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12033165-DS-4 | 27,665,810 | Dear Mr. ___,
You were admitted for lamotrigine toxicity. We have put you on
your correct dose of 250mg twice per day. You were also
evaluated by physical therapy and found to be very unsteady on
your feet. As a result, we got an MRI of your head, which was
unremarkable. You were kept on continuous EEG while your
phenytoin was weaned off. You are to continue lamotrigine 250mg
twice per day and carbamazepine 600mg in the morning and 800mg
in the evening.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team | ___ man with focal onset epilepsy who was admitted ___
with slurred speech and falls concerning for lamotrigine
toxicity. He had been on a slow lamotrigine uptitration to goal
dose 250mg po BID but continued to a total 500mg po BID after
his pills changed from 100mg to 200mg. Initial exam showed R
beating nystagmus, R ataxia to FNF, and ataxia on R HKS. This
morning's exam was much more symmetric and only showed intention
and postural tremors. NCHCT negative for acute processes. Labs
showed decreased PHT levels, which might be ___ increased
lamotrigine levels. He was evaluated by ___ who found him to have
great difficulty walking steadily. MRI was normal. EEG showed
mild diffuse background slowing and a slow posterior dominant
rhythm. No seizures were captured. He was weaned off his home
Dilantin, and lamictal was kept at 250mg po BID. Home
carbamazepine was maintained the whole hospitalization. | 101 | 151 |
18799590-DS-13 | 24,976,727 | 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.
*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. | The patient presented as above. She underwent a CT Abd/Pelvis
with PO contrast in the ED that showed high-grade small bowel
obstruction, transition point in the left lower quadrant, with
adjacent free fluid. There was no free air or evidence of
perforation. Consequently she was admitted to the ___ service
under Dr ___ conservative management.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed IV tylenol which was
then transitioned to oral medications once the patient was
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO/IVF with a NGT in
place. She passed flatus on HD1 and had a bowel movement on HD2
so her diet was advanced sequentially to regular diet which was
well tolerated. Patient's intake and output were closely
monitored. NG tube output was minitored closely and the tube was
dc'ed when the output tapered off. The patient had a Foley
placed for monitoring which was dc'ed on HD2 and the patient
voided adequately afterwards.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions and verbalized understanding of and
agreement with the discharge plan. | 185 | 311 |
18340010-DS-5 | 20,208,137 | You were admitted to the hospital because of increased sedation
and concern that you were having difficulty managing your oral
secretions. We stopped your Seroquel, a medication that was
likely making you more sleepy. A workup for infections was all
unremarkable. You were assessed by Physical Therapy and
Occupational Therapy, who recommended a new motorized wheelchair
and home suction equipment in order to have safer care at home.
In the hospital, you developed a urinary tract infection. This
was treated with IV antibiotics (Ceftriaxone), then changed to
oral antibiotics (Cefpodoxine) on discharge.
We made the following changes to your medications:
1. STOPPED Seroquel
2. STARTED Modafinil (Provigil) 2.5mg in AM
3. STARTED Cefpodoxine 200mg twice daily for 7 days to treat UTI
(first day = ___, last day = ___ | ___ with a PMH of HTN and advanced secondary progressive
multiple sclerosis, bed to wheelchair bound and dependent for
all ADLs under Dr ___ with dyphagia and aspiration pneumonia
s/p PEG tube insertion ___ recent admission to neurology
___ for visual hallucinations at which point amantadine
was stopped and quetiapine started now presents with decreased
verbalising and difficulty managing her secretions over the past
3 days.
# NEURO: She was admitted to the General Neurology service for
monitoring of her mental and respiratory status. The quetiapine
was stopped as was likely worsening her sedation. Toxic
metabolic and infectious workup were unrevealing, and no
hypercarbia on VBG. Over the next 5 days, there was not
significant improvement in her mental status. She remained
nearly nonverbal, able only to say a couple of words in ___.
Her family felt this was worse than her prior baseline, but
recent Neurology notes document a fairly similar exam. Also, she
may have become more lethargic in setting of Amantadine being
stopped in late ___. Thus, after discussing with her MS ___
(___), she was started on low-dose Provigil 2.5mg qAM
to help with arousal. She was also evaluated by ___ and OT in the
hospital, who recommended a new wheelchair with neck support as
well as home Yankauer suction equipment to help with oral
secretions. Both of these will be delivered directly to the
home.
# ID: On hospital day 4, patient developed gross hematuria, and
was found to have a UTI on repeat urinalysis (which had been
clean one day before). She did not spike any fevers. Was started
on IV ceftriaxone on that day (___), then narrowed to
Cefpodoxime 200mg BID on discharge. She will complete 5 day
course (last day ___, and PCP ___ follow up results of urine
culture. Importance of this was discussed with family.
=============================
STUDIES PENDING ON DISCHARGE:
- Urine culture from ___ (should be followed up by PCP, as
discussed w family) | 128 | 323 |
10766131-DS-16 | 25,184,449 | Dear Ms. ___,
You were admitted to ___ because you had severely infected
skin wounds on your back, kidney failure, and a very fast heart
rate. You were treated with antibiotics, but your condition
continued to worsen.
After an extensive conversation with your family, we switched
you to comfort-based care. We started medications to control
your symptoms. You were seen by our hospice team for control of
your symptoms, but you family declined hospice care at this
time. You will be followed by a palliative care visiting nurse
after discharge.
Your family was provided with instructions on administering pain
and anxiety medications through your PEG tube. Your family
should ask the visiting nurse if they have any questions
regarding use of the PEG tube or inadequate control of your
symptoms.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team. | ___ yo ___ woman with history of HFpEF, AF on
rivaroxaban, s/p PPM, prior traumatic SAH/SDH, and recent
admission for infected sacral and R scapular decubitus ulcers
s/p 4 week course of vanc/cef/flagyl for polymicrobial
infection, who was admitted on ___ for acute renal failure and
found to be in septic shock and in afib with RVR. Patient was
transitioned to ___-based care after extensive discussion
with patient's family and health care proxy given her
significant comorbidities and poor prognosis. Tube feeds were
stopped given goals of care discussion and patient was started
on oral care regimen. Patient's symptoms were controlled with
dilaudid liquid administered through PEG tube, Ativan for
anxiety (which she did not require), and glycopyrlate for
secretions. Her symptoms were well controlled and she stabilized
for transition to home-based care. She will be followed by a
palliative ___ after discharge with follow up with palliative
care doctor/hospice per family wishes. Hospice saw patient in
the hospital, but patient's family declined hospice in favor of
___.
#Goals of care: Patient with multiple serious comorbidities
including end stage dementia, multiple severe skin ulcers, acute
renal failure, and serious infection. After extensive discussion
with family regarding the patient's poor quality of life over
the last month and potential for pain with further
interventions, her family felt it appropriate to focus care on
comfort. Her tube feeds were stopped and her symptoms were
controlled with dilaudid, lorazepam, zofran, and glycopyrollate.
Per family wishes, she will be discharge with palliative ___
instead of hospice. Family was concerned regarding nutrition
status of patient, but reiterated that tube feeds were not
helping patient given multi-organ failure and poor prognosis
even with treatment and were not well tolerated.
#Septic Shock ___ pneumonia
#UTI:
CXR at admission showed LLL infiltrate. Patient with multiple
chronic decubitus ulcers, but these were not thought to
represent the souce of infection per infectious disease. She had
been previously treated with 4 week course of
vanc/cefepime/flagyl which ended ___. She was started on
meropenem at admission which was discontinued after ___
discussion on ___.
#Acute Renal Failure:
Presented with Cr increased to 3.3 from baseline of 0.5. Likely
in the setting of hypovolemia from infection with possibly
contribution from supratherapeutic vancomycin levels. Stopped
trending based on GOC.
#Anemia: Worsening anemia without clear course of bleed. Likely
bone marrow suppression in setting of critical illness and
nutritional deficiency. Stopped monitoring.
#Acute toxic-metabolic encephalopathy on chronic vascular
dementia
Baseline bedbound, A+Ox ___. Persistently somnolent and not
following commands. Intermittently opens eyes, but no further
interaction. CT head negative for acute bleed. This remained
throughout course and likely in setting of infection, kidney
failure, and metabolic derangements.
#NSTEMI (type 2): Trop peak at 0.7, with flat CK-MB. Likely
demand in setting of renal failure and hypovolemia in setting of
Afib with RVR.
#Afib with RVR.
RVR occurred in setting of sepsis/hypovolemia. Converted back to
sinus rhythm after volume resuscitation and broadening
antibiotics. Likely precipitated by hypovolemia and underlying
infection.
#HFpEF: LVEF >55% in ___. Moderate edema may be from low
albumin vs. HF. Did not diurese after GOC dission.
#Sacral decubitus ulcer
#R upper back pressure ulcer
No signs of new acute infection and has completed 4 week broad
abx course for polymicrobial infection.
#Severe malnutrition
PEG tube placed last admission on ___ secondary malnutrition
and inability to take PO. Patient continued with low albumin
despite initiation. After extensive discussion with family
regarding poor prognosis, multi-organ failure, and inability to
tolerate feeds, decided to stop tube feeds and focus on comfort
based care. She continued to receive medications through G-tube.
#HTN: Held lisinopril.
#Constipation: Held lactulose BID, docusate, and bisacodyl PRN.
Will give bicacodyl PR for use after discharge if pain.
#Hypothyroidism: Held home levothyroxine after CMO.
Transitional Issues
===================
[] Transitioned to comfort-based care during this
hospitalization. Will be discharged with palliative ___ per
patient's family preferences instead of hospice.
[] Palliative ___ will refer patient to palliative care MD
depending on how she does after discharge with reconsideration
of hospice referral.
[] Filled out MOLST forming prior to discharge indicating no
further hospitalizations and CMO
[] Started morphine PO to be given through PEG tube for
discomfort and respiratory distress
[] Started lorazepam PRN for anxiety. Patient did not require
this medication during hospitalization
[] Started scopolamine patch to be given for excess secretions
q72 hours
[] Tube feeds will not be continued after discussion with
patient's family. She will only use PEG tube for medications to
control symptoms and improve comfort.
[] All other medications were discontinued that did not directly
improve comfort.
# CMO
# CONTACT: Proxy name: ___
Relationship: son Phone: ___
Comments: alternate ___ ___ | 149 | 768 |
17256089-DS-12 | 22,181,930 | Hello Ms. ___,
It was a pleasure to take care of you. You came in after you
fainted. We believe that it was due to an irregular heart rate
called atrial fibrillation. You were put a medication called
diltiazem that put your heart rhythm back to normal. Because of
your age and other factors, you were also started on a blood
thinner, coumadin in order to decrease the chances of having a
stroke with this type of heart rhythm.
You will resume your home medications but with the following
changes: Your losartan will be 25 mg twice a day instead of 50
mg twice a day. You have been started on two new medicines. The
first is diltiazem extended release 120 mg every day. This is to
prevent you from going into the irregular rhythm that brought
you to the hospital. The second is coumadin, also called
warfarin, 5 mg to thin your blood and decrease your risk of
having a stroke. Coumadin requires that you have follow up blood
checks to decrease the risk of bleeding. Please follow up with
your primary care doctor to setup these check ups. Since you
have been started on coumadin, we will stop your aspirin, which
is a blood thinning drug. Lastly you will no longer be taking
the amolodipine unless directed by your primary doctor.
We wish you the best. | Patient is a ___ year old woman with a PMH of HTN, HLD, prior
LBBB noted on EKG, retinal vein occlusion, p/w syncope
# Syncope: Likely due to unstable afib as patient was found in
this rhythm in the field and hypotensive. She was converted in
the ED which restored her blood pressures and converted her back
to normal sinus rhythm. In house, she remained in normal sinus
rhythm on telemetry. Had no chest pain with (-) troponin x 1. No
focal neurological signs and most recent echo done ___ showed
no concerning structural abnormalities.
# Afib w/ RVR: With a CHADS2 score of 2, we began rate control
and started her on coumdadin. She will follow up with PCP and
___ clinic to check her INR
# HTN: The Patient's amolodipine was held when diltiazem for
rate control was initiated. The patient's losartan was
continued. After starting the diltiazem her SBP had one
measurement of high ___, for which she was clinically stable,
with all other in the 120s. As a result, her losartan dose was
halved at discharge. In summary, at discharge she will no longer
be on amlodipine and her losartan dose was downtitrated to 25 mg
BID.
# Retinal vein occlusion: Anticoagulated on warfarin, we
discontinued her ASA 325. She will follow up in eye clinic
# Hypothyroidism: TSH in house was normal. Her synthroid was
continued
# Transitional issues
- Follow up with PCP and ___ clinic for INR checks
- Follow up with PCP for blood pressure monitoring now that she
has been started on diltiazem for afib rate control and her
prior HTN regimen was changed in the hospital | 227 | 280 |
16263225-DS-19 | 22,254,884 | Dear ___ came to the hospital because ___ had an episode of amnesia.
We did a CT scan and an MRI of your brain, which did not show a
stroke. We also did an EEG, which showed that your brain waves
were slightly slower on one side compared to the other, and did
not show any seizures. This slowing is probably from scar tissue
in your brain that we are unable to see on MRI.
We think that your memory loss is either from a condition called
Transient Global Amnesia, or potentially from a seizure.
We would like ___ to have a repeat EEG in 3 months and follow up
in neurology clinic as an outpatient.
If ___ have any more episodes of memory loss, please come back
to the ED for evaluation.
___ have previously been diagnosed with atrial fibrillation, but
were not on treatment because your risk of stroke was low. ___
were previously told to take Aspirin daily, but ___ hadn't been
doing this regularly. We would recommend taking Aspirin 81mg
daily for stroke prevention, and we started this medication
while ___ were in the hospital.
It was a pleasure taking care of ___ and we wish ___ the best! | Brief Hospital Course:
Ms. ___ is a very pleasant ___ R handed woman with a
history of paroxysmal atrial fibrillation diagnosed over ___
years ago, not on anticoagulation, hypertension, osteoporosis,
and history of breast cancer ___ years ago s/p chemotherapy,
radiation, and lumpectomy now in remission. She presented to
___ on ___ with her family for sudden confusion and
anterograde amnesia. She was admitted to the stroke service for
evaluation of possible transient global amnesia, vs. seizure vs.
TIA/ Stroke.
#Anterograde amnesia/confusion:
-Patient underwent ct head in the ER with CTA head and neck
which was unremarkable. She had stroke risk factor labs drawn
including an LDL which was pending at discharge, A1C of 5.6, and
a TSH of 3.2.
-She was placed on an aspirin 81mg daily in the ER
-The next morning on ___ the patient underwent an extended
routine EEG and MRI brain. The MRI brain did not reveal any
acute strokes, no large areas of encephalomalacia to suggest
prior large infarcts, nor any hippocampal DWI changes that can
be seen in TGA.
-EEG was read by the epilepsy fellow/attending as bursts of L
temporal slowing without epileptiform discharges. The final
report is pending. For this, we will set the patient up with
outpatient neurology f/u and repeat EEG in about 3-months. She
did not have any epileptiform activity and therefore the
likelihood that this represented a seizure is very low
-Her neurologic examination remained stable during the entire
admission without any further episodes of confusion, memory
loss, nor any other focal deficits
#Paroxysmal Atrial Fibrillation:
-Patient's ___ score was calculated at 3 , scoring points
for her age, sex, and hypertension history, which results in a
3.2% risk of stroke. Given that we feel this episode was more
likely a TGA and not a true stroke or TIA, we did not want to
start the patient on systemic anticoagulation. In addition, her
MRI brain did not reveal any evidence of prior embolic strokes
in the past.
-We counseled the patient on taking a baby aspirin 81mg daily
for stroke prevention
# Hypertension:
-Patient was continued on amlodipine 5mg daily which is her home
medication without issue
#Breast cancer:
-In remission, no issues during hospitalization.
Transitional Issues:
1. Please follow-up in the Neurology Clinic with Dr. ___.
___ on ___ at 3pm
2. We have ordered an outpatient EEG to be done prior to her
outpatient neurology appointment. The point of this study is to
ensure that the EEG remains stable as compared to the one we did
during her hospitalization and has not changed.
3. Patient to continue taking aspirin 81mg daily
4. Patient to follow-up with her PCP in the next two weeks | 202 | 451 |
12923696-DS-5 | 20,868,096 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated on the right leg
- Please remain in full extension in the locked ___ brace at
all times unless instructed otherwise
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 80 mg every 12 hours by subcutaneous
injection AND Coumadin 5 mg every night by mouth until you
follow-up with your PCP to get your INR re-checked.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- ___ brace must be left on until follow up appointment
unless otherwise instructed
- Do NOT get ___ wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic ___
days post-operation for evaluation. Call ___ to
schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within 3 days for anticoagulation management, an INR
check, and for and any new medications/refills. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right patellar tendon disruption and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for a right patellar tendon repair,
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
weight bearing as tolerated in the right lower extremity in a
locked ___ brace in full extension, and will be discharged
on therapeutic Lovenox 80mg SC q12h bridge to Coumadin 5mg PO
daily for anticoagulation. 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. | 365 | 275 |
11899569-DS-22 | 29,944,185 | You were admitted to the trauma surgery service with a
right-sided rib fracture, right pneumothorax, and subcutaneous
emphysema. You had a chest tube placed and your pain control was
optimized. You are being discharged home in stable condition
with the following directions:
* Your injury caused a 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.
*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 trauma surgery service after
presenting with right 10th rib fracture and associated right
pneumothorax and extensive subcutaneous emphysema. A right chest
tube was inserted and initially placed to suction, then was
transitioned to water seal. The patient had persistent
subcutaneous emphysema as well as small R pneumothorax on repeat
chest X-ray on hospital day 5, so the thoracic surgery service
was consulted and recommended non-contrast chest CT, which
showed no residual pneumothorax. The chest tube was pulled the
next day, with post-pull CXR showing no residual PTX. The
patient's respiratory status remained stable. Additionally, the
patient's pain control regimen was optimized during his stay to
allow for adequate respiratory effort. His respiratory status
was stable throughout his stay, and he was discharged him in
stable condition. | 576 | 133 |
16577443-DS-6 | 24,683,073 | Dear ___,
___ was a pleasure caring for ___ while ___ were hospitalized at
the ___. ___ were admitted for facial
asymmetry that likely reflected a transient ischemic attack. We
did not find anything on our work-up which would merit
intervention, but did start ___ on aspirin to decrease your
future risk of stroke.
We made the following changes to your medication list:
- We STARTED ___ on ASPIRIN 81mg once a day
Please continue to take your other medications as previously
prescribed.
If ___ experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of ___ on this hospitalization. | ___ is a ___ with h/o advanced Alzheimer's dementia,
HLD, PVD, PMR (on chronic prednisone), who presented with a
transient episode of slumping to the right with a possible R
facial droop and unresponsiveness then with subsequent return to
baseline within 20 minutes likely representative of TIA.
.
# TIA: Her exams were limited by her mental status, but the only
abnormality that is not part of her known baseline was a mild
flattening of the nasolabial fold noted on ___, which
subsequently resolved. She had a NCHCT which showed no new
strokes. She had a CTA of her head and neck which showed no
blood vessel abnormalities. She had carotid dopplers which
showed no significant stenosis. She had an EEG that was normal
(in case her transient event could have been a seizure). She
had a HgA1C which was normal as was her lipid panel. Her echo,
however did show some apical hypokinesis. Therefore, given the
liklihood that her event was a TIA, we started her on a baby
aspirin (after discussing this with her PCP's nurse
practitioner). This will help modify her stroke risk factors as
well as her cardiovascular risk factors.
.
# Dementia/AMS: Her mental status on this admissiton initially
appeeared to be slightly worse than pt's fluctuating baseline
per her daughter. UA and CXR done on admission were negative for
infection, but a repeat CXR done on the day prior to D/C showed
a question of an opacity. She was observed for an extra day to
ensure that she did not spike a fever or her WBC elevated and
when neither of these happened it was felt that the opacity was
likely atelectastis. While here, for her dementia we continued
her home dose memantine, donezepil, citalopram and trazodone.
. | 111 | 301 |
19857454-DS-21 | 29,355,998 | Dear Ms. ___,
You were admitted with fever of unknown origin. Your fever is
likely due to the drug minoxidil or from the antibiotic
vancomycin. You underwent workup with tagged white blood cell
scan with was positive only for slightly increased uptake in the
right upper extremity, however ultrasound of your graft does not
indicate that it is infected. While here you also developed a
COPD exacerbation, and were found to have some infiltrates on CT
of your chest. A bronchoscopy was performed without signficant
growth. A small amount of bacteria grew on culture which your
outpatient doctors ___ follow up ___ final results
regarding these bacteria are still pending. In light of your
overall clinical status, a pneumonia appears unlikely.
The following changes were made to your medications:
Please START prednisone 40mg daily for 1 more day.
START colace scheduled daily, senna as needed, and miralax daily
for your constipation.
START guaifenasin for your cough
STOP minoxidil as this may have caused your fevers
STOP vancomycin as this may have caused your fevers
- Your Insulin doses on the insulin pump have been changed and
will need to be changed further at your Endocrinology
appointment tomorrow. ** Please be sure to make it to your
Endocrinology appointment this week. **
- You will also be prescribed glucagon injectable to be used as
needed for low blood sugars. | Ms. ___ is a ___ year old woman with a past medical history
significant for end stage renal disease on hemodialysis, type 2
diabetes mellitus and chronic obstructive pulmonary disease
admitted for fevers x1 month, which were ultimately felt to be
drug fever from either Vancomycin or minoxidil. Hospital course
was notable for a mild COPD exacerbation and steroid induced
hyperglycemia
#Fever of unknown origin/Drug Fever: Given history of bacteremia
with strep mitis and preceding 1 month of persistent fevers with
normal TTE and CT abdomen, initially our efforts focused on
finding a source persistent infection. Initial culprits were
thought to be the dialysis graft or endocarditis. Negative TTE
at OSH, and negative TEE in house made endocarditis unlikely.
Unremarkable US of right upper extremity graft made this
unlikely. Furthermore, there was only a mild increase in tracer
uptake in the right upper extremity compared to the left upper
extremity on tagged white blood cell scan. Bilateral lower
extremity vascular ultrasounds were negative for DVT. Blood
smear was negative for parasites. Hepatitis serologies were also
negative and LFTs were normal. An MRI was also obtained given
spinal hardware and was negative for signs of
infection/inflammation. Due to worsening shortness of breath
discovered in house, a CT of the chest was performed which was
significant for ground glass opacities involving the posterior
aspect of left upper lobe, lingula and left lower lobe. BAL and
bronchial biopsy were significant only for ___ cfu of gram
negative rods and respiratory flora. A transbronchial biopsy was
non-specific without evidence of malignancy or granulomas. Six
sets of blood cultures were obtained while Ms. ___ was off of
antibiotics. Beta Glucan and Galactomannal were within normal
limits.Rheumatologic labwork was relatively unimpressive with a
normal ANCA/RF and intermediate ___ (1:80). Given absence of
positive infectious workup, Vancomycin was discontinued, as was
minoxidil as patient gave history fevers starting around the
time of minoxidil initiation. After stopping these medications,
the patient defervesced and was afebrile for >5 days suggesting
drug fever.
#Mild exacerbation of chronic obstructive pulmonary disease:
Overall Ms. ___ respiratory symptoms and radiographic
findings were seen as most consistent with a COPD exacerbation.
Patient was treated with azithromycin and prednisone 40mg po
with improvement in symptoms and patient was discharged to
complete a one week total course. Of note, it took ~4 days for
patient to start responding to the steroids, which was similar
to when patient has required steroids for COPD exacerbation in
the past. Although patient grew ___ cfu E. coli in the BAL it
was not felt that these were pathogenic as patient responded to
treatment with azithro and prednisone.
#End stage renal disease on dialysis: MWF dialysis was continued
in house. Due to hypophosphatemia, revela and phoslo were
temporarily discontinued.
#Type II diabetes mellitus: Ms. ___ was maintained on her
insulin pump which was closely monitored by the ___.
Her blood sugars increased while on steroids (up to 400s), and
basal parameters of her pump were increased while she was on
steroids with input from ___. She was discharged with close
followup in ___ clinic two days post discharge and was
made aware that her insulin requirements will fall once her
steroids are completed. She is aware of signs of hypoglycemia
and was discharged with glucagon injectable as needed.
# BPPV: Meclizine was continued.
#Disposition:
Patient was discharged home with one more day of prednisone to
take. She ___ with her Endocrinologist who will give her
instructions on how to change her insulin as she comes off
prednisone. She will also follow up with her PCP, outpatient
renal and pulmonary doctors. | 223 | 597 |
16577068-DS-6 | 27,452,794 | Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
came for further evaluation of a new mass in your abdomen.
While here, a cystoscopy and TURBT procedure was performed and
biopsies were taken. The mass was found to be lymphoma and you
had a port placed to receive chemotherapy. You received one
cycle of chemotherapy without any complications.
Your kidney function worsened while you were admitted, which may
have been related to obstruction from the mass. With
chemotherapy, the mass grew smaller in size and your kidney
function improved.
You also were found to be have an atypical rhythm to your
heartbeat. This resolved with medication.
It was a pleasure caring for you,
Your ___ Team | ___ year old woman with dementia, prior hx of afib admitted for
intra-abdominal mass found to be high grade diffuse large B cell
lymphoma, completed C1 of R-mini-
CHOP without any complications. Hospital stay was complicated by
development of rapid afib now well controlled in NSR on
metoprolol, and renal failure likely ___ obstruction by tumor
with a foley in place for drainage. She was hemodynamically
stable with a Cr of 0.7 on discharge.
#High grade large b-cell lymphoma: Found on MRI on ___ that
showed "Pelvic mass at the posterior bladder base which appears
to demonstrate mass affect on the bladder, possibly arising from
the bladder wall or posterior bladder neck." Cystoscopy/TURBT
procedure done with biopsies showing high-grade diffuse large
b-cell
lymphoma. The patient had a port placed by ___ and completed one
cycle of R-mini-CHOP without complications. She was discharged
with allopurinol ___ mg daily and Neupogen 300 mcg daily with
___ services organized for teaching her how to administer it.
Patient is to follow-up with Dr. ___ on ___. Patient was
also given Ciprofloxacin 500 mg BID in case of fevers or chills,
but it was noted after discharge that the patient had an allergy
to the medication (reaction not noted). The pharmacy as well as
the patient and her son were notified and the prescription was
discontinued. She also has home visiting services with physical
therapy.
#Atrial fibrillation: Hx of afib for which she was on warfarin
for ___ weeks until discontinued a week ago due to hematuria and
anemia. Developed afib with RVR on ___, infectious workup
negative, TSH wnl, Echo showed normal EF with mod to severe MR
which can be a possible etiology. Patient was started on
metoprolol 75 mg TID and was in NSR since. Patient was
discharged on metoprolol 37.5 mg TID due to episodes of
bradycardia and hypotension.
#Acute renal failure: Cr increased up to 2.0 and returned to
baseline at 0.7 on discharge. This was likely ___ to obstruction
from the mass, which decreased in size with the chemotherapy.
Renal U/S showing evidence of b/l hydronephrosis which was
discussed with urology and a foley was placed for drainage.
Repeat renal U/S on ___ showed improved hydronephrosis
bilaterally. The patient had a void trial and was producing good
urine. She was discharged home without a foley. | 126 | 385 |
13199590-DS-5 | 28,595,761 | ___ abscess: Discharge Instructions
You have undergone a surgical procedure for drainage of an
abscess near your rectum. You did not have any fevers or a high
white blood cell count (an indication of infection), so you did
not receive antibiotics. Your wound was initially packed tightly
with iodoform packing. It was replaced once yesterday, and came
out on its own. You do not need to have this replaced. You may
place some gauze near the anal opening if you continue to have
any drainage or bleeding.
Home care:
*For the next several days, as healing takes place, take two or
three warm baths daily ___ baths)
* You should also keep a cotton or gauze dressing tucked against
the opening of the abscess to absorb any drainage or bleeding -
it is normal to have some drainage for up to 10 days
* normal activities can be resumed as tolerated
* If constipation has been a problem or if you are taking pain
pills that make you constipated (any narcotic pain meds), take a
stool softener such as Colace (docusate sodium)
* Do not drive or operate heavy machinery while taking narcotic
pain medication | Mr. ___ was admitted and underwent examination under
anesethia of the ___ abscess, which was excised,
drained, and packed with iodoform and kerlex dressing. He
tolerated the procedure well, was extubated and brought to the
PACU and then the floor for observation. He remained afebrile
and his white blood cell count decreased, so he was not placed
on antibiotics. The plan was for him to be discharged home on
post-operative day 2 after removal of the packing, however as he
was walking to the bathroom he felt very lightheaded and nearly
fainted, and had some mild orthostatic hypotension, which was
thought to be due to a vasovagal response from the tight
packing. The packing was removed and replaced, and later fell
out on its own on post-operative day 3. A light gauze dressing
was placed over the wound, and he was discharged on
post-operative day 4 with instructions to follow up in ___
clinic in ___ weeks. | 188 | 158 |
18458018-DS-20 | 21,261,167 | Dear Ms. ___,
You were in the hospital because you had fevers and dizziness.
We did blood work which showed you had a bacterial infection in
your blood. We think this was caused by a urinary tract
infection.
You were given antibiotics to treat the infection and you felt
better.
Now that you are going home, it will be important for you to
take all of your medicines as prescribed. You will need to take
the antibiotic "ciprofloxacin" twice a day for 11 days until
___. Please call your doctor if you develop new joint
stiffness or pain in your tendons while taking this medicine.
Please call your doctor if you have any of the danger signs in
this discharge paperwork. Please follow-up with your PCP ___
2 weeks to ensure you are feeling better. We are working on
scheduling this appointment for you.
We wish you the best!
-Your ___ Team | Ms. ___ is a ___ yo F with IDDM c/b neuropathy who presents
with several days of dizziness and fever who was found to have
UA suspicious for infection and GNRs in BCx.
# E. Coli acute bloodstream infection due to UTI
She was initially tachycardic, tachypneic, and febrile to 103
with rigoring on admission. She was started on vanc/zosyn and
then narrowed to zosyn, followed by Cipro, when BCx were
positive for GNRs sensitive to ciprofloxacin. Ultimately
speciated to E. coli. UCx were negative, but she may have
received first dose of antibiotics prior to UCx. Her
tachycardia, tachypnea and fevers resolved shortly after
admission and she was afebrile w/neg BCx >48 hours prior to
switching her to PO ciprofloxacin (end ___ for total 14 day
course).
# Anion gap metabolic acidosis- Presented with gap 18, lactate
3.3 and bicarb 20. Thought to be related to sepsis. Normalized
with fluids and antibiotics.
# Hyponatremia: Thought likely hypovolemic, hyponatremia.
Normalized with fluids.
# Acute kidney injury: Cr 1.2 on arrival suspicious for acute
kidney injury iso of sepsis/poor PO intake. Resolved with
fluids. Trended to .___ throughout hospital course.
# IDDM c/b neuropathy: pt hyperglycemic on arrival to the ED.
Received 10U regular insulin with persistently elevated sugars.
No sign of DKA. BG well controlled during the rest of the
admission w/ lantus 28U, Humalog 14U and ISS while inpatient.
Metformin held. Gabapentin continued for neuropathy.
# HTN: Held Lisinopril 10 mg iso sepsis. Did not resumed on
admission. Recommend resuming as outpatient.
# HLD: continued simvastatin 10 mg.
CORE MEASURES
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS: ciprofloxacin 500mg bid (end ___ for full
___bx)
# HELD MEDICATIONS: lisinopril 10 mg (iso sepsis and held on
discharge)
[] Additional BCx pending at time of discharge
[] If continues to have recurrent UTIs would consider further
w/u, including abdominal imaging (cannot be sure of urinary
source as UCx was negative, can consider potential abdominal
abscess)
[] Please restart lisinopril as tolerated
# CODE: Full
# CONTACT: Son ___ (lives close by: ___ or daughter
___ (lives in ___: ___ | 151 | 340 |
18974686-DS-16 | 23,471,876 | Dear Mr. ___,
You were hospitalized for numbness in your legs reaching up to
your waist area. An MRI of your thoracic spine had previously
shown a suspected demyelinating lesion at T6. This likely led to
your symptoms. We also checked an MRI of your head which was
normal.
We believe that this lesion in your spinal cord is likely a
'post-infectious demyelinating lesion'. In other words, your
body produced anti-bodies to fight a virus that likely also
attacked myelin in that one area of your spinal cord. As you
have no other lesions in your brain or in other areas of your
spinal cord, you do not have MS at this time.
Your symptoms should improve with time. You have also been
started on gabapentin to help decrease the tingling sensation in
your legs.
We wish you all the best! | Mr. ___ is a ___ ___ gentleman who presented to ___
___ with worsening bilateral lower limb numbness spreading up
to the waist area. MRI done as an outpatient on ___ showed a T2
hyperintense and non-enhancing spinal cord lesion at T6 that may
have been the sequela of transverse myelitis. He was admitted to
the general neurology service for further management.
He underwent an MRI of the head with and without contrast that
was unremarkable. On hospital day #2, his exam improved without
any intervention (temperature sensation was intact throughout).
Given he had minimal symptoms, he underwent no other work-up and
was not given steroids. He was diagnosed with an acute
post-infectious demylination syndrome and close neurology
follow-up was arranged at discharge. He was also started on
gabapentin 300 mg TID for paresthesias in his toes bilaterally
at discharge.
======================
TRANSITIONS OF CARE
======================
-B12 level was pending at discharge.
-Final read of MRI brain was pending at discharge.
-Pt was started on gabapentin for paresthesias in his left leg;
this medication can be uptitrated as an outpatient. | 139 | 172 |
15273049-DS-14 | 23,074,485 | Ms. ___,
You presented with GI bleeding, likely related to your
diverticular disease. This bleeding ultimately stopped on its
own, and your blood counts remained stable. You were seen by
the GI service.
You also had pain in your lower back. This was ultimately felt
to be related to arthritis as there was no evidence of fracture
or other disease on your CT scan or X-ray. You should continue
to take Tylenol around the clock and follow up with your PCP to
discuss ongoing physical therapy. | ___ y/o F with diverticulosis, here with GIB. Course complicated
by lower back / hip pain.
# L Back / Flank Pain: Ddx included SI joint arthritis
(exacerbated by lying in bed during hospital course) vs. GI
pathology related to her current presentation. Hip films
negative. CTA without acute process on prelim read. She was
placed on standing Tylenol and Lidoderm for pain control. ___
evaluated her and recommended home versus rehab. Since she lives
near so many family her family preferred that she go home with
home services. She was discharged home with home ___.
# GI Bleeding / Diverticulosis / Acute Blood Loss Anemia: Given
known diverticulosis, GI bleeding is likely diverticular in
nature. Other considerations would be AVM vs. hemorrhoidal (less
likely given volume) vs. malignancy (less likely given sudden
onset). Bleeding initially resolved spontaneously but then
recurred during hospitalization. H/H had initial drop from
baseline but then remained stable thereafter. Pt never required
transfusion. GI evaluated patient and recommended against
emergent scope. CTA performed during recurrent bleeding episode
revealed no active extravasation.
# HTN: HCTZ held ___ bleeding. The patient's blood pressure was
well controlled and HCTZ was held until PCP follow up.
# HLD: Continue statin.
# Asthma: Albuterol PRN. Pt not taking Advair at home. | 88 | 207 |
18237362-DS-12 | 25,962,268 | Dear Mr. ___,
You presented to the ___ on
___ after suffering a snowmobile accident. You experienced
loss of consciousness, an injury to your head and right-sided
rib fractures. You were admitted to the Trauma/Acute Care
Surgery team for further medical management.
Given your injuries and your history of shoulder surgery, you
will need to follow with your regular orthopedist and may
require imaging of the shoulder. Please follow with your
outpatient orthopedist to make sure that your shoulder implant
is MRI compatible before any MRI imaging.
You were evaluated by the Neurology and Neurosurgery teams for
your head injury. The Neurology team recommends alcohol
cessation to prevent further health issues, and possible
outpatient counseling regarding alcohol if needed. The
Neurosurgery team recommends you stay on the medication Keppra
to prevent seizures.
You are now medically cleared to be discharged home to continue
your recovery.
Please note the following discharge instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Rib Fractures:
* Your injury caused right-sided 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).
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms | Mr. ___ is a ___ y M admitted to the trauma surgical service
on ___ at ___ after a snowmobile accident. He was found
down by a neighbor and is amnesic to the event. Imaging revealed
right subarachnoid hemorrhage and right rib fractures ___.
Neurosurgery was consulted and recommended a repeat head CT
scan, Keppra, maintaining systolic blood pressure less than 140,
and hourly neurological checks. He was admitted to the trauma
surgical ICU.
On HD2 his neurological exam remained intact and he was
transferred to the floor for further neurological monitoring and
pain control.
On HD3 he was ambulating, tolerating a regular diet, and pain
was controlled on oral medications. He was evaluated by physical
therapy and occupational therapy who recommended discharge to
home and follow up with the concussion clinic.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Per Neurosurgery
recommendations he will complete 7 days of seizure prophylaxis
with Keppra. Follow up appointments were arranged. He will
follow up with an MRI of his right shoulder as an outpatient. | 535 | 211 |
12971370-DS-17 | 23,595,339 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for pain in your stomach, confusion, and
chills.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you had a CT scan which showed
inflammation in your intestines.
- We found that you also had injury to your kidneys.
- We treated you with antibiotics for the infection in your
abdomen.
- You were improved so we felt it was safe for you to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | BRIEF SUMMARY OF ADMISSION
==========================
Ms ___ is a ___ F PMHX HTN, DMII, COPD, CKD III, prior stroke,
morbid obesity who presented to an OSH with AMS and abdominal
pain, CT abdomen pelvis initially concerning for colovesicular
or colovaginal fistula, for which she was transferred to ___
for further management, briefly admitted to the MICU for
transient hypoxia requiring BiPAP. Course was complicated by
___, precluding CT with IV contrast. Ultimately it was felt that
symptoms were secondary to complicated diverticulitis and given
patient's significant agitation and fear when CT scan was
attempted, along with her clinical improvement on antibiotics,
this was deferred. | 135 | 104 |
18628529-DS-7 | 23,429,111 | Dear Mr. ___,
You were admitted to the ___ for pain in your shoulder. You
were treated with pain medications. Your pain improved. We are
discharging you with pain medications. We encourage you to
follow up with hematology, orthopedic surgery and your primary
care doctor. We wish you all the best. | ___ with sickle cell disease with known R shoulder avascular
necrosis, and recurrent pain crises in that shoulder, presents
with right shoulder pain.
ACTIVE DIAGNOSES
# R shoulder pain- represents pain crises vs. acute on chronic
shoulder pain unrelated to vasocclusive event. Given hct at
baseline, lack of evidence for acute hemolysis, and lack of
fever, chest pain, abd pain, decreased oxygen saturation, or
triggers for pain crises this episode likely represents
non-vasoocclusive shoulder pain, possibly rebound pain secondary
to opiate dependence. Given history of frequent admissions for
pain, and absence of HR and BP elevation consistent with
physiologic response to pain, likely a component of opiate
dependence contributing. He was treated with home dose of
methadone 10 mg TID and IV hydromorphone 2 mg Q3H and IVF
overnight. He required 1 additional po hydromorphone 2mg PRN.
Given good po intake, he was then transitioned to po 30 mg
oxycodone Q4H. He decided he was ready to be discharged at that
point. He was continued on home bowel regimen. He was asked to
see outpatient specialists.
CHRONIC DIAGNOSES
# Sickle Cell Anemia- the patient is on folate, but not on
hydroxyurea. He has not seen his hematologist or primary care
provider in ___ months. He reports good hydration at home, but
has frequent pain episodes requiring admission and opiate
escalation. He currently denies fevers or chest pain, and clear
lungs on exam and CXR are reassuring for no signs of acute
chest. Bilirubin and reticulocytes were not elevated, making
hemolysis less likely.
# Asthma- he was continued on home doses of albuterol PRN.
TRANSITIONAL ISSUES
# CODE: full
# CONTACT: patient
# Issues to discuss at followup:
-pain medication titration
-R shoulder avascular necrosis management
-sickle cell anemia management | 50 | 281 |
10626477-DS-8 | 20,688,698 | Dear ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were found to have a clot in your lungs, which is likely
a complication of the orthopedic surgery
What happened while I was in the hospital?
- We did several lab and imaging tests to show that the clot
was not impacting your heart function. We treated you with a
medication to help prevent further clot formation in your lungs
(blood thinner). You will need to take this medication when you
leave the hospital for at least 3 months. Your primary care
doctor ___ help determine when it's ok to stop the medications
What should I do once I leave the hospital?
- We started you on iron supplementation for your low iron
levels. This sometimes can cause constipation so if you become
constipated you should use more of your stool softeners or start
taking miralax every day to keep you regular. If you become too
constipated then talk to your doctor about receiving iron
through the IV.
- Be sure to take your blood thinner every day until your
primary care doctor says you should stop. You will take 10 mg
twice a day for 3 more days and then on ___ you should start
5mg twice a day.
- Take your medications as prescribed and follow up with your
doctor appointments as listed below.
We wish you the best!
___ Care Team | Ms. ___ is a ___ woman with a history of HTN, HLD,
CVA (___), DM2, hypothyroid, obesity, GERD, who presented with
provoked pulmonary embolism in the setting of hip surgery.
Patient managed with anticoagulation and discharged on apixaban. | 262 | 39 |
17556194-DS-7 | 25,207,594 | Dear Ms. ___,
You came to the hospital after you felt very weak and could not
get up off the ground. We discovered that you have something
called pachymeningitis. We did many tests and two brain biopsies
to try to find out what was causing your symptoms and the
pachymeningitis but we were unable to discover the cause. We
have worked with many consulting services and have decided that
it would be bets to continue to finish the treatment for Tb
meningitis. You will continue to be treated for c. difficille
for 2 weeks after you finish the Tb treatment. Additionally, we
will continue your prednisone and decrease it every week. We
wish you and your family the very best and hope that you
recover.
It was a pleasure taking care of you,
Your ___ Team | PATIENT:
___ year old woman with a medical history of Hash___'s
thyroiditis, RLL fibrothorax (non-malignant, non-mycobacterial),
history of IGRA positivity and IgG4 nasal turbinate disease,
recent admission for headache with imaging showing
pachymeningeal enhancement and CSF studies showing lymphocytic
pleiocytosis but with negative TB NAAT, who was re-admitted on
___ for generalized weakness and imaging consistent with venous
sinus thrombosis. The patient had an acute worsening of mental
status the morning of ___ during which she became unresponsive
albeit without changes in her vital signs, prompting MICU
transfer and extended MICU course including chronic intubation
resulting in trach/peg placement with full course detailed
below. After stabilization, she was sent to the medicine floor
for further management. Patient remained stable on the medical
floor with stable respiratory status and unchanged neurological
status for 1 week after call out from MICU. At that time, felt
that patient safe for discharge to ___ for further
treatment where they will be able to continue monitor patient
and help her continue to heal neurologically as able.
ACUTE ISSUES
# PACHYMENINGITIS AND LYMPHOCYTIC PLEIOCYTOSIS:
- Patient was admitted between ___ for left-sided
frontal headaches x1 week. At that time she would shake her head
to Yes/No questions and would follow commands, but she would not
verbally communicate (even with a ___ interpreter). During
that admission she was found to have CSF with a lymphocytic
pleiocytosis (WBC 450, lymphocytes ~90%), elevated protein (191)
and low glucose (39). She also had pachymeningeal enhancement on
FLAIR MRI sequences, as well as a small left corona radiata
lacunar infarct. She had negative Lyme, HSV, VZV and arbovirus
serologies. CSF enterovirus culture was negative, as was CSF EBV
PCR and CSF TB PCR x3. RPR w/ prozone was negative for syphilis.
Flow cytometry was consistent with reactive lymphocytosis.
Patient was initially treated with ceftriaxone, acyclovir but
these were discontinued after workup for infectious etiologies
was unrevealing and patient made substantial recovery in terms
of her mental status. It was presumed that the etiology of her
meningitis with aseptic/viral and she was able to be discharged
home with follow up.
- The patient represented on ___ after sudden onset of
generalized weakness preventing her from standing. She was
incontinent of urine and endorsing ongoing headache. She was
encephalopathic, oriented to person and place only. She was
admitted and covered broadly for infectious etiologies of
meningitis (vancomycin, ceftriaxone and acyclovir) but continued
to rapidly decline in terms of her mental status, and within 1
day of admission she required transfer to the medical ICU and
intubation for airway protection in the setting of becoming
unresponsive (albeit with unchanged vital signs). Neurology,
neurosurgery, neuro-oncology and infectious disease services
were consulted. The differential for her presentation was felt
to include TB meningitis, IgG4-related disease, vasculitis,
venous sinus thrombosis, lymphoma, or an idiopathic hypertrophic
pachymeningitis.
- At time of transfer to the medical ICU, empiric treatment with
rifampin, isoniazid, pyrazinamide, ethambutol and levofloxacin
were started for empiric TB meningitis treatment. She was also
given methylprednisolone 500 mg IV daily x6 days for empiric
treatment of vasculitis and IgG4 related disease, however no
improvement was seen during this time. Acyclovir and ceftriaxone
were discontinued once CSF HSV PCR and cultures from CSF
returned negative. Plan to treat for 2 month course (end date
___
- The patient underwent right frontal craniotomy with meningeal
biopsy on ___. This biopsy was unrevealing (dura w/ patchy
acute and chronic inflammation, mild meningeal chronic
inflammation, no evidence of vasculitis), although the validity
of the biopsy result was uncertain due to difficulty obtaining
an area of the meninges with pachymeningeal enhancement. MRI/MRA
Brain on ___ revealed no significant change in the
leptomeningeal enhancement, while repeat on ___ showed slight
interval increase in the intensity with stable distribution of
the pachymeningeal and lepomeningeal enhancement. After
multidisciplinary meetings and given the differential diagnosis
centering on either TB meningitis or IgG4/Vasculitic disease, it
was decided to obtain angiography of the brain to assess for any
evidence of vasculitis. This was performed on ___ and did not
show significant findings: there was a mild narrowing of some
vessels which was consistent with meningitis, and not
vasculitis. Concomitantly outpatient pathologic samples were
examined by our rheumatology and pathology teams to assess for
evidence of IgG4 vasculitis. This analysis was inconclusive and
somewhat limited by the lack of multiple levels of biopsy sample
provided to ___. Repeat MRI showed new findings which were
concerning for an underlying infectious process, possibly
fungal. A repeat brain biopsy was performed on ___ which did
not reveal any clear etiology. Universal PCR from the second
brain biopsy was negative for mycobacterium tuberculosis, non Tb
mycobacterium, fungi and bacteria. Despite that, it was felt
from an infectious disease standpoint that the radiological
findings of pachymengitis were still consistent with Tb, which
would be treatable so they recommended completing the 2 month
course of RIPE+levofloxicin.
# VENOUS SINUS THROMBOSIS:
- ___ on ___ showed hyperdensity of distal left transverse
sinus consistent with venous sinus thrombosis. CTA/CTV confirmed
a focal thrombus in the left distal transverse sinus. Neurology
was consulted. No anticoagulation was initiated per their
recommendations, although she was continued on ASA 81mg qday.
The size of this thrombus was noted to progressively decrease on
follow up MRI/MRA imaging on ___ and ___.
# CEREBRAL VASOSPASM:
- MRI/MRA Brain on ___ revealed severe narrowing and
irregularity of the intracranial arteries bilaterally, involving
the middle and anterior cerebral arteries to a greater extent
than the basilar and posterior cerebral arteries. This was felt
to be consistent with severe vasospasm secondary to the
patient's underlying meningitic process. She was subsequently
started on nimodipine and atorvastatin per neurology's
recommendations. MRI/MRA on ___ revealed interval resolution of
vasospasm. On ___ the patient's Nimodipine was
discontinued and a repeat MRI/MRA brain was ordered which showed
nodular leptomeningeal enhancement.
# HYDROCEPHALUS:
- On ___, at time of the patient's rapid change in mental
status, neurosurgery was consulted emergently for consideration
of hydrocephalus secondary to meningitis. Patient was known at
that time to have communicating hydrocephalus. Neurosurgery
placed an EVD for ICP monitoring. Opening pressure was elevated
(___). EVD remained in place until ___ at which point it was
removed due to risk of infection.
# NON-CONVULSIVE STATUS EPILEPTICUS:
- Patient being found in non-convulsive status epilepticus on
___. Subsequently, a number of her medications were modified
including a discontinuation of metronidazole (previously on for
C.difficile infection). She was loaded with Keppra and later
lacosamide without complete suppressoin of seizure activity.
Propofol was therefore used for burst suppression. After several
days of propofol and ongoing maintenance dosing of Keppra and
lacosamide, propofol was able to be weaned without recurrence of
her seizures. There were no further episodes of status noted on
repeat EEG.
# PUPILLARY CHANGES:
- On admission, neurology recorded her exam as PERRL 4->2 brisk,
sharp discs on fundoscopy bilaterally, visual fields full to
number counting, EOMI, no nystagmus. However, on ___ (in
setting of acute worsening of her mental status shortly after
admission), she was noted to have developed dilated and fixed
pupils as well as intermittent horizontal nystagmus concerning
for either increased intracranial pressure or seizures. CT Head
at that time revealed no significant changes. Neurology felt
that imaging showed concerns for focal infarcts in the
brainstem. Over the subsequent 2 weeks, her neurological exam
was noted to fluctuate with intermittently asymmetric pupils and
presence of horizontal nystagmus.
- On ___, there appeared to be some improvement in her
neurological exam. She had intermittent spontaneous movement of
her extremities was observed although she still was not
withdrawing to painful stimuli. She was also noted to have a
new, albeit weak, gag reflex on ___.
# RESPIRATORY FAILURE:
- Patient was intubated on ___ for airway protection in setting
of rapidly worsening mental status and obtundation. For the
entirety of her stay she required only minimal ventilator
support, largely remaining on pressure support only. On ___,
however, the patient starting exhibiting periods of apnea that
required switching her to MMV.
- On ___ the patient underwent tracheostomy and percutaneous
endoscopic gastrostomy (PEG) with the Interventional Pulmonary
service given her inability to be weaned from the ventilator and
her family's desire to pursue ongoing maximally intensive care.
- On the floor she continued to have high oxygen saturation
(around 100%) on tracheal mask.
- Can consider downsizing trach and possible removal at ___ if
able
# HYPOTENSION:
- On ___, the patient's BP dropped to 87/52. SBPs had
previously between 100s-120s. Norepinephrine gtt was started at
that time to maintain MAP > 60. Etiology was hypotension
remained unclear, with extensive infectious workup negative.
Patient was also on high doses of steroids which made adrenal
insufficiency improbable. Patient was started on midodrine 10mg
PO TID on ___. Norepinephrine gtt was weaned and eventually
able to be discontinued on ___. On the floor she was maintained
on midorine 5mg every 8 hours with stable baseline SBPs ranging
___ systolic to 100.
.
# Sodium Handling Abnormalities:
- The patient had several episodes of extremely rapid
fluctuations in her serum sodium (as rapid as Na 138 to 161 in
10 hours). These were managed with a combination of D5W and
desmopressin. Central diabetes insipidus was definitively
diagnosed on ___ with steady rise in urine osmolality from 169
(pre-ddAVP) up to 840 (post-ddAVP) in setting of serum sodium
value in low 150s. Patient's central DI stabilized with a
regimen of 1mcg ddAVP qday which was started on ___. Prior to
transfer from the MICU to the floor, she developed hyponatremia
consistent with SIADH (elevated UOsm in setting of hyponatremia
to 129) which improved to 137 with 2g Na tablets and free water
restriction to 1.5L.
# ABNORMAL THYROID FUNCTION STUDIES:
- TSH was 0.082 on ___ with T4 being 6.3 at that time. Repeat
TSH on ___ was 1.6, with T4 and T3 being 3.8 and 55
respectively. Endocrinology was consulted and felt that these
changes were consistent with reactive changes to critical
illness (sick euthyroid syndrome). Nevertheless, given her
history of ___'s thyroiditis and subsequent risk of
developing true hypothyroidism (and given the setting of her
altered mental status and obtundation) they recommended started
levothyroxine 50mcg daily.
# C. Diff Infection: Patient with significant watery diarrhea
and tested positive for C. Diff infection. Started on PO
Vancomycin with plan to continue treatment for 2 weeks after
completion of TB treatment as above. Assume stop TB treatment on
___, continue PO Vancomycin until ___.
# GOALS OF CARE:
- Multiple goals of care discussions were conducted on
___ and ___ with the family desiring
ongoing maximally intensive care with understanding that patient
is DNR though ok for ventilation if needed given trach. During
meeting on ___, discussed with sister and nephew/HCP patients
overall clinical status as well as poor prognosis, specifically
explaining that patient's diagnosis remains elusive but best
chance is to treat for TB infection however with understanding
that the patient may not regain significant cognitive or
functional status.
CHRONIC ISSUES
# HYPERTENSION: Hypotensive this admission. Losartan stopped
during last hospitalization.
# S/P LACUNAR STROKE: ASA daily. Started atorvastatin 80 mg
daily.
TRANSITIONAL ISSUES
- 4mm aneurysm at left M1/M2 bifurcation seen on CTA Head from
___
- Will need thyroid panel rechecked as outpatient to distinguish
euthyroid sick syndrome from true hypothyroidism
- Please have neurology follow with her once a week at the ___.
- Continue slow prednisone taper decreasing 10mg/week. Currently
30 mg; decrease to 20mg ___, 10mg ___ for 7 days and stop
___
- Continue SS Bactrim while on steroid taper
- Continue RIPE + Levofloxacin for full 2 month course (last
dose date ___ can discuss with ID doctors after
___ and follow up scheduled
- Note: patient with intermittent fevers and mild tachypnea. Low
suspicion for true infectious etiology and feel Central fevers.
However, lower for aspiration. Consider changing PEG to J tube
once tract matures (___) if continued concern for aspiration;
can coordinate with ___ as outpatient procedure if needed
- Continue PO Vancomycin for C. Diff infection. Continue dosing
until 2 weeks after completion of TB treatment
- f/u with ID specialist at ___. Will call facility with
appointement
- continue ___ rehab at ___
- Monitor Na weekly to ensure Na stable as stable SIADH this
admission but treating with Na tabs | 133 | 2,005 |
11596691-DS-14 | 28,995,014 | Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech and left
facial droop resulting from a seizure. We were unable to find a
source of your seizure while in the hospital, but you will need
to take medications to prevent future seizures.
We are changing your medications as follows:
- Start taking LevETIRAcetam (Keppra) 500 mg twice daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician.
-Please follow up with your primary care physician ___ 2
weeks of hospital discharge
-Please follow up with neurology in 2 to 4 week after hospital
discharge. If you do not hear from the clinic within a week,
please call ___
Also, take the follow seizure precautions:
- Take seizure medication as prescribed above
- Avoid activities that require being alert such a operating
equipment that could cause injury
- Where an ID bracelet or necklace at all times
- Do not stop your seizure medication without being instructed
by your doctor
___ you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team | ___ is a ___ year old woman who presented with
confusion at home & left sided facial droop with reported left
sided plegia in the ED, GTC in ED requiring intubation.
#ICU Course
CTH did not show any hemorrhage or large volume acute infarct.
Patient was admitted to the neuro ICU after intubation in the ED
for airway protection in the setting of receiving 4mg of Ativan
for seizure. Patient was weaned off sedation, and was notably
moving all 4 extremities spontaneously and pulling adequate
tidal volumes despite not following commands. The decision was
made to extubate patient as she was agitated with ETT in place
and would require significant sedation to continue ETT. Patient
was extubated at 8:30AM ___, and she did well with face tent O2
and was quickly weaned to NC only. She remained on NC as she had
desaturations while sleeping, consistent with her known sleep
apnea. Her continued altered mental status and inability to
follow commands was attributed to medication effect, as she had
received 4mg of Ativan in the ED, followed by multiple boluses
of propofol overnight while intubated. Her EEG showed no
seizures and no epileptiform discharges. An MRI was done, which
showed no acute stroke. Although patient initially received a
dose of antibiotics out of clinical concern for pneumonia, there
was no consolidation seen on chest x-ray, she was afebrile with
no leukocytosis so antibiotics were not continued. Her sodium on
admission to the NICU was 129, when corrected for glucose was
131. This was unchanged from her prior sodium in ___, so no
changes were made, and this hyponatremia was not thought to be
the source of her seizure. She was noted to have a new elevation
of her LFTs, with rising CK thought to be related to seizure;
these values trended down to normal. Patient had improving
mental status overnight until ___ AM, at which point she was
answering questions and following commands appropriately albeit
sleepy. Etiology of her event was thought to be a partial
seizure followed by secondary generalization with post-ictal
___ and subsequent agitation likely complicated by multiple
sedating medications. Seizure thought to be secondary to a
contribution of several things including patient's age, alcohol
use, and possibly recent trauma (fall 3 days prior). She was
started on Keppra 500mg PO BID for seizure prophylaxis. Since
she did not have a stroke, she was continued on her home aspirin
regimen which was 81mg ___, and ___. She was
stable for discharge from the ICU, and was transferred to the
step-down unit on ___.
#Floor course (___):
No events except brief formed visual hallucination in setting of
poor sleep. Received 1 time dose of fosfomycin for UTI | 293 | 447 |
17781343-DS-13 | 24,611,724 | Dear ___,
You were hospitalized due to mild left face droop. You were
admitted for evaluation for possible stroke. We obtained an MRI
of your brain which did NOT show stroke. Since your face droop
was noted by somebody one week ago and you also had some left
eye irritation (potentially from dry eye due to weak lid
closure), we think that you may have idiopathic Bell's palsy
which is already improving at this time. As Lyme is sometime a
cause for Bell's palsy, we sent blood test to check that. The
result of the Lyme test is pending and can be followed up by
your primary care doctor. As your facial weakness is very mild,
you will not require any medication or eye drop.
While you are here, we spoke to your podiatrist's office and
discussed your warfarin. Since you are ambulating right now, we
do not think you need anticoagulation. Please discontinue your
warfarin.
Please take your other medications as prescribed.
Please follow-up with your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body | The ___ is a ___ RH F with a PMHx significant for provoked
DVT (on Coumadin) and chronic pain syndromes who presents to the
___ ED for L lip drooping x2 days. The ___ underwent a
brain CT without contrast which was unremarkable for hemorrhage.
She also had a brain MRI which did not reveal any acute
ischemia. On neurological exam, she had a subtle flattening of
the left nasolabial fold. Otherwise, she had full strength of
her facial muscles. The ___ mental status, motor exam,
sensory exam, and coordination exam were without deficits. Lyme
titers were sent and pending at discharge, however the ___
has no history of tick exposure.
Per her covering podiatrist ___ at ___
___, Ms. ___ was started on Coumadin postoperative
after a club foot surgery ___ to her history of
provoked DVTs. However, since the ___ was now ambulatory
with a walker, she may be taken off of Coumadin. The ___
Coumadin was discontinued on this hospital course.
She was to be discharged with the diagnosis of possible subtle
Bell's palsy pending bilateral lower extremity imaging. However
she decided to leave the hospital as was not pleased with her
care. She was given discharge instructions and the number to
call for a follow up appointment with the neurology service. | 285 | 217 |
13330210-DS-17 | 25,157,266 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
You came into the hospital because you were having chest pain,
trouble breathing, and were fatigued.
What did you receive in the hospital?
While you were in the hospital, we found that you had fluid
around your heart and you had a procedure to remove that fluid.
You also had some fluid in your lungs, so we gave you a diuretic
called Lasix to help remove it. We also found that you had
pneumonia that might have been contributing to the fluid in your
lungs, and gave you antibiotics to treat that.
What should you do once you leave the hospital?
-You should follow up with the appointments we have listed
below.
-Since you do not have a spleen you should always carry
antibiotics with you. If you have a fever >100.4F you should
take a dose of augmentin (we provided you with a prescription)
and present to urgent care immediately as this may be the sign
of a series illness.
We wish you the best!
Your ___ Care Team | PATIENT SUMMARY STATMENT:
=====================
___ year old woman with remote Hodgkin lymphoma s/p radiation to
chest and pelvis in ___ and hypothyroidism who presents with 3
months of recurrent pleuritic chest pain and more recent
systemic symptoms and leg swelling, with apparent loss of pulse
at ___ s/p 2 minutes of CPR with ROSC, neurologically
intact after CPR, found to have pericardial effusion of unclear
etiology with early tamponade physiology s/p drainage, hospital
course also notable for treatment for multifocal pneumonia, now
clinically much improved with O2 Sats 92-94% on RA, with ongoing
asymptomatic desaturations to ~88% with ambulation.
ACUTE ISSUES ADDRESSED:
=======================
# Hypoxemic respiratory failure:
# Community acquired pneumonia
Likely multifactorial in etiology with multifocal pneumonia and
pleural effusions contributing. CTA negative for PE.
Additionally patient with evidence of small pleural effusions
persistent on CXR and received IV diuresis. ID was consulted
given concern for atypical organisms given asplenic status.
Legionella Ag was negative, Strep pneumo antigen negative.
Patient was treated with Azithromycin (___) and
Ceftriaxone (___), then transitioned to oral
cefpodoxime (___). Last chest x-ray ___ with bilateral
improvement of pleural effusions.
# Pericardial effusion:
S/p drainage of 220cc serosanginous fluid on ___ with drain
left in place. TTE showed an EF 75% and mild AR. Concern for
recurrence of malignancy with multiple processes (pleural and
pericardial effusions) and systemic symptoms, however cytology
negative for malignant cells. Alternative DDx: delayed
post-radiation process, effusion ___ viral infection, autoimmune
process. Cell studies not suggestive of infectious process and
culture negative. Cardiology followed the patient and did not
recommend further intervention, but recommended a repeat echo in
___ weeks time. Will establish appointment with cardiologist to
follow up after echo.
# Anemia - borderline:
Decreased TIBC, transferritin, iron and increased Ferritin,
likely reflective of anemia of chronic disease. Possibly a mixed
picture with iron deficiency anemia as well. No overt signs of
bleeding. Monitored with plan for transfusion in Hgb <7 but did
not require transfusion. | 202 | 326 |
10834132-DS-3 | 24,726,815 | Dear Mr. ___,
What brought you to the hospital?
- You came to the hospital with fatigue, worsening breathing and
leg swelling
What happened while you were in the hospital?
- You were given IV diuretics (medications to help get rid of
extra fluid in your body)
- We also changed your blood pressure medications since we
believe your high blood pressure is the cause of your difficulty
breathing and fluid build up
What should you do when you leave the hospital?
- Continue to take your medications as prescribed. See below for
a complete list of your new medications.
- Please make sure that you follow up with your primary care
doctor, cardiologist and nephrologist
- Please weigh yourself every morning and call your cardiologist
if you gain more than 3 lbs.
It was a pleasure taking care of you.
-Your ___ Team | ___ with HFpEF (EF 65%) HTN, IDDM2, CKD IV who presented with
dyspnea, orthopnea and lower extremity edema due to acute on
chronic heart failure exacerbation likely ___ uncontrolled blood
pressures.
ACTIVE ISSUES:
==============
# Hypertensive emergency
Presented w/SBPs in the 170s and had difficult to control blood
pressures on the floor with persistent hypertension. Hydralazine
held due to concern for poor renal perfusion. Isosorbide
mononitrite was increased from 30 mg daily to 120 mg daily.
Nifedipine 90 mg was continued. Hydralazine was restarted and
increased to 100 mg TID daily. Losartan was briefly held due to
rise in renal function, but then restarted at 100 mg daily.
Carvedilol was continued at 6.25 mg PO BID and not increased due
to history of symptomatic bradycardia.
Presented w/elevated BPs with acute HF exacerbation. Torsemide
was increased to 100 mg qd.
# Acute diastolic heart failure:
Volume overloaded on admission with JVP elevation, rales,
and leg edema to knees. Weight (after diuresis) 158lb, from last
clinic weight 165lb 5 weeks ago. Trigger likely multifactorial
given self-endorsed dietary indiscretion and liberal fluid
intake as well as poor blood pressure control and concern for
poor compliance. Pt initially treated with IV diuretic and then
transitioned to PO torsemide at 100 mg qd. Her
anti-hypertensives were changed as above.
# CKD IV:
Creatinine slightly elevated compared to last check, but
essentially within his recent range. Presumed secondary to
longstanding HTN and DM2. Given persistently elevated Cr and
hypertension, nephrology consulted who recommended BP management
and follow-up with them.
# IDDM2: Continued on home insulin
**TRANSITIONAL ISSUES**
Discharge weight: 70.1 kg
Discharge Cr: 4.1
Discharge diuretic: Torsemide 100 mg qd | 133 | 263 |
11325821-DS-13 | 21,191,857 | Mrs. ___,
___ was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after sustaining a fall that resulted in multiple bone
fractures, as well as a small intracranial hemorrhage. Luckily,
none of these injuries required a surgical intervention. We now
feel that you are ready to be discharged to a rehabilitation
facility, where you should continue with your ongoing recovery.
Please follow these recommendations in order to ensure a speedy
and uneventful recovery.
Discharge instructions:
-Your injury caused a 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 antiinflammatory 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 return to the emergency room if you
have any of the following:
-You experience new chest pain, pressure, squeezing or
tightness.
-New or worsening cough or wheezing.
-If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
-Any serious change in your symptoms, or any new symptoms that
concern you.
-Please resume all regular home medications and take any new
meds as ordered. | Patient was transferred from outside hospital after sustaining
mechanical fall down four steps with positive loss of
consciousness. At outside hospital, she was found to have a
small right tentorial SDH, a right 11th rib fracture, transverse
process fractures of L2 and L5 and bilateral sacral fractures.
CT c-spine was negative of injury and CT torso was negative for
solid organ injury. On presentation to the OSH she was noted to
be hypotensive to the ___'s and was started on levophed via a RIJ
TLC however the pressor has been weaned off. She also briefly
desated and had to be place on a non-rebreather. She was
transferred to our institution for further evaluation and
management of her injuries.
On admission to the trauma ICU patient was on a non-rebreather
mask but satting well on 2L NC. She denied any palpitations,
dyspnea or chest pain prior to the fall. On initial labs her
troponins rose from 0.03 to 0.22 however her MB was normal at 5.
She had a lactate of 3.5 and a Cr of 1.4. Orthopaedics, spine
and neurosugery were consulted for evaluation of injuries, all
of which were deemed non-operative. She was noted to be
hypotensive and thus started on pressors, and resuscitated with
cristalloids, and later colloids. On HD#2 she was started on
Keppra for seizure prophylaxis per neurosurgery recommendations.
A bedside echocardiogram showed good ejection fraction. On HD#3
patient worked with physical therapy. Haldol was given for
increasede aggitation and physical restraints ordered. Pressors
were weaned off. On HD#4, patient developed tachypnea when
haviing breakfast, wheezy. Albuterol neb was initiated and
respiratory rate dropped from 35 to 20. EKG showed T wave
inversion at I, avL, avF, V2, and poor R progression in
comparison with previous EKG, ABG ___. Cycled
troponins were negative. Furosemide 20 IV and ~1.5L urinary
output afterwards with improved respiration. Cardiology team was
consulted and did not make further recommendations. On HD#5 she
was given another dose of intravenous lasix with good response.
Keppra was discontinue due to altered mental status. A repeat
head CT was performed and found to be unchanged from that
obtained on admission. Scheduled nebs every 4 hours added due to
wheezing on exam and oxygen requirement.
On HD#6 she was transferred to the floor. Anticipating
discharge, she was once again evaluated by physical therapy who
recommended recovery at a rehabilitation facility. Case
management was involved in the screening process. On HD#7 Foley
catheter was removed. Given improvement, patient was deemed
suitable for discharge. She would remain touchdown
weight-bearing on right lower extremity. Follow-up appointments
with Neurosurgery, Orthopedic Surgery and Acute Care Surgery
were scheduled.
At the time of discharge patient still complained of
mild-to-moderate lower back pain, controlled with medications.
She was tolerating a regular diet and on 2L of oxygen via nasal
cannula. Destination ___ rehabilitation facility was
updated on patient's status. Patient and family memebers
received teaching and follow-up instructions, with verbalized
understanding and agreement with the discharge plan. | 429 | 494 |
15474970-DS-7 | 25,581,402 | Dear Ms. ___:
It was a pleasure caring for you during your most recent
admission. You were admitted for poor oral intake. While you
were here you had a PEG tube inserted and were started on tube
feeds. Please continue tube feeds on disharge. | ___ with clinical T4b anaplastic thyroid cancer status post
total thyroidectomy, radioactive ablation, and currently on
concurrent chemoradiotherapy with carboplatin AUC 2 weekly and
Taxol 50 mg presenting with poor PO intake for more than 2
weeks. Patient had peg tube placed on ___. Hospital course is
summarized by problems below:
#Nutrition: Patient presented with poor oral intake for over 2
weeks secondary to pain associated with swallowing. Her
baseline nausea is likely related to chemotherapy. Her dysphagia
is likely secondary to radiation or related to site of tumor.
Swallow study on ___ showed no abnormalities. Patient had PEG
inserted on ___. She continued to have nausea with tube feeds
requiring trying several feed formulations. It was unclear
whether nausea was truly related to tube feed formulations.
Patient was started on omeprzaole for possible acid reflux and
standing zofran. Overall, patient had difficulty with tolerating
tube feeds, which seemed to be related to formula and gastric
accomodation. Nutrition was consulted multiple times, and the
patient finally was able to tolerate peptamen cycled feeding
with an anti-emetic and pro-motility regimen. Plan will be to
see if she continues to tolerate and convert to bolus feeding
per nutrition recommendations.
# Anaplastic thyroid cancer: Patient received radiation therapy
while in house. She will be getting chemotherapy with
carboplatin and taxol as an outpatient. She was continued on
home levothyroxine.
# Rash: Patient presented with rash underneath armpits and groin
area. Likely rash was secondary to candidal skin infection.
Patient was treated with fluconazole from ___ to ___
with improvement in rash.
# Leukopenia and thrombocytopenia - Patient presented
pancytopenia likely in setting of chemotherapy and poor
nutrition. Counts were monitored and remained stable.
# Borderline hypocalcemia: This is favored to be secondary to
thyroid radiation with resultant parathyroid dysfunction. She
was continued on calcitriol and calcium carbonate.
# Hypothyroidism: Stable, continued on levothyroxine
# Code Status - FULL
# EMERGENCY CONTACT:
Name of health care proxy: ___ (daughter)
Phone number: ___
Cell phone: ___
# Transitional issues
- continue chemoradiation therapy for thyroid cancer as
outpatient
- consider conversion from cycled to bolus tube feeds if patient
continues to tolerate tube feeds
- titrate of anti-emetic and pro-motility regimen as needed for
tube feeds | 43 | 366 |
10030753-DS-40 | 25,629,024 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for lightheadedness and
low pressure. This was likely due to your new blood pressure
medications and the water pills. Some of these symptoms are also
related to the longstanding diabetes that causes nerve damage
that prevents you blood vessels from maintaining a stable blood
pressure. You were give intravenous fluid and your blood
pressure improved. We have stopped your nifedipine and decreased
the dose of the carvedilol you were on. We restarted you on a
small dose of the water pills to keep you from accumulating
fluid. You should follow-up with your primary care physician
___ 2 days of discharge. This appointment has been scheduled
for you.
We wish you all the best!
Your ___ Team | Ms. ___ is a ___ with PMhx of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
presents for hypotension and prescyncope in the setting of
up-titrating her anti-hypertensives. On admission, the patient
was given 1L NS and her nifedipine and Lasix were held. Her
symptoms resolved. She remained significantly orthostatic,
likely ___ longstanding diabetes and autonomic dysfunction.
Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO
QPM and Lasix 20mg PO daily with plans to continue to adjust her
blood pressure medications as an out-patient and possible
outpatient ABPM.
#Presyncope/hypotension:
Patient presented with hypotension i/s/o starting multiple
antihypertensives and a new diuretic regimen. Held
antihypertensives and diuretics for ___ and gave IVF with
improvement of blood pressure. Likely d/t medication effect, as
no evidence of infection. See "Hypertension" for discharge
regimen.
#Hypertension/Orthostasis:
Essential hypertension in the setting of tacrolimus therapy with
very poorly controlled blood pressures and difficult medication
titration given orthostasis and hypotension. Patient initially
hypotensive on admission but quickly became hypertensive to SBPs
of 200s with IVF and holding antihypertensives. However patient
was very orthostatic with drop to SBPS of 120s from 200s with
standing, despite being asymptomatic. Concern for diabetes
induced dysautonomia. Patient was maintained on carvedilol
12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with
SBPs in the 160s-170s. Plan is forcontinued titration of BP meds
and monitoring of orthostatics as an out-patient with ABPM.
# CKD
# S/p living unrelated donor kidney transplant ___:
Recent admission with renal bx showing diabetic changes without
signs of rejection. Her immunosuppressive regimen was increased
and she was discharged with a more aggressive antidiabetic
regimen and antihypertensive regimen.
- Decreased cyclosporine to 50mg BID given levels
- Continued home prednisone 5mg PO daily
- Continued home MMF 500mg BID
- Continued home diabetes regimen as below
# DM1, hyperglycemia: A1C 7.5% (___), had issues with
hypoglycemia d/t poor intake.
- Continued prior discharge regimen:
* Lantus 22 units qAM and 17 units qhs
* Humalog 8 units TID with meals
* Humalog sliding scale TID with meals
* ___ c/s
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69
- Continued home levothyroxine 125 mcg QD
# PE. Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# CAD. S/p ___ and OM ___. Completed 6 months on Plavix
- Continued home ASA 81 mg QD
- Continued home Ranexa ER 500 mg BID
# Nausea
- Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID
# Gout
- Continued home allopurinol ___ mg QD
# HLD
- Continued home atorvastatin 20 mg QD
# CREST:
- Held home esomeprazole 40 mg capsule BID
- Pantoprazole 40 mg BID while inpatient
# PVD
- Continued home cilostazol 100 mg QAM, 50 mg QPM | 135 | 504 |
15924948-DS-21 | 25,282,237 | You were transferred to ___ after cardiac arrest.
You were also being treated for pneumonia and recent colitis.
You were given IV antibiotics for your colitis and pneumonia
which finished on ___. You underwent a heart
catheterization on ___ which did not show any
significant coronary artery disease that required intervention.
You underwent an echocardiogram on ___ which showed your
ejection fraction to be 60%. On ___ you underwent an internal
defibrillator placement in case you should have any further
lethal heart arrhythmias.
You were seen by neurology and they recommended a brain MRI
which showed..... | BRIEF SUMMARY STATEMENT:
================================
Mr. ___ is a ___ year old male with a PMHx of atrial
fibrillation who presented after a cardiac arrest in the setting
of recent colitis and diarrhea. Cardiac arrest was in the
setting of hypokalemia and ventricular fibrillation, and had
ROSC in the field. He was extubated, stabilized on amiodarone,
and transferred from the ICU to the floor on ___.
#. VFIB arrest
- ROSC after 1 shock and epinephrine.
- cath on ___ showed LAD 30% stenosis, diag 50%, LCX
40-50%, RCA minor irregularities
- on amio, asa, metoprolol, statin
#. PAF
-Continue Xarelto. Copay will be $20/month.
-Amiodarone 400 mg BID for 2 weeks (from start date in CCU
___ then 400 mg QD x 2 weeks then 200 mg daily.
- Continue Metoprolol
- ___ dual AICD placed yesterday: CXR this morning without
acute abnormalities. 3 days (___) of antibiotics
(vancomycin). Device interrogated this morning- functioning
well.
#. Systolic HF s/p VF arrest
- initial EF was 30% now on repeat echo on ___ EF 60%,
trivial MR, moderate pericardial effusion without signs of
tamponade
- continue Lasix, metoprolol
-weights, labs, I&Os daily
- no need for repeat echo unless tamponade signs
#. Pneumonia
-Completed Ceftriaxone course
#. Colitis
- CT on ___ showed ascending colitis potentially reflecting
arrest related hypoperfusion/ischemic bowel versus
infectious/inflammatory. No abscess seen.
-Last dose of Flagyl is ___
#. Cognitive changes post VF arrest and resuscitation
-___ consult/OT consult. - recommended rehab
- neurology consulted- initially recommended MRI with contrast
however new AICD and can't have MRI for at least 6 weeks post
implant of device (it is MRI compatible). Recs were to follow up
outpatient with neuro in 3 months. If symptoms persist then will
undergo outpatient neuropsych testing.
#. Pruritic rash on back
- improving. Cont gold bond powder as needed.
#. PROPHYLAXIS:
- DVT ppx with NOAC
- Pain management with tylenol
- Bowel regimen with Senna/Colace (Hold for loose stools)
#.Dispo:
-Inpatient. Plan for rehab. Will need follow up with his
cardiologist Dr. ___ at ___. | 96 | 330 |
11681010-DS-13 | 23,407,541 | Dear Mr. ___,
You were admitted to ___ on ___ for chest pain. You
underwent a procedure called 'cardiac catheterization' with
placement of a stent in one of the vessels that supplies blood
to your heart. This procedure resulted in resolution of your
chest pain.
Your hospital course was complicated by fluid in the lungs that
necessitated placing a breathing tube temporarily and
transferring you to the intensive care unit. You recovered well
from this complication and are now safe to go home with close
follow up with both your cardiologist and primary care doctor.
Please weigh yourself every morning and call your doctor if your
weight increases by more than 3 lbs.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team | ___ year old male with PMH significant for CAD s/p MI with
ischemic cardiomyopathy, complete heart block s/p pacemaker
placement, T2DM and HTN who presented with episodes of chest
pain while at rest which were relieved by SL nitro.
# UA/NSTEMI: The patient has a history of chronic stable angina,
normally occurring with ___ctivity, but no
prior episodes of chest pain at rest. Initial EKG on admission
showed LBBB with STE by Sgarbossa criteria concerning for STEMI.
Labs notable for troponin negative x 2.
He was initially treated with medical management. He continued
to have episodes of chest pain, the decision was made to
proceded with cardiac catheterization on ___. In the cath
lab, he was found to have a narrow L circumflex, and a bare
metal stent was placed in the ostial left circumflex. Access was
R radial. He received 300 mg Plavix, and was placed on an
integril gtt for planned total course of 18 hours.
After the cardiac cath, the patient became acutely delirous. He
was given flumazenil without improvement. Also received haldol 5
mg x1. Of note, he has had similar reactions to benzos in the
past. He then became hypertensive and hypoxemic concerning for
flash pulmonary edema. He was subsequently intubated. He then
developed hypotension, thought secondary to propofol vs
cardiogenic shock, so he was transferred to the CCU for further
management.
In the CCU, he was started on dopamine and diuresed with IV
lasix boluses and later lasix drip in addition to metolazone.
Vasopressin was later added for persistent hypotension. Swan
catheter placed the following day on ___. In addition, while
in the CCU; though patient's hypoxia was thought to be ___ to
pulmonary edema and improved with diuresis above, patient was
empirically treated for a 5 day course (CTX and Azithromycin,
___ for CAP. Subsequently patient's pressors were
weaned and patient's swan and pressors were off by ___.
# ___ on CKD: Patient's Cr downtrended while in CCU from peak of
1.9 to 1.6, thought to be ___ to ___ on CKD in setting of poor
renal perfusion in the context of cardiogenic shock. 5 mg
lisinopril was started on ___ while Cr was downtrending.
Discharged on this dose of lisinopril but recommend titrating
this up as an outpatient once his creatinine returns to baseline
and as tolerated by his blood pressure.
# Thrombocytopenia: Patient had downtrending platelets
concerning for HIT (4T score = 4) so heparin was held. HIT
antibodies were negative (OD = 0.312).
# Diarrhea: Patient noted to have diarrhea on ___, C.
diff was sent and was negative. Patient was subsequently started
on loperamide for presumed non-infectious antibiotic-associated
diarrhea.
# Hematocrit drop: Patient was noted to have a downtrending
hemoglobin over several days (12.8 -> 12.0 -> 11.1 on ___. He
has never undergone a colonscopy. Repeat hemoglobin check in the
afternoon of ___ was 11.0 (stable). The patient expressed a
strong desire to be discharged home and since there were was no
acute change in his CBC, it was felt that close outpatient
follow up and re-checking his CBC by his primary care provider
___ 3 days was appropriate.
# Delirium: Patient exhibited several brief ___ hours)
episodes of delirium during his hospital stay during which he
A&Ox1 (self only). These tended to resolve with redirection and
non-pharmacologic measures to reduce delirium, although he did
receive one dose of seroquel 25mg during his stay.
==== TRANSITIONAL ISSUES ====
# Hematocrit drop: Last hemoglobin was 11.0 on ___.
- Patient has been instructed to see his PCP ___ ___ days of
discharge for repeat complete blood count.
- Please consider referral for outpatient colonoscopy given that
patient has never had one and his anemia raises concern for GI
bleeding.
# Hypertension and Systolic CHF
- Please titrate up lisinopril to his pre-hospitalization dose
of 40mg qday once his creatinine normalizes and as tolerated by
his blood pressure.
# Cardiology follow-up
- Patient instructed to schedule follow up appointment with
cardiologist with ___ weeks.
- Recommend considering ICD as outpatient if EF doesn't improve.
# Home Physical Therapy
- Patient will need to continue home ___ for his deconditioning
# Discharge weight: 53.1kg | 124 | 677 |
14188048-DS-9 | 24,795,918 | Dear Mr. ___,
You were admitted to the Acute Care Surgery team on ___
with abdominal pain. You had an ultrasound of your abdomen that
showed inflammation in your glallbladder and your liver enzymes
were elevated. You were taken to the endoscopy suite to have an
ERCP, sphincterotomy, and placement of a stent. Your liver
enzymes were monitored and decreased. Therefore, you were taken
to the operating room on ___ and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now ready to be discharged home to continue your recovery.
You will need to follow up with Dr. ___ in his outpatient
clinic to have the stent removed in approximately 4 weeks.
Please note the following discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr. ___ is a ___ yo M who presented to ___ emergency
department on ___ from an outside hospital with epigastric
and right upper quadrant pain with jaundice. On HD2 he underwent
an ERCP that showed no filling defects within the biliary ducts,
no stones or sludge were found with balloon sweeps. A
sphincterotomy was preformed resulting in significant oozing of
blood, requiring a 10 mm x 40 mm Wallfelx fully covered metal
stent. The Acute Care Surgery service was consulted post-ERCP
for consideration for laparoscopic cholecystectomy.
After successful ERCP, the patient was transferred to the Acute
Care Surgery Service for further management of his gallbladder
disease. His liver enzymes were decreasing and therefore to
extirpate the source of the common duct stones, he was taken to
the operating room on ___ for a laparoscopic
cholecystectomy. Procedure was tolerated without incident, he
was extubated and taken to the PACU in stable condition. He was
then transferred to the surgical floor for further management.
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
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. He was prescribed a 5
day course of ciprofloxacin post ERCP.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 807 | 288 |
11453452-DS-12 | 29,485,689 | Dear Ms. ___,
You were admitted to the hospital with coughing. Your chest
x-ray did not show any obvious pneumonia, but we gave you some
antibioitcs (azithromycin, "Z-pack") to treat you, because you
had fever.
You were evaluated and felt to benefit from rehabilitation, so
you were discharged to rehab.
It was a pleasure caring for you!
We wish you the very best,
Your care team at ___ | This patient is a ___ year old woman with a PMH notable for type
II diabetes, hypertension, dementia and chronic constipation who
presented with progressive weakness without falls, and abdominal
pain.
ACTIVE ISSUES
# Acute bronchitis
# Lethargy - toxic/metabolic encephalopathy:
# Productive cough, low grade fevers: likely secondary to viral
URI, given absent findings on CXR. Unable to obtain full history
from patient, given dementia. Subacute SDH could be contributing
to lethargy, as could infection. UA negative and influenza PCR
negative. Did have initial low-grade fever, then persistent
temperatures in 99.5-100 range, but had no other localizing
signs/symptoms of sepsis or infection. She was started on
azithromycin empirically for 5 day course with ongoing clinical
improvement.
- Last day of azithromycin, ___
# Subdural hematoma
No midline shift or neurologic deficits appreciated.
Patient was seen by neurosurgery in the ED, and no further
imaging, evaluation, or treatment recommended
# Abdominal pain,
# Chronic constipation: CT unimpressive. Does have history of
chronic constipation with large stool burden noted on CT
abdomen/pelvis. UA unremarkable as well. Pain appears to have
resolved with increased bowel regimen resulting in large BM.
Continue bowel regimen aggressively.
CHRONIC ISSUES
# Chronic renal failure: baseline Cr 1.6-1.8. Cr 1.4 here.
# Hypertension: BP elevated to >150s here, even up to 190s.
Subacute SDH as well, based on imaging. Continued amlodipine 10
mg daily and hydralazine 10 mg PO Q8H (holding for SBP <130).
# Anemia: normocytic. Stable. No signs of bleeding or
hemodynamic instability.
# Chronic diastolic heart failure: Furosemide stopped as
outpatient. Continued to hold.
# Hyperlipidemia: Decreased simvastatin to 20 mg given
interaction with amlodipine, though would favor discontinuing
given lack of benefit at age ___.
# Glaucoma and Cataracts: continue home eye drops
================================
## TRANSITIONAL ISSUES ##
================================
-- Monitor temperatures. Has had elevated temperature, though
not fever (high 99, to 100.2, maximum) while in house, and on
azithromycin. No further localizing symptoms and no
leukocytosis. Repeated CXR just prior to discharge unchanged.
Continue to monitor for development of true fever (greater than
to 100.4F) and consider infectious evaluation if becomes truly
febrile.
-- Goals of care: DO NOT RESUSCITATE, DO NOT INTUBATE | 64 | 360 |
17551032-DS-17 | 29,815,112 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
due to abdominal distension and constipation. After giving you
medications for your bowels, you were able to have a normal
bowel movement and your symptoms improved.
Medication Changes:
STOP Tesselon Perles
-We recommend discussing with your PCP stopping your lisinopril
and using a different medication such as losartan, as the
lisinopril may be causing your chronic cough.
Incidentally we found a small cyst in your left kidney on your
CT Scan, you should discuss further workup with this with your
primary care provider.
We have setup and appointment with your primary care provider,
please see below. Please discuss the possible medication
changes. | Mr. ___ is a ___ year old man with a history of Chronic
Diastolic Heart Failure, COPD, who presented with increasing
abdominal distention and constipation.
.
# Abdominal Distension/Constipation: His CT showed (see report
above) stool in the colon and patient had not had a BM in
several days. Patient had increasing distension over the last
few days prior to presentation, minimal discomfort in his
abdomen. His CT did not reveal any acute infection, patient was
afebrile, no leukocytosis. The most likely cause of his
distension was thought to be constipation. The patient was put
on an aggressive bowel regimen with Miralax, lactulose, Senna,
Docusate, and a bisacodyl suppository. He had one very large BM,
no diarrhea, no blood in his stool. He reported that his
distension had decreased afterwards, without complaints prior to
discharge.
.
#Chronic Diastolic CHF: Last echo in ___ showed EF of 55%, but
a component of diastolic heart failure. His BNP was 619 on
admission, CXR without evidence of cardiomegaly. He did not
appear to be decompensated on exam, he was continued on his home
lisinopril and torsemide as an inpatient and will follow this
regimen at home.
.
#COPD: Patient reports shortness of breath and wheezing at
baseline. He had a mild non-productive cough throughout his
admission. He was given an increasing dose of tesselon perles,
and nebs PRN. Patient had good sats on room air 93-95%. He was
continued on his home COPD medications. He will stop tessalon
perles as an outpatient, as this has been known to numb the
throat and cause an increased risk of aspiration. Patient also
on lisinopril and has a chronic cough, we have notified the
patient that he should discuss switching his lisinopril due to
chronic cough (possible ___.
.
#Left elbow Effusion: Patient had a small left elbow effusion
(chronic per patient), non-erythematous, no signs of infection.
He was given Tylenol for pain control.
.
#Hyponatremia. Appears chronic per OMR and has been attributed
to SIADH. Hyponatremia had resolved prior to discharge
.
#BPH: Patient continued on his finasteride.
.
#Cognitive Impairment: Continued donepezil 5mg.
. | 113 | 353 |
19777832-DS-16 | 28,022,225 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with abdominal pain due to
gallstones. You underwent surgical removal of your gallbladder
to prevent recurrent episodes of pain.
Please take all medications as prescribed and follow up with all
appointments as detailed below.
ACTIVITY: -Do not drive until you have stopped taking pain
medicine and feel you could respond in an emergency. -You may
climb stairs. -You may go outside, but avoid traveling long
distances until you see your surgeon at your next visit. -Don't
lift more than ___ lbs for 4 weeks. (This is about the weight
of a briefcase or a bag of groceries.) This applies to lifting
children, but they may sit on your lap. -You may start some
light exercise when you feel comfortable. -You will need to stay
out of bathtubs or swimming pools for a time while your incision
is healing. Ask your doctor when you can resume tub baths or
swimming. HOW YOU MAY FEEL: -You may feel weak or "washed out"
for a couple of weeks. You might want to nap often. Simple tasks
may exhaust you. -You may have a sore throat because of a tube
that was in your throat during surgery. -You might have trouble
concentrating or difficulty sleeping. You might feel somewhat
depressed. -You could have a poor appetite for a while. Food may
seem unappealing. -All of these feelings and reactions are
normal and should go away in a short time. If they do not, tell
your surgeon.
YOUR INCISION: -Tomorrow you may shower and remove the gauzes
over your incisions. Under these dressing you may have small
plastic bandages called steri-strips. Do not remove steri-strips
for 2 weeks. (These are the thin paper strips that might be on
your incision.) But if they fall off before that that's okay).
If your incisions are closed with dermabond (surgical glue),
this will fall off on it's own in ___ days. -Your incisions may
be slightly red. This is normal. -You may gently wash away dried
material around your incision. -Avoid direct sun exposure to the
incision area. -Do not use any ointments on the incision unless
you were told otherwise. -You may see a small amount of clear or
light red fluid staining your dressing or clothes. If the
staining is severe, please call your surgeon. -You may shower.
As noted above, ask your doctor when you may resume tub baths or
swimming.
YOUR BOWELS: -Constipation is a common side effect of narcotic
pain medications. If needed, you may take a stool softener (such
as Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription. -If you go 48 hours without a
bowel movement, or have pain moving the bowels, call your
surgeon.
PAIN MANAGEMENT: -It is normal to feel some discomfort/pain
following abdominal surgery. This pain is often described as
"soreness". -Your pain should get better day by day. If you find
the pain is getting worse instead of better, please contact your
surgeon. -You will receive a prescription for pain medicine to
take by mouth. It is important to take this medicine as
directed. o Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed. -Your pain
medicine will work better if you take it before your pain gets
too severe. -Talk with your surgeon about how long you will need
to take prescription pain medicine. Please don't take any other
pain medicine, including non-prescription pain medicine, unless
your surgeon has said its okay. -If you are experiencing no
pain, it is okay to skip a dose of pain medicine. -Remember to
use your "cough pillow" for splinting when you cough or when you
are doing your deep breathing exercises. If you experience any
of the following, please contact your surgeon: - sharp pain or
any severe pain that lasts several hours - pain that is getting
worse over time - pain accompanied by fever of more than 101 - a
drastic change in nature or quality of your pain
MEDICATIONS: Take all the medicines you were on before the
operation just as you did before, unless you have been told
differently. If you have any questions about what medicine to
take or not to take, please call your surgeon.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with the past medical history
and findings noted above who presents with RUQ pain, found to
have symptomatic cholelithiasis.
# SYMPTOMATIC CHOLELITHIASIS:
Patient presented to OSH following acute right-sided abdominal
pain with obstructive LFT pattern and gallstones observed on
RUQ. Patient transferred given concern for choledocholithiasis
requiring ERCP. Upon arrival, pain had resolved, LFTs
downtrending, and repeat RUQ with persistence of gallstones but
no CBD dilation, overall consistent with passed stone. Per
surgery team request, MRCP obtained and confirmed no persistent
choledocholithiasis. On ___, she was taken to the OR and
underwent a laparoscopic cholecystectomy. For details of the
procedure please see the surgeon's operative report.
Following a brief uneventful recovery in the PACU the patient
was transferred to the surgical floor. Her diet was advanced to
a regular diet which was well tolerated. Her pain was well
controlled with oral pain medication.
Prior to discharge the patient was tolerating a regular diet,
her pain was well controlled with oral pain medication. She
voided without issue, and was ambulating independently. She was
afebrile and hemodynamically normal, she was deemed medically
appropriate for discharge home with close follow up in the
surgery clinic. | 742 | 199 |
14357885-DS-15 | 21,961,642 | Admitted s/p arrest. Found to have cerebral edema and
herniation. INitally on max support, but following prognosis
discussion with the family made CMO and passed away with the
family at his side. | ___ with asystole -> PEA arrest with ROSC p/w cerebral edema and
herniation.
#Cardiac Arrest/Brain Herniation: The patient was found down in
the field and resusicated and had return of circulation after 39
minutues from the time of EMS arrival on the scene. He was
unresponsive and was placed on blood pressure support. His
troponin was elevated, indicating a likely cardiac source for
his arrest. He had a head CT that was notable for severe
cerebral edema at the outside hospital. He was transfered to
___ for further care. Here he required increased blood
pressure support and was ultimatly on maximum dose of 3
medications to raise blood pressure. He was unresponsive to
painful stimuli. He was noted to have a left pupil that was
fixed and dialated. He underwent repeat Head CT that was notable
for severe cerebral edema with efacement of the grey/white
matter and both tonsilar and uncal herniation. Neurosurgery was
consulted who did not believe that any surgical or medical
intervention would be successful in return of any type brain
function. Given these findings multiple family meetings were had
to explain the prognosis and that he would not improve.
Following the family discussions the family decided to make the
patient CMO and the pressors were stopped and he was extubated.
The patient quickly passed and was pronounced dead at 2240. The
family was informed and autopsy was declined. | 32 | 232 |
18136887-DS-76 | 22,212,186 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had fatigue, palpitations, muscle discomfort after
having a recent UTI treated with Bactrim, being found to have a
high potassium level, and concern for crisis of your Addisons
disease. Fortunately, you did very well with IV steroids and
your blood pressure was never low. We recommend that you take 20
mg of prednisone on ___ and ___ 10 mg on ___, and
then resume your normal dose of 5 mg prednisone. Please continue
to take your fludracortisone as prescribed by your
endocrinologist (0.1-0.2 mg per day). Please have labs drawn on
___ and follow up with your endocrinologist.
In the future, if you have a UTI, please do not take Bactrim, as
it can cause high potassium levels. You can be treated with
other antibiotics such as Macrobid.
Best wishes,
Your ___ Medicine Team | Hospital course: ___ with history of Addison's disease,
rheumatoid arthritis, and hypothyroidism presented with weakness
and palpitations, hyperkalemia to 6.3 with associated ECG
changes after being treated for UTI with bactrim now status-post
4L IVF, IV lasix, and stress-dose IV hydrocortisone, discharged
with resolution of hyperkalemia, ECG changes, and symptoms with
plans to continue PO prednisone and fludricortisone and follow
up with primary care and endocrinology | 148 | 66 |
13614963-DS-17 | 23,740,284 | Dear ___,
___ were hospitalized due to symptoms of trouble speaking
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 ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High cholesterol
We are changing your medications as follows:
- Started aspirin 81 mg daily
- Started atorvastatin 40 mg daily
- Started vitamin B12 100 mcg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
This is an otherwise healthy ___ year old woman who presented to
the ED after 2 episodes of inability to produce speech. Though
she describes two distinct episodes, it is not clear that she
ever returned to normal in between them. Alternatively, it is
possible that she had a single continuous episode lasting
several hours.
Neurologic exam is currently only notable for very slight right
facial asymmetry, and increased tone in the legs with loss of
large fiber sensation.
MRI shows a small subacute infarction in the left posterior
insular cortex and tiny infarction in the left temporal lobe.
Etiology thought to be cardioembolic vs. artery-to-artery given
moderate atherosclerotic calcifications at the carotid bulbs and
carotid siphons bilaterally.
She was started on aspirin 81 mg daily and atorvastatin 40 mg
daily while in house. She had an unremarkable TTE.
Patient found to have B12 deficiency in house. She was started
on vitamin B12 100 mcg daily. | 290 | 156 |
18855582-DS-2 | 26,192,789 | * You were admitted to the hospital to rule out esophageal
perforation following your endoscopy. Your barium swallow was
normal, without evidence of perforation. You may have had a
"micro" perforation which sealed off quickly. You have remained
afebrile and your white blood cell count is normal.
* You will remain on clear liquids for today and can have full
liquids tomorrow. Remain on full liquids until you see Dr. ___
___ week. All medication should be in liquid form or a tablet
that dissolves under your tongue.
* Call Dr. ___ you have any fevers > 101, chills or any new
symptoms that concern you. | Ms. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for observation.
She remained NPO and was hydrated with IV fluids. Her barium
swallow showed no perforation and Tylenol took care of her chest
discomfort. She was placed on broad spectrum antibiotics
prophylactically and her WBC was 12K at ___.
As she remained afebrile and her WBC trended down to normal,
clear liquids were started. She was able to swallow without
difficulty. Her IV antibiotics were changed to Augmentin
suspension which she will continue for a ___nd her
diet will be advanced to full liquids tomorrow. As she continues
to progress well, she was discharged to home on ___ and
will follow up with Dr. ___ week. She will also follow up
with her ___ physician but may want to be referred
here to the GI service. She will let us know at her follow up
visit. | 104 | 156 |
14791055-DS-13 | 26,595,601 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had cough for several weeks and shortness of breath
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a low blood level (hemoglobin) and were
given a blood transfusion
- You were found to have a pneumonia, and were treated with
antibiotics, to be continued after you leave the hospital
- Your shortness of breath got better with the above medications
as well as breathing treatments
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
====================
___ is a ___ year old female with a history of
DM, HTN, CKD presenting with 3 weeks of cough productive of
clear sputum, wheezing, and decreased exercise tolerance, found
to have Hgb ___ s/p 1u pRBC with appropriate response, as well
as multifocal pneumonia and concern for aspiration, treated with
antibiotics. | 129 | 52 |
12142836-DS-12 | 22,726,122 | Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with abdominal pain
and imaging concerning for lesions in your brain and spine. We
did additional imaging which showed that you had a small stroke,
causing you to lose vision in part of your right eye. We did
further imaging of the blood vessels in your ___ and neck, as
well as an echocardiogram of your heart, which did not reveal
any abnormalities. Review of your spine imaging also did not
reveal any lesions that may be contributing to your pain.
Please followup with Dr. ___ repeat imaging of your
brain in 2 months time. we started you on aspirin to help
reduce your chance of having another stroke.
Imaging of your abdomen did show enlarged lymph nodes in your
abdomen as well as thicking of your bowel wall. We controlled
your abdominal pain with morphine. We discussed your case with
Dr. ___ eventually performed a colonoscopy with a
biopsy of the thickened region of your bowel wall. At the time
of discharge, the biopsy results were pending. Please followup
with Dr. ___ further management of your abdominal
findings.
We made the following changes to your medications:
STOPPED:
-Amlodipine-valsartan
-Atenolol
-Loperamide
-Maalox:benadryl:2%lidocaine
-Nystatin
-Famciclovir
STARTED:
-Trazodone
-Metoprolol succinate
-Simethicone
-Acetaminophen
-Aspirin
Please continue taking your other medications as usual.
Please followup with your doctors, see below. | ___ yo F with history of lung cancer admitted with abdominal
pain, back pain, visual deficits found to have 4cm L lesion in
occiptal lobe now thought to be subacute stroke. She also had
abdominal ___ vs. metastatic disease, and ileal thickening all
suggestive of metastatic cancer, possibly due to lung vs. ___
primary.
.
#Brain lesion: Ms. ___ was transferred to ___ with new
right temporal hemianopia, imaging from OSH concerning for
metastatic deposit in left occipital lobe, as well as in the
L-spine. She was started on dexamoethasone for these processes
and admitted to the neuro-onocology service for furtehr
management. She was seen by radiation-oncology. However,
review of imaging of L-spine was nnot consistent with
metastasis. she underwent MRI with gadolinium here, which was
read as being more consistent with subacute infarct than with
metastatic deposit. Repeat imaging on ___ confirmed that
the imaging was more consistent with stroke. TTE with bubble
study was normal. MRA ___ and neck showed only toruosity of
ICA in cavernous sinus, no other vascular abnormalities. We
stopped dexamethasone, started aspirin and she will need to
followup with repeat MRI with Dr. ___.
# Metastatic lung carcinoma: Ms. ___ presenting symptom
was abdominal pain. While here, she continued to have
intermittent pain, poor oral intake, intermittent diarrhea and
constipation. C. diff toxin was negative. She was found to
have diffuse abdominal lymphadenopathy and ileal thickening on
CT from OSH. She was seen by gastroenterology, and underwent a
colonoscopy with biopsy on ___, which showed encroaching and
ulcerated ileal lesion. The biopsy was consistent with
metastatic lung cancer. We discussed this finding with the
patient and her family, as well as with her oncologist Sr.
___. Per Dr. ___, she was evaluated by
general surgery who felt that they would not offer her any
surgerym but that she would be a candidate for G-tube to help
improve her nutritional status, and to avert any issues with
intestinal obstruction. The patient declined this option at
present. She will followup with Dr. ___ after
discharge, and also with surgery.
# Acute renal failure, most likely pre-renal, but will need to
consider obstructive process as well given the numerous lymph
nodes in the abdomen. We gave her some hydration during her
hospital stay, but her creatinine remained elevated around 1.4.
She will require ongoing monitoring of her renal function by her
oncologist.
# Hypertension: Had been holding home atenolol given elevated
creatinine, but hypertensive with SBP in 160s-180, have started
metoprolol. We discontinued her home antihypertensives and
maintained her on metoprolol. | 228 | 439 |
14863235-DS-11 | 29,278,274 | Dear Mr. ___,
You were admitted to ___ because you had a large stroke. At
___, you were given medications to control your
blood pressure along with a medication to reverse your blood
thinner. You were then transferred to ___ for neurosurgery
evaluation.
We believe the reason for the hemorrhage was a atrial-venous
malformation. Neurology evaluated you and felt there was no need
for intervention. You were not a candidate for surgery given the
location of the lesion. Neurology will see patient for repeat
angiogram in 1 month with plan for definitive therapy at that
point.
You developed fevers, high blood pressure, and high blood sugars
during that prompted transfer to the medicine service. You were
also seen by cardiology for a mild heart attack, but they did
not recommend any treatment and your heart recovered. We used
diuretic medications to eliminate additional fluid, started you
on medications to control your blood pressure,
You were unable to swallow and so we placed a tube in your
stomach for you to receive nutrition.
You should follow up with neurosurgery in 1 month for a repeat
CT scan of your head along with consideration of treatment for
your AVM.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team | ===================
Neurology Course
===================
Mr. ___ presented to ___ ED with a large left IPH. He was
evaluated by neurosurgery in the ED and was admitted to the
neuro ICU under the stroke neurology service for spontaneous
IPH.
#IPH/AVM
The patient's aspirin and apixaban were held. He received
KCentra at OSH. He underwent a CTA head and neck which showed
unchanged large left temporal IPH with surrounding edema and 3
mm rightward midline shift. It also revealed tangle of vessels
adjacent to the hemorrhage which appear to drain into a cortical
vein, and is concerning for an AVM or dural AV fistula. He
underwent another CT on the following day which showed slight
interval increase in the left IPH, now with 4mm of rightward
shift and effacement of the left lateral ventricle. His sodium
was kept at a goal of 140-150. His son at the beside stated he
was his HCP and made the patient DNR/DNI. Later when 3 sisters
were visiting they said they were all Health Care Proxys and
said he should be full code for now. Patient went for a cerebral
angiogram on ___ which revealed a small pial arteriovenous
malformation. Please see separately dictated angio report by Dr.
___ complete details of the procedure. Post-operatively
he returned to the neuro ICU and was transferred from the
neurology service to the neurosurgery service for further
management. He was not a surgical candidate due to the location
of the AVM in the speech center and the vessels were not
amenable to embolization given small size. The plan was made for
repeat angio in 1 month and likely radiation thereafter. He was
transferred out to the ___ on ___. His BP goal was
liberalized to SBP less than 160 on ___.
#Fever
On ___ overnight patient was noted to be febrile to 102.9. He
was initiated on empiric Vancomycin and Ceftriaxone. Blood
cultures were sent which revealed ***. UA was also sent on ___
which was negative for infection. EKG at that time with slight
ST depression, troponins were cycled 0.01 and 0.02. Likely
demand ischemia. MRSA swab sent on ___ due to recurrent fevers
that was negative. Antibiotics were discontinued ___ per
Medicine recommendations given no clear infectious source.
Repeat CXR ___ showed new pulmonary edema and worsening
atelectasis, but no consolidation.
#Hypertension
Home meds were held on admission but gradually resumed. He
required Nicardipine gtt was discontinued after his SBP goals
were liberalized to less than 160. He was started on PO
labetalol and amlodipine which were titrated but per Medicine
recommendations.
#Diabetes
Home metformin and glipizide were held. He was started on
insulin sliding scale. He was started on glargine ___ per
Medicine recommendations.
#Hypoxia
On ___, the patient's SpO2 was 91% on 5L NC following his chest
x-ray, and he was temporarily put on a non-rebreather. After a
couple hours, he was weaned back down to supplemental oxygen via
nasal cannula and his SpO2 was mid-high 90%. When he required a
NRB, an ABG was drawn that revealed high pO2. He was given Lasix
20mg IV x 1 and diuresed to a goal of -500cc-1000cc daily for
fluid overload per Medicine's recs. A foley was placed for UOP
monitoring and BMPs were checked twice-a-day to follow his
electrolytes.
#Nutrition
The patient was evaluated by SLP and made NPO. A NGT was put in
place for tube feedings and medications. On ___, SLP again
evaluated the patient, but was unable to complete the evaluation
secondary to lethargy. ACS was consulted to place a PEG on ___.
=======================
Medicine Course
=======================
Mr. ___ is a ___ y/o man with history of DMII, HTN, atrial
fibrillation on apixaban who presented with a large
intraparenymal hemorrhage with underlying cause believe to be a
parieto-occipital AVM. Patient was deemed not to be a candidate
for surgical intervention. He will follow up with neurosurgery
after his discharge from rehab for consideration of radiotherapy
for treatment of AVM.
# Patient developed instability to speak and presented to
___ where he was found to have a large left IPH.
CTA demonstrated findings concerning for AVM or dural AV
fistula. He underwent angiogram on ___ that demonstrated
pial AVM. He was deemed not to be a surgical candidate due to
location and age/comorbidities. Recommended SBP < 160, holding
home ASA and eliquis indefinitely. Also recommended neurosurgery
follow up after discharge from rehab facility for consideration
of radiotherapy. *** There is no plan for radiation or
chemotherapy while patient is in rehab ***
# HTN
Multifactorial including IPH, pain, and essential hypertension.
Goal SBP < 160 per neurosurgery. He was continued on amlodipine,
HCTZ, and lisinopril with good BP control.
# Volume overload
# Acute hypoxemic Respiratory Failur
New onset ___, likely secondary to pulmonary edema and
mucous
plugging. Oxygen requirement rapidly decreased with diuresis and
was euvolemic prior to discharge. He will need a voiding trial
at rehab. He was not discharged on a diuretic. Will need close
monitoring and restart Lasix 20mg daily if his weight increases.
# Fevers
Most likely non-infectious etiologies of IPH and/or aspiration
pneumonitis over pneumonia. MRSA swab neg, cultures neg.
# Dysphagia
Due to stroke. A PEG tube was placed as he failed speech and
swallow evaluation. Will need close monitoring after discharge.
# DM
Baseline A1c 7.0%. On ___ with full tube feeds, required 36U
regular insulin. Will restart metformin after discharge and
adjust insulin.
Transitional Issues
====================
# Discharge weight: 101.5kg
[ ] Discharged with foley catheter. Please conduct voiding trial
in ___ hours and if fails replace and refer to urology
[ ] Follow up in 1 month with Dr. ___ Will need
a repeat NCHCT at the time of this appointment. Call
___ with questions. You may need a repeat diagnostic
angiogram in the future.
[ ] After discharge from rehab, consider radiotherapy for
treatment of AVM per neurosurgery. There are no plans for chemo
or radiation while patient is in rehab.
[ ] Follow up daily weights and consider restarting Lasix 20mg
daily if patient starts to retain fluid
[] Cardiology follow up as outpatient for consideration of
further work-up of TWI including stress test, though notably
patient is contraindicated from taking aspirin or
anti-coagulation given recent IPH.
[] PEG tube placed for dysphagia. Patient will need follow up
with speech and swallow and re-evaluation to determine if he has
recovery.
[ ] Stopped glipizide and started insulin. Please monitor blood
glucose carefully and can likely restart glipizide upon
discharge from rehab
[ ] Stopped metoprolol and replaced with labetolol 400mg TID for
blood pressure control. Consider started carvedilol as
outpatient.
[ ] Increased HCTZ to 25mg daily and amlodipine to 10mg daily
[ ] Stopped aspirin and apixaban. Patient should not be
restarted on these medications given IPH
[ ] Stopped risperadone given encephalopathy and sedation.
Consider restarting if patient is agitated. | 215 | 1,115 |
13823173-DS-18 | 22,959,391 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever greater than 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated left lower extremity
Functional mobility
No range of motion restrictions
Treatments Frequency:
Your incision is closed with staples that will be taken out at
your 2-week postoperative visit.
If the dressing falls off on its own three days after surgery,
no need to replace the dressing unless actively draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left midshaft femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for surgical fixation left femur,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 594 | 256 |
11599852-DS-20 | 29,182,497 | Dear Ms. ___,
You were admitted to the hospital after you experienced a fall
at your home. Because you hit your head, you underwent CT scans
of your head and neck which did not show any fractures or
bleeds. You were diagnosed with a urinary tract infection likely
because of your chronic urinary catheter, and were treated with
antibiotics. You were also given IV fluids because you were
dehydrated.
We found a good rehab for you to go to in order to build up your
strength before returning home. It is very important that you
are careful when you walk, and always use a walker or cane
(preferably a walker) to help prevent falls.
We wish you the best,
Your ___ Care Team | BRIEF SUMMARY
=============
___ PMH DM2, PVD, HTN, HLD, COPD w/recent admission for NSTEMI
and urinary retention with chronic foley brought to ED for fall
with head strike. A NCHCT was performed, which was negative for
acute process. Her CXR on admission was concerning for
pneumonia, although she had little to no respiratory symptoms. A
UA showed evidence of a UTI, and she was treated with
ceftriaxone then transitioned to levaquin to complete a 7-day
course to cover both UTI and CAP. She was also found to have
hyponatremia and dehydration clinically, which resolved with
fluid administration. Because of her recent falls, she was
discharged to rehab for ___.
ACUTE ISSUES
============
# FALL: Patient has history of recurrent falls, with bilateral
hip fractures from prior falls in the past. The patient reports
that she fell a few days prior to her admission, she fell and
injured her arm. On the day of admission, she fell again and hit
her head. She reports that both were related to loss of balance;
no syncope. The etiology of her fall may be related to
dehydration and/or infection, in combination with likely
age-related balance issues (several year hx of balance
problems). She reports that she has had diarrhea for the past
two weeks and felt dehydrated; she was given IVF with
resolution. On admission, she was noted to have a UA positive
for infection, likely related to her chronic foley for urinary
retention. She was treated as below. A CXR also showed a right
middle lobe opacity concerning for aspiration or pneumonia; she
had no respiratory symptoms but her abx coverage would cover CAP
as well. EKG showed no evidence of cardiac event. CT head
negative. The patient reports that independence is her number
one priority, even if her health is at risk because of it. Due
to this desire, she was discharged to rehab for physical
therapy, with home services to help mitigate her fall risk at
home.
# Urinary tract infection: The patient was found to have a
positive urinalysis while in the ED. She was asymptomatic but
has a chronic foley catheter, so was treated with ceftriaxone
then transitioned to levofloxacin to complete a 7-day course
(also to cover CAP given possible PNA)
# Lung nodule: Patient was noted to have a right mid-lung nodule
noted on CXR on admission. This may represent either aspiration
or underlying pneumonia, but repeat CXR is warranted in the near
future to assess for resolution. If this fails to resolve,
consider further evaluation for malignancy.
# HYPONATREMIA: Patient's admission sodium was 124, likely due
to poor PO intake and diarrhea. Normalized with IVF.
# URINARY RETENTION: Patient has been intermittently
straight-cathed at her extended care facility. She was seen in
___ clinic where she was unable to do this herself. We
continued her foley, and she will follow up with urology as an
outpatient. | 122 | 474 |
14422845-DS-20 | 26,201,013 | Please call the Transplant Clinic ___ if you have any
of the following:
temperature of 101 or greater, chills, nausea, vomiting,
inability to take any of your medications, worsening abdominal
pain, decreased urine output or pain/burning/urgency with
urination, incision redness/bleeding/drainage, constipation,
diarrhea or concerns.
** Please record your urine output.
No driving while taking pain medication.
No heavy lifting/straining (nothing heavier than 10 pounds)to
prevent an incision hernia from developing.
You may shower with soap and water, rinse/pat dry. Do not apply
powder/lotion/ointment to incision. No tub baths or swimming
yet. Keep incision out of sun to avoid scarring.
Refer to transplant binder.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Pt was admitted with constipation & gastroparesis on ___. He
was placed on sips, IVF, IV Zofran, scopalamine patch, and a
bowel regimen. On HD2, he was advanced to clears. He was also
given milk of magnesia, Dulcolax PR, and a tap water enema; he
did have bowel movements. Tacrolimus was continued and dosed
daily.
The patient had been started on glipizide 5 mg QD one day prior
to admission by Dr. ___ was consulted for glucose
control and an insulin sliding scale was started in-house. His
Valcyte was changed to QOD. He reported chills, so he was
pan-cultured (NGTD.) A UA was positive, so he was started on
ciprofloxacin; urine culture showed no growth. On HD 3, he was
advanced to regular diet and heplocked. At the time of
discharge, he was AVSS and tolerating PO without n/v.
The patient was discharged home on decreased dose of Tacro ___.
Patient is a free care patient and currently has no access to
insulin, syringes, or testing supplies at home, so he was
discharged on a decreased dose of glipizide (2.5 mg QD) while on
1 week course of ciprofloxacin for UTI. He will follow up in
clinicon ___ with labs. | 112 | 210 |
19790164-DS-5 | 22,992,582 | Dear Mr. ___,
You were admitted to the hospital for complaints of persistent
nightly cough productive of sputum and food material that was
keeping you from sleeping. You were found to have low oxygen
levels on presentation to the emergency department with oxygen
saturations in the 80's on room air. Imaging revealed
compression of your lungs by a dilated conduit concerning for
persistent outlet obstruction. Our advanced GI endoscopy team
performed an upper endoscopy and noted twisting of your
intrathoracic stomach. Unfortunately, there is no surgical
correction for this. Continue the PPI therapy and keep your head
of bed elevated. We would encourage you to avoid eating by mouth
going forward and only take liquids for comofort - utilizing
your J-tube for tube feeding as your dominant form of nutrition.
It was pleasure taking care you.
Sincerely,
Your ___ team | ___ with PMH significant for metastatic esophageal
adenocarcinoma (s/p esophagectomy with gastric pull through and
chemoradiation - surgery complicated by GOO with pyloric
dilation and laparoscopic reduction of hiatal hernia then J-tube
placement, ___ who presented with hypoxia and persistent
cough.
# Likely chronic aspiration, leading to hypoxia with persistent
productive cough - Imaging suggestive of impaired lung function
in the setting of markedly dilated gastric conduit (with
evidence of air-fluid level and food material in the thorax -
suggesting chronic gastric outlet obstruction). Patient
presented complaining of productive cough attributed to chronic
aspiration and GERD. CTA chest showed no pulmonary embolism or
PTX but severe dilated of the intrathoracic stomach. No evidence
of consolidation. Thoracic surgery was consulted, relaying he
was not a surgical candidate given his metastatic disease. He
was placed on aspiration precautions and GI was consulted who
performed an EGD on ___ which demonstrated gastric volvulus
that was managed with NG tube decompression. We recommended
strict NPO and only sips for comfort - using a J-tube for
primary nutrition. He was also discharged on home oxygen given
some ambulatory desaturations.
# Gastric outlet obstruction - Patient developed gastric
obstruction after total esophagectomy with gastric pull through.
Etiology unclear to primary surgeon, but there is a suggestion
of longstanding pyloric spasm. Attempts to improve the
obstruction with pyloric dilatation and hiatal hernia reduction
have not provided relief and he now has a J-tube for nutrition.
Imaging on admission revealed significant distention of gastric
conduit, as patient had been eating food recently. Of note, he
enjoys eating and expressed desire to keep eating. He was placed
on aspiration precautions and GI was consulted who performed an
EGD on ___ which demonstrated gastric volvulus that was
managed with NG tube decompression. We recommended strict NPO
and only sips for comfort - using a J-tube for primary
nutrition. He continued on once daily PPI therapy. Thoracic
surgery did mention that aggressive head of bed elevation to
___ degrees will be important to prevent GERD and aspiration -
thus a hospital bed was requested for home.
# Leukocytosis - WBC elevated to 16.7 on admission with
neutrophilia, but resolved spontaneously without intervention.
He had no localizing symptoms and imaging (CXR and CT) without
consolidation. Urine culture with coagulase negative Staph and
he had no symptoms - antibiotics were deferred.
# Metastatic esophageal adenocarcinoma - Patient is s/p
esophagectomy with gastric pull through with chemoradiation in
___. Esophageal adenocarcinoma found to be Her 2+ and recently
with bilateral pulmonary lung nodules also found to be Her 2+,
supporting metastatic disease. Dr. ___ (primary
oncologist from ___ was made aware of his hospitalization and
is planning for palliative chemotherapy after hospitalization
with follow-up scheduled the week of his discharge. | 139 | 452 |
10370502-DS-21 | 29,192,243 | Dear Ms. ___,
.
You were admitted to the gynecologic oncology service with
bilateral adnexal masses, pain, and fever. You were found to
have bilateral tubo-ovarian abscesses, one of which connected
with your colon. Interventional radiology placed tubes into the
abscesses to drain and these were later replaced with larger
drains. You were given antibiotics which you will continue when
you go home. You have recovered well after this procedure, and
the team feels that you are safe to be discharged home close
outpatient followup. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen in 24 hrs.
* No strenuous activity until cleared by your physician.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
. | Ms. ___ was admitted to the gynecologic oncology service
at the ___ after transfer from
___ on ___ for bilateral pelvic masses,
fever, and pain.
On hospital day #1, she underwent CT-guided drainage of
bilateral collections with drainage of foul-smelling material
and she was started on gentamycin and clindamycin for suspected
tubo-ovarian abscesses bilaterally.
On hospital day #3,she was transitioned to ceftriaxone and
flagyl after consultation with Infectious Disease given gram
stain and drain output concerning for feculent material.
Infectious disease was consulted; the patient was started on IV
ceftriaxone/flagyl then transitioned to meropenem.
On hospital day #4, Ms. ___ had a fever to ___ and her
antibiotics were then changed to meropenem. She underwent a
repeat CT of her abdomen and pelvis which revealed
re-accumulation of the abscesses bilaterally to their
pre-drainage size as well as contrast extravasation from the
sigmoid colon to the left tubo-ovarian abscess. Colorectal
surgery was consulted and recommended repeat drain placement and
conservative management. The patient then underwent CT-guided
exchange of the previous 2 drains with larger drains and
placement of a third drain by interventional radiology. Enteric
contrast from her previous CT scan was aspirated from the left
adnexal collection, confirming the presence of a colonic
fistula.
On hospital day #6, Ms. ___ received 2 units of packed
red blood cells as well as vitamin K for a hematocrit of 20.6
and INR of 1.8. There was no evidence of bleeding and she had an
appropriate rise in her hematocrit and improvement in her INR.
On hospital day #9, Ms. ___ experienced numbness and
tingling in her left upper extremity. Ultrasound revealed a
non-occlusive basilic vein thrombosis around her PICC. The PICC
was removed and she was continued on prophylactic lovenox.
Repeat imaging on hospital day #10 showed interval improvement
in drainage of bilateral adnexal collections without active
drainage of enteric contrast into the collection.
During her admission, Social Work was consulted for assessment
and support in coping with this unexpected hospitalization and
diagnosis. The patient was found to have adequate social support
and coping mechanisms for self care and was given resources for
further support as an outpatient.
By hospital day #11, she was afebrile with stable vital signs,
tolerating oral intake and ambulating independently. Her
infectious disease doctors agreed with ___ to oral
ciprofloxacin and flagyl and the gynecology oncology team, in
conjunction with the colorectal surgery service, felt the
patient was safe for discharge home with continued antibiotics
and close outpatient followup. She was then discharged home in
stable condition with home nursing services and close outpatient
followup scheduled. | 198 | 425 |
18906643-DS-26 | 22,323,011 | Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for low blood sugar. You were unresponsive at home and
found to have a blood sugar of 11 by the EMTs. This was likely
due to not eating as much as you usual do last night. You were
seen by the ___ team and your home sliding scale insulin was
changed, as below. Please continue to check your blood sugar at
home. You will also follow-up with your PCP and Dr. ___ at
the ___ after discharge.
You had some pain in your left shoulder, your EKG was unchanged
and your cardiac enzymes, which help tell us if your pain is
from heart damage, were normal.
Please remember to space apart your simvastatin and amlodipine
by at least a few hours.
The following changes have been made to your medications:
CHANGE Insulin U-500 sliding scale three times daily as below:
Sugar Breakfast Lunch Dinner
----- -------- ----- ------
<80 10 10 ___ 15 15 12
181-280 17 17 14
___ 19 19 16
>480 20 20 16 | ___ with T2DM (A1c=6.3%), CHF (EF=50-60%), CAD s/p CABGx4, HepB,
asthma, and h/o CVA who presents with hypoglycemia.
#Hypoglycemia - Thought to be related to lower than usual PO
intake the night before admission. She took her normal amount
of evening insulin but then did not have her usual pre-bedtime
snack. She rapidly improved after receiving dextrose
pre-hospital. On the floor, she was no longer hypoglycemic.
___ was consulted and we changed her home U-500 sliding scale
to lower the amount of insulin she takes in the evening.
#CAD s/p MI - No anginal sx this admission. Trop x1 was neg in
the ED.
#HTN - BP was slighly elevated upon arrival but she missed her
AM meds when she was taken by ambulance to the hospital. She
was continued on her home antihypertensive regimen.
#H/o CVA - Has baseline asymmetric weakness in her ___ after
stroke ___ years ago. No recent neurological changes. She was
continued on her home ASA 81mg and Plavix.
#Chronic CHF (EF=50-60%) - Has some evidence of vascular
congestion on CXR, but did not appear significantly volume
overloaded on exam. She was continued on her home Bumex as well
as ACEi and beta blocker, no aldosterone antagonist on her med
list.
#HepB - high viral load on last lab work and she was continued
on her home dose of Ciread.
#CKD (baseline Cr 1.1-1.3) - Creatinine at baseline upon arrival
to the ED
#Asthma - Had some dyspnea on exertion but maintained her O2 sat
on room air. She was continued on her home Advair and inhalers.
#Code status this admission - FULL CODE
#Transitional issues:
-Has follow-up arranged with her PCP and with ___ need
her evening blood sugar followed and her insuln dosing adjusted
as necessary | 266 | 313 |
19123639-DS-5 | 27,422,270 | Do not smoke.
Take your pain medication, including Tylenol, 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.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
You must wear your TLSO brace for support for 8 weeks,
until follow-up. Please wear your TLSO at all times when OOB or
ambulating
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.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control). | Mr. ___ was admitted to Neurosurgery on ___. He remained
on spinal precautions until his TLSO brace arrived on ___. He
a C/A/P CT scan on ___ which showed multiple incidental
lesions including renal hypodensities. His bun/crea bumped on
___ and a renal u/s was obtained which showed simple renal
cysts. His bun/crea trended back down with IVF resuscitation.
___ evaluated this patient and he was deemed stable for
discharge. He had a thoracic x-ray with TLSO brace which showed
mild kyphosis without canal compromise and patient remained
asymptomatic. Now DOD, he is afebrile, VSS and neurologically
intact. He has been instructed to wear TLSO brace at all times
when OOB or ambulating. | 141 | 121 |
12902839-DS-17 | 23,476,629 | ACTIVITY AND WEIGHT BEARING (left upper extremity):
- Non weight bearing in your left upper extremity with a sling.
- Out of the sling at least three times daily for elbow range of
motion exercises.
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.
Your wound was closed with sutures. You may wash your hair
only after sutures have been removed.
You may shower before this time using a shower cap to cover
your head.
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 prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCPs
office, but please have the results faxed to ___.
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. You have had a seizure and
will not be able to drive for 6 months.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
***You are being sent to rehab while being treated for a low
potassium. Please take your second dose of 40mEq of potassium in
the evening of ___. Please have your potassium levels
checked on ___.
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. | Ms. ___ was admitted to the ___ at ___ on ___ with
a SDH, L shoulder fracture and L rib fractures. She was taken
to the OR by neurosurgery on ___ for decompressive
craniotomy and drainage of SDH. She had a drain placed in the
OR that was d/ced on POD1.
Neurosurgery assumed care of the patient on the evening of ___.
On ___ her exam was improving. Dilantin level corrected to 30
and her morning Dilantin dose was held. Her INR was found to be
1.8. She was given 1 dose of Vitamin K and a head CT was
obtained which was stable. EEG demonstrated no seizure
activity. Patient reported pain in L hand which ecchymosis and
edema were seen on examination, a L hand x-ray was ordered. On
___, patient's exam remained stable. Her dilantin level
corrected was supratheraputic and was once again held. Another
level was reordered for the afternoon. She was transferred to
the floor to be evaluated with ___ and OT.
On ___ patient developed tachycardia and intermitant shortness
of breath and elevated WBC. Patient had LENIs, Cardiac enzymes
and a Cxr ordered, all of which were negative for any acute
processes.
On ___, the patient no longer had an elevated WBC and remained
afebrile. Her potassium was replenished and she was sent to
rehab with orders to repeat her potassium levels and to
administer a second dose of potassium. At the time of discharge
on ___, POD #7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
voiding without assistance, stable neuro exam and pain was well
controlled. The patient was sent to rehab given written
instructions concerning precautionary instructions and the
appropriate follow-up care. All questions were answered prior
to discharge and the patient expressed readiness for discharge. | 338 | 315 |
13097115-DS-6 | 26,766,426 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted for pain control after you sustained multiple rib
fractures after a fall last week. You will be going to a
rehabilitation center to recover and get stronger.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | ___ with h/o Afib (no longer on Coumadin), dCHF, SSS s/p PPM,
hemochromatosis, Parkinsonism with autonomic dysfunction and
multiple falls presenting s/p fall, found to have multiple rib
fractures.
# Mechanical Fall: History of multiple mechanical falls in the
setting of pt recalling slipping and falling without LOC or
prodrome makes mechanical fall most likely. Very little concern
for seizure or arrhythmia, has PPM a-paced but had one 8-beat
run of asymptomatic Vtach. Electrophysiology interrogated St.
___ pacer on ___ and found no arrhythmias, stable lead
parameters, and normal functioning pacemaker. Somewhat
orthostatic with physical therapy, though BUN/Cr ratio improved,
and so PO intake was encouraged. ___ rehabilitation was
recommended by physical therapy, and he was discharged in
medically stable on condition.
# Rib Fractures: ___ fall, comfortable when sitting and lying
down though had pain with movement and deep breaths. He was
dischargede with standing acetaminophen, Lidoderm patches, and
tramadol prn breakthrough pain.
# Altered mental status: Briefly episode of confused and
paranoid behavior, but resolved completely with hours of
receiving his carbidopa/levadopa dose (a pattern that his wife
recognizes as typical), since he had missed several of his 6
daily doses over the previous 24 hours during his ED and early
hospital stay. ___ have also been secondary to the one dose of
morphine he received.
# Afib: No longer on Coumadin as of ___ due to multiple
falls. CHADS score ___ (age and possible CHF). Previously on
dronedarone (still listed in OMR), but not listed in meds per
visiting NP through ___ most recently on ___. Currently
atrially paced at 60. His aspirin was decreased from 325mg to
81mg, and his cardiologist Dr. ___ was contacted and in
agreement with this plan.
# Elevated Troponin: chest pain free throughout hospitalization,
trop 0.02->0.01, normal MB index makes epicardial plaque rupture
unlikely. EKG with leftward axis, and he had no ST-T segment
changes or other evidence of ischemia. Likely from demand
ischemia in the setting of stress.
# Elevated CK: not high enough to merit concern for
rhabdomyolysis, and Cr was within normal limits. CK decreasing
from 1000 to 500 on admission, and this was not trended further.
# Elevated BP: 200/98 on arrival to the floor, but became
normotensive when patient became more comfortable. Pt does not
take any BP meds at home and was not started on any BP
medications in-house.
# ___: Currently euvolemic. Since he was euvolemic and had no
evidence of heart failure contributing to his chief complaint,
no TTE was ordered as an inpatient.
# Parkinsons Disease: appears well-controlled with only very
mild intermittent resting tremor. He was continued on home
Carbidopa-Levodopa 6 times per day.
# ? mild dementia: prescribed Donepezil, though refuses to take
it at home per outpatient NP though it remains on his med list.
Of note, CT head with normal ventricular size. This can be
further discussed as an outpatient.
# Anemia: Chronic, deferred to further outpatient workup if
needed | 58 | 503 |
17265476-DS-3 | 24,786,386 | Dear Ms. ___
.
You were admitted to the gynecologic oncology service for
abdominal pain and diarrhea. You had imaging performed of your
abdomen that did not show any signs of bowel injury or
infection. You had 24 hours of bowel rest and your symptoms have
resolved. We recommend that you continue a bowel regimen with
Colace and senna to help with constipation but you can stop
either of these medications if you have diarrhea or loose
stools.
Laparoscopic instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 4 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was admitted to the gynecologic oncology service for RLQ
abdominal pain and complex pelvic fluid collection on POD10
status post laparoscopic lysis of adhesions, tubal occlusion and
partial salpingectomy, with low suspicion for delayed bowel
injury.
Upon admission, she was afebrile and her white count was noted
to have downtrended to 12.1 from 15 at OSH. Her lactate was also
within normal limits at 1.3. A second read of CT abdomen/pelvis
by ___ radiology revealed 5cm heterogeneous but dependently
hyperdense collection along superior aspect of bladder
consistent with postoperative hematoma, cannot exclude
superinfection. There was also prominent loop of bowel within
lower pelvis without definite transition point or upstream bowel
dilatation, most like;y ileus. Blood cultures were drawn and
pending. She was also tested for gonorrhea and chlamydia at the
outside hospital, which returned negative. She was transitioned
from NPO to clears the evening of HD#1. By HD#2, she continued
to remain afebrile, her white count normalized to 9.5. Her
abdominal pain had resolved and she tolerated a regular diet
without issues. Her loose stools also resolved spontaneously.
By HD#2, she was afebrile, tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with oral medications. She was then discharged home in stable
condition with outpatient follow-up scheduled. | 229 | 212 |
18459751-DS-15 | 28,906,098 | Dear. Ms. ___,
You were admitted to the hospital with newfound bone lesions of
unclear cause. You underwent numerous imaging studies as well
as a biopsy of one of your spinous vertebrae to figure out the
diagnosis. While this important test result is pending, you do
not have to stay in the hospital in the mean time.
Because the lesion in your right hip is possibly destabilizing,
we ask that you continue to use "toe touch weightbearing" only
on the right lower extremity. The orthopedics and oncology
teams will be able to advise you on whether you can return to
normal activity as soon as the biopsy result comes back.
We have made no changes to your medications
I wish you the best of luck, ___. | Ms. ___ is a ___ with a history of reversible
cerebrovascular vasoconstriction syndrome and meningioma who
presented for workup of diffusely scattered lytic ___ lesions
seen on outside imaging, including a potentially unstable right
hip lesion, she underwent L2 biopsy prior to discharge. | 125 | 43 |
12350449-DS-17 | 29,387,442 | Dear Ms ___,
You were admitted to the hospital with back pain and
diverticulitis. Your diverticulitis was treated with antibiotics
and bowel rest. You will need to continue to have only clear
liquids today, and you will continue to take antibiotics for a
few days. Tommorrow, advance to full liquids, including soups.
The next day, if your stomach can tolerate, advance to a regular
diet. In the future, you should eat a high-fiber diet to help
prevent diverticulitis from occuring again. This involves plenty
of fruits and vegetables and whole grains. You may consider a
fiber supplement. Hydration is also very important, so drink
plenty of fluids.
You also had back pain from your prior back compression
fracture. This was treated with pain medications. These can make
you constipated, so you have a prescription for a stool softener
to use sa needed. You were evaluated by our physical therapists,
who thought you would benefit from home physical therapy. We
also will refer you to the Spine Clinic for further care.
The following changes were made to your medications:
** START flagyl (antibiotic)
** START augmentin (antibiotic)
** START oxycodone (pain medication). It is important you do not
take more than 1 pill every 6 hours.
** START miralax as needed for constipation (this is a powerful
stool softener)
** START compazine as needed for nausea | Ms ___ is a ___ with h/o diverticulitis ___ years ago,
breast cancer, PAF, HTN, HLD, osteoporosis, recent admission for
L1 compression fx, who presents with 2 weeks of worsening nausea
and back pain, found to have sigmoid diverticulitis, unable to
tolerate PO's.
.
# Diverticulitis: a mild case. She has only mild tenderness in
LLQ, and is moderately nauscious. She was treated with a 7 day
course of augmentin/flagyl, compazine PRN nausea. She was
initially NPO, then transitioned to clear liquids, which she
tolerated well. She should be on a high-fiber diet once she
recovers from this acute episode.
.
# L1 compression fracture: she has been in substantial pain
since her compression fracture occured several weeks ago. She
has been on tramadol at home without much relief. Her pain was
controlled in house with oxycodone 2.5mg PO PRN, which did help
some. She was evaluated by ___, who felt she would benefit from
___, so she was discharged with a referral for home ___. The
etiology of her compression fracture is likely osteoporosis. Her
calcium and alk phos where normal, making malignancy / lytic
lesion less likely. However, after discussion with the
Radiologist, it was decided that it would be reasonable for her
to have repeat imaging of her L-spine in ___ weeks time. Will
set her up with PCP appointment to follow up on this issue. Low
dose oxycodone was added to her home regimen for increased pain
control. She has been tolerating this very well inhouse.
.
# Paroxysmal atrial fibrillation: Not on warfarin. On metoprolol
for rate control. She is on aspirin 81mg PO daily at home.
.
#CKD: Pt with baseline creatinine of 1.5-1.8. Creatinine on
admission was 1.8. Renally dosed all medications
.
# Anemia: chronic, normocytic with normal RDW. Unlikely related
to acute presentation, though checked iron, B12, folate for
easily correctable causes.
.
# Hypertension: Well controlled. Continue amlodipine and
metoprolol
.
# Hyperlipidemia: Continue simvastatin 20mg daily
.
# Hypothyroidism: Continue synthroid ___ mg dialy.
.
# Osteoporosis: continue nasal calcitonin daily
.
# GERD: Pt claimed to no longer take omeprazole and was
therefore not continued
================================================
TRANSITIONAL ISSUES
# Consider repeat lumbar spine imaging in ___ weeks to further
work-up possible lytic lesion as underlying cause of compression
fracture
# F/u with Spine clinic on ___ for further treatment of
symptoms
# Add low dose oxycodone to home regimen
# Complete ___ugmentin/flagyl for diverticulitis
# advance diet slowly over a few days for diverticulitis
# Home physical therapy | 222 | 413 |
10208867-DS-21 | 22,470,664 | ___ were admitted to the hospital with right upper quadrant
pain. ___ underwent an ultrasound of your abdomen and ___ were
found to have gallstones. ___ were taken to the operating room
and ___ had your gallbladder removed. ___ are recovering from
your surgery. Your vital signs are stable and ___ are preparing
for discharge home with the following instructions:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern ___.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. ___ may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
___ may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if ___ have increased pain, swelling,
redness, or drainage from the incision sites. | The patient was admitted to the acute care service with right
upper quadrant pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging of the abdomen. On
ultrasound, she was reported to have gallstones with an immobile
9-mm gallbladder neck stone. On HD #1, she was taken to the
operating room for a laparoscopic cholecystectomy. Her
operative course was stable with minimal blood loss. She was
extubated after the procedure and monitored in the recovery
room.
She was has been started on a regular diet. Her vital signs have
been stable and she has been afebrile. She has been voiding
without difficulty.
She is preparing for discharge home with follow-up with Dr.
___. | 284 | 123 |
12250606-DS-8 | 29,153,321 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
a fracture of your jaw bones, your right orbital bones and
thyroid cartilage. The Ear Nose and Throat team had scoped your
airway and did not see exposed cartilage or mucosal injury, and
a patent airway. You have recovered and are now ready to be
discharged to home before you return for your surgery with oral
& maxillofacial surgery team to have your fractures fixed.
Someone will give you a call to let you know more about the
surgery schedule. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the endoscopy.
YOUR DIET:
As per oral & maxillary surgery team's recommendations, your jaw
bone has not healed and so chewing is not advised. Please stay
on your full liquid diet until you have undergone surgery and
have recovered from it.
Please make sure that the night before your surgery, you should
refrain from drinking or eating after midnight.
Please also use your chlorhexidine mouth wash twice a day to
ensure your mouth to be clean
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | The patient presented to the ED with a lefort ___ fx, R orbital
fx, mandibular fx, thyroid cartilage fx, significant R neck subq
emphysema. He was seen by ENT in the ED who performed a
fiberoptic endoscopic exam which showed no obvious mucosal
injury or exposed cartilate but significant blood, and mild
edema in the posterior trachea, but airway was otherwise patent.
He was transferred to the ICU for close monitoring and airway
protection. He maintained saturation on nonrebreather overnight.
However, he had some urinary retention of 850 ml on arrival to
ICU and so a foley was placed.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was managed with IV pain medications
including IV dilaudid and IV Tylenol and was subsequently
changed to oral medications such as liquid oxycodone, liquid
Tylenol and IV dilaudid breakthrough. Pain was very well
controlled.
#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. We gave him
duo nebs to help with his airway mild edema. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed in the ICU for
urinary retention of 850ml and it was removed the next day when
he was transferred to the floor. He had autonomous return of
voiding. ___ was consulted for maxillary and mandibular
fractures and so they believed surgery was warranted
non-urgently. Anesthesia was also consulted for a airway
clearance per ___'s request. Also, the patient was put on a
full diet, which he will continue to be on until his OR per
___'s request. Since the patient was clinically stable and was
awaiting for surgery, he was discharged home and was instructed
to return for his surgery.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
#OTHER: | 546 | 339 |
12805878-DS-15 | 23,390,591 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ year old male with known coronary artery and aortic valve
disease. He underwent CABG/AVR on ___ with unremarkable
OR/postop course. Following fall at home ___, he presented to
___ where head CT was normal but had new
rapid atrial fibrillation. He was transferred here and was
seen by Dr. ___ cardiology. He remained in rapid
atrial fibrillation despite increased Metoprolol dosing. His
eventual TEE on ___ could not definitively rule out thrombus,
so planned cardioversion was deferred. His INR was therapeutic
on ___ and Amiodarone was added. He remains in atrial
fibrillation with improved rate control. He completed postop
Lasix course and his lisinopril/amlodipine doses were adjusted.
He has had mild leukocytosis without fevers. His CXR is
unremarkable CXR, his first Urine culture grew mixed flora and
second one is pending. He has trace amount edema/erythema at
___ site, but otherwise incisions are healing well. He has
no obvious sequela s/p fall and has been ambulating halls
without difficulty. He will be discharged home on POD 12 with
Amiodarone ___ of Hearts monitor for 2 weeks, and will
have repeat CBC with second INR check to trend ___. Appropriate
follow up visits have been arranged. Of note, he wishes to
change his cardiologist to Dr. ___ call
himself to cancel his previously scheduled appointment with Dr.
___. | 104 | 233 |
18687750-DS-15 | 26,263,768 | Mr. ___,
You were admitted to the neurology stroke service at ___
___ because you had a stroke in your brainstem which
caused you to develop left hand weakness as well as some
unsteadiness of your gait and abnormal speech.
You were started on a medication called Plavix (also known as
clopidogrel) to help keep your platelets from being too sticky
and causing another stroke. This medication can increase your
risk for bleeding if you cut yourself or fall.
You were also started on a cholesterol medication called
atorvastatin to help lower your cholesterol and prevent strokes.
You are being discharged to an acute rehab facility.
It is important to follow-up with your neurologist as well as
your primary care doctor. You will also need to have an
echocardiogram done as an outpatient. | Mr. ___ was admitted to the neurology stroke service. He
remained hemodynamically stable throughout his admission. He had
a brain MRI which showed an acute right paramedian pontine
infarct which corresponds with his symptoms -- collectively
known as the "clumsy hand dysarthria syndrome" due to a pontine
lesion. His imaging also suggested narrowing of the basilar
artery, likely due to a thrombus, and calcifications in the
bilateral vertebral arteries, suggestive of atherosclerosis. His
LDL was elevated to 133 -- much higher than our goal LDL in
stroke patients of <70. His TSH and HbA1c were both within
normal limits.
He was started on daily aspirin (reported to only be taking
aspirin periodically at home) as well as clopidogrel (75 mg
daily x3 months) and atorvastatin (80 mg nightly).
His symptoms remained stable-to-minimally improved during his
admission. He continues to struggle with left proximal UE
weakness and distal ___ weakness. Additionally, he has noticeable
dysmetria on the left that is out of proportion to his weakness.
He also has an unsteady gait and ataxic speech.
He will be discharged to an acute rehab facility. | 133 | 184 |
15918578-DS-15 | 27,779,508 | Dear Mr. ___,
It was a pleasure taking care of you.
You were hospitalized due to symptoms of dysarthria and
increasing weakness in your left arm resulting from an ACUTE
ISCHEMIC STROKE, a condition where your vessels aren't carrying
enough blood to provide oxygen and nutrients to parts of the
brain. 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: radiation therapy.
We are changing your medications as follows:
-Please take Aspirin 81mg and Plavix together daily.
-Fluoxetine 20 mg daily for mood, also shown to help improve
return of strength in patient's who have had a stroke
Please take your other medications as prescribed.
Please follow up with Neurology on ___ at 3:45
___. Please schedule an appointment with your primary care
physician ___ ___ weeks of hospital discharge.
*******************
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ right-handed man with history
notable for remote brainstem tumor s/p radiation and VPS
placement (aged ___ s/p VPS revision, meningioma s/p resection,
HLD, and recent admission (___) for a new left pontine
ischemic infarct who presented from ___ on ___ with new-onset left arm weakness and worsening
dysarthria. He was found to have a new right pontine stroke.
# Right Pontine Infarct
On presentation, examination notable for apparent left deltoid
and biceps weakness and recent setback in recovery from his
dysarthria. MRI showing new right pontine infarct. Given
localization of recent strokes and otherwise well controlled
risk factors, it is most likely that this could be sequelae to
previous radiation therapy patient received for brainstem tumor.
- ___: 5.3, TSH: 1.0, LDL: 31
- Continue home clopidogrel and add ASA 81 daily, continue
statin
- Start fluoxetine 20mg daily per ___ trial and for depressive
affect. This medication can be discontinued at the discretion of
PCP
# Cardiopulmonary:
CXR w/ no acute changes. Telemetry did not reveal arrhythmia.
Did not repeat ECHO at this time as etiology of stroke most
likely sequelae from previous radiation.
- Continue home statin and fibrate
_
_
_
________________________________________________________________
1. Patient started on Aspirin and Plavix for stroke prevention
as he failed both agents individually.
2. Follow up with stroke neurology ___
3. Patient was started on fluoxetine 20 mg daily for depressive
affect ad per ___ trial. Continuation of this medication at
discretion of PCP.
4. Patient to see PCP ___ ___ weeks post discharge
5. Patient to continue all other home medications
_
_
_
_
_
_
________________________________________________________________
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 31) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A | 321 | 562 |
16625317-DS-18 | 23,425,322 | Dear Ms. ___,
You were admitted to ___ on ___ for low blood sugars
(hypoglycemia), likely due to a mixup in the medications you
were taking. Your blood sugars remained stable after we gave you
some sugar. Please be careful in taking your medications and ask
the visiting nurse for any help.
Thank You, It was a pleasure taking care of you
Your ___ Medicine Team | PRIMARY PRESENTATION:
___ year old female with hxistory of ESRD on HD, epilepsy, right
MCA stroke (___), HTN/HLD, anxiety presenting confusion, found
hypoglycemic, likely due to accidental intake of husband's
glipizide, with symptomatic improvement after dextrose and
glucose administration, monitored in ICU overnight, with stable
FSS and no further symptoms. | 70 | 49 |
19686663-DS-12 | 22,530,853 | You were admitted to Acute Care Surgery Service after sustaining
a fall. You are recovering well and are ready to be discharged.
Please call us or come to the nearest emergency deparmtment if
you experience any of the following:
Dizziness or lightheadedness
Numbness or tingling
Change in vision
Confusion
Headache
Weakness in arm, leg, or face
Difficulty walking
Difficulty talking
Loss of balance
Incontinence of urine or stool | Patient was admitted to the Acute Care Surgery service from the
Emergency department. Please refer to the HPI for details of the
initial presentation. Patient's injuries included small a small
(6mm) Right sided frontal subdural hematoma, T1 body fracture
vs a lytic lesion and a minimally displaced left sacral
fracture. Patient had CT scans at the outside hosptial however
given time gap and the presence of known injuries, a CT scans of
the L,T spine and head was repeated at ___. A repeat head CT
showed grossly stable, small right frontal
subdural hematoma with no evidence of change. Neurosurgery was
consulted and given the small size, normal neurologic exam and
patient's stability, she was recommended to take Keppra 500mg PO
BID for 7 days and follow up in ___ clinic only if she
experiences any neurologic symtpoms for over 30 days.
Orthopaedic surgery was consulted for the sacral fracture which
was minimally displaced. She was recommended pain control weight
bearing as tolerated and follow up in orthopaedic trauma clinic
in 2 weeks.
On the night of admission, there were concerns of mild
anisocoria on her serial neurologic exams (R pupil > L pupil).
She underwent a repeat CT scan without any changes and intact
serial neuroexams thereafter. She was re-evaluated by
neurosurgery with the same recommendations. A tertiary survey on
HD2 was nonrevealing. Patient was seen by physical therapy and
occupational therapy and was cleared to be discharged home with
adequate teaching. Patient was discharged home on HD2 with
follow ups for ___ clinic, Orthopaedic trauma clinic regarding
her sacral fracture and with her primary care physician to
workup ___ likely chronic/lytic lesion in her T1 spine. This was
communicated to the patient's daughter and her son as well.
Patient agreed and verbalized adequate understanding. | 57 | 298 |
16030584-DS-18 | 24,624,510 | Dear ___,
You were admitted to the hospital for increased weight and
hypoxia concerning for heart failure. We started you on an IV
Lasix drip and got off some fluid. We discharged you on your
home dose of torsemide as well as your other home medications.
You also had a CT scan which showed that the nodules in your
lung that were identified over a year ago are still present and
are stable.
Because of your tendency to accumulate fluid, we recommend that
you weigh yourself every morning, and call MD if weight goes up
more than 3 lbs.
It is very important that you continue to take your medications.
All of your medications are detailed in your discharge
medication list. You should review this carefully and take it
with you to any follow up appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ with a history of idiopathic PAH (mPAP to 61), CKD, HTN, and
DMII presents with weight gain c/f decompensated heart failure.
# Acute on chronic diastolic heart failure:
On last ECHO patient had LVEF 75% on ___ and was noted to
have RV dilation with depressed free wall contractility likely
secondary to PAH. Patient on 140mg daily torsemide at home in
addition to twice weekly 5mg metolazone. Though patient reported
20 lb weight gain over past ___ weeks, weight gain documented in
record over past month was only 7 lbs. Gain in past 8 months was
more significant (around 25 lbs) Weighed 228 in ___.
In fact patient seemed only mildly volume overloaded on physical
exam, with no ___ edema on physical exam; no overt pulmonary
edema on xray, no increased O2 requirement from baseline
(patient uses 3L O2 at night at home); BNP elevated (1700s)
however less than prior admissions for heart failur.. Patient
does report increased abdominal fullness, which may represent
fluid retention, but he believes he has gained body fat, not
water. He endorses increased appetite for past few months. We
attempted to diurese him using a lasix drip. Some diuresis
occurred, but was also immediately accompanied by an increase in
Creatine. Since patient was eager to leave we then discharged
him on his home medications, with the plan for him to schedule a
right heart cath with his pulmonologist in 3 days. We continued
him on his CHF regimen, including Carvedilol and losartan.
# Type 1 Pulmonary Arterial Hypertension: Patient with mPAP 61
on RHC on ___, presumed to be idiopathic. Is on sildenafil
and macitentan (endothelin receptor antagonist) at home. Patient
has been on 2L NC at home at night. Denies any increase in home
O2 requirement or worsening shortness of breath. Continued home
macitentan, sildenafil. Follow up with pulmonologist.
# Acute on chronic kidney disease: Cr 3.0 on admission;
baseline unclear - ___, 2.8 ___ be
pre-renal in setting of decreased pre-load from PAH and RV
failure / 3+ TR. Renal function improved during previous
admission with diuresis. However on this admission renal
function decreased with diuresis; we concluded he was not
significantly volume overloaded.
# hypertension:
- continue home carvedilol 12.5 mg BID
- cont losartan
# Type 2 DM: on glipizide at home. HISS while in house
- adjust as needed
# GERD: on nexium at home, non-formulary
- omeprazole while in house
# Gout: Continued on allopurinol | 151 | 429 |
16858272-DS-7 | 25,398,127 | You were admitted to the hospital after you were struck by a car
while riding your bike. You reported back pain when you were
admitted and found to have fractures of your lower back.
Because of your injuries, you were seen by Neurosurgery and they
recommended a special brace for back stabilization. You were
also found to have a fracture of your left lower leg and had a
brace for immobilization. You were evaluated by physical
therapy and recommendations made for discharge home with the
following instructions:
Because you sustained rib fractures, please follow these
instructions:
* Your injury caused left 12 th 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 antiinflammatory 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 ).
You also sustained a fracture to your back:
Please wear the TLSO brace when ambulating
*report increased numbness/tingling lower extremities
* weakness in legs
* bowel or bladder changes
You also sustained a fracture to your left leg:
*Report increased pain left foot
*increased swelling, numbness of toes left foot
*pain in calf of left leg
*air cast left foot when ambulating
You also hit your head and may note increased headache,
dizziness, and memory changes. We recommend follow-up with
cognitive neurology for further evaluation. | The patient was admitted to the hospital after being struck by a
car while he was riding his cycle. As a result of the accident,
he sustained loss of consciousness. Upon admission to the
hospital, he was made NPO, given intravenous fluids and
underwent imaging of his head, neck, spine. He was reported to
have a left posterior rib fracture, T12-L1 fracture, and a left
fibular fracture. In addition to this, he was reported to have a
pneumo-mediastinum reflective of small airway injury. His
respiratory status was closely monitored and he did not require
a chest tube. Because of the extent of his injuries, the patient
was admitted to the trauma intensive care unit for monitoring.
The Neurosurgery service was consulted for his spine injury
which was reported to be neurologically intact with an unstable
T12-L1 fracture. An MRI was ordered which showed known T12
lamina fractures and L1 compression fracture with minimal loss
of vertebral body height and no retropulsion. There was no
evidence of epidural hematoma or other cause of spinal canal
compromise. The patient was placed on log-roll precautions and a
TLSO brace was ordered. During the initial assessment, he was
reported to have a left distal fibular fracture which was
splinted. The orthopedic service was consulted and recommended
an air cast boot after the patient progressed to ambulation.
Serial chest xrays were obtained due to his pneumomediastinum
and these remained stable. A repeat chest CT on HD #2 was
stable. The patient was transferred to the surgical floor on HD
#3.
Upon admission to the surgical floor, the patient was reporting
lower back pain despite the medical regimen. The Chronic Pain
service was consulted and revised his analgesics including
medication for break-through pain. This provided minimal
relief. The patient was tolerating a regular diet and voiding
without difficulty. Physical therapy evaluated the patient after
the TLSO brace arrived and upon examination determined that the
patient was a candidate for discharge home with family support.
The social worker also met with the patient about his substance
abuse and he declined information on Narcotics Anonymous.
The patient was discharged home on HD # 7 with stable vital
signs. Follow-up appointments were made with the acute care
service, neurosurgery, orthopedics, and with his primary care
provider. | 430 | 394 |
12325058-DS-23 | 21,606,220 | Dear ___,
You were hospitalized due to symptoms of left facial droop,
left-sided weakness, and difficulty speaking 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
- Hypertension
We are changing your medications as follows:
- Stop taking aspirin
Please take your other medications as prescribed.
Please follow up with neurology and your primary care physician
as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
___ is a ___ year old woman with PMH HFrEF, newly
diagnosed atrial fibrillation recently started on Eliquis,
remote history of breast cancer, and hypothyroidism who was
admitted with a right MCA syndrome subsequently found to have
distal R M2/proximal M3 occlusion on CTA. | 294 | 46 |
12678882-DS-22 | 25,047,389 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because your
right knee has been swollen and painful. X-rays of your right
knee showed that you did not any fractures. We believe that
your right knee was swollen because your INR was very high and
that you may have injured your knee, resulting in an
accumulation of blood in that joint. You were evaluated by
Orthopedic Surgery, and received medication, ice packs, and
compression wraps to treat your knee pain. Because your INR was
very high, we initially stopped your Coumadin. You had an ECHO
of your heart to check the size and function of your heart
chambers and to see if the clot in your heart had decreased in
size. The ECHO showed that your heart chambers are now normal
and that the clot is gone. Therefore, we did not restart your
Coumadin since you do not need it anymore.
Besides stopping your Coumadin, we did not make any other
changes to your medications.
Thank you for allowing us to participate in your care. All best
wishes for your recovery. | Ms. ___ is an ___ PMHx diabetes, HTN, ESRD on HD, CHF with
LV thrombus requiring warfarin, osteoarthritis and chronic
diarrhea who presents from from ___ clinic with diarrhea,
worsening R knee pain, and admission for placement. | 201 | 38 |
11048128-DS-10 | 24,126,049 | Dear Mr. ___,
You were admitted to the hospital because you fell and broke
your hip.
WHILE YOU WERE HERE:
- You had surgery to repair your hip.
- We found out that you have a large blood clot in your lungs (a
"pulmonary embolism", or "PE"). We gave you blood thinners to
treat this.
- The clot caused your heart to go into an abnormal rhythm
("atrial fibrillation", or "A-fib"). We gave you medicines for
this and you get better.
WHEN YOU LEAVE THE HOSPITAL:
- Work with the physical therapists to rebuild your strength.
- Take all of your new medicines exactly as prescribed. See
below for detailed list.
- Let your nurses and doctors know immediately if you have any
chest pain, shortness of breath, palpitations, dizziness, or any
other symptoms that worry you.
- See below for more instructions from your surgeons.
We wish you all the best!
Sincerely,
Your ___ Care Team
==============================================
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. You can bear weight on your
left leg as long as it is not too painful.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 8 hours around the clock.
2) Add oxycodone as needed for increased pain. Aim to get
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 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 apixiban every day, every 12 hours. You need this
to treat the blood clot in your lungs and to prevent strokes
from your abnormal heart rhythm (atrial fibrillation).
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other symptoms that worry you
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB | BRIEF SUMMARY
===================
Mr. ___ is an ___ y/o healthy independent man with no
significant PMH, admitted with L hip fracture after mechanical
fall. He underwent successful TFN without immediate
complications. However, on POD#3 he developed new onset atrial
fibrillation with RVR and was found to have a saddle pulmonary
embolus with RV strain. Fortunately he remained hemodynamically
stable and was transitioned from IV heparin to apixiban. He was
discharged to acute rehab with close Cardiology and Orthopedics
follow-up.
ACUTE ISSUES
==================
# Left intertrochanteric femur fracture
The patient presented with hip pain after a mechanical fall and
was found to have an intertrochanteric fracture. He was
initially admitted to the Orthopedic Surgery service and was
taken to the operating room on ___ for left TFN, which he
tolerated well. 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 worked
with ___ who determined that discharge to rehab was appropriate.
# Submassive pulmonary embolism and deep venous thrombosis -
acute, provoked
# Right ventricular strain
On POD#3, the patient developed new onset a-fib with RVR with
right bundle branch block and was found to have a large saddle
pulmonary embolus on CTA chest. Troponins and BNP were
moderately elevated, consistent with RV strain. TTE showed RV
dilation but preserved RV function. Left ___ doppler found a
small distal DVT. MASCOT team was consulted and felt that no
advanced therapies were needed given patient's hemodynamic
stability. He was treated with IV heparin for >48 hours and then
transitioned to apixiban.
# New onset paroxysmal atrial fibrillation
Patient had two episodes of rapid a-fib to 130s-140s which
abated with low-dose beta-blockade. Likely provoked by PE/RV
strain. He was discharged in sinus rhythm on metoprolol
succinate 25mg daily and anticoagulation as above. He would
likely benefit from indefinite anticoagulation (CHADS2Vasc = 2).
# Acute hypoxemic respiratory failure
Patient developed mild hypoxemia post-operatively ___ NC),
attributed to PE and atelectasis. No evidence of pulmonary edema
or pneumonia. He was treated with anticoagulation, incentive
spirometry, and mobilization and weaned to 2L O2 on discharge.
# Acute blood loss anemia
Patient required 4u pRBCs post-operatively. CT A/P showed no
evidence of intra- or retro-peritoneal bleeding. Hgb and BP
remained stable after starting anticoagulation.
# Reactive leukocytosis
WBC was mildly elevated immediately post-op with no localizing
symptoms of infection. Cultures and CXR were negative, and this
was felt to represent leukemoid reaction to surgery and DVT/PE.
Normalized by discharge.
# Mild thrombocytopenia
Platelets dipped to low 100s post-operatively and then
normalized prior to discharge. Likely due to consumption from
surgical blood loss and DVT/PE. Time course was not consistent
with HITT, and platelets normalized prior to discharge. | 651 | 449 |
10602633-DS-24 | 21,305,860 | Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you were having a heart failure
exacerbation.
WHAT WAS DONE WHILE I WAS HERE?
We gave you medication through your IV, furosemide, to help you
urinate.
WHAT SHOULD I DO WHEN I GO HOME?
-You should take your medications as instructed. You should go
to your doctors ___ as below.
-Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs in two days or more than 5 lbs in one
week.
-Try to limit your salt intake
We wish you the ___!
-Your ___ Care Team | SUMMARY ASSESSMENT
====================
Ms. ___ is a ___ woman with a history of
heart failure with preserved ejection fraction (LVEF 55%), CAD
s/p PCI
to RCA (___), hypertension, type 2 diabetes, morbid obesity,
chronic obstructive pulmonary disease, and depression who was
referred to ED for weight gain and progressive dyspnea
concerning for HFpEF exacerbation. Patient underwent diuresis in
hospital with 100 mg IV Lasix twice per day. Patient was
discharged at weight of 318.61 pounds. | 101 | 71 |
16625196-DS-16 | 20,094,482 | Mr. ___,
You were admitted to ___ with a blockage of your common bile
duct. The pictures we took (ultrasound, MRCP) and the ERCP
showed that the pancreatic mass caused this blockage. During the
ERCP we placed a stent to open up the blockage and also took new
biopsies. The gastroenterologists, surgeons, and oncologists
will review these with the pathologist (the doctor who looks at
the biopsies under the microscope) and call you with the results
as well as set up a clinic appointment.
Please take the antibiotic ciprofloxacin 500 mg twice daily
through ___. | ___ with hx of melanoma (removed in ?___, htn, HLD,
nephrolithiasis, pancreatic mass (original biopsy suggesting
mucinous neoplasm with high-grade dysplasia) presenting with
nausea, fevers, and elevated liver enzymes.
# Pancreatic mass:
# CBD obstruction: Pt with known pancreatic mass who presented
with fevers, vomiting, and US plus MRCP showing intra and
extrahepatic bile duct dilatation. Alk phos and transaminases
were elevated though Tbili was WNL. ERCP was performed which
demonstrated the obstruction as well as thick mucus in the duct.
A double pigtail stent was placed, brushings taken. EUS was also
performed with core needle biopsy. The patient did well after to
procedure. His diet was advanced to solids without development
of pain or nausea. He was initially treated with ceftriaxone and
metronidazole due to concern for cholangitis. He will complete a
course of ciprofloxacin on ___. He will follow up with the
multidisciplinary pancreas team in clinic to discuss the biopsy
results.
# Anemia of chronic disease: Normocytic, with normal RDW, likely
anemia of chronic inflammation from his pancreatic mass. Iron
studies support this diagnosis, given low serum iron, ferritin
at high end of normal range, and low TIBC and transferrin. He
has also been experiencing hemorrhoidal blood loss, but only
intermittently, and has been scheduled for a hemorrhoidectomy.
His hgb remained stable, and he has not been experiencing
fatigue.
# EtOH use disorder: No reported history of EtOH withdrawal
symptoms, although unclear if patient has days on which he does
not drink. He did not develop signs of withdrawal.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 93 | 283 |
14918528-DS-13 | 25,937,436 | Dear Ms. ___,
It was a pleasure taking care of you here at the ___
___. You presented with chest pain and
history of a positive blood culture for staph aureus. You were
found to have septicemia and tricuspid endocarditis with septic
emboli in the lungs. We treated your septicemia and endocarditis
with antibiotics, including vancomycin initially and nafcillin
later on. We managed your pain with non-steroid
anti-inflammatory medications and acetaminophen. A PICC line was
placed for administration of longterm antibiotics. Based on
infectious disease recommendation, you are to receive 4-week
course of nafcillin. We started nafcillin on ___ here and
thus, end date would be ___. An arrangement was made with
Shattuc and you will be receiving the remainder course of your
antibiotics at their facility until ___.
You have chronic Hepatitis C and infectious disease recommended
that you follow up with infectious disease clinic in the future
to establish care. Their phone number is ___.
Please take your medication and follow up with your outpatient
appointments as instructed. | Pt is a ___ y/o F with history of HepC and IV drug abuse
presenting with chest pain and history of S. aureus positive BCx
from OSH. | 169 | 28 |
16860511-DS-8 | 28,657,317 | Dear Mr. ___,
You were admitted due to numbness and tingling in your hands as
well as lab values concerning for liver injury. You had a
significant work-up including MRI of the cervical spine that was
normal. Your abnormal liver tests were slightly improving by
the time of discharge and you should have close follow-up with
your PCP to follow these labs (scheduled for ___ you should
have repeat CBC, chemistry, LFTs, LDH, reticulocyte count).
Your symptoms were thought to be due to excess colchicine use as
well as a likely viral illness. Your symptoms should slowly
resolve over time. We started you on folic acid (dietary
supplement) to help your body recover faster. Please seek care
if you have worsening or new symptoms.
Best,
Your ___ Neurology Team | Mr. ___ is a ___ man with history of gout who presented
with an acute gout flare treated with colchicine and
indomethacin, who developed bilateral hand numbness and tingling
for 4 days. His exam was notable for intact strength and
reflexes, and mild decreased sensation to light touch and
temperature over bilateral hands and feet but intact to pain and
proprioception. His labs were significant for mild normocytic
anemia (Hgb 13.4, Hct 39.2, MCV 86), thrombocytopenia (PLT 146)
with occasional poiklocytes, ovalocytes and burr cells, with
reticulocyte count 2.0%. Elevated liver enzymes (AST 863, ALT
649) with normal alk phos (65) and normal total and direct
bilirubin (0.6 and <0.2, respectively). Coags were normal. LDH
was elevated (863) and haptoglobin low (<10). TSH was normal.
Hepatitis viral testing was unremarkable. Monospot was negative.
CRP was 3.0. Blood parasite smear was negative. He had an LP
that was traumatic, with >35,000 RBCs and 43 RBCs (decreased to
907 RBCs and 17 WBCs with lymphocytic predominance in tube 4).
Pending tests include direct coombs antibody testing, tick-borne
illness testing (Lyme, Babesia, Anaplasma/Ehrlicia).
The Medicine team was consulted, and together we thought his
presentation was likely secondary to a viral process in addition
to colchicine toxicity. A RUQ ultrasound showed splenomegaly
with unremarkable liver. The day of discharge his LFTs had
slightly improved to AST 819 and ALT 530. There was no evidence
of myelopathy and his C-spine MRI showed mild disc generative
changes at C5-C6 level and right paracentral disc protrusion at
C6-7.
He should avoid colchicine, acetaminophen, alcohol, and other
hepatotoxic agents until labs are improved. He should also
avoid contact sports at this time given splenomegaly.
He will have follow-up with his PCP on ___ (in 3 days) and
Neurology in 1 month. | 132 | 305 |
10597762-DS-29 | 23,838,403 | Dear Ms. ___,
You were admitted to the hospital because you fell on broke some
ribs on the right side. This caused difficulty breathing. At
first, you required oxygen. We think this is from pain, lack of
deep breaths, and from some fluid in the right lung. Over your
hospital stay, your breathing improved and you no longer
required oxygen. Your pain was better controlled and the fluid
on the right side of your lung also looked improved on chest
xray. You are being discharged to rehab so that you can get
stronger and they can help prevent falls in the future.
The imaging studies during this hospitalization showed that you
also may have an old rotator cuff injury in your left shoulder.
This does not require any immediate intervention. However, you
should follow up with your PCP ___ this issue.
Imaging also showed that you have a mass inside your pancreas
and inside your left adrenal gland. We are not sure about the
significance of these findings, since according to your medical
record, these have been noted before. Please discuss these
findings with your PCP ___ whether or not you need
further imaging.
It was a pleasure to take care of you during this
hospitalization. We wish you the best,
Your ___ Team | Ms. ___ is an ___ year-old woman with hypertension, diabetes
mellitus type II, breast cancer, CKD stage III, asthma and
significant kyphoscoliosis who originally presented with rib
fractures s/p fall and was then transferred from ACS to medicine
due to hypoxemia in the setting of acute ___ and ___ right rib
fractures. Her respiratory status improved, as detailed below,
and she was discharged to rehab after evaluation by Physical
Therapy.
# HYPOXEMIA, DYSPNEA: The patient's dyspnea and hypoxemia (desat
to ___ on room air with ambulation) was likely secondary to pain
on inspiration due to rib fractures, in the setting of low lung
volumes and significant scoliosis. There may also be a small
contribution from enlarging right sided effusion, which looked
hemorrhagic on CT and may be secondary to trauma and rib
fractures. She was treated with incentive spirometry, pain
control with acetaminophen and oxycodone, and continued on home
inhalers. On repeat chest xrays, her right-sided effusion
appeared to improve. Her respiratory status improved and she had
O2 sat of mid-90s on room air. Her small right apical
pneumothorax did not progress on repeat chest xrays.
Additionally, her hct remained stable around 30, so there was no
concern for extension of her small possibly hemorrhagic right
pleural effusion. We discussed her case with Dr. ___
patient's outpatient pulmonologist, who will continue to follow
up with the patient after discharge.
# s/p FALL: Clinical history is most suggestive of mechanical
fall. UA showed pyuria suggesting possible contribution of a
UTI. She was empirically started on IV ceftriaxone on ___ and
narrowed to cefpodoxime 200mg Q12H on discharge. Last dose
should be on ___ for a 3 day course. Urine culture grew mixed
flora that was not speciated. She was seen by physical therapy,
who suggested discharge to rehab. She was placed on Fall
Precautions while in the hospital.
# LEFT SHOULDER PAIN: On presentation, the patient had
complained about left shoulder pain. Xray of the left shoulder
showed no acute fracture and possible rotator cuff injury. The
patient states that she has baseline trouble abducting her left
shoulder, and this has not changed since her fall; therefore,
rotator cuff injury most likely chronic. This issue should be
followed up by the patient's PCP as an outpatient. | 210 | 377 |
16085322-DS-26 | 25,659,486 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with confusion. This may have been due
to recent medication changes. You had an MRI of your brain that
did not show an acute change. You are now stable for discharge.
You will need to work with ___ to build up strength before you
can return home | ___ y/o F with PMHx of HTN, DM2, GERD, polymyositis on chronic
steroids, as well as dementia, who presented to the ED with
progressive weakness and confusion.
# Acute Encephalopathy
# Dementia
The patient presented with worsening weakness, confusion for the
past 6 weeks. However, this is superimposed on a slower
years-long decline in the setting of a dementia diagnosis. Most
likely, this represents progression of the patient's known
dementia. The patient was evaluated by neurology who did not
think that the patient's presentation was consistent with NPH.
MRI brain without acute findings and was consistent with
diagnosis of mixed Alzheimers and vascular dementia. The patient
was started on ASA for secondary prevention. Her mental status
may also have been worsened by medications recently introduced-
Gabapentin, Oxaprozin which have been held. The patient
returned to baseline mental status prior to discharge.
# POLYMYOSITIS: On chronic prednisone for many years which was
continued. CPK is lower than prior indicating polymyositis is
likely not contributing to acute presentation. Colchicine and
NSAID held for now
#Type 2 diabetes without complications:
Metformin was held while hospitalized and resumed on discharge.
# HTN: BP was quite elevated throughout much of ED stay but has
since downtrended. Of note, review of most recent ___ clinic
visit note also mentions a BP of 203/75 on arrival with
improvement to 140/70 during exam. Per daughter no longer on
Lisinopril at home. BP frequently elevated in AM and then
improves throughout the day. The patient was continued on her
home regimen of amlodipine, carvedilol. Did not aggressively
control blood pressure in setting of advanced dementia.
Chlorthalidone was initiated at a low dose of 12.5mg daily for
BP
- titrate BP meds as needed
# DEMENTIA: Mixed components of Alzheimer's disease and vascular
disease per neuro notes. She was most recently seen by her
neurologist (Dr. ___ in ___, as which time it was noted,
"Overall she continues to have a slow decline is now somewhere
between moderate and severe in terms of her stage of dementia."
Addition of memantine was discussed at that time; however, the
patient declined additional medications. Continued home
donepezil, sertraline
# HLD:
- continued home statin
# HYPOTHYROIDISM
- continued home levothyroxine | 67 | 361 |
13370962-DS-4 | 27,612,427 | Dear Ms. ___ & family,
It was a pleasure caring for you at ___
___
You were admitted to the hospital because you were having blood
from your rectum and your mental status was different than
usual.
You were not found to have any infections or any abnormalities.
Your goals of care were discussed with her family and it was
decided that doing invasive and aggressive procedures is not
within the goals for your care right now. We monitored your
blood levels and they remained stable. He will be discharged
with home hospice, which will help focus on your comfort and
symptoms.
Sincerely,
Your ___ Medicine Team | Ms. ___ is an ___ woman with a history of advanced
dementia secondary to Alzheimer's disease who presents with
altered mental status and hematochezia.
# GOC
Presently patient is DNR, DNI. Patient has had a marked
cognitive decline over the past several months and the family
had been considering transitioning to ___, but had not
yet pursued this. Multiple goals of care conversations in the
ICU with family, and decision was made to not pursue
interventions including imaging, EGD, colonoscopy, chest
compression, shocks or intubation. Transfusions, finger sticks
and IV fluids are all within goals. Family has decided to pursue
hospice and preference is home hospice. Case management was
involved in hospice coordination and Ms. ___ is being
discharged with home hospice. For symptom management, we
continued IV Tylenol for pain (ulcers).
# BRBPR
# Anemia
Hemodynamically stable, BUN elevated. Given BRBRP + stable
hemodynamics, likely lower GIB. Presently HDS with fluids &
blood, ongoing maroon stool. Diverticular vs angiodysplasia
(unlikely) vs malignant. EGD or colonoscopy is not within goals
of care. However, supportive blood transfusion and IV fluids are
both within her goals WHILE inpatient. Fluids were bolused as
needed. She was treated with an IV PPI for her inpatient stay. 2
large-bore IVs were maintained an active type and screen was
maintained. She only required 1 blood transfusion throughout
this admission which was on ___. Hemoglobin and hematocrit
remained stable thereafter and labs were not checked towards the
end of her admission as she was clinically stable.
# Hypothermia
By history, lab, imaging no clear evidence for infectious
source. TSH elevated. Nutritional status in setting of
significant Alzheimer's could be driving it as well. Alb 2.6.
Antibiotics were discontinued as we did not feel that she had an
infection.
# Alzheimer's dementia
Baseline nonverbal. End stage.
# Hypoglycemia Likely iso poor PO intake, low liver stores.
Fingersticks were checked 4 times daily, IV dextrose was given
as needed for hypoglycemia, and maintenance fluids with D5 NS
were given as needed. | 105 | 329 |
11953944-DS-16 | 23,127,334 | 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 the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed appendicitis. WBC was
elevated at 12.7. The patient underwent laparoscopic
appendectomy, 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 on
IV fluids, and dilaudid for pain control. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. 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 pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 293 | 202 |
17249596-DS-14 | 22,360,547 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___. You were seen at our hospital because you had
joint pain and high levels of your blood thinner, as well as
some signs of low blood counts ("anemia"). Your joint pain was
likely due to another gout flare; we added a new medicine
("colchicine") which helped your gout. Your low blood counts
were related to your recent heart valve repair; we gave you a
small amount of blood, and you did not have any active blood
loss before you went home. We held your blood thinner
("warfarin") for a few days given some concern for blood loss,
but restarted it before you left.
You also had some fluid around your heart ("pericardial
effusion") that we saw on a picture of your heart. This fluid
was not making your heart worse, and not related to bleeding.
This can happen after heart surgery, and the heart surgeons
believe that it will likely resolve on its own.
Initially we thought you had a urinary tract infection, based on
a test of your urine. Repeat testing did not show an infection.
We briefly gave you antibiotics, but stopped them as you did not
appear to have an infection.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ with a PMH significant for HTN,
atrial fibrillation, mitral and tricuspid valve regurgitation
and repair of both ~2 months prior, CHF, and gout evaluated due
to a supertherapeutic INR of 4.8, 8 weeks of downtrending Hct,
and joint pain. He was admitted due to his above issues as well
as pericardial effusion and anemia found on initial evaluation.
Workup notable for a hemolytic anemia (likely mechanical due to
recent valve repair), moderate-sized pericardial effusion
without tamponade physiology, and no evidence of UTI. No
hemodynamic instability or lab work consistent with DIC.
Hemoglobin stabilized prior to discharge, and supra therapeutic
INR resolved after correction with Vitamin K and holding
warfarin for several days (restarted prior to discharge).
Folate/iron/B complex vitamins provided for his anemia. Given
patient continued to complain of moderate left ankle joint on
day of discharge, he was discharged on an extra 5 days of
colchicine 0.6 mg PO BID.
=================
TRANSITIONAL ISSUES
=================
# CODE: presumed full
# CONTACT: cousin ___ # ___
# Patient will need repeat echocardiogram in 7 days and then
frequency to be determined thereafter. THIS NEEDS TO BE
SCHEDULED PLEASE.
# MEDICATION CHANGES:
- Added colchicine (0.6mg daily), to be continued for a total of
6 months.
- Added ferrous sulfate 325mg daily.
- Discontinued furosemide. Can be restarted if clinically
volume overloaded.
- To continue taking warfarin indefinitely given prior Afib and
anticoagulation risk. Start with 1mg daily, titrate to goal INR
___.
# FOLLOW-UP LABS:
- Please monitor CBC once weekly to ensure stability and
evaluate for worsening hemolysis.
- Please check INR, goal ___.
# WARFARIN DOSING: Came in supratherapeutic on warfarin 2mg
daily. Please titrate to goal ___ as above.
Discharge weight: 84.8 kg
Discharge Hg: 7.7
Discharge Cr: 0.9
Discharge INR: 1.4 | 234 | 297 |
15668278-DS-8 | 25,348,295 | Discharge Instructions
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
** PLease continue to wear your brace at all times, Sponge baths
only, do not remove your brace.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
New weakness or changes in sensation in your arms or legs. | Mr. ___ was admitted to the floor from the emergency room
after a CT of his cervical spine showed a C2 odontoid fracture.
A CTA of the neck was obtained to rule out vertebral dissection
which showed no acute findings and no evidence of dissection. A
MRI of the cervical spine was also obtained to rule out
ligamentous damage.
On ___, the patients exam remains stable. He continues to wear
his cervical collar. His MRI was negative for any ligamentous
injury. He will be fit for a long term cervical collar today.
If he can tolerate the cervical collar he can continue to wear
that until cleared, otherwise he will have to wear a halo. Dr.
___ to discuss with the patient today.
On ___, the patient remained neurologically and hemodynamically
stable. An Xray of the cervical spine was obtained to evaluate
his fracture in the new collar. He is to wear the collar on at
all times. Case management is working on transportation to rehab
in ___.
On ___, the patient and family expressed readiness to be
discharge home. However, the patient was uncomfortable with his
brace. Rep from the brace shop was called to re-evaluate fitting
of the neck brace. Physical therapy evaluated the patient for
home safetyness and recommended dispo to home. The patient was
discharged home in stable conditions. All discharge instructions
and follow up was given prior to leaving. | 150 | 238 |
16642859-DS-15 | 28,221,447 | Spine Surgery-Wound Revision
Dr. ___
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
* You have sutures and staples, please keep them dry until they
are removed.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
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.
Do not take any medications such as Aspirin unless directed by
your doctor.
Unless you had a fusion, you should take Advil/Ibuprofen
400mg three times daily
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.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Follow Up Instructions/Appointments | ___ y/o F s/p L1-5 laminectomies and resection of meningioma
presents with erythematous incision concerning for infection.
Patient was admitted to the neurosurgery service. An MRI of the
T spine shows fluid collection at C7-T1 through, T3-4 level with
increased mass effect. Patient was made NPO and pre opped for
the OR tomorrow morning
On ___ Patient remained neurologically intact. She was taken to
the OR for a wound revision. Intraoperatively, patient had an
inflitrated L arm. She was extubated and transferred to the PACU
for recovery. She remained stable post operatively and was
transferred to the floor in stable condtion. ID was consulted.
On ___, patient remained stable, incision was clean and intact.
She was started on vancomycin and cefepime while awaiting ID
recommendations. A PICC line was ordered and she was consented
for the PICC. An MRI was ordered to check for an residual
postoperative fluid collection, however, the patient was too
anxious and unable to lay still for exam.
On ___, the patient remained stable. Her Vanco level was 7.2,
her vancon was redosed. A PICC line was placed for antibiotic
administration, with good placement. The TLC catherter was
removed.
On ___, the patient remained stable. Her hemovac was removed
without difficulty, the wound is slowly improving. Based on
Infectious Disease recommendations, the patient's vancomycin and
cefepime were discontinued. She was then started on Nafcillin 2
grams every four hours. The course of therapy is expected to be
approximately four weeks. The ID service will contact the
___ rehabilitation facility to schedule a follow-up visit.
As noted on the discharge summary, the patient will need to
have weekly CBC with differential, BUN, Cr and LFTs ordered.
On ___, the patient remained neurologically stable and was
awaiting acceptance to a rehabilitation facility.
On ___ she continued to mobilize and was neurologically stable
while awaiting rehab bed.
On ___, the patient remained neurologically and hemodynamically
intact. She was discharge to the rehab facility in stable
conditions. | 235 | 335 |
13138359-DS-3 | 27,478,855 | Ms. ___, you were admitted to ___
___ due to low blood pressure in the setting of pneumonia and
urinary tract infection. | Brief Hospital course:
Ms. ___ is a ___ female with COPD, HTN, CAD, CKD, hx of
recurrent UTI's admitted for hypoxic respiratory failure
secondary to LLL pneumonia and urosepsis leading to septic shock
and care from the ICU.
# Health-care associated pneumonia: Pt with infiltrate suggested
on CXR, fevers. Pt resides at a nursing home, so concern for
HCAP. Pt was intubated on arrival from ___ given
respiratory distress. CXR showed increasing consolidation on the
left. Given that, she had a bronchoscopy on ___ that showed
copious secretions but no endobronchial lesions. She was
initially started on vancomycin and cefepime (d1 = ___ and
this was eventually transitioned vancomycin and meropenem
___ past cultures with E. coli resistant to cefepime.
She was extubated on ___ without difficulty.
# Hypoxia Respiratory distress: Likely ___ pneumonia and
possible contribution from volume overload. She was intubated at
___ prior to transfer to ___. She was treated for
pneumonia as above. Bronchoscopy on ___ showed LLL PNA but no
evidence of endobronchial obstruction. She was extubated
post-bronchoscopy and was weaned to 2L NC. Given some vascular
congestion on imaging, pulmonary edema thought to be
contributing and she was given a two doses of lasix 10 mg IV in
the ICU and responded well with > 1.5L diuresis over 24 hours.
# Septic shock: As above, likely secondary to HCAP. She has also
had resistant UTI's in the past. She was initially on
Vanc/Cefepime for PNA and UTI; however, pt spiked on HD #2 to
103. She was started on Meropenem. Outside cultures showed E.
coli ESBL. She defervesced and remained hemodynamically stable.
Her pressors were weaned on evening of ___. Planned for 8 day
course with Vanc/Meropenem.
# COPD: No home oxygen requirement. She is only on Flovent at
home with no inhalers. In the ICU she was started on albuterol
and ipratropium nebs with Advair given BID.
# Tremor, mouth: Could be tardive diskenesia. But per nursing
home, did not have this mouth tremor before. Unclear if this is
related to holding her home antipsychotics while intubated and
sedated. This improved prior to discharge and could be worked up
further if she has more episodes.
# Mental status: Her mental status is improving and she is able
to follow commands. Per SNF, is alert and oriented to self only
at baseline. After recovering from sedation, she returned to
baseline with intermittent agitation/delerium, which resolved on
restarting home risperidone and ativan. She may have been less
alert/oriented after receiving lorazepam, so dose was decreased
to 0.5mg BID.
# CAD: Troponins at 0.12 and 0.11 in setting of CKD. Likely does
not represent ischemia given that EKG in sinus rhythm, with no
acute ST-T changes. Echo this admission was also unconcerning.
# Schizoaffective: Continued on home Depakote and risperidone.
Ativan was initially held given that she was on Midazolam during
intubation. Following extubation, Ativan was restarted at lower
dose of 0.5mg BID.
# CKD: Cr was 1.7 on admission (unclear baseline) in the setting
of likely volume depletion. Creatinine improved to 1.1 with
fluids.
# HTN: Initially hypotensive in the setting of sepsis (above) so
amlodipine was held on admission. On resolution of hemodynamic
stability, her amlodipine was restarted on ___ and SBPs
remained in the 130s-160s range on discharge.
# Anemia: Patient presented normocytic anemia with hematocrit of
30.4. Unclear baseline. She had no evidence of bleeding and
hematocrit remained stable throughout admission.
# Code: Full
# Contact: ___ (son) ___. ___
(___, lawyer) ___
### Transitional issues:
- Patient with anemia of unclear etiology, should be worked up
as an outpatient
- considering tapering ativan to improve mental status
- please check electrolytes ___ in morning and replete as
needed
- please check vancomycin trough 1 hour before vanc dose in
morning of ___ and adjust dose as needed
- last dose of vancomycin to be given ___ for 8 day course
- last dose of meropenem to be given ___ for 8 day course
- please perform chest physical therapy to mobilize thick
purulent secretions
- please follow up on sputum speciation and pending blood
cultures | 22 | 696 |
14066425-DS-29 | 26,034,894 | Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You had fevers and body aches.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-We treated you with broad-spectrum antibiotics
-You had a procedure called an ERCP to remove sludge from your
gallbladder. You got better after this.
-We found that you have a virus in your blood called CMV, which
sometimes happens after transplant.
-You had a biopsy of your liver which did NOT show any
rejection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please get your labs drawn in one week.
We wish you all the best!
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
___ with a history of cryptogenic cirrhosis complicated by
portal HTN, ascites and esophageal varices, status post DDLT
(___), complicated by acute T-cell mediated
___ and mild T-cell mediated rejection (___),
and biliary strictures status post stent placement (___) and
replacement (___), recurrent cholangitis, GERD, and restless
leg syndrome, who presents with elevated LFTs and fever. Initial
concern was for cholangitis versus transplant rejection. He was
started on Vanco/cefepime/Flagyl empirically. ERCP was performed
and biliary sludge was removed, with visualization of patent
stent and no evidence of obstruction. These findings,
downtrending LFTs, and resolution of his fevers with only
antibiotic treatment suggested that likelihood of transplant
rejection was low and liver biopsy was deferred. He also
developed watery diarrhea after being started on antibiotics,
and our infectious work-up revealed a newly detectable CMV
viremia with 3000 copies per milliliter. His stool CMV PCR was
pending at discharge. He had a biopsy of his liver for LFT
elevation which did NOT show acute rejection. CMV pathology was
pending at discharge. | 132 | 173 |
11107570-DS-16 | 24,386,603 | Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox injections for 2 weeks to help prevent the
formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: weight bearing as
tolerated in the right lower extremity.
Physical Therapy:
WBAT RLE. ROMAT
Treatments Frequency:
right hip daily dressing changes with dry sterile dressing until
no drainage.
R hip staples to be removed upon follow up in ___ clinic
in 2 weeks. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have rgiht intertrochanteric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip ORIF/DHS which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. While here, it was noted that she is very
deconditioned/emaciated, and nutrition was consulted who
recommended high calorie foods with extra protein shakes such as
ensure. 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
WBAT RLE, and will be discharged on lovenox injections x 2 weeks
for DVT prophylaxis. The patient will follow up in two weeks
with Dr. ___ routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 501 | 284 |
17419071-DS-6 | 20,523,433 | Dear Mr. ___,
You were admitted for confusion. We treated you by replacing the
steroids and thyroid hormone in your body and you improved. You
will be transferred to ___ for a second opinion regarding
surgery.
Sincerely,
Your ___ Team | ___ yo ___ speaking male with PMH of DMII, tachycardia of
unclear cause, dementia, and craniopharyngioma s/p resection 6
months ago now presenting with several days of weakness,
confusion, and falls. Treated for adrenal
insufficiency/hypothyroidism due to hypopituitarism with
improvement of acute issues. However, underlying behavioral
issues remained from previous surgery 6 months ago. Neurosurgery
recommended draining the cystic lesion at the sight of the
crandiopharyngioma, but patient's daughter requested a second
opinion from another center and therefore was transferred to
___.
The patient was persistently very agitated while inpatient and
after multiple medication trials was responsive to Seroquel. He
was seen by both medical and surgical consulting services while
inpatient: endocrinology assisted with treatment of
panhypopituitarism; neurology aided with diagnostic workup of
his imbalance, delirium, and behavior issues; and neurosurgery
ultimately wished to place an Ommaya for an imaging visualized
cystic lesion at the site of previous surgery. Ultimately the
patient's daughter deferred having surgery at ___ and wished
to seek a second surgical opinion at ___ regarding his
behavioral problems including outbursts, agitation, and
aggression. | 37 | 176 |
17181854-DS-16 | 26,081,144 | Dear Ms. ___,
Thank you for choosing ___ as
your site of care!
Why was I admitted to the hospital?
-You were admitted to the hospital because you were experiencing
chest discomfort and trouble breathing at home.
What was done for me while I was in the hospital?
-A tracing of you heart was taken, this did not show obvious
changes.
-Your heart markers were slightly elevated.
-Because of your history, and your chest pain you had a heart
catheterization.
-This study showed the blood vessel that you had stented
previously was blocked again.
-We spoke to our cardiac surgeons and your previous doctor, ___.
___.
-A second procedure was completed ___ and a new ___ was
placed in your heart.
-After the procedure you went to the ICU briefly to help manage
your blood pressure.
-You were initially placed on medication to thin your blood.
-You continued your home medications, including your Aspirin,
Brillinta and Metoprolol.
-Once your chest pain resolved, you were felt safe to be
discharged home.
What should I do when I leave the hospital?
-Please continue taking your aspirin and Brillinta daily. This
medication is important to keep your ___ open.
-Please also continue to take amlodipine 2.5 daily and
metoprolol XL 25mg daily. You may stop your HCTZ
(hydrochlorothiazide).
-Your atorvastatin dose was increased to 80 mg daily. While on
this higher dose, you should take coenzyme Q10, 200 mg daily.
You can get this over the counter at the pharmacy.
-You are also being discharged with nitroglycerin sublingual
which you can take if you develop chest pain (and call your
doctor).
-If you notice you are having chest pain or trouble breathing,
please return to the hospital.
-Please follow up with your outpatient providers. You should
call Dr. ___ office to schedule follow up at ___,
please follow up within 2 weeks.
-Please all call Dr. ___ at ___ to schedule PCP
follow up within one week of discharge.
We wish you the best,
Your ___ treatment team | Patient Summary for Admission:
===============================
Mrs. ___ is a ___ year old woman with a history of SVT,
hypertension, dyslipidemia, and recent admission for ___
complicated by LAD perforation and tamponade (___) who
presented to the ___ ED for evaluation of chest pain. EKG on
admission without obvious ischemic changes, troponins elevated
to 0.12. Patient admitted for NSTEMI management. While in the
ED, patient received an aspirin load, Brillinta and started on a
heparin gtt. She was transferred to ___ service for
further management. Patient underwent cardiac catheterization
___ which demonstrated ___ restenosis of the previous DES
placed in the LAD. Intervention was initially deferred, however
patient underwent cardiac catheterization with stenting to the
LAD on ___ with Dr. ___. Post catheterization course
complicated by hypotension and subsequently hypertension
requiring brief CCU stay. Patient transferred back to ___
service ___ where she remained hemodynamically stable and
follow evaluation by ___ was felt safe to discharge home. | 314 | 154 |
18172623-DS-30 | 29,452,997 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
- You initially came to the hospital because of confusion and
fever, and you were found to have a pneumonia
What happened during your hospitalization?
- You were given antibiotics in order to treat your pneumonia
- You had a second pneumonia during the hospital and you were
treated with another course of antibiotics
- You also had a chest tube placed in order to help drain fluid
from around your lungs
- You had your J tube exchanged because it was frequently
clogging
- You were given blood because you had some bleeding in your
abdomen
- You had severe constipation and we gave you enemas and
laxatives
- We decreased your methadone dosing to prevent further
constipation
What you should do when you leave the hospital?
- Continue to take all of your medications as prescribed
- Please keep all of your scheduled healthcare appointments
listed below
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ year old male with history of CAD s/p MI
with stent, L pontine stroke, recurrent aspiration PNA with
more than 15 hospitalizations this year for recurrent
aspirations, with J tube, who presented from rehab with fever
and AMS concerning for aspiration PNA, was also hypotensive
requiring a brief ICU admission however did not require
pressors, completed a 7 day course of vancomycin and meropenem.
He also had a parapneumonic effusion and underwent chest tube
placement and drainage. Hospital course was complicated by a
recurrent aspiration pneumonia and he completed a second 7 day
course of Vancomycin and meropenem. Due to frequent clogging of
his J tube, he underwent ___ exchange. He also had an acute
bleed in the setting of heparin for a right calf DVT that was
identified. He was found to have a hemoperitoneum thought to be
from an abdominal wall bleed or bowel wall bleed at the
insertion of the PEJ tube. We stopped anticoagulation and his
bleed spontaneously stopped. At time of discharge based on
ongoing goals of care conversation patient was transitioned
from strict NPO to NPO allowing for ice chips with nursing
supervision. He developed severe constipation and was found on
CT A/P to have ileus/stercoral colitis. The patient was started
on aggressive bowel regimen. Bowel regimen was held for a
period of time while patient was having diarrhea. The patient's
bowel regimen was restarted prior to discharge and patient was
having regular bowel movements.
# Recurrent aspiration pneumonia
# Acute hypoxic respiratory failure
# Sepsis
# Toxic metabolic encephalopathy - Patient has had recurrent
aspiration pneumonias in the setting of a left pontine stroke,
with PEJ tube and > 15 admissions this year for recurrent
aspiration pneumonia. He presented with altered mental status
and fevers consistent with sepsis secondary to aspiration
pneumonia. He was initially hypotensive, requiring an ICU
admission, however never required vasopressors. He was started
on vancomycin and meropenem for coverage of resistant organisms
given a history of MRSA, multi-drug resistant Klebsiella and
acinetobacter. He completed a 7 day course (___). Sputum
cultures were unrevealing. He had a recurrent aspiration
pneumonia and completed a ___ 7 day course of vancomycin and
meropenem through ___. Sputum culture was ultimately
contaminated and unable to obtain an adequate repeat specimen.
He required frequent suctioning. Of note, his CXR showed
extensive pulmonary fibrosis thought to be secondary to his
chronic aspirations. In consultation with palliative care, he
was initially made strict NPO however based on goals of care
conversations, allowed for ice chips with nursing supervision
for comfort. He was weaned to room air at time of discharge.
# Pleural effusion - Patient likely had a parapneumonic
effusion in the setting of pneumonia per above. He had a chest
tube placed that drained serosanguinous fluid. Pleural fluid
studies were consistent with a parapneumonic effusion. The
pleural fluid was also notable for atypical lymphocytes
initially concerning for malignancy. Flow cytometry was
consistent with a reactive process however. Pleural effusion
was drained and chest tube was removed.
# Acute on chronic Anemia
# Hemperitoneum: Baseline Hb 7.0-8.0 thought likely due to
anemia of chronic disease. Patient with sudden onset
downtrending in his hemoglobin. This occured 24 hours after
being placed on heparin for a right calf DVT. A CTA showed a
hemoperitoneum but no identifiable bleeding vessels. ACS
evaluated and thought that the PEJ tube likely was causing some
irritation accompanied by the heparin gtt causes a vessel to
slowly bleed. Heparin was stopped and his bleed ceased. We got
a repeat US to eval for the DVT and it was no longer
visualized. We stopped all anticoagulation for him.
# Right Calf DVT: patient noted to have right lower extremity
edema. Bilateral ultrasounds were performed which demonstrated
a right peroneal vein DVT. He was started on heparin gtt but in
the setting of the bleed as noted above this was stopped. A
repeat US showed resolution of this DVT. At this time,
anticoagulation was discontinued due to hemoperitoneum. CTA
chest with no sign of PE.
# Goals of care
# Chronic dysphagia and aspiration
# Nutrition - With chronic G-J tube for enteral feeding. He was
initially noted to have mild tenderness to palpation and
erythema surrounding his G-J tube. ACS was consulted however
there was lower suspicion for infection. His G-J tube
frequently became clogged and was later replaced by ___. Given
the patient's recurrent hospitalizations for aspiration
pneumonia, palliative care was consulted to help clarify goals
of care. He is very interested in being able to eat/drink, but
does not want to stop being treated for recurrent pneumonias.
He continued tube feeds and was made NPO with aspiration
precautions, eventually allowing ice chips with nursing
supervision for comfort.
# Stercoral Colitis:
# Constipation - Patient had ongoing issues with constipation,
was on an aggressive standing bowel regimen however had
worsening abdominal distention, KUB showed severely dilated
loops of bowel. CT Abdomen and Pelvis was obtained which showed
a large fecal load, no evidence of obstruction, with some
thickening suggestive of stercoral colitis. Constipation was
relieved with mineral oil enemas and manual disempaction.
Patient then developed profuse diarrhea for which aggressive
bowel regimen was held. C. diff was negative. His bowel regimen
was restarted when his diarrhea resolved and he was having
regular bowel movements before he left the hospital.
# Hypernatremia - The patient had hypernatremia to 150 likely
from insensible loses and too few free water flushes. This
improved with increasing free water flushes and with D5W.
# Hyponatremia - The patient developed hyponatremia, which was
likely due to combination of hypovolemic hyponatremia and
SIADH. The hyponatremia was resolving with IVF and decreasing
free water flushes at time of discharge.
# Coagulase negative staph bacteremia - Was noted to have
positive blood cultures, but this was most likely a
contaminant. He was already on vancomycin for HAP coverage as
above. Repeat blood cultures were obtained which were negative. | 160 | 980 |
19524729-DS-13 | 20,545,608 | Ms. ___,
You were admitted for your severe lethargy and diarrhea and were
found to have an anemia (low blood count). We transfused you
with blood while you were admitted at ___. Your blood counts
improved. We continued you on your heart medications for your
congestive heart failure. Dr. ___ cardiologist, and
your son are aware of this plan.
Two of your medications, gabapentin and risperidone have been
decreased because of kidney injury.
You will follow up with Dr. ___ shortly to discuss the
possibility of further changing the medications.
Finally, we believe these symptoms were due to taking too many
laxatives. Please do not take more laxatives than instructed and
let your doctor know if you are constipated and uncomfortable.
If you have worsening symptoms of diarrhea, weakness, or
dizziness please return for further evaluation.
It was a pleasure taking care of you at ___!
Sincerely,
Your ___ Team | ___ with CAD s/p CABG, pAfib on apixaban, SSS s/p PPM/ICD,
spinal stenosis, dCHF on Bumex, ?TIA h/o but never with positive
imaging, presented with worsening anemia c/f GI bleed after
diarrhea and facial droop.
# Anemia: baseline Hgb is ~9, presented at 7.8, no reported
melena or hematochezia, rectal occult positive in ED. No
symptoms/signs c/f other sources of bleeding, history of large
volume transfusion back in ___ but none since then; no
abdominal tenderness. Perhaps secondary to diarrhea but given
h/o constipation and then followed by significant diarrhea with
bowel reg, bleeding likely in setting of abnormal GI motility
rather than GI pathology (diverticular, malignancy). Patient was
transfused 1u RBC given her anemia and likely dehydrated state.
She was encouraged to take in PO fluids but IV fluids were not
given in the setting of congestive heart failure. Her H/H at the
time of discharge improved 9.8/32.6%.
# Facial droop: initially c/f stroke given prior history of
TIAs. Difficulty with anticoagulation due to bleeding although
now on eliquis. Had severe epistaxis on xarelto in the past; has
had repeat epistaxis on eliquis and thus switched to aspirin
until recent TIA, then put back on eliquis 2.5mg bid. Carotid
duplex ___ without interventions; son, who is an ___
was contacted and was not concerned about acute neurologic
change; mild facial droops is likely baseline per son and speech
is normally slow; some asymmetric weakness in her R lower
extremity. Pt continued on apixaban 2.5mg bid throughout
hospitalization and had no further episodes concerning for
TIA/stroke.
# dCHF: last ECHO ___ with EF > 55%, dry weight 94.8kg on
previous admission. Chronic fatigue/SOB and chronic 2+ pitting
edema for decades, this has been documented in cardiology notes.
Given diarrhea in the setting of laxative overuse, dehydration
and intravascular depletion likely; stable respiratory status
with no oxygen requirement, pitting edema in legs is reported to
be chronic per son (however appears asymmetric R>L). She was
continued on Bumex 4mg tid and spironolactone 25mg qd. Dr.
___ cardiologist, was aware of this plan and involved
in the discussion to continue her on her diuretics. LENIs were
done to assess for the edema with no evidence of acute clot. She
was discharged on her home diuretic regimen with close follow up
with Dr. ___.
# Sick sinus syndrome: s/p PPM in ___, dual chamber, ___
Sensia. No reported abnormalities in PPM since placement,
followed by cardiology as outpatient. Concern for possible
arrhythmia at home given history of lethargy, but no syncopal
episode and no overt events on telemetry. PPM was interrogated
and found no arrhythmias at all since ___, where she had
several hours of AF with complete
heart block and demand V pacing.
# Acute on chronic renal failure: Cr 2.4 here, usually between
1.7 to 2.2; concern for dehydration and given IVF in ED. Pt was
continued on bumex and spironolactone per above. Discharge Cr
was 2.8 on ___ with repeat drawn and pending on discharge. Her
son (internist at ___ requested discharge and will draw
labs and results will be followed by Dr. ___ will make
adjustments to diuretic regimen as necessary.
# pAfib: V paced. Interrogated PPM per above. Continued on
apixaban and metoprolol.
# Troponinemia
# Multivessel CAD s/p LAD PCI ___, s/p urgent 4v-CABG ___.
Troponins were elevated in the setting ___ but CK-MB was
normal without chest pain. Pt continued on metoprolol,
simvastatin and apixaban.
# HTN: Fractionated metoprolol initially but later started home
metoprolol succinate upon discharge. Continued on spironolactone
per above.
# Diabetes: Continued on sliding scale and held home
glimepiride. Gabapentin dose reduced to 100mg QD due to ___.
Please dose adjust as necessary as renal function improves.
# Psych: Hx of hallucinations after husband passed away.
Continued on home duloxetine. Risperdal dose reduced to 1mg QHS
due to ___. Please dose adjust as necessary as renal function
improves.
TRANSITIONAL
===============
Please follow-up with Dr. ___ on ___
Patient discharge on home diuretic regimen: bumex 4mg tid and
spironolactone 25mg qd with PRN metolazone
Discharge weight: 84.2 kg (standing) * standing weight ___ was
89.4 kg - which was more closely correlated to bed weight 90.4
kg *
MEDICATION CHANGES
Gabapentin dose reduced to 100mg QD due to ___. Please dose
adjust as necessary as renal function improves.
Risperidone dose reduced to 1mg QHS due to ___. Please dose
adjust as necessary as renal function improves. | 153 | 730 |
12228394-DS-17 | 29,028,970 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· Please keep your staples along your incision dry until they
are removed.
· It is best to keep your incision open to air but it is ok to
cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· *You have been discharged on Keppra (Levetiracetam) and
Dilantin (Phenytoin). These medications helps to prevent
seizures. Please continue this medicatiosn as indicated on your
discharge instruction. It is important that you take the
medications consistently and on time and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
· 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 symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | ___ with R SDH crani evaculation s/p repeat crani for worsening
MLS now with post operative simple focal seziures and ICU
delirium with stable interval head CT after drain removal.
#Subdural hematoma: Patient was taken to the operating room on
___ for right craniotomy for evacuation of SDH with Dr.
___. Aspirin for cardioprotection was held and he was given
platelets in the ED. He underwent an uncomplicated procedure and
was successfully extubated. Postoperatively he was transferred
to the Neuro ICU. On ___ he was found to have increased
confusion and lower extremity weakness. Repeat STAT head CT
showed interval increase in SDH with increased midline shift to
14mm. He was emergently taken back to the operating room with
Dr. ___ re-do craniotomy for ___ evacuation. Procedure
was uncomplicated and 2 drains were placed (subdural and
subgaleal). Post operatively, the repeat head CT was still
concerning for continued bleeding, and he received DDAVP and
platelets. A TEG was performed inter-operatively without
deficiency and hematology was consulted. He was extubated on
___ without issue. He remained neurologically stable. Both
drains were removed on ___. Post-pull head CT was stable. He
was transferred to the neurosurgery floor on ___ and remained
stable.
over the weekend the patient continued do well, he was
discharged to rehab in stable conditions on ___. All discharge
instructions and follow up were given prior to discharge.
#Simple partial seizures: In the evening on ___ he was noted to
have multiple (14+) left simple motor seizures of the face,
necessitating Keppra load and increase to 1500mg bid as well as
Dilantin and 100mg q8h. EEG was applied. After 24 hours without
seizures, his EEG was removed and have begun AED taper.
Currently on Keppra to 500 mg BID and Dilantin 200mg to bid. The
patient will need to follow up with his neurologist as
scheduled. Dilantin level on ___ was 9.1.
#H/o alcohol abuse: He was started on daily thiamine and folic
acid PO. No evidence of withdrawal.
#Urinary retention: He had episodes of delirium d/t bladder
retention, which improved with foley placement. He was started
on Floman. Foley was subsequently removed on ___ and he was
voiding on his own without retention. Continued on Flomax. | 626 | 370 |
13740336-DS-19 | 24,210,178 | 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 in the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Clinical Impression/Prognosis: Pt is a ___ y/o F with a history
of
chronic back pain who presents to physical therapy during
hospitalization for RLE trimalleolar fx requiring ORIF. Pt is
functioning well below baseline limited by impairments in body
structure and function including decreased balance, and
endurance
consistent with RLE fx s/p surgery requiring NWB. Pt also
presents with activity limitations in mobility and self care
contributing to difficulty in fulfilling societal role of
caregiver for father. Pt is currently functionally appropriate
for home d/c when medically stable. Pt does not require
additional inpatient ___ prior to D/C but will f/u to progress
endurance/higher level balance if pt remains at ___ for
medical
reasons. pt will require AC's and home ___ following discharge.
Goals: Time Frame: 1 Week
- Pt will amb 200' with AC and I while maintaining NWB status
- Pt will be I with a FOS while maintaining NWB status
Recommended Discharge: ( )rehab (X)home with home ___, following
0
___ visits
Treatment Plan:
Progress functional mobility including bed mobility, transfers,
gait and stairs as tolerated.
Balance training
Pt/caregiver education RE: fall risk
D/C planning
Frequency/Duration: ___ for 1 week
Recommendations for Nursing: Amb with AC's and S 3x/day. OOB for
all meals and at least 3 hours a day, no more than 1 hour at a
time to prevent skin breakdown.
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right trimalleolar fracture with posterior subluxation
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for ORIF right
ankle, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 785 | 255 |
15264952-DS-22 | 22,306,996 | Dear Ms. ___,
===================================
WHY DID YOU COME TO THE HOSPITAL?
===================================
- You vomited blood
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- We monitored your blood counts for several days after a blood
transfusion.
- You had a procedure called an "EGD" which looked at the lining
of your stomach and esophagus. This study showed severe
irritation to the esophagus called "esophagitis" which probably
explained the bleeding.
- We started medication to help with healing your esophagus.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Please take all of your medications as prescribed.
- Please stop taking the potassium and alendronate for now.
- Follow up with your medical team (see below).
We wish you the best!
- Your Care Team at ___ | ========================
BRIEF SUMMARY
========================
___ is a ___ year old women with EtOH cirrhosis
complicated by portal hypertension, esophageal variceal
bleeding, and small volume ascites who presented with
hematemesis, found to have severe esophagitis on EGD with no
clear evidence for variceal hemorrhage.
She also has a history of a bile duct injury from a distant
cholecystectomy, and is s/p roux-en-Y hepaticojejunostomy with
separate hepaticojejunostomy to right posterior duct. Given the
findings on her EGD and that her bleeding stabilized, it was not
felt like she needed any additional evaluation to look for
alternative bleeding sites such as a marginal ulcer.
She was given 1 blood transfusion on admission but her counts
remained stable for 2 days and she was discharged with
hepatology follow up for repeat outpatient EGD, high dose PPI
therapy, and sucralfate. | 116 | 134 |
12713097-DS-14 | 26,982,691 | Dear Ms. ___,
You were hospitalized due to symptoms of confusion and a fall
resulting from an ACUTE ISCHEMIC STROKE, a condition in which a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed 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:
Valvular atrial fibrillation due to myxomatous mitral valve
Hypertension
Hyperlipidemia
We are changing your medications as follows:
Coumadin - dose to be determined by doctor based on blood levels
Metoprolol ER 75mg by mouth once a day
Lisinopril 20mg by mouth once a day
Please stop your Verapamil
Please take your other medications as prescribed.
Please followup with Neurology, Cardiology, and your primary
care physician as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Ms. ___ is a ___ woman with a history of hypertension
and hyperlipidemia who was found down in her apartment after a
fall on ___. She presented to the ED with altered mental
status and obvious trauma to the R forehead, arm, and knee. She
was found to have marked leukocytosis, elevated lactate, and
hypokalemia. Due to concern for sepsis she was rescusitated per
sepsis protocol and transferred to the medical ICU. She
developed Afib with RVR while in the ED and was successfully
converted with metoprolol. No source of infection was identified
on UA, CXR, or CT Torso. ___ revealed no acute intracranial
process. Due to concerns for ataxia and aphagia, she had an MRI
while in the medical ICU which showed infarcts in the L medial
midbrain, L medial temporal lobe, and L occipital lobe. This was
likely the result of a large clot that caused transient ataxia,
evolving into several discrete embolic infarcts. The most likely
etiology is cardiac embolism from paroxysmal valvular atrial
fibrillation.
She remained stable in the ICU and was transferred to the floor
on ___. There was initial concern that her aphasia may be
secondary to seizure (stroke in L medial temporal lobe), but EEG
was within normal limits. On discharge she continued to have
some confusion, limited attention, and amnesia. Her exam has
improved, but is still notable for L ptosis, limited L eye
movement, RUQ visual field cut, limited attention, and amnesia.
Her newly diagnosed Afib was investigated with TEE and TTE,
which showed myxomatous mitral valve with worsening mitral
regurgitation leading to valvular Afib. Per cardiology,
metoprolol was titrated for rate control. She was anticoagulated
with heparin gtt and coumadin was started on ___. She will be
sent to rehab on heparin gtt bridge and follow-up with
cardiology as an outpatient.
Her blood pressure was allowed to autoregulate in the acute
setting. On HD4 her home HCTZ was added to metoprolol. Blood
pressure control was suboptimal so lisinopril was titrated to
normotension.
# Neuro
- Left midbrain, temporal, and occipital acute infarcts
- Exam findings consistent with a ___ nerve palsy due to infarct
of the fascicle, R sided weakness from infarct of the cerebral
peduncle, and impaired coordination from infarct of the superior
cerebellar peduncle.
- Continue heparin gtt: check PPT q6h, goal 50-70, can stop
heparin gtt once INR theraputic
- Continue coumadin with heparin bridge, trend daily INR, goal
INR ___
- BP Control: Continue HCTZ 25mg PO daily, lisinopril to 20mg PO
daily, metoprolol succinate 75 mg PO daily
- Continue rosuvastatin 10mg PO daily
- Continuous EEG within normal limits
- Risk Factors: HbA1C (5.9) LDL (65)
#CV
- History of hypertension, hyperlipidemia, and myxomatous mitral
valve with worsening mitral regurgitation leading to Afib
- Continue coumadin with heparin bridge, trend daily INR, goal
INR ___
- BP Control: Continue HCTZ 25mg PO daily, lisinopril to 20mg PO
daily, metoprolol succinate 75 mg PO daily
- Continue rosuvastatin 10 mg daily
- TTE/TEE: Myxomatous mitral valve with worsening mitral
regurgitation leading to valvular Afib
#ID
- Initial concern for sepsis but no source of infection on UA,
CXR, or CT Torso (WBCs 22 -> 12.7)
- Briefly on broad spectrum abx for meningitis coverage, stopped
once MRI showed acute infarcts
#Endo
- HgbA1c 5.9
- History of hypothyroidism, continue home synthroid 75 mcg
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
65) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: LDL below goal on current regimen
]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A | 329 | 786 |
12113804-DS-10 | 25,961,532 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you felt dizzy and short of breath. We had the neurology
doctors ___, and they felt that your neurologic symptoms
were due to your old stoke, and we confirmed that there were no
new signs of stroke with an MRI of your brain. Your shortness of
breath was due to fluid back up in your lungs, so we gave you a
medicine through your veins to help you urinate more to remove
the excess fluid from your body. This helped you to breath
easier. Unfortunately, we were unable to get you off the oxygen
completely and may still require the oxygen once at home,
especially when ambulating.
Please make the following changes to your medications:
INCREASE Lasix to 140mg daily
INCREASE coumadin to 3 mg daily
STOP clobetasol
STOP metoprolol
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Brief Course:
___ w/ afib/copd, recent RP bleed R, nephrolithiasis on L, with
recent admission to medicine service for nephrolithiasis, CHF
flare, a. fib with RVR, disharged on ___, who was transferred
back from rehab for dizziness and worsening SOB. Patient was
presumed to have preserved ejection fraction CHF and was
diuresed aggressively with improvement in the patient's
respiratory symptoms. | 154 | 59 |
10506944-DS-12 | 21,261,205 | Dear ___,
___ was a pleasure taking care of you while you were here at
___. You were admitted for chest pain that was concerning for
possible heart attack. Your EKGs and blood tests were negative
for this and you were no longer having chest pain as we watched
you. You had a very thorough lung scan as well, which was able
to rule out many other potentially dangerous causes of chest
pain. Your chest pain was likely due to irritation related to
vomiting recently. In addition, a component of chest pain was
reproduced when pressure was applied to your chest, suggesting
some component of musculoskeletal pain.
None of your medications have changed. | ___ yo with h/o HTN, HLD, CAD (sp DES to RCA in ___, has known
diffuse LAD 60%, OM1 70% from ___ cath) who presents with chest
pain. | 113 | 30 |
16173911-DS-12 | 28,116,170 | Dear Mr. ___,
You were admitted to ___ with acute appendicitis. You
underwent a laparoscopic converted to open appendectomy.
Post-operatively, you had a tube inserted into your nose for
treatment of an ileus. You have recovered well and are now ready
for discharge. Please follow the instructions below to ensure a
speedy recovery:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
You have small plastic bandages called steri-strips. Do not
remove steri-strips for 2 weeks. (These are the thin paper
strips that might be on your incision.) But if they fall off
before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery Team | Mr. ___ presented to the ___ ED on ___ with
abdominal pain that began one day prior. CT at an outpatient
facility on ___ showed acute appendicitis. He started on IV
antibiotics, admitted and taken to the Operating Room where he
underwent a laparoscopic converted to open appendectomy. For
full details of the procedure, please refer to the separately
dictated Operative Report. He was returned to the PACU in stable
condition. After satisfactory recovery from anesthesia, he was
transferred to the Surgical Floor for further monitoring.
He was kept NPO with IV fluids and urine output was monitored
via suprapubic catheter which patient had in place at time of
admission. On POD1, patient had worsening abdominal distention
and bilious emesis. An NGT was placed with symptomatic relief.
White count continued to decrease post-operatively. Pain was
managed initially with IV medications and transitioned to oral
medications once he was tolerating PO.
On POD1, patient was noted to have ___ and ___ HIV medications
were renally dosed. ___ resolved and creatinine was back at
baseline on POD2 after adequate fluid resuscitation.
Patient was discharged home on ___. At the time of discharge,
he was tolerating a regular diet, ambulating independently,
voiding via suprapubic catheter, and pain was well controlled
with oral medications. | 740 | 212 |
19514951-DS-25 | 24,278,388 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You were confused and had some bruising and pain
What was done for me while I was here?
- You had a small fracture of your right ankle, and were given a
walking boot. The Orthopedic doctors saw ___, and recommend you
___ with them in the next two weeks, but you do not need
surgery.
- You were monitored for withdrawal and given medications to
avoid withdrawal.
- You had a CT scan of your head which did not show any acute
bleeding or acute processes
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should attend all of your ___ appointments.
- Work with your PCP on weaning down the Xanax and Dilaudid,
over time
- Do not take the Lorazepam (Ativan)
We wish you the best in the future.
- ___ teams | Mr. ___ is a ___ male with history of HIV on
ART (last CD4 799 in ___ and Polysubstance use (opioid,
benzo), who presented with oxycodone and valium overdose on the
day prior to admission, was then discharged to home. Patient
___ with altered mental status and right lateral
malleolar fracture.
# Toxic Metabolic Encephalopathy
# Benzodiazepine and opiate intoxication/withdrawal:
Patient presented with altered mental status, with concern that
he became intoxicated between time he left the ER and then
___. He was monitored with CIWA protocol and given
diazepam. CT head showed no acute intracranial process and
neurologic exam was ___. CT ___ was unremarkable.
Social work was consulted to evaluate patient as partner stated
he wanted patient to get treatment for substance use disorder.
He had been taking both Xanax and Ativan at the same time. He
was told to stop the Ativan, and use the Xanax and Dilaudid only
as prescribed, to minimize polypharmacy. This was discussed at
length with the patient and his partner/HCP on the day of
discharge.
# R lateral malleolar fracture:
Mildly displaced R malleolar fracture seen on XR ___.
Orthopedics evaluated in ED and recommended walking boot to R
ankle with outpatient f/u in 2 weeks, with weight bearing as
tolerated.
# L shoulder pain:
XR negative for acute fracture, did show an old Healed fracture
which the patient was able to report having in the past.
# L odontogenic maxillary sinusitis:
Incidentally found on CT maxillofacial/sinus. Patient was
asymptomatic and had prior CT with similar findings suggesting a
chronic process. Given patient's neutropenia, OMFS was consulted
and recommended outpatient ___ given stability of imaging
findings and lack of symptoms
# Vertebral fracture:
Prescribed hydromorphone in the past for this. Plan was made at
rehab to wean this. Held Hydromorphone on admission given AMS,
OK to resume at home dose on discharge but did extensive
counseling on proper taking of this medication.
# HIV: Last CD4 count 799 in ___.
Patient is on Genvoya at home which was ___. Thus
patient was treated with Stribild. CD4 count was drawn, and
pending on discharge.
# Pancytopenia
Stable. Thought due to T cell LGL lymphoproliferative disorder.
# T2DM
Held home metformin and glipizide while admitted, but OK to
resume on discharge.
# Anxiety
Continued home fluoxetine, buspirone, and prazosin. Held home
alprazolam while patient received diazepam on CIWA protocol
initially, but can resume on discharge. Stop Lorazepam.
# Seizures
Continued home Keppra
# HTN:
Continue home meds
#CAD:
Continue atorvastatin/ASA on discharge
#Gastroparesis:
Continued home metoclopramide, zofran, erythromycin
#Asthma/COPD
Continued home proair
#Allergies:
Continued home loratadine.
TRANSITIONAL ISSUES
==================================
- Wean Xanax and Dilaudid as tolerated. Will require long term
discussion and management with PCP
- ___ using Ativan given already on Xanax
- Extensive counseling done with patient and partner re:
importance of adhering to medications as prescribed
- Outpatient Ortho in next 2 weeks for malleolar fracture follow
up (could not schedule for them on weekend; gave them the number
of clinic)
- CD4 count pending on discharge | 154 | 476 |
19789921-DS-15 | 22,420,138 | Dear ___:
You were admitted for fever and rash. We thought this was zoster
(also called shingles). You will be treated with one week of a
medication called Valtrex. We did many tests for other types of
infections that did not show anything else.
Please continue taking Valtrex (last day ___.
We wish you all the best!
- Your ___ care team | SUMMARY: ___ year old man non-verbal man with Down's Syndrome,
VSD s/p repair and hypothyroidism presenting with acute painful
vesicular rash consistent with localized herpes zoster. | 58 | 26 |
16848121-DS-10 | 21,328,479 | Dear Ms ___,
It was a pleasure taking care of you at ___.
You were admitted for an infection of your urinary tract and
kidneys. You were treated with antibiotics.
The following changes were made to your medications:
STARTED Ciprofloxacin to treat your infection (14 days total)
STOPPED Amlodipine since your blood pressures have been fine
here | ___ yr/o ___ speaking female with past medical history of
hypertension presenting to the ER with 3 days of symptoms
consistent with pyelonephritis also found to have elevated
WBC/dirty urine and admitted to the MICU for Sepsis.
# Sepsis/Pyelonephritis: Patient with hypotension and SBP in
___, likely urinary source. BP responsive to fluids after 3L -
received a total of 6L between the emergency department and
MICU. Had CVL placed in ED over concern for development of
septic shock, but never required pressors. Source is presumed
urinary in setting of classic pyelo symptoms and UA evidence of
infection. Ceftriaxone started in ED and urine cultures remained
negative, though the patient had taken amoxicillin at home that
could have cleared culture. No evidence of infection on CXR. Bcx
negative. No other obvious source. Patient remained
hemodynamically stable following IVF and was called out to
medicine floor. On the medicine floor, the patient was
transitioned from ceftriaxone to PO ciprofloxacin. She appeared
clinically very well and felt back to her baseline state of
health. However, urinalysis returned demonstrating that her UA
was sterile which was confusing as 90% of pyelonephritis cases
have positive urine cultures. Due to the uncertainty caused by
this result, the patient was kept for further observation and
investigation. It is possible that her dose of amoxicillin
which she took prior to presentation was enough to wipe out
growth from the urine vs she has some sort of perinephric
abscess that is not draining into her kidneys vs her source is
not the kidneys. Pt did have rise of LFTs so a complete
abdominal ultrasound was conducted which did not visualize any
abnormalities of her liver or gallbladder. Lipase on
presentation was normal. Abdominal exam was completely benign
throughout her hospital course. Ultrasound did now show any
abnormalities of kidneys, and though this isn't as sensitive as
a CT scan for pyelonephritis or abscess visualization, given her
well appearance, more aggressive imaging was deemed unnecessary.
As she was doing well, she was discharged to follow up with her
PCP.
# Elevated LFTs and alk phos: Unclear cause. Possibly related
to ceftriaxone. US results showed normal liver and gallbladder
and patient was asymptomatic without right upper quadrant pain.
She is documented HbS ag negative, ab positive. Given stable
values, no signs of acute hepatitis, and no symptoms further
work up was deferred to the outpatient setting.
# HTN: Amlodipine held at presentation given hypotension. This
was not restarted due to normal BPs. This should be restarted
as an outpatient when blood pressure rises.
#. Chest pressure: Pt ruled out for MI. ECG non concerning. | 53 | 449 |
11285534-DS-12 | 27,028,349 | Dear Ms. ___,
It was a pleasure working with you at the ___.
You were seen because you had vertigo (dizziness that feels like
the room is spinning). This was from two problems: an infection
in your right ear, and ear wax in your right ear. We gave an
antibiotic called amoxicillin the infection. You should start
using ear drops to reduce the amount of ear wax in your right
ear. You can use Debrox Earwax Removal Aid Drops; you can buy
this at ___.
You also had low mineral levels (like magnesium) in your blood.
We fixed this problem.
While you were in the hospital, you had brain imaging that told
us you did not have a stroke.
We fixed your low mineral levels and started treating your ear
infection with an antibiotic.
When you go home, you should make these changes to your daily
medicines:
For your dizziness:
-Continue taking Amoxicillin 500mg by mouth every day for 8 more
days, until ___. This is for your ear infection.
-Start using daily ear drops on your right ear to soften the
wax. You can buy Debrox Earwax Removal Aid Drops at ___
for this. Generic is fine too. Use this until your dizziness
goes away, or until your doctor tells you to stop.
For your kidney disease:
-Continue taking your other home medications, but with these
changes:
-Take sodium bicarbonate 650mg by mouth three times each day
-Take calcium carbonate 500mg by mouth with meals
For your diarrhea:
-Continue to buy lactose-free dairy, like Lactaid milk.
-Start taking Lactaid pills with meals when you drink
non-Lactaid milk, or eat non-Lactaid icecream. One option is
Lactaid Fast Act Lactase Enzyme Supplement, Chewable Tablet,
from ___. Generic is fine.
You also need a physical therapy home safety evaluation. They
will come to your home and make sure that you can walk safely
even with your dizzy spells. | Ms. ___ is an ___ old woman with a past medical history
of stage V CKD, HTN, hyperlipidemia, and IDDM who presented with
an episode of room spinning vertigo on awakening during episode
of AM hypoglycemia.
#Vertigo, nausea/vomiting
Initially thought hypoglycemic + seizure
In the ED, had neuro consult (no
___, negative vertigo
maneuvers), ___ CT and brain MRI (no acute process, no stroke /
lesion)
Neuro thought peripheral vertigo, rec'd otitis->labrynthitis
workup, vestibular ___.
Pt had fullness and pain in R ear; unable to visual R TM (even
with flushing with warm fluid)
-Began 500mg amoxicillin q24H on ___: to receive 10 day course
for severe (presumed labrynthitis complication), with final day
___
-WBC trended down to 8.8K
-Will begin ear wax softening ear drops on discharge with
instructions
-___ recs: home ___ for home safety evaluation; once at baseline
mobility, rec outpt vestibular ___ for assessment +
exercises/training
#Electrolyte disturbance: Initially Mg 1.0 HCO3 16 with AGap 23
(metabolic acidosis), Ca 7.7, Phos 5.8. Likely wasting Mg from
chronic diarrhea.
-Mg repleted (6g IV total), 2.4 on discharge
-Started calc carb PO with meals on ___ for phos binding per
renal
-1g IV Calcium gluconate given in ED
#Acute worsening of Stage V CKD: Cr bump 4->6.0, BUN ___,
large proteinuria; likely secondary to diabetic nephropathy. ___
___ ATN vs. prerenal or worsening of baseline CKD. Patient being
worked up for dialysis in next few weeks (Dr. ___, Dr.
___. Seen by Dr. ___ vascular team);
previously saw them in clinic for vein mapping, will get AVF
placed in a few weeks. There was not time in the schedule for
her to get AVF placed while inpatient.
-Started calc carb PO with meals on ___ for phos binding per
renal
-Home torsemide 5mg PO BID restarted ___ euvolemic without
___ edema on discharge
-Increased bicarb to TID per renal
-Renal, diabetic diet while in hospital
-Strict I/O to monitor urine output
-Renally dosed all medications
#Insulin-dependent diabetes, on Lantus 30 units + novolog with
meals at home. A1C 5.7.
Reported hypoglycemia with episode of dizziness each morning
after waking.
-Renal diabetic diet, as above
-Fingerstick blood glucose and insulin sliding scale; no ___
basal dosing (held lantus) because patient was not eating much,
and wanted to avoid morning hypoglycemia.
-No glipizide while inpatient, ISS only
#Diarrhea - patient reports frequent / daily diarrhea (worse
after eating dairy, vegetables, glucerna shakes). She says that
___ year ago, she lost her sense of taste (she now can only taste
salt and sugar). Loss of taste likely secondary to late stage
CKD. Diarrhea likely due to known lactose intolerance. Chronic
diarrhea may be causing Mg wasting.
-No known diarrhea during this admission
-C-dif negative
-Provided teaching on lactose free diets and lactase pills
-Consider testing for celiac as an outpt given diarrhea
history**** - transitional
#Abnormal EKG: Initial EKG with QTc 465, frequent PVC's, and
T-wave inversion in lateral leads with Trop 0.03 (repeat = 0.03;
likely chronic trop retention in CKD)
-Given 1g IV Calcium gluconate in ED
-Lytes repleted as above
-On continuous telemetry
-Fewer PVC's after Mg repletion, lyte correction
-no chest pain / palp during admission
#Hypomagnesaemia: in the setting of chronic diarrhea ___ year)
and nausea/vomiting (1 day). Re: diarrhea, hypomagnesaemia might
represent chronic magnesium wasting. frequent PVCs on tele, less
after Mg repletion
- Mg 2.4 at discharge
- Trended and repleted Mg >2.2
#Noted to have post-menopausal vaginal bleeding, thickened
endometrium on US in ___. Patient previously
recommended to make follow-up appointment with gyn.
-Will include as transitional issue
#Anemia: Hb 9.2, Hct 28.1
-At her baseline. Monitored here, stable.
-Baseline Hb: 8.3-8.5; Baseline Hct: ___ in ___.
#Elevated Alk Phos: 121
-Noted to be at her baseline. Baseline: 121-124 in ___
-Likely due CKD-MBD (mineral bone disease) with high bone
turnover; normal transaminases
================================ | 301 | 593 |
14418443-DS-14 | 27,920,169 | You were admitted to the hospital after you were struck by a car
while driving your car. You sustained a right clavicle
fracture. You did not require any operative intervention.
Since the accident, you have reported left wrist pain. Imaging
was done and did not indicate a fracture. Your pain has been
controlled with oral analgesia. You are preparing for discharge
with the following instructions:
Please call the Acute care clinic if the following occur:
___
*fever
*chills
*nausea, vomiting, abdominal pain
*chest pain
*increased pain right shoulder, decreased movement fingers right
hand, numbness fingers right hand, inability to move fingers
right hand
*sling for comfort
*ROM exercises as reviewed with occupational therapy
*please take food with the ibuprofen
*do not drive while on the narcotic medication | ___ year old male admitted to the hospital after he was struck by
a car while riding his bicycle. The patient went up on the
windshield and fell onto the curb. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging of
his head, neck, and torso. On review of the imaging, the
patient was reported to have a displaced distal right clavicle
fracture. The Orthopedic service was consulted and determined
that no surgical intervention was indicated. No neurovascular
compromise was present. A sling was recommended for comfort.
The patient's pain was controlled with oral analgesia. He
resumed a regular diet and was voiding without difficulty. He
was evaluated by Occupational therapy and techniques for ADL's
were outlined. On tertiary exam, the patient was noted to have
left wrist pain. Imaging studies of his left wrist showed no
fracture or dislocation. The patient was discharged home on HD
#2 in stable condition. An appointment for follow-up was made
with Dr. ___. The patient was instructed to call the
Orthopedic service for a follow-up appointment. Discharge
instructions were reviewed and questions answered. | 126 | 203 |
10509294-DS-21 | 26,377,782 | You were admitted to West 3 surgery for treatment of small bowel
obstruction. You were treated conservatively and made NPO, IVF,
and an NG tube was inserted. Your small bowel obstruction
improved and at time of discharge you were passing flatus,
tolerating a regular diet, and ambulating. You are now ready to
continue your recover at home. | Mr. ___ was admitted to ___ Surgery for 2 days of
worsening abdominal pain, nausea, and bilious vomiting. CT scan
in the ED showed small bowel obstruction involving proximal
jejunum with dilated jejunal loop through ventral hernia.
Patient was admitted to ___ 3 surgery for conservative
management of SBO. He arrived on the floor NPO, IV fluids, NG
tube, and foley for urinary output monitoring. Patient's
creatinine in the ED was 3.8 consistent with renal insufficiency
for which he was given fluid rehydration. Additionally he had a
lactate of 5.2 and wbc of 18.1 at time of admission.
Hospital day 2: patient had flatus and stool in his ostomy bag.
Pain was better controlled and he was ambulating with no
difficulties. He was advanced to sips. He remained afebrile with
wbc of 11.4, renal function improved with Cr value of 2.4, and
lactate was at 1.3
Hospital day 3: Patient self removed his NG tube overnight. He
was doing well with sips. His ostomy bag was full of flatus and
he felt better.
Hospital day 4: Patient was advanced to fulls and IV fluids were
discontinued as he was toleating the diet. In the afternoon
patient began experiencing nausea and emesis. An NG tube was
reinserted which produced 2 L of bilious fluids upon insertion.
Ostomy bag was producing minimal flatus. Patient was
transitioned back to NPO, IV fluids, and IV medications. Foley
was removed and patient had no difficulties voiding afterwards.
Hospital day 5: Patient remained NPO,IVF, with NG tube.
Creatinine rose to 1.6 from 1.2 the day prior with a decrease in
urinary output for which patient received IV fluid boluses.
Urinary output responded appropriately to the boluses.
Hospital day ___: NGT with decreased output. Patient's ostomy
showed increased flatus and stool output. NGT was removed after
a successful clamp trial. Patient was out of bed. Improved
urinary output with creatinine of 1.3. Patient was started on
clears with continuing IV fluids given high ostomy output.
Hospital day ___: Patient started on regular diet which he
tolerated well. Patient was maintaining adequate urinary output
with creatinine of 1.3 and IV fluids were discontinued. Patient
had chronic contact dermatitis surrounding ostomy site for which
ostomy nurse evaluated the patient and left appropriate supplied
by bedside.
Hospital day ___: Patient was started on loperamide 2 mg TID
for increased ostomy output which decreased his ostomy
output,although it still remained high. Patient's loperamide was
increased to 2mg QID.Patient was taught to titrate his ostomy
output to 1.5L/day. He was also told to measure the output
daily. He was tolerating regular diet, producing good urinary
output, and ambulating. | 58 | 435 |
18751419-DS-27 | 26,907,984 | Dear Mr. ___,
You came to the hospital because you were not feeling well
overall.
While you were here, we found that your liver tests are not
normal, probably because of a virus. You have 2 viruses that are
active in your blood, called ___ (EBV) and Hepatitis C.
You received IV medicine to help your liver heal. You worked
with physical therapy and nutrition staff to get stronger.
When you leave the hospital, please:
- use a cane to walk
- take your medicines as prescribed
- see the infectious disease doctor and your primary care doctor
as below
- make an appointment to see your psychiatrist
- keep taking supplements and make sure you eat enough to help
regain your strength
It was a pleasure caring for you and we wish you the best,
Your ___ Team | Mr. ___ is a ___ year old male with opioid use disorder
on methadone, depression (untreated), HCV (previously recorded
as spontaneously cleared but now with positive viral load), and
homelessness who presented with nonspecific complaints (fevers,
nausea, myalgias) and developed acute hepatitis of unclear
etiology, likely viral, with overall improvement but continued
hospitalization for abdominal pain, nausea, decreased PO intake,
and generalized weakness, ultimately attributed to hepatitis. | 132 | 66 |
13714199-DS-25 | 20,737,880 | you were treated for sickle cell pain crisis
take pain meds as directed
speak with your hematologist to schedule your next visit
drink plenty of water
seek medical care if you have shortness of breath, chest pain,
focal neurological problems, worse pain, fatigue, fever
do not stay immobile in bed, make sure to walk in regular
intervals | ___ female with hx of sickle cell disease here with fever and
a
pain crisis.
Sickle Cell Pain crisis No evidence for bacterial infections,
no end organ dysfunction, infiltrate on chest xray. management
involved supportive care with ivf, iv dilaudid and then
transition to oral opiod. Hgb 9.6 and stable for 48hrs prior to
discharge with elev ldh, retic and bili. Pain at discharge was
focused on R leg, some radiation from hip where she has known
avascular necrosis.
I was not able to feel the R neck nodule described by past MD,
Dr. ___. Patient aware and can bring it to attention of her
PCP if it changes.
gerd
continue home ppi, h2 blocker | 52 | 121 |
15031793-DS-15 | 22,715,250 | You were admitted to the hospital with chest pressure after
having had a cardiac catheterization the previous day. The
possible serious causes of your symptoms were ruled out. You
also received hemodialysis. Please take your medications as
presribed, and follow up at the medical appointments listed
below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ y/o female w/ CAD, DM, ESRD, PVD s/p DES to LAD the day prior
to admission who presents with chest discomfort.
# Chest Discomfort/CAD: Given recent cath ___ there
was intial concern for ___. Troponins were flat. CTA
was negative for dissection or PE, but did show a right pleural
effusion. Patient was continued on aspirin, plavix. Metoprolol
was increased and amlodopine was added.
# ESRD: Currently being evaluated for transplant. Renal
medications were continued and Patient received HD during which
4L of fluid was taken off.
# HTN: Patient had SBPs in the 170's. She was continued on
losartan, metoprolol was increased and amlodopine was added.
# sCHF: EF ___ in ___. She was continued on home lasix and
cardiac medications as above.
# DM: Continued on home insulin.
# Chronic Pain: Continue on home narcotics regimen.
# HLD: Continue Rovustatin. | 60 | 151 |
18531583-DS-15 | 25,831,706 | Dear Ms. ___,
You were admitted to the hospital after a fall and found to be
somewhat confused, possibly due to a urinary tract infection. We
treated you for the infection and you improved. Fortunately you
had no injuries from the fall.
It was a pleasure taking care of you. | ## Acute encephalopathy - Resolved. Likely related to possible
UTI, which was treated with ceftriaxone. No electrolyte
abnormalities. No e/o seizure activity.
## Fall
Clear description of mechanical fall. Denied loss of
consciousness, seizure activity, chest pain, SOB. Difficulty
getting up likely due to underlying difficulty with ambulating
due to CVA, also may be due to UTI. No head strike from fall.
## Right shoulder pain, after fall. Shoulder xrays with no overt
fracture, improving.
## Chronic asthma, hyperlidipdemia, neuropathy, hypertension -
continued home medications. BPs stable.
##CVA
##Deconditioning
Worked with ___ during hospitalization, they felt that the
patient was limited by impaired balance and functional mobility
___ decreased strength and endurance consistent with
hospitalization and prolonged time on floor after fall before
being found. | 48 | 120 |
17077190-DS-22 | 24,927,813 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You fell and broke you hip. You had surgery to fix it with the
orthopedic team
- Your heart rate was found to be fast and you had fluid
overload
- You were found to have a urinary tract infection
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a partial hip replacement by orthopedic surgery.
- Your home diltiazem dose was increased and a new medication
called metoprolol was added to control your heart rate and you
were treated with IV direutics to remove excess fluid from your
body.
- Your pain was controlled with oxycodone and Tylenol and worked
with ___, who recommended that you go to rehab on discharge to
continue to regain your strength. As you surgery heals and your
pain decreases you should be able to wean off of the oxycodone.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Weigh yourself every morning, and call your doctor if your
weight goes up more than 3 lbs in a day or 5 pounds in a week.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
Discharge Cr: 0.9
Discharge Hgb: 9.4
[ ] Follow up heart rates on increased diltiazem and new
metoprolol. If persistently well controlled would stop
metoprolol then decrease her diltiazem XR back to 240MG daily.
[ ] Currently on Tylenol, oxycodone 2.5MG Q4PRN for pain,
continue to wean opiates as tolerated. ___ need to decrease
bowel regimen off of opiate medication.
[ ] Monitor volume status with daily weights; decreased
torsemide to 10mg QOD given fluctuating renal function (was on
20mg QOD)
[ ] Would recheck CBC and CHEM7 at PCP follow up from rehab
discharge to ensure stable kidney function and anemia. Consider
repeat iron studies and iron repletion as needed.
[ ] Vitamin D low-normal this admission, continue to monitor and
start supplementation as needed.
[ ] Follow up with orthopedic surgery at outpatient appointment,
may need repeat imaging at this time
[ ] Follow up with Dr. ___ cardiology
#CODE: Full (patient and family have been urged to discuss this
further, apparently patient's husband was given CPR when he did
not want it and this has left its mark on the family)
#CONTACT: ___ (DAUGHTER) ___ | 219 | 183 |
Subsets and Splits