophagus. Continued omeprazole.
TRANSITIONAL ISSUES
=================
[]Drain left-sided tunnel pleural catheter three times weekly
(i.e., ___.
[]Complete doxycycline/cephalexin for 10-day course of
antibiotics in total.
[]Note torsemide was increased to 40 mg daily. Weight at
discharge is 125 pounds. Adjust accordingly.
[]Repeat BMP within the next week. Consider magnesium supplement
for cramps if hypomagnesemic. Do not administer with
doxycycline.
[]Expedite outpatient TAVR assessment as planned. An appointment
was not secured prior to discharge (___).
[]INR was not yet therapeutic by discharge. Next INR is due
___. | 199 | 453 |
17791449-DS-18 | 22,840,621 | Dear Mr. ___,
It was a pleasure taking part in your care. You were admitted to
the hospital because you had an infection of the peritoneum. We
believe this is because of your peritoneal dialysis catheter.
Your peritoneal dialysis catheter was removed and you were
treated with antibiotics. Your PD catheter was replaced but the
peritoneal dialysis did not go as well as we hoped. Given that,
an HD line was placed and you were started on hemodialysis,
which you tolerated well. You are being discharged on
hemodialysis but we have left your PD catheter in place as you
may be able to resume this after discharge.
The following changes were made to your medications:
1. Start vancomycin with hemodialysis for at least ___ weeks.
The final course will be determined by your outpatient
providers. STOP the intraperitoneal vancomycin.
2. Start dulcolax per rectum as needed for constipation
3. Stop oral iron and start IV iron with hemodialysis
4. Stop taking calciferol
5. Start taking acetaminophen 650mg by mouth every 6 hours as
needed for pain.
6. Start taking oxycodone ___ by mouth every 8 hours as
needed for pain.
Please keep your follow-up appointments. | PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ with a history of ESRD on Peritoneal
Dialysis since ___ who presented as a direct admission from
___ for a recurrent episode of
bacterial peritonitis. | 199 | 35 |
14119974-DS-17 | 21,570,683 | Dear Mr. ___,
Thank you for letting us take care of you during your hospital
stay at ___.
What Happened on this admission:
- You were admitted for leg weakness caused by pressure on your
spinal cord. You had a spinal surgery to relief that pressure
around your nerve roots.
- You had a coronary catheterization performed in order to see
if you were having a heart attack. No stents were put in your
arteries because you needed to go to surgery.
- You had a follow-up stress test done to see if you needed
stents placed in your heart, but since you were not having chest
pain or other symptoms, the decision was made to not give you
stents.
- You were given 1 unit of blood to restore your blood levels
after your surgery.
- You were treated with fluids for a kidney disease, which
improved back to your baseline
- You were treated for suspected pneumonia with antibiotics for
7 days
- You were started on treatment for a urinary tract infection
that you will take for 7 days
When you leave the hospital it is important that you:
- Follow up with your orthopedic surgeon for follow up on your
spinal surgery
- Follow up with Cardiology about your heart
- Take all of your medications as prescribed
- Avoid salty foods including canned foods, chips, processed
meats and foods etc.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ man with a history of CHF, CAD,
DMII, and a remote history of prostate cancer who presented
after a fall one week PTA with new bowel incontinence, now s/p
cardiac catheterization and spinal decompression ___.
===============================
Acute medical issues addressed
===============================
# Back pain ___ cord compression: Patient diagnosed with cord
compression (cauda equina) on CT and MRI of the spine and had
fecal incontinence and lower extremity weakness. Patient
underwent L1-S1 laminectomy evening ___. His post-op pain
was managed with scheduled Tylenol, prn Tramadol initially, and
lidocaine patch. ___ worked with him during admission. Patient
initially had a foley post-op and had issues with some urinary
retention post-op despite an intact neurologic exam and had to
be straight cathed. Due to ongoing urinary retention, a foley
was placed on ___. On discharge, he had some weakness in his
lower extremities still as described in his discharge physical
exam. He will need to have a voiding trial at rehab but likely
has permanent damage from his cauda equina. If there continue
to be ongoing urinary retention issues, patient should have
urology follow-up scheduled as an outpatient.
#NSTEMI in setting of HFrEF (EF 45% in ___ and prior PCI in
___ of proximal LAD and distal RCA. Patient underwent cardiac
catheterization on ___ prior to laminectomy with two stenotic
coronary vessels. Given need for urgent spinal decompression,
decision was made not to place bare metal stents due to concern
for dual antiplatelet therapy during surgery. Patient did not
undergo POBA. Patient was treated with atorvastatin 80 mg PO
daily, ASA 81 mg PO daily, amlodipine 10 mg PO daily for BP
control, metoprolol 6.25 mg PO q6h. His Bumex was initially held
in setting of ___. He was given nitroglycerin available PRN
chest pain. On ___, he was cleared for any future DAPT.
Cardiology was reconsulted who recommended repeat EKG and trops.
Trops were elevated (0.11), which they felt was from his
catheterization. These were trended and they went down. Repeat
EKG was unchanged and patient was asymptomatic. Pharmacologic
stress testing was done on ___ which showed partially
reversible, medium sized, severe perfusion defect involving the
RCA territory. However, due to the fact that the patient was
asymptomatic, the decision was made by Cardiology not to do an
interventional procedures and instead treat the patient
medically. Bumex 1 mg PO daily was restarted on ___ for crackles
on exam and ___ edema. His losartan was held due to initial ___.
#Concern for CAP. Patient with new productive cough and
bilateral infiltrates on
CXR concerning for PNA. However, patient afebrile and without
leukocytosis. The decision was made to treat the patient for
community acquired pneumonia as he was so stable. He was given
azithromycin for 5 days and ceftriaxone, later transitioned to
cefpodoxime for his outpatient treatment for a total of 7 days.
He will require one day of cefpodoxime 200 mg PO q12h while at
rehab (stop date ___.
___, likely prerenal in the setting of two interventional
procedures and getting IV contrast. Cr peaked at 2.2. Spun urine
showed sediment/casts which showed granular casts only. He was
given prn IVF and his Bumex was held initially. His Cr improved
and was 1.0 on discharge. His losartan was held due to initial
___.
#Acute on chronic normocytic anemia: Patient's Hgb dropped to
6.9 ___ from 7.6 and 8.6, thought to be ___ intraoperative
losses. He was given 1 unit PRBCs ___ with appropriate bump
in his hemoglobin. His H&H stayed stable throughout his
admission. He should have further outpatient workup of his
anemia.
#Elevated anion gap metabolic acidosis: Resolved. Patient
acidemic on ABG found to be a primary metabolic acidosis with a
slight superimposed respiratory acidosis, which resolved with
IVF. However, he later developed a mild non-gap metabolic
acidosis of unclear etiology. Would continue to trend
electrolytes at rehab.
#Delirium. Patient saying some non-sensical statements
throughout hospital course and was not sleeping well at night.
Likely multifactorial ___ PNA, spinal surgery, and urinary
retention. Patient was never agitated and delirium has been
improving, especially with treatment of PNA and after placement
of foley.
#UTI
Patient with worsening delirium on ___. UA checked which was
positive for 42 WBCs, few bacteria, and large leukocyte
esterase. He was started on Bactrim DS 1 tab BID for a total of
7 days (stop date: ___. Urine culture was pending on
discharge.
#Thrombocytosis
Plts increased >400k starting ___, most likely ___ UTI, 538k on
day of discharge, may continue to trend.
# DM II with recent hypoglycemic episode. Last HbA1c 6.3% on
___. Patient was given low dose sliding scale insulin. | 252 | 771 |
15090495-DS-22 | 29,223,190 | Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having vomiting due to
intestinal obstruction from your tumor. You had an EGD where a
stent was placed to open up your duodenum. Your symptoms
improved and your diet was advanced.
You had an elevated white count, cough, and probable pneumonia
on CXR. You were started on levfloxacin 750mg once a day for 5
days. | Mr ___ is a pleasant ___ yo gentleman with hx of
cholangiocarcinoma, s/p biliary stenting on ___ now returning
with vomiting and evidence of duodenal wall thickening on CT,
concerning for partial SBO.
# PARTIAL SBO: likely due to duodenal thickening, likely from
spread of his cholangiocarcinoma. Patient underwent EGD with
duodenal stenting with good results. He was able to slowly
advance to a regular diet. He will avoid large food boluses,
ruffage, or fiber, which could get stuck in the stent. He was
seen by Nutrition to discuss appropriate food and nutritional
supplement intake.
# CHOLANGIOCARCINOMA: Patient is s/p ERCP on last admission.
Although LFTs were elevated above baseline on this admission,
they trended down without intervention. Patient will follow-up
with his oncologist as an outpatient or seek cancer care closer
to home in ___.
# COUGH/ELEVATED WBC/?PNA: Patient with cough, elevated WBC
and question of PNA on CXR. Patient likely aspirated during
procedure in light of duodenal blockage. Levofloxacin 750mg QD
was started for a total of 5 days.
# ASTHMA: Advair was continued. Singulair was held in an
effort to minimize medications patient needed to take orally.
# HICCUPS: Patient with severe hiccups. Reglan was helpful at
time. This medication can be continued as an outpatient. He
also found that deep breathing and relaxation helped this.
# GLAUCOMA: Latanoprost was continued. | 79 | 239 |
10246786-DS-16 | 27,344,677 | Mr ___:
You were hospitalized at ___
for difficulty breathing. You were given an extra dialysis
session which helped your breathing. During your stay here, you
had a fall. You were evaluated by physical therapy who
determined that it would be beneficial for you to receive home
physical therapy. You and your family expressed understanding
about your risk to fall at home and decided against
rehabilitation at this time. We will send you home with physical
therapy services.
We did not make any changes to your medications. You should
continue with your home medications as prescribed by your
doctor. You should also continue with your dialysis sessions
every MWF.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team | ___ w/ hx dCHF (EF>55%), ESRD on MWF HD since ___, ex-smoker
(quit ___) p/w dyspnea and mild somnolence today preceded by
___ weeks nonproductive cough with concern for hcap and acute on
chronic dCHF. | 117 | 36 |
15776313-DS-15 | 28,565,689 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
You were admitted with several seizures. You were very sleepy
because of the seizures and the medicines we needed to give you
to stop the seizures, and you needed a breathing tube for a
short period.
We did some additional testing to make sure there were no other
treatable reasons for you to have epilepsy. You had an MRI scan,
which looked normal. You also had a spinal tap, which was
normal.
Keep taking the levetiracetam (Keppra) without change.
Increase your lamotrigine as directed below:
Date AMPM ___ daily dose
150 mg tabs 25 mg tabs 150 mg tabs 25 mg tabs
___
___ mg
___
___
For more epilepsy information, you may want to look at the
following web sites:
___
___ Epilepsy Foundation
___ International League Against Epilepsy
These sites have very reliable information about seizures,
diagnosis, medications and other treatments, written by medical
professionals with expertise in epilepsy care. They also have
helpful tools to help you manage your seizures, such as seizure
diaries, medication information sheets, and seizure preparedness
plans. Finally, several of the sites have online patient
support
groups and links to additional information.
You can also reach our local Epilepsy Foundation affiliate,
Epilepsy Foundation ___, ___ Island, ___ &
___ for local educational events, programs, and support groups
at:
___/
Phone: ___
Toll free ___
_______________________________________________________________
FIRST AID FOR SEIZURES
_______________________________________________________________
Don't panic. Stay calm during the seizure. Speak calmly to the
person and to others in the area. Don't expect the person to
talk during the seizure. Look for identification or a medical
alert bracelet.
Realize that you cannot stop the seizure. Don't try to bring
the
person out of the seizure by using cold water, or by slapping or
shaking the person.
GENERALIZED TONIC-CLONIC SEIZURE (GRAND MAL)
During the seizure: The person may fall, stiffen, and make
jerking movements. The person may turn pale or blue from
difficult breathing.
1. Help the person into a lying position and put something soft
under the head.
2. Remove glasses and loosen any tight clothing.
3. Clear the area of hard or sharp objects.
4. Do not put anything into the person's mouth or force anything
between his/her teeth. It is impossible to swallow the tongue.
You don't need to try to keep the person from swallowing his or
her tongue.
5. Do not try to restrain the person; you cannot stop the
seizure
and you may injure them.
6. Turn the person onto his or her side as soon as possible to
help breathing and to allow saliva to drain from the mouth.
After the seizure: The person will awaken confused and
disoriented.
1. Stay with the person until he or she is fully alert
2. Do not offer the person any food or drink until fully awake.
3. Let the person rest or sleep. Be reassuring.
COMPLEX PARTIAL SEIZURES (TEMPORAL LOBE, PSYCHOMOTOR)
During the seizure: The person may have a glassy stare; give no
response or inappropriate responses when questioned; sit, stand,
or walk about aimlessly; make lip smacking or chewing motions;
fidget with clothes; appear to be drunk, drugged, or confused.
1. Do not try to stop or restrain the person unless there is
danger - for example, if the person could fall down stairs or
walk into traffic.
2. Try to remove harmful objects from the person's pathway or
coax the person away from them.
3. Do not upset the person.
4. When alone, do no approach the person who appears to be angry
or aggressive.
After the seizure:
1. The person may be confused or disoriented after regaining
consciousness and should not be left alone until fully alert.
IT IS RARELY NECESSARY TO CALL FOR MEDICAL HELP UNLESS:
1. You know that the person does NOT have epilepsy.
2. You know that the person has diabetes or low blood sugar.
3. The person does not start breathing after the seizure. Begin
mouth-to-mouth resuscitation.
4. The person has one seizure right after another, or a seizure
lasting longer than ___ minutes.
5. The person is pregnant, ill, or injured.
6. The seizure occurred in water, because the person may have
inhaled or swallowed water.
7. The person requests an ambulance.
________________________________________________________________
SEIZURE SAFETY
________________________________________________________________
The following tips will help you to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way you
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when you have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when you're by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If you wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless you live on your own, tell a family member ___
before you take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if you have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so you won't be hurt if you have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure you
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
___
Out and about:
- Carry only as many medications with you as you will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that you have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If you wander during a seizure, take a friend along.
- Don't let fear of a seizure keep you at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when you are close to water.
- Avoid swimming alone. Make sure someone with you can swim
well
enough to help you if you need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on
side roads or bike paths.
Driving:
- You may not drive in ___ unless you have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If you are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if you should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when you are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if you have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.
_______________________________________________________________
EPILEPSY AND DRIVING IN ___
_______________________________________________________________
One of the most uncomfortable discussions that doctors and
___
have with patients with epilepsy involve restrictions on
driving,
because your driver's license may seem essential to your
independence.
Although most state laws about driving and epilepsy are now less
restrictive than they were many years ago, these laws were
written to lessen the chance of harm to yourself or others
resulting from you having a seizure while driving.
Therefore, every state regulates driver's license eligibility
for
people with epilepsy. As a driver's license holder, it is your
responsibility to know the regulations in your state. The most
common requirement is that you must be seizure-free for a
certain
period of time before you can be allowed to drive. The seizure-
free period varies from state to state. Some states do not
specify a set seizure-free period. Instead, they ask for
your doctor's recommendation about whether you can drive safely.
Although physicians can offer an opinion on your ability to
drive
safely, the department of motor vehicles makes the final
decision. In some states, the physician can offer such an
opinion
if your seizures do not interfere with consciousness or control
of movement, you may be able to continue driving, if your
seizures occur only at certain times (especially during sleep)
or
if you always have an aura that would warn you to pull off the
road before a seizure begins. In a few states, some people with
seizures can get a restricted license, which allows them to
drive
under certain conditions.
If you are still having seizures, don't hide it from your doctor
in order to keep your driver's license. Not reporting seizures
makes it impossible for your doctor to treat your epilepsy
effectively. The doctor may be able to prevent more seizures
from
occurring by making a small change in the dosage of your seizure
medicine, for instance, but that won't happen if the doctor
doesn't know that it's necessary. Inadequate treatment may lead
to more seizures and then you or someone else may be injured.
If your seizures make it unsafe for you to drive, you will need
to find other means of transportation. Public
transportation, carpooling, van transportation, and even bicycle
riding can be used to preserve your sense of independence while
keeping you and others safe. Remember that restrictions do not
always last a lifetime. They may be temporary, just until your
seizures are under good control.
If your seizures are well controlled, use your driving
privileges
as a reason to take good care of yourself. If you always take
your seizure medicines as prescribed, get enough sleep, limit
your alcohol consumption, and visit your doctor regularly, you
will be more likely to be able to continue driving safely and
legally.
Below are the driving laws in ___
You must be free of seizures for at least 6 months.
In some cases, your doctor can submit a statement concerning
your
ability to drive safely, which may lessen the time before you
can
drive.
You must report your seizures to the ___ department of motor
vehicles and voluntarily surrender your license, or be subject
to
suspension or revocation.
If your license is surrendered, your doctor must submit a letter
stating that you have been seizure free for 6 months before you
can begin driving.
All the best,
Your Neurology Care Team! | ___ year old female with focal seizure with decreased awareness
and secondary generalization admitted with breakthrough
seizures.
#Seizures: Seizures since the age of ___, unknown etiology.
She presented with breakthrough seizures, thought to be from
missing doses as well as irregular schedule and sleep
deprivation. Also possibly some catamenial component as
increased seizures with menstruation. She was intubated for
airway protection in the ED. While in ICU she was quickly
extubated. She had an event after extubation consisting of right
arm triple flexion, rightward gaze preference but no EEG
correlate. For workup of her epilepsy that has been difficult to
control recently she had MRI that did not show any focal
cortical dysplasia, focal lobar encephalomalacia, grey matter
heterotopia, or mesial temporal sclerosis. LP was done as well
without evidence of increased protein or infection.
Encephalopathy panel was sent and pending at time of discharge.
She was continued on lamictal 150/175mg, Keppra 1000mg BID.
Level of lamictal was checked and pending at time of discharge.
Overall feel that breakthrough seizures are iso non compliance
as she has difficulty taking her morning medications due to her
friends seeing her and not wanting them to know she takes
medications. | 1,922 | 198 |
13625109-DS-18 | 28,328,537 | Dear Mr. ___,
You were admitted to the ___ on ___
with slurred speech and word finding difficulty. MRI that you
had a number of tiny strokes on both sides of your brain, which
we think may be related to atrial fibrillation and
hypercoagulability from cancer. While you were here we
transitioned you from elequis to lovenox. We did an
echocardiogram to look for a source of stroke coming from your
heart and we found no pathology. Your exam showed stable to
slightly improved and physical therapy felt that you were safe
for discharge home with services. Incidentally, we found that
your platelet count was quite low on this admission (27) and
with input from your oncologist we transfused you a unit of
platelets. Your counts improved (to 57), but it is important
that we monitor the levels closely, going forward. You will
follow up in Oncology on ___
Please follow up in stroke clinic as listed below and remain on
the medications listed in your discharge packet. It was a
pleasure taking care of you during this hospitalization.
Sincerely,
Your ___ Neurology Team | # Neuro: Patient presented with worsening dysarthria and word
finding difficult with MRI revealing late acute b/l cerebellar
hemisphere and left temporal lobe infarcts, suggestive of
cardioembolic etiology, also complicated by his underlying
metastatic malignancy which may place him in a hypercoagulable
state. Patient showed improvement in aphasia over course of
admission, with improvement in naming objects and fewer phonemic
and paraphasic errors. The patient was transitioned from
apixaban to enoxaparin for therapeutic anticoagulation and
medication was delivered to patient in the hospital. Blood
pressures were initially allowed to auto regulate and then
restarted on home antihypertensives upon discharge.
-Risk factor labs:
-HbA1c: 7.2 LDL: 149 TSH: 3.2 (CEA 218)
-CTA H/N: unremarkable
-MRI: Multiple new foci of slow diffusion involving the
bilateral cerebellar hemispheres and left temporal lobe,
demonstrating associated FLAIR hyperintense signal without
definitive enhancement, compatible with a combination of late
acute to subacute infarcts of varying chronicity. Additional
scattered foci of diffusion-weighted hyperintense signal without
clear ADC hypointensity and equivocal FLAIR hyperintense signal
of the bilateral frontal and right parietal lobes, concerning
for subacute infarcts. Subacute left temporal lobe infarct, now
demonstrating encephalomalacia and mildly enhancing gyriform
diffusion-weighted cortical hyper intensity with pseudo
normalization on ADC and associated pseudo laminar necrosis.
There is gradient echo susceptibility blooming artifact within
the subacute infarct compatible with hemorrhagic transformation,
noted on prior CT examination.
-Echo: Apical hypokinesis, worse from ___. No discrete
thrombus. Mild symmetric left ventricular hypertrophy. Increased
left ventricular filling pressure. Mild mitral and tricuspid
regurgitation
# CV: Admitted in atrial fibrillation with RVR, improved after
multiple IV doses of metoprolol and PO+IV Diltiazem, for which
increased home metoprolol from 250mg daily to 300mg total daily
dose.
# HEME: Pancytopenia, especially thrombocytopenia during
admission, likely secondary to recent chemotherapy
administration on ___. Platelets downtrended to 27 on
admission, without evidence of bleeding. After discussing case
with Oncologist Dr. ___ 1u platelets with
improvement in platelets to 57 upon discharge.
# ENDO: DM, continued on insulin with SSI as needed.
# ID: No evidence of infection on UA/UCx, CXR.
# Global:
- FEN: Maintained initially on cardiac heart healthy diet,
transitioned to regular per patient preference. Releted
electrolytes as needed
- DVT PPx: Therapeutic Lovenox, pneumoboots
- Bowel regimen
- Precautions: fall and aspiration
- Dispo: Floor bed with telemetry, ___ recommended outpatient ___,
paperwork filed for home ___ | 189 | 393 |
10746056-DS-24 | 29,256,625 | Dear Ms. ___,
You were admitted to ___
because you were experiencing nausea, vomiting, and diarrhea due
to a condition called gastroparesis -- this is a condition where
your stomach does not process food correctly, which causes all
of the symptoms you were experiencing.
Your care team offered you medications to help control the pain
and nausea, and preformed a procedure that placed a tube in your
small intestine to allow for food to bypass the stomach so you
do not experience the symptoms you were experiencing before you
came to the hospital.
When you leave the hospital, this is how you will feed yourself:
Glucerna 1.5 at 65 mL/hr x 16 hours
Your insulin regimen has changed, and when you leave the
hospital, this is how you should take your insulin:
Take 12 units of 70/30 insulin at the start of your tube feed
Take 50 units of lantus at bedtime
Take 12 units of Humalog with meals, plus your usual sliding
scale
It was a pleasure caring for you! | Summary
======================
___ female with PMHx significant for IDDM c/b
neuropathy, severe gastroparesis with frequent flares, macular
degeneration with legal blindness, and obesity, who is
presenting with nausea, vomiting, and abdominal pain, consistent
with gastroparesis. She underwent GJ tube placement and was
restarted on tube feeds.
ACTIVE ISSUES
=======================
# Nausea/vomiting/abdominal pain with gastroparesis: Patient
presented with two days of symptoms consistent with prior
gastroparesis flares. Patient was recently discharged with NJ
trial (to see whether permanent g tube would be beneficial).
Symptoms were improved with NJ, though temporary tube was
dislodged and prompted nausea/vomiting/abdominal pain, for which
pt was admitted this time. During this hospitalization, she
underwent gastric emptying study which was grossly abnormal and
then GJ tube placement on ___. Nausea, vomiting and abdominal
pain largely resolved on post-op day 2, tolerating tube feeds
and oral pain medication. She was discharged on pre-admission
pain regimen. Nutrition and ___ Diabetes were consulted, and
recommendations regarding tube feed regimen and diabetes
management were made (discussed below). | 166 | 162 |
17973532-DS-20 | 20,301,569 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had a skin infection on
your abdomen
What happened while I was admitted to the hospital?
-You were started on broad-spectrum antibiotics to treat your
skin infection
-Your lab numbers were closely monitored and you were continued
on your home medications
Your surgeons (Dr. ___ evaluated you and determined that
your elective cholecystectomy to remove your gallbladder needed
to be pushed back because of your active skin infection
The surgical coordinator will be in contact with you to
determine your surgery date
-Your being discharged with oral antibiotics that you should
continue to take
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
We wish you the very best!
Your ___ Care Team | Patient is a ___ with history of depression with prior suicide
attempt complicated by exploratory laparotomy for acute abdomen
and appendectomy, anxiety, and dyslipidemia who presented with
abdominal wall erythema and pain, concerning for abdominal wall
cellulitis. | 148 | 37 |
17724244-DS-7 | 21,151,984 | 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.
Please resume all regular home medications , unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service for
evaluation and treatment on ___. On (.___.), the
patient underwent ventral hernia repair w/ mesh, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids. The patient was
hemodynamically stable.
Neuro: The patient received IV morphine with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
on ___ and 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. | 330 | 285 |
15730484-DS-17 | 23,290,881 | Dear Mr. ___,
You were admitted to ___ with
shortness of breath and chest pain. Your symptoms are likely due
to your aortic stenosis. Blood tests showed that you were not
having a heart attack and did not have any damage to your heart.
It does appear that your weight has been stable. You were
evaluated by Cardiac Surgery for potential surgery to repair
your aortic valve. You had some preliminary blood tests and
carotid ultrasound. You will follow-up with Cardiac Surgery to
determine a plan for your surgery.
Please avoid strenuous activities while at home. You should also
limit your salt intake. Please call your Cardiologist if you
gain more than 3 pounds in 24 hours or 5 pounds in one week.
All the best,
Your ___ Team | This is a ___ ___ speaking with a history of CAD (s/p DES
to ___ at ___ ___ and DES to LCX and ___ into bifurcation
of LAD and LCX in ___ ___, severe AS, who presents with
worsening chest pressure on exertion for the past few days.
# Chest pressure: The patient presents with worsening chest
pressure on exertion, concerning for unstable angina or symptoms
from severe AS. Troponin negative x2. BNP is elevated to 2991
but we have no recent baseline. He was diuressed with 20mg IV
lasix and then transitioned to his home dose. His symptoms were
likely due to his severe aortic stenosis. Cardiac surgery was
consulted for evaluation of aortic valve replacement. They
recommended initial studies, including carotid artery ultrasound
and several lab tests which are pending at time of discharge. He
was doing well and discharged in stable condition. He was
continued on aspirin, imdur, and statin. His plavix was held in
anticipation of upcoming surgery. He will follow-up with Cardiac
Surgery next week.
# Lower Extremity Ddema: He has bilateral lower extremity edema,
which per report is chronic. ___ negative for DVT.
# Chronic Kidney Injury: Cr currently 1.6, from baseline per
Atrius records 1.4-1.5
# Atrial fibrillation on Coumadin: Continued atenolol and
coumadin.
# Hypertension: Normotensive now. On atenolol and losartan at
baseline.
# BPH: Continued doxazosin.
==================== | 125 | 230 |
17260918-DS-22 | 23,158,118 | No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Loss of control of bowel or bladder functioning | Mr. ___ is a ___ y/o M s/p mechanical fall presents with L1
compression fracture. He was admitted to neurosurgery for
further management. A TLSO brace was ordered and was measured
for brace. On ___, TLSO arrived. He had low urine output and a
500cc bolus was given. ___ was consulted as well.
On ___, patient was neurologically stable on examination in the
AM. MRI L-spine was completed and showed PLL injury. TLSO brace
was ordered to be worn when HOB>30 degrees and when OOB. He
developed hypotension with a systolic of 88, 500cc bolus was
given. He continued to be hypotensive with a systolic 69. He was
placed in reverse Trendelenburg and began to desaturate. He also
became dysarthric and lethargic. His O2 was increased to 5L. ABG
was performed and was normal. Labs were sent and showed
significant decrease in hct and plt count. Medicine was
consulted. CXR was performed and showed some congestion. He was
given an additional liter of fluid for continued hypotension.
Neuro stroke was consulted for concern of stroke. Medicine
recommendations were to transfer patient to the ICU and obtain
CTA head, neck, chest, abdomen, and pelvis. Hematology was
consulted for question of HIT. SQH and aspirin were held.
He was transferred to the ICU after CTAs were preformed. Repeat
labs showed improvement in hct and plt. He was restarted on SQH
and aspirin given the erroneous labs and decreased risk of HIT.
Neuro stroke recommended EEG, tegretol and lamictal levels, and
discontinuing antihypertensives.
On ___ Patient was normotensive and O2 sats were WNL. He was
neurologically stable. Patient was transferred to the floor with
telemetry. CXR revealed minimal pulmonary edema and some
atelectasis at the lung bases. BLE dopplers revealed no evidence
of DVT in the bilateral lower extremities.
On ___ routine EEG shows L temporal periodic discharges.
Patient was loaded with Keppra 1g then started on 750mg BID.
On ___ EEG positive for epileptiform discharges, but no active
seizures. Keppra was increase to 1000mg BID. EEG lead were
removed.
On ___, ___ evaluated the patient and was unable to work with him
due to back pain. His pain regimen was increased.
On ___, patient was unchanged. He had a positive U/A and was
started on cipro.
Mr. ___ was discharged to a rehabilitation facility on ___.
As discussed in the discharge summary paperwork, the patient
should follow up with Neurosurgery, Neurology and his PCP.
Because of new-found pulmonary nodules on a chest CT, radiology
recommended that he have follow-up screening by his PCP in
approximately ___ months.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically stable. | 167 | 440 |
19354516-DS-6 | 29,453,484 | Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital with
a worrisome painful ulcer on your ___ right toe. We did
multiple tests that showed the blood flow to your foot is
severely compromised. You are safe to go home on oral
antibiotics but we plan to have you return to the hospital for
an angiogram. At that time we hope to place a stent in the
blocked arteries to improve your circulation and promote healing
of this wound. If that is not possible, we may need to do a
bypass surgery to get this wound to heal.
Please keep the toe dry and clean. | ___ year old man with known peripheral arterial disease noticed
an ulcer on his right second toe that progressively had became
more painful, black and swollen.
He presents to the ER for evaluation. As right ___ pulses were
not dopplerable, we obtained ABI/PVR which showed the femoral
and popliteal waveforms are monophasic and the posterior tibial
and dorsalis pedis Doppler waveforms are absent at the ankle.
Metatarsal waveforms are flat.
Further workup showed no evidence of osteo in the right second
toe. He did not require pain medication and had no systemic
infection with normal temp and wbc. Vein mapping showed
excellent RLE conduit for bypass. Given these finding we will
discharge him to home to return for angiogram within the next
week secondary to no OR availability.
He was discharged to home with family, ambulatory at baseline
with a cane on all home medication. We will start him on
bactrim prophalaxtically for the next week until angiogram
scheduled for ___. | 119 | 166 |
11985393-DS-8 | 22,582,374 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
- You came to the hospital because you had worsening back pain.
WHAT HAPPENED WHILE YOU WERE HERE?
- You had imaging which showed two fractures in your spine, one
older one newer.
- The neurosurgeons evaluated you and did not feel you needed
surgery.
- You were given a brace to help with your back pain.
- You had imaging which showed some concerning findings that you
should follow up with as noted below.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to take all of your medications as directed,
and follow up with all of your doctors.
- Please continue to use your TLSO brace anytime you are out of
bed.
- Please follow up with your new primary care doctor
___ information below.)
- ****Please follow up with the Spine Surgeons in ___ weeks. You
can call to schedule an appointment at ___
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team | ___ female with a history of compression fracture in
___ presented with nontraumatic worsening lower back
pain found to have compression fractures of L1 and T7, and
possible malignant masses on CT torso.
# L1 acute compression fracture:
# T7 subacute compression fracture:
Patient with known T7 compression fracture from earlier this
year presenting with a nontraumatic L1 compression fracture.
Given the lack of trauma there was concern for a pathologic
fracture due to either malignancy or osteoporosis. CT torso was
pursued which showed small nodules of the right upper lobe, left
upper lobe and left breast along with mediastinal
lymphadenopathy together concerning for malignancy.
Interventional pulmonology was consulted who recommended PET CT
first. Notably vitamin D levels were low, patient was possibly
on vitamin D and calcium supplementation in ___ though
she denies imaging/DEXA scans in the past. She was fitted with
TLSO brace with marked improvement in pain after ___ evaluation
and treatment. No focal neurologic deficits developed during the
hospital course. Follow-up was arranged with PCP to organize
PET/CT as well as DEXA scan for workup of possible pathologic
fracture.
# Concern for malignancy:
As noted above hilar adenopathy, lung lesions and breast lesions
were noted. Otherwise no endometrial thickening, labs were not
suggestive of malignancy. Patient denied weight loss. Follow-up
was arranged with PCP to continue the workup.
# Hypertension:
Patient is a history of hypertension and she was continued on
her home medications without marked periods of hypertension or
hypotension.
==================== | 173 | 242 |
10427288-DS-21 | 27,075,708 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add gabapentin, Flexeril, and as a last resort oxycodone
as needed for increased pain. Aim to wean off this medication in
1 week or sooner. This is an example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
URINARY STATUS:
- Patient experienced difficulty voiding postoperatively. She
was straight cathed multiple times with failure to void post
straight cath. A foley was ultimately placed, with plans for a
void trial at rehab in ___ days.
Physical Therapy:
Nonweightbearing right lower extremity in splint
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Unless you are in a splint, incision may be left open to air
unless actively draining. If draining, you may apply a gauze
dressing secured with paper tape.
- If splinted, splint must be left on until follow up
appointment unless otherwise instructed. Do NOT get splint wet. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D as well as open reduction
internal fixation of right ankle, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ anticoagulation per
routine. While inpatient, the patient was continued on IV Ancef
for prophylaxis against surgical site infection. This was
converted to p.o. Keflex at discharge.
Pain control was somewhat of an issue during this
hospitalization. The patient reported poor pain control and on
___ her narcotic pain regimen was increased slightly. At this
time the patient had a spell where she stared blankly forward
for roughly 1 minute as witnessed by her family members. Her
family was concerned about a possible seizure and neurology was
consulted. Neurology was not concerned for a seizure and
recommended no further workup. They suggested the patient
follow-up in neurology clinic as desired. The pain service also
saw the patient after this event and suggested achieving pain
control through gabapentin and Flexeril in addition to Tylenol
and, if needed, oxycodone used sparingly. With this regimen,
her pain was well controlled.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact. She did
have some difficulty with urination postoperatively. She was
straight cathed multiple times and ultimately a Foley was
placed. A trial of removal of this Foley should occur in ___
days. The patient is NWB in the right extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 476 | 427 |
13406208-DS-9 | 23,598,294 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with unstable angina and were found to have restenosis (or
blockage) of the stent in one of the main arteries supplying
your heart. Another stent was placed. You complained of
persistent mild chest pains after the procedure but these were
felt to be related to indigestion as they resolved with Maalox.
You were sent to rehab to help you build up your strength.
.
The following medication changes have been made:
NO MEDICATION CHANGES
.
You should NOT STOP TAKING YOUR PLAVIX OR ASA UNLESS otherwise
instructed by your cardiologist | Mr. ___ is an ___ year old man with a past medical history
significant for CAD, lung cancer, and prostate cancer who
presented to his PCP's office with unstable angina.
.
ACTIVE ISSUES
# Unstable Angina: Initially there was concern for unstable
angina versus NSTEMI given 1 week of chest pain. There were no
EKG changes concerning for STEMI, and no troponin elevations so
unstable angina was diagnosed. Although levofloxacin was given
in the ED, in the floor we doubted pneumonia given lack of
clinical findings concerning for pneumonia (no cough, sputum
production, fever, pleuritic chest pain) and CXR findings are
not very impressive; LUL infiltrates may correspond to prior
area of radiation. Positive stress test on ___ by EKG, but
no areas of ischemia on nuclear imaging possibly consistent with
balanced ischemia. Cardiac cath was performed on ___ which
demonstrated restenosis in the BMS in the proximal LAD. A DES
was placed in the mid LAD. The post-procedure course was
notable for significant improvement of his chest pressure. He
continued to complained of intermittent atypical chest pains not
accompanied by EKG changes or cardiac enzyme elevations and
relieved by maalox. Pt was seen by ___, who recommended rehab.
.
# Thrombocytopenia: Given quick onset < 48 hours after
initiation of heparin, likely HIT type I (benign non-antibody
mediated, self-resolving) vs. volume mediated. Upon discharge
platelet count was 133.
.
CHRONIC ISSUES
# Depression/Bipolar: Lithium was continued.
.
# Failure to thrive/Anorexia: Differential included worsening
depression, malignancy, CAD, and indolent infection. Doubt
malignancy given that Mr. ___ was recently deemed to be in
total remission per Dr. ___. Pt was HIV negative. Nutrition
consult recommended encouragement of Glucerna shakes.
.
TRANSITIONAL ISSUES
# CODE STATUS: DNR/DNI
# MEDICATION CHANGES: none
# FOLLOW UP PLAN:
- Gerontology appt on ___
- Cardiology appt with Dr. ___ on ___ | 102 | 301 |
15874317-DS-41 | 29,276,221 | Dear Ms. ___,
It was a pleasure caring for you at ___. You
were admitted for swelling in your neck and found to have an
infected and obstructed salivary gland. You were seen by the ear
nose and throat doctors who agreed that antibiotics and
aggressive drainage was the best treatment option. We gave you
antibiotics and your symptoms improved. You will need to
complete a course of oral antibiotics as an outpatient and
follow up with the ear nose and throat doctors.
It was a pleasure caring for you in the hospital.
Sincerely,
Your ___ Team | SUMMARY: Ms. ___ is a ___ woman with a history of
hypertension, paroxysmal atrial fibrillation (on home
anticoagulation), pacemaker for tachybrady syndrome, and
peripheral vascular disease, who is presenting with fever and
sore throat for three days, now in the ICU for airway monitoring
given concern for Ludwig's angina.
# Submandibular swelling: Patient presented with right
submandibular gland sialadenitis with 2 stones in Wharthin's
duct. There was initial concern for Ludwig's Angina. ENT was
consulted and evaluated the patient. Bedside scope was performed
which showed airway edema. She was given dexamethasone 10mg,
started on unasyn (d1 = ___. Per ENT recs she was given warm
compresses, firm salivary gland massage, and sialogogues. Her
swelling quickly improved. She improved and was discharged home
with a 10-day course of augmentin.
# Leukocytosis: Patient presented with a WBC of 16. Most likely
related to siladenitis as above. Patient had no other localizing
symptoms and other studies were not concerning for UTI or PNA. | 94 | 161 |
12057219-DS-3 | 20,709,012 | Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take heparin three times 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 in 2 weeks at rehab.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight-bearing as tolerated
Physical Therapy:
Weight-bearing as tolerated in right lower extremity.
Treatments Frequency:
Please assess wound daily for erythema, drainage, or other signs
of infection.
Please remove stables ___ days after the operation.
Please provide physical therapy.
Please provide anticoagulation for DVT prophylaxis for 2 weeks. | Ms. ___ presented to the ___ emergency department on
___ and was evaluated by the orthopedic surgery team. The
patient was found to have right intertrochanteric femur fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for ORIF right hip
fracture with TFN, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight-bearing as tolerated in the
right lower extremity, and will be discharged on subcutaneous
heparin 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. | 189 | 244 |
12535246-DS-11 | 25,368,294 | Dear Ms. ___,
It was a privilege to care for ___ at ___.
WHY WAS I IN THE HOSPITAL?
___ had trouble breathing and were coughing up blood.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We took pictures of your lungs, which suggested that they had
blood in them. This was due to a disease called "vasculitis,"
which means the blood vessels in your lungs were irritated and
inflamed. We treated ___ with ___ steroids and other
immunosuppressive drugs, as below.
- Your biopsy results returned while ___ were in the hospital,
and ___ were found to have a type of cancer called "mantle cell
lymphoma." We started treatment for your cancer. These
immunosuppressive drugs also helped your vasculitis. We also
placed a port on your chest to better deliver the drugs.
- Throughout your stay, ___ met with our kidney, lung, and
rheumatology doctors, who helped us manage your conditions.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Continue to take all your medicines and keep your appointments.
___ will be seen by the oncology and diabetes team this upcoming
week.
- Continue taking prednisone 80 mg daily until ___ and then
decrease to 60mg daily. ___ will continue this dose until
instructed to decrease by a physician
- ___ should follow up in the ___ clinic with Dr. ___
___ ongoing management of your cancer
- Monitor your blood glucose at home. Please call your primary
care provider or Dr. ___ blood glucose is <70 or
>400.
We wish ___ the best.
Sincerely,
Your ___ Team | SUMMARY
=======
Ms. ___ is a ___ female with COPD, DMII, and
hypothyroidism who presented with dyspnea and hemoptysis,
diagnosed with ___ ANCA vasculitis (positive MPO
antibody), diffuse alveolar hemorrhage, and mantle cell
lymphoma. Her hospital course was complicated by acute hypoxic
respiratory failure and ___ from vasulitis. She was started on
high dose steroids and received Cytoxan/rituximab (___) for both
her vasculitis and lymphoma, and was stable on room air by time
of discharge.
ACUTE ISSUES
============
# ___ Vasculitis
# Hemoptysis
Patient initially presented with one day of hemoptysis. Initial
work up notable for CXR and CT chest showing diffuse alveolar
hemorrhage vs multifocal infection. Given lack of systemic
symptoms (including leukocytosis or fever) or concerning for
infection, this was presumed to be alveolar hemorrhage, which
also fit with her recent hemoptysis. Interventional pulm was
consulted but pt was deemed a poor candidate for bronchoscopy
d/t diffuse nature of pulmonary hemorrhages. Given concurrent
___ and recent epistaxis, vasculitis was considered as etiology
of hemoptysis, and vasculitis labs were sent. Work up notable
for CRP 170, ANCA positive, and myeloperoxidase Ab positive (>8)
consistent with ___ vasculitis. Proteinase 3 Ab
negative, C3/C4 normal, HIV negative, ___ negative, ___
negative, and ___ Abs negative. IgG and IgM returned at
1478 and 60 respectively. Rheumatology, nephrology and
pulmonology were consulted and provided assistance with
management. She was given 1000mg methylpred daily for 3 days
followed by prednisone 80mg/kg. Given concurrent hematologic
malignancy, pt was transferred to ___ service for further
management. Her vasculitis was thought to be a paraneoplastic
workup related to her mantle cell lymphoma, and she was started
on cyclophosphamide, rituximab, and prednisone 100mg daily for
treatment. Following her course of cyclophosphamide and
rituximab, she was continued on 80mg prednisone daily with taper
per rheumatology. Her symptoms, including hemoptysis and
shortness of breath improved with treatment. Additionally, her
kidney function improved and she was weaned to room air. She
will follow up with heme/onc, rheumatology and nephrology for
further management.
#Mantle Cell Lymphoma
Diffuse lymphadenopathy was initially discovered on CT chest at
___, and seen again on repeat CT at ___. A lymph node
biopsy from ___ showed mantle cell lymphoma. Her G6PD was
normal, and she had neg HIV/Hep on workup. On ___, a PICC was
placed, and she was started on rituximab/cyclophosphamide, and
given 100mg prednisone for 4 days (she received 80mg prednisone
on D1). She was also started on atovaquone for PCP ppx, ___
500mg q48h (renally dosed)(switched to azithromycin on ___,
and allopurinol, renally dosed at 100 mg qd. Her PICC was
replaced with a ___ port on ___. She will follow up in
___ clinic for further management.
#Acute hypoxic respiratory distress iso DAH, vasculitis
#COPD
Hospitalization complicated by acute hypoxic respiratory failure
requiring increasing doses of supplemental oxygen, up to 6L NC
and shovel mask, with occasional desaturations into the ___.
These episodes typically resolved with deep breathing. She was
treated with steroids and chemotherapy as above. Additionally,
she received IV Lasix, duonebs q6h and albuterol nebs prn.
Pulmonary was consulted, recommended adding azithromycin 250mg
MWF and acapella TID. Her O2 requirement decreased throughout
her stay and she was on room air by discharge with stable
saturations during ambulation.
#New onset paroxysmal atrial fibrillation
#NSVT
On ___ AM, she noted heart palpitations and increased trouble
breathing. She was found to be in atrial fibrillation on
telemetry and EKG for about 15 minutes. She responded to IV 5mg
bolus of metoprolol, and returned to ___ without symptoms. She
was continued on telemetry for the next week without recurrent
afib. Etiology felt to be ___ acute illness. Anticoagulation and
nodal blockade were deferred given lone episode with obvious
trigger and concern for developing thrombocytopenia.
Additionally, on ___ AM, she had a 20 second run of NSVT with
symptoms. Her electrolytes were repleted. EKG showed no acute
ischemic process. She remained in NSR for the duration of her
stay.
#Anemia
In ED, pt H/H 7.3/24.2, but on following H/H had dropped below
6, she received 2 units pRBCs with good response and H/H
remained stable. Anemia was presumed ___ hemoptysis/diffuse
alveolar hemorrhage, but given resolution of hemoptysis, H/H
remained stable through stay on floor prior to transfer to ___
service. While with BMT, we administered blood products as
needed. Her discharge Hgb was 7.4, and she was transfused 1u
pRBC prior to discharge.
___
In ED, Cr 2 from a baseline of 0.8. Elevated Cr similar to
presentation at ___ one week prior. No hx of kidney
disease. Initial ___ included UA showing proteinuria,
hematuria, 31 WBC, hyaline casts. Renal U/S normal. Initially
presumed ___, given IVF, but pt had concurrent pulmonary
symptoms and recent epistaxis. With concern for systemic
vasculitis, rheumatology and nephrology consulted. Work up
notable for vasculitis as described above. Renal biopsy was
considered, but given tenuous clinical picture and positive
diagnosis by ANCA, was deferred. Nephrology agreed with
rheumatology and heme/onc plan to start high dose steroid course
for 3 days. Medications were renally dosed and nephrotoxic
medications, including NSAIDS, were held. She was also
diuresised with furosemide prn as above. Her Cr continued to
improve during her stay and was 1.6 at time of discharge. | 261 | 855 |
13123895-DS-17 | 28,669,189 | You have undergone the following operation: Open Reduction
Internal Fixation Odontoid Fracture
- 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:
o ___ 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.
o 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 need to wear the
brace at all times until your follow-up appointment which should
be in 2 weeks. You may remove the collar to take a shower.
Limit your motion of your neck while the collar is off. Place
the collar back on your neck immediately after the shower.
- 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.
- 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 please plan ahead. You 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 prescriptions
(oxycontin, oxycodon, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions.
o 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#1.
Physical therapy was consulted for mobilization OOB to ambulate.
Plastic surgery was consulted for frontal bone fractures. They
did not recommend any further intervention or follow-up for your
fractures.
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. | 563 | 157 |
14975577-DS-12 | 21,098,893 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for chest pain and cough. A CT
scan of your chest showed a pneumonia for which you received
antibiotics. Your pain is likely related to the musculoskeletal
system and not to your heart or lungs. The pain should improve
over time with conservative measures such as Tylenol and local
heat/cold compresses.
Please take your medications as prescribed and follow up with
the appointments listed below. | ___ yo F with DM, COPD, peripheral vascular disease with
claudication and polymyalgia rheumatica presenting with right
sided chest pain.
# Right-sided Chest Pain: On exam, pain is reproducible with
movement and palpation. Presentation likely due to
costochondritis. No evidence of ACS or pericarditis given
unremarkable EKG and cardiac biomarkers. CXR notable for L-sided
atelectasis. CTA negative for PE. No dermatomal rash to suggest
Zoster.
She was managed with Tylenol, lidocaine patch, and continued on
her hme oxycodone. NSAIDs were avoided given CKD. The patient
had mild improvement in her symptoms at the time of discharge.
She was discharged with Lidocaine patches for her pain.
# Pneumonia: Exam most notable for inspiratory crackles at RLL,
dyspnea, and increased sputum production concerning for
pneumonia. Initial labs most notable for leukocytosis to 15.
Patient recently hospitalized in ___, patient meets
criteria for HCAP. Chest CT notable for pulmonary nodules with
atelectasis concerning for possible post-obstructive pneumonia.
The patient received IV Ceftriaxone in the ED. The patient was
subsequently transitioned to Augmetin 875 mg PO BID x 10 days. | 81 | 173 |
17420619-DS-27 | 26,178,493 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for a low sodium
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
-Your sodium was monitored
-You had scans of your teeth and chest
-You were started on medication for low sodium
-You had 5 teeth taken out
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY
===============
___ year old male has ETOH cirrhosis complicated by varices,
ascites, SBP on cipro prophylaxis, listed for liver txp with
MELD
30, GAD, OA of bilateral hips s/p right THR (___) presenting
for
hyponatremia. His tolvaptan dose was uptitrated to 30mg daily
with stabilization of serum Na. He maintained euvolemia on this
dose of Tolvaptan without any other diuretics and thus his home
diuretics were held on discharge. | 103 | 67 |
16145315-DS-19 | 28,833,494 | Mr. ___,
You were admitted with urinary retention and blood in your
urine, which required a foley catheter while you were admitted.
The foley was removed today and you were able to urinate without
any difficulty. You will follow up with urology to further
discuss bloody urine. | ___ h/o hematuria & urinary retention h/o remote prostate
cancer, dementia with significant decline 1 month ago, HTN, and
hypothyroid was sent from ___ for hematuria noted to have poor
PO appetite and 25 pound weight loss over the past
month.
1. Hematuria with urinary retention h/o prostate cancer
-Foley placed in ED for retention (?obstruction from
mass/prostate vs blood clots) with mention of pyuria however
urine culture without growth and antibiotics not continued.
Attempted to remove foley ___ but patient developed bleeding
and significant pain and it was left in. Foley was removed
successfully ___, and patient able to void without retention
noted on bladder scans.
-Hematuria is concerning for malignancy especially in setting of
h/o prostate cancer; sister notes prostate cancer about ___ years
ago treated with radiation ?+/-surgery, but I do not have access
to these records. He had seen a urologist before, but she does
not believe he sees one anymore. At this point sister (HCP)
with support from her daughter-in-law who is a hematologist they
would like to see urology and likely pursue cystoscopy. This
will be done as an outpatient.
2. ___ vs CKD
Due to paucity of records unknown baseline Creatinine.
Creatinine stable at 1.3.
3. Microcytic anemia
-Due to paucity of records unknown baseline hemoglobin with
differential of anemia including hematuria vs underlying
malignancy. This can be followed outpatient.
4. Dementia
___ Alzheimer's with dementia workup unrevealing for
alternative cause. Discussed progression of dementia with
sister who is very familiar with this as their sister died with
dementia. At this time will continue with supportive care, which
includes 1:1 assistance with feeding. Continue donepezil.
Patient's sister ___ ___ is HCP and I also
spoke with her daughter-in-law ___ ___
(hematologist) to help make goals of care decision. Need to
continue to address code status as patient currently full code.
5. Malnutrition, poor PO intake
Appreciate recommendations from SLP and nutrition. Patient is
having difficulty eating in setting of dementia essentially
forgetting to chew & swallow. With prompting and 1:1 assistance
he does fine with regular foods; in setting of absent back
molars he can be changed to ground meat consistency if he has
further difficulty. Continue ensure enlive TID with meals and
magic cup BID.
Chronic Medical Problems
1. HTN: continue amlodipine and metoprolol
2. HLD: holding simvastatin (due to interaction with amlodipine
and risk>benefit given age and comorbidities)
3. Hypothyroid h/o Grave's: continue levothyroxine
>30 minutes spent on discharge planning | 49 | 411 |
Subsets and Splits