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12538508-DS-16 | 28,076,497 | Dear Mr. ___,
It was a pleasure caring for you while you were hospitalized at
the ___. As you recall, you were admitted
because of an untreated lung infection which worsened to the
point where you were not getting enough oxygen in through your
lungs. You briefly required a stay in the intensive care unit,
but you quickly improved and were sent to the floor. You
responded well to antibiotics. A swallowing study was done which
suggested chronic aspiration of contents from your
gastrointestinal tract into your lungs. It is likely that this
contributed to this pneumonia and this certainly may cause lung
infections again in the future.
Medication changes:
START Augmentin (amoxicillin-clavulinate) for 10 days after
discharge | Mr. ___ is a ___ yo M w/ PMH of recurrent aspiration,
pneumonia presenting with fever and respiratory distress found
with a right lobar infiltrate consistent with pneumonia
(possibly aspiration) or aspiration pneumonitis.
ACTIVE ISSUES
# aspiration pneumonia vs. aspiration pneumonitis - The patient
met ___ SIRS criteria and satted in the high ___ on NRB on
admission and was sent to the ICU. He had a new right lobar
infiltrate and a left sided effusion, which on review of records
was found to be chronic. Blood cultures were done (sputum
attempted, not completed). Urine legionella was negative. He was
started on levofloxacin and ceftriaxone for CAP coverage. He was
rapidly weaned to 2L NC in the ICU and transferred to the floor
in good condition. His oxygen saturation remained high and he
was weaned to room air. His antibiotics were transitioned to
Augmentin PO and he was discharged to ___, to complete
a 10 day course of antibiotics.
# Hyponatremia: Baseline is in high 130s with a recorded sodium
of 128 early in his hospital course. Given his elevated Uosm and
pulmonary process, SIADH was considered. Given poor PO intake,
hypovolemic hyponatremia was also considered. With no further
fluids (but no restriction either), the patient's hyponatremia
spontaneously corrected. It was not investigated further.
# Hypotension: The patient's blood pressure was in the high ___
on admission to the ICU. His anti-hypertensive regimen was held
and his pressures recovered to the 120s shortly thereafter. He
became hypertensive at his previously recorded home levels once
transferred to the floor, so we opted to continue home
amlodipinel. He remained normotensive for two days before being
discharged.
INACTIVE ISSUES:
# BPH: tamsulosin was held while hypotensive but resumed on the
floor without incident.
# DM: ISS while in house. Blood sugars were well controlled.
# CAD status post CABG ___: aspirin continued while in house
# Chronic kidney disease, baseline creatinine 1.0-1.3. His
creatinine here was reliably less than 1.
. | 116 | 321 |
13306109-DS-17 | 26,225,840 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. As you recall, you were admitted because your
white count was significantly elevated. Due to your history of
CMML, we were worried that your disease transformed into acute
leukemia. We did a bone marrow biopsy, which fortunately did not
show any leukemic cells. We believe the cause of your elevated
white count is from progression of your CMML as well as your
osteomyelitis. We started you on a new medication, hydroxyurea,
which will help keep your white blood cell count low. You had a
surgical revision of your right foot and the preliminary results
did not show any evidence of worsening infection. You will need
to continue your antibiotics until ___ and you will need to
follow up with your infectious disease doctors. You will need to
follow up with Dr. ___ your blood counts, and your
new medications (hydroxyurea/allopurinol). Lastly, you will need
to follow up with the podiatrists regarding your foot. You
should not remove the dressing until your follow up appointment.
As far as your rash, the dermatologists believe this is
secondary to a drug, most likely vancomycin. As you are aware,
these rashes tend to get worse before getting better. The
infectious disease doctors saw ___ and recommended continuing
you on the same antibiotics- daptomycin, ciprofloxacin, and
flagyl until ___.
The podiatrists also took you to the operating room and removed
a small piece of your right ___ metatarsal which fortunately
does not appear to be infected, though final cultures are still
pending. You should continue your antibiotics as directed and
follow up with your infectious disease doctors. | BRIEF HOSPITAL COURSE:
==========================================
___ PMH HIV (undetectable viral load), CAD, osteomyelitis on
Abx, and CMML, who presents with marked increase in
leukocytosis, concerning for transformation from CML to acute
leukemia but biopsy more c/w progression of CMML who is s/p
right ___ metatarsal partial resection on ___ on Abx for
previous ostemyelitis who had hospital course c/b drug rash that
improved prior to discharge | 274 | 63 |
14117743-DS-23 | 22,297,834 | Mr ___,
You were admitted due to concern for fever. After much work up
and no fevers while you were here, you were treated with
Vancomycin, the antibiotic you were admitted with. You remained
stable while inpatient with no fevers.
You will need weeks of antibiotic treatment until ___.
It was a pleasure being part of your care.
Your ___ team | ___ PMH of IVDU, HCV, recent MSSA endocarditis, osteomyelitis,
and epidural abscess at L5-S1 (admitted ___, who was
recently admitted from ___ for MSSA endocarditis, was
treated w/ IV vancomycin (projected end date ___ and
tricuspid valve replacement, who returns from rehab w/ question
fevers and increased musculoskeletal pain.
# Infection: There was initial concern for pneumonia and
initially treated with meropenem in addition to his vancomycin.
Sources for him included MSK (given pain in rib and back, but
low suspicion for osteo given labs and imaging), Pneumonia
(given CT findings, however no cough or fevers or WBC,
Osteomyelitic/epidural abscess (given known issue from prior
admission, MRI spine ___ showed persistent osteo L5/S1 but
decreased epidural abscess with no drainable fluid collection).
Meropenem was pulled off once patient was stable and no
localizing source of infection. He was continued on vancomycin
with plan for end date ___.
# Hyperkalemia: Unclear etiology. It was initially thought most
likely cause could be iatrogenic due to heparin and inhibition
of ROMK channel. Switched heparin and used fondaparinaux but
still elevated. Fondaparinaux stopped and hemolysis labs
obtained. Patient transitioned to Pneumoboots/ambulation for DVT
prophylaxis. Resolved by ___. Patient was discharged on lasix as
above for ___ edema, and K was stable at time of d/c.
# Volume overload: as evidenced by ___ edema, elevated JVP to
jawline, crackles on exam. BNP 1342 (___). Denies orthopnea/PND,
but endorses DOE. Of note, patient reports indiscretion with
drinking lots of water and eating salty foods from outside the
hospital (eg ___ food). Recent ECHO on ___ showed normal
EF, but did not fully evaluate for diastolic dysfunction. Also
possibly related to tricuspid valvular dysfunction (no postop
ECHO in our system since ___. Responded well to 40 mg iv lasix
on ___, and was subsequently transitioned to 40 mg po lasix on
___. He should continue PO lasix and have his electrolytes
followed on ___. He should also undergo repeat ECHO as
outpatient by ___ to evaluate for diastolic dysfunction and
possible tricuspid regurgitation.
# ___ swelling: asymmetric (R > L). Discomfort in RLE started
about ___ days ago, same time as when legs started swelling.
LENIs negative for DVT. Given low CK, rhabdo unlikely.
Discomfort may just be due to edema from recent transfusions and
discontinuation of diuresis. Edema and pain resolved with
lasix.
# Anemia: normocytic, hypoproliferative (retic 0.6 on ___.
Baseline Hgb is ~8. Stable between 7.6-8.1 over ___.
Patient required 1 unit of pRBC on ___ and 1 on ___
for Hgb<7.0. Hemolysis workup negative despite elevated K.
Vitamin B12 WNL. No chronic kidney dysfunction to argue for
anemia of renal disease. Iron studies (elevated iron, normal
TIBC, elevated ferritin) argue against ___, and possibly for
chronic infection. Also possibly due to phlebotomy. Rehab to
check HGB on ___ and transfuse for Hgb <7.
# Type II NSTEMI due to demand: EKG showed new T wave inversions
in V1 and V2 with depressions on admission. These were stable
and trops trended down. Patient was asymptomatic. Most likely in
the setting of elevated heart rate. Cardiology saw the patient
and there was no indication for treatment.
# Musculoskeletal pain: persists over last 10d, felt mainly in L
parasternal areas from ___ - 4th ribs. Likely related to
previous surgery. CRP 21.8 (___) -> 15.7 (___) -> 7.2 (___).
These findings in conjunction with normal portable CXR make
osteo of ribs less likely. Received tylenol and dilaudid for
pain. PCP to consider obtaining rib series X-rays if patient
starts developing symptoms of osteomyelitis.
# Dispo concerns/social: sister thinks she can handle him if
he's discharged home but there's concern of discharging him home
with a PICC line in him given h/o IVDU and behavior concerns
from different rehabs etc. Concern that a visitor in the
hospital might have given him a blue pill (possibly morphine)
during this stay. Urine was seen to be + for opioids; urine sent
for mass spec, which was positive for hydromorphone, codeine,
and morphine. Only hydromorphone was administered during this
hospitalization.
## TRANSITIONAL ISSUES
=========================
- Discharged on 40 mg PO lasix daily please recheck chem 7 on
___
- Obtain repeat ECHO as outpatient to evaluate for diastolic
dysfunction and possible tricuspid regurgitation (due by ___
- Will be continued on IV Vancomycin 750g IV Q12H until ___
- Because patient is on Vancomycin long-term, he will need
following labs checked weekly and sent to OPAT (fax
___: CBC with differential, BUN, Cr, Vancomycin
trough, ESR, CRP.
- Consider outpatient psych to address likely depression
- Heparin caused hyperkalemia during this admission and was
discontinued
- Monitor crit weekly (next time on ___ and transfuse if
H/H< ___
-Drug abuse: patient has had difficulty with IVDU leading to
endocarditis, he should be constantly advised to avoid IVDU and
would benefit from consideration of addiction services int he
future, potentially suboxone, methadodone suppressive therapy. | 58 | 808 |
13756747-DS-12 | 27,251,698 | -Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-Please AVOID aspirin or aspirin containing products and
supplements that may have blood-thinning effects (like Fish
Oil, Vitamin E, etc.) unless you have otherwise been advised.
This will be noted in your medication reconciliation.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in 4 weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up and/or
as directed in the handout
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room. | ___ with hx RCC s/p left nephrectomy on ___ presenting with
abdominal pain, nausea and fever. ___ had: PROCEDURE: Robot
assist laparoscopic left partial nephrectomy, flexible
cystoscopy. Discharged ___. Patient has not had a bowel
movement since ___. Extremely nauseated with any PO intake.
Able to keep a few grapes and cereal down. +fever/chills which
started yesterday (to 100 today). No hematuria or dysuria, but
with difficulty voiding. No leg swelling. +baseline anxiety. She
was admitted to urology, given intravenous fluids and oral bowel
regimen. She was given dulcolax suppository and with minimal
response, a soap suds enema. With evacuation of her bowels she
was subsequently discharged home. | 420 | 108 |
17010236-DS-25 | 22,593,443 | You were admitted to ___ because you were having chest pain
and high blood pressures. You underwent a cardiac
catheterization which showed your heart is working well so this
is not the cause of your pain. We think your pain will improve
with control of your anxiety and blood pressures.
You will be going home with a visiting nurse who can check your
blood pressures and will make sure that you are taking your
medications appropriately. | ___ with a history of CAD s/p BMS in D1 (___), DM, HTN, asthma,
transferred from OSH for chest pain, admitted to MICU in setting
of hypotension, now being called out to cardiology for further
management.
# Chest pain: Per PCP, patient has recurrent atypical CP with
multiple admissions to ___ before. Patient had
recurrent chest pain as high as ___ though with negative
cardiac enzymes and ECGs. Often these symptoms would occur in
the setting of elevated blood pressures. As history was
concerning for unstable angina, patient underwent cardiac
catheterization on ___ which revealed non-obstructive coronary
artery disease. Thus, we felt her symptoms were related to
anxiety or poorly controlled BPs as patient is not fully
compliant with BP medications. Her BP regimen was adjusted (see
below). Recommended maalox, valium and ___ with her PCP
for management of her symptoms. Continued home dose aspirin and
statin. Discontinued ranolazine as it is unlikely that this is
anginal.
# Hypertensive Urgency: Patient had an episode of hypertensive
urgency in the setting of all of her anti-hypertensives being
held due to initial presentation of hypotension. SBPs were in
the 200s and patient noted ___ chest pressure. Patient was
started on a nitroglycerin drip with improvement of her blood
pressures and chest discomfort. Patient was weaned off the drip
and started on carvedilol 25mg BID, lisinopril 20mg, imdur 30mg,
and amlodipine 5mg. Her verapamil and minoxidil were
discontinued. She was discharged with ___ for medication
management and blood pressure monitoring.
# Hypotension: Presented with hypotension to the ___ systoli and
was briefly on peripheral pressors at OSH. Unclear etiology and
resolved without intervention. Likely related to vagal episode.
No signs or symptoms of sepsis.
Chronic Issues
# Diastolic CHF: Patient appears euvolemic at the moment.
Continued torsemide.
# Asthma: Physical exam does not show severe asthma
exacerbation. Continued home regimen.
# DM2: Held metformin while inpatient. Sugars were controlled
with sliding scale.
Transitional Issues
-Patient should have stress tests rather than cardiac
catheterization if she presents with recurrent pain, normal ECG,
and negative enzymes because her symptoms are likely not of
cardiac etiology
-Patient was reportedly on apixaban though the indication for
this medication was unclear and should be clarified
-Patient should have outpatient ___ of her anxiety and
workup for non-cardiac etiology of her symptoms
-Metformin should be restarted on ___, 48 hours after
catheterization | 76 | 390 |
18451124-DS-14 | 25,844,451 | Dear ___,
It was a pleasure looking after you. As you know, you were
admitted after being found down on the street. There were
initial concerns that you sustained a heart or brain related
event which caused you to pass out. However, after medical
workup, it appears that the cause for you passing out was more
related to a recent binge in alcohol drinking.
There is some evidence that alcohol drinking may be affecting
your liver and red blood cell count. Please moderate its use,
if possible. Otherwise, there are no medication needs.
You would benefit from getting a sleep study when you find a
doctor ___ treat the obstructive sleep apnea).
We wish you well and good health!
Your ___ team | ___ no PMH who presented after being found down, found to have
alcohol intoxication. | 146 | 15 |
19457057-DS-20 | 27,065,737 | You were admitted to ___ on
___ with complaints of abdominal pain. CT scanning revealed
perforated diverticulitis. You were admitted to the inpatient
ward for further management and observation.
You were given bowel rest, started on IV fluids as well as
antibiotics. As your pain improved, you were given oral
medications and started on a clear diet. The diet was advanced
as you improved.
Now that you are tolerating a regular diet, you are being
discharged home with oral antibiotics. Please continue to take
all doses of antibiotics until they are gone.
A follow-up appointment with your PCP was established so that
you can address any further issues such as this with him/her. | Mr. ___ was admitted to the Acute Care Surgery service after
presenting to the ED with complaints of abdominal pain. CT
imaging revealed perforated sigmoid diverticulitis without
abscess. He had a leukocytosis of 21.7 on admission.
The patient was admitted to the inpatient ward. He was kept
NPO, given IV fluids and antibiotics. He was receiving
intermittent IV morphine for pain. While NPO, his electrolytes
were checked and repleted as necessary. His WBC decreased from
21 to 13. He was afebrile. As his pain improved, he was given
a clear liquid diet. He was later advanced to a regular diet
which he tolerated well without any pain, nausea or vomiting.
At the time of discharge, Mr. ___ was afebrile, hemodynamically
stable and in no acute distress. He was given a prescription
for antibiotics (Cipro, Flagyl) for a total of a two-week
course. He was instructed to continue taking her home
medications as she was prior to this admission. A follow-up
appointment was established with the patient's PCP. A
colonoscopy is recommended after resolution of acute
inflammation to exclude underlying colonic mass. | 114 | 194 |
15160731-DS-20 | 22,962,718 | Dear Ms. ___,
It was a pleasure to take care of you during your
hospitalization at ___. You were admitted after fainting
during an exercise class. You were evaluated and we made sure
you did not have a heart attack, that you weren't dehydrated,
had normal B12/thyroid studies, and no signs of a urinary tract
infection. We actually think the immodium you were taking may
have caused this, and also we feel that when you turn your head
abruptly it may worsen the situation because of hypersensitivity
in one of the receptors in your neck.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP taking immodium | ___ with PMH of HTN presenting to the emergency department after
a near syncope versus syncopal episode. | 107 | 17 |
12484308-DS-16 | 21,096,684 | You were admitted to ___ with abdominal pain after comsuming
alcohol. This was likely an episode of pancreatitis, alcoholic
heaptitis, and potentially narcotics withdrawl. You were treated
with pain and nausea medications and your symptoms improved.
Please do not drink any alcohol. | ___ with a history of EtOH abuse, cirrhosis, admitted after an
episode of heavy ETOH use.
# Alcoholic Hepatitis and Chronic Pancreatitis: Pt presented
after and episode of very heavy drinking. The pt presented with
severe abdominal pain and was treated supportively with IVF,
narcotics and made NPO. He slowly improved and was discharged on
regular diet and a limited script for narcotics. His LFTs and
bili trended down. Kept on CIWA while in house but was without
DTs and was scoring >10 primarily for anxiety.
.
# Narcotics Abuse: The pt notes he was recently taking suboxone
for prior oxycodone addiction. While in house the pt did receive
narcotics and was discharged with a limited script.
.
# Anxiety: Pt given a limited script for ativan upon discharge. | 42 | 124 |
17119291-DS-3 | 29,751,564 | Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up.
- You may 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 narcotics or any other sedating
medications.
- Because you experienced a seizure, you are NOT allowed to
drive by law.
- No contact sports until cleared by your neurosurgeon.
Medications:
- Please do NOT take any blood thinning medications (aspirin,
Coumadin, ibuprofen, Plavix, etc.) until cleared by your
neurosurgeon.
- You have been discharged on levetiracetam (Keppra). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You can also try an over the counter
stool softener if needed.
When To Call Your Neurosurgeon At ___:
- Fever greater than 101.5 degrees Fahrenheit.
- Nausea or vomiting.
- Extreme sleepiness and not being able to stay awake.
- Severe headaches not relieved by pain medications.
- Seizures.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden numbness or weakness in the face, arms, or legs.
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination.
- Sudden severe headaches with no known reason. | ___ year old female with an intraventricular ___ lesion.
#Intraventricular ___ Lesion
The patient was admitted to the Neurosurgery Service for further
work-up. She was started on Keppra for seizure prophylaxis and
dexamethasone for cerebral edema. The patient underwent an MRI
of the ___ for better characterization of the ___ lesion.
The patient was also placed on continuous EEG given her new
onset seizures. Continuous EEG was negative for seizures, and
the patient was continued on Keppra. Neuro Oncology and
Radiation Oncology were both consulted and saw the patient. This
case will be discussed at the ___ Tumor Conference next week.
Further management recommendations are pending this discussion.
The patient will be discharged in the meantime. She will
follow-up with Dr. ___ Dr. ___ in the ___ Tumor Clinic
next week. She will also follow-up with Dr. ___ in the
___ Clinic in ___ weeks with an MRI of the ___.
Additionally, she will follow-up with Dr. ___ in the
___ Clinic for further endocrine evaluation given the
location of the ___ lesion. On ___, the patient was
afebrile with stable vital signs, ambulating independently,
tolerating a diet, voiding and stooling without difficulty, and
her pain was well controlled with oral pain medications. She was
discharged home with no needs on ___ in stable condition.
#Disposition
The patient was discharged home with no needs on ___ in
stable condition. | 295 | 225 |
12406461-DS-20 | 29,133,890 | Dear ___,
You were admitted to the ___ for evaluation of your abdominal
pain and nausea and vomiting. You underwent an endoscopy, which
did not show any acute changes. Biopsies were taken, and the
results are still pending. You were also given IV erythromycin
to treat your gastroparesis. Because you did not have your
mikey extension, your home medications were given to you
intravenously. You were given IV promethazine to treat your
nausea and vomiting. Because of your chronic anemia, you were
also given IV iron, per your GI doctor's regimen. Prior to
discharge, it was agreed it was safe for you to go home. You
are to follow up with your GI doctor at ___ and your primary care
to discuss the biopsy results, a potential plan to change your
jtube, or initiate medical therapy for treatment of your
EOE/EGE.
Thank you for letting us provide you care during this admission,
Your ___ care team | Ms. ___ is a ___ year old woman with a history of left
Hickman for home TPN, eosinophilic gastrointestinal disease,
gastroperesis, and postural orthostatic tachycardic syndrome
presenting with left sided abdominal pain and pain at her J tube
site and increased frequency in vomiting for ___ weeks. CT A/P
and tube check studies were reassuring. The patient did not
appear to obstructed, and her abdominal pain seemed to be most
related to her gastroparesis, tightening around her Jtube site,
or a flair of her EOE/EGE. She was treated with IV erythromycin
for empiric relief of gastroparesis. The GI service was
consulted and they suspected tightening of her Jtube site.
Endoscopy was performed and biopsies were taken. Chronic gastric
ulcers were appreciated but were not thought to be the cause of
her pain. She was empirically given IV erythromycin for
treatment of gastroparesis. The patient was given IV
promethazine, IV morphine, and IV Zofran for symptom relief
given she did not bring the proper tubing to administer her home
meds via her Jtube. Given her chronic anemia, she was also given
IV iron per her outside GI's recommendations given her prior
history of angioedema with certain IV iron formulations. She was
premedicated with Tylenol, famotidine, and Benadryl and she
tolerated the therapy without complication. Her symptoms
improved after her EGD and she was discharged with plans to see
her BI GI physician to discuss the biopsy findings.
# Abdominal pain: The patient's pain was not only localized at
her Jtube site but also on left lateral abdomen. Etiology
thought to be due to improper positioning/tightening of the
Jtube, gastroparesis flare, or EOE/EGE flare. This pain was new
and likely not representative of her ongoing PUD. Imaging in ED
including tube study and CT A/P negative for abscess or tube
dislodgement/obstruction. Patient reports the jtube has not
malfunctioned and has continued to work over night in recent
days. The patient was treated with IV erythromycin for empiric
treatment of her gastroparesis. She was otherwise given IV
morphine for pain control, since the patient did not bring her
Jtube connecting tube to administer her home PO dilaudid. The
patient had an EGD and biopsies were taken to evaluate for a
flare of her EOE/EGE. Her symptoms improved prior to discharge.
# Nausea/Vomiting: She has known history of gastroparesis.
These symptoms may have been an exacerbation of chronic
gastroparesis vs. gastroenteritis. She was given IV
promethazine for symptom relief, given she did not bring her
Jtube extension tube to administer PO promethazine via her
Jtube. She was also treated with IV erythromycin.
# Anemia: The patient is known to have iron deficiency anemia
as well as PUD with bleeding from ulcer in the past. The
patient remained hemodynamically stable throughout her hospital
course. EGD showed chronic PUD. She was given IV iron therapy
with IV iron dextran per her outside GI's regimen to minimize
potential angioedema. She had tolerated this in the past. She
was premedicated with Tylenol, pepcid, and Benadryl and
tolerated the therapy without complication.
# Nutrition: The patient normally receives TPN daily, so she was
continued on her TPN via her ___ line. Nutrition was
consulted for TPN recs. The skin around the line was monitored
for signs of infection given her history of line infections.
The skin appeared non-erythematous and intact during her
hospital stay.
# Eosinophilia: The patient had elevated eosinophils, similar
to recent values. Absolute count is 1.31. These were monitored
daily. Patient has follow up scheduled with heme/onc as
outpatient.
# POTS: The patient's VSS were stable during this admission and
her POTS was asymptomatic during this admission. Her home PO
beta blocker was held during admission given she did not bring
her Jtube extension tube to administer PO medications. She
remained asymptomatic.
==================== | 161 | 643 |
12733987-DS-15 | 22,627,440 | Dear Ms. ___,
You were admitted to ___ for blood clots in your lungs. We
started you on a medicine called Lovenox, which is injected
under your skin twice per day. You were also seen by the
Oncology doctors who ___ also see you as an outpatient. We
performed another CT Scan of your abdomen and pelvis, and prior
to the scan you received fluids through the vein to protect your
kidneys. Please have your lab work checked tomorrow and send the
results to your PCP.
START:
-- Lovenox ___ under the skin, twice per day
Please check your lab work tomorrow.
Best of health,
___ Team | ___ with PMH HTN, HLD, DMII, obesity, CKD III, p/w finding of
multiple PEs on CT scan and new diagnosis of metastatic cancer
(liver mets from unknown primary). Patient had normal vital
signs with no symptoms of the PEs, submassive. We initially
started Heparin gtt and then transferred to ___. She was
seen by ___ Oncology who recommended CT ABD/PELVIS with
contrast while in patient and we pre-hydrated with 1L NS.
Patient should have her Chem7 checked tomorrow as an outpatient
and sent to her PCP.
# Multiple Acute Pulmonary Emboli:
Submassive PE seen on CT on ___, admitted on tele via the
ED. Patient remained clinically stable, without complains of
dyspnea, HDS VSS satting well on RA. Likely related to active
malignancy of unknown primary. Started on heparin gtt in ED
while the PTT was trended. The patient felt comfortable with
injections as she had long since provided insulin treatment for
her husband. Her GFR was found to be 45 once admitted to the
floor and her creat decreased to 1.1 on the day of discharge.
She was discharged home to self injection therapy of Lovenox.
# New metastatic cancer (unknown primary) - based on ___
Biopsy of liver. Shows poorly differentiated carcinoma. Prelim
CT head negative, no neurological deficits noted. Elevated CEA
found on outpatient labs. Seen by Dr. ___
___ who recommended CT Abd/Pelvis with contrast after
prehydration with 1L NS, which was performed and shows
metastatic disease in the liver, possibly gallbladder primary.
She was discharged to outpatient labwork and follow-up with her
PCP and ___ very closely for further work up and
treatment.
CHRONIC
# DM - at home on Repaglinide and Metformin, held while
admitted. Maintained on ISS while in house.
# GERD
Continued Omeprazole 20mg/d
# HTN - in setting of PEs, held home anti-HTN meds given risk
for volume collapse if new PE occured
Held home HCTZ (25mg/d) and Losartan Potassium 100 mg PO DAILY
# HLD
Continued home Sivma 40 and ASA 81
# Glaucoma
Continued home Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES
HS
TRANSITIONAL
-- Follow up on Final CT ABD/PELVIS read
-- Chem7 check on ___, fax to PCP ___ MD ___
___
-- Follow up with ___ Oncology
-- Follow up with PCP | 101 | 365 |
18938959-DS-4 | 28,674,409 | Dear ___,
___ were admitted to the hospital for nausea, vomiting, cough,
and chest pain. Your airway stent was blocked, so ___ underwent
tumor ablation and airway dilatation by interventional
pulmonology. ___ also had a PET-CT, then initiated radiation
therapy.
We started ___ on a number of new medications to help with your
cough, including:
-albuterol by nebulizer as needed for wheezing or shortness of
breath
-ipratropium by nebulizer as needed for wheezing or shortness of
breath
-Chlorpheniramine-Hydrocodone cough syrup 5mg every 12 hours as
needed for cough
-lidocaine 1% nebulizer treatment every 4 hours as needed for
cough
-benzonatate 200mg three times per day
-Oxycodone and tramadol for pain.
-dexamethasone: ___ will take 2 pills twice a day for 2 days,
then 2 pills once a day for 2 days, then 1 pill once a day for 1
day and then stop this medication.
It was a pleasure taking care of ___ during your
hospitalization, and I wish ___ all the best going forward. | Active issues:
#stage IV non small-cell lung cancer - Diagnosed by EBUS biopsy
on ___, likely adenocarcinoma. Encasing left mainstem
bronchus, s/p hybrid alveolus stent in the LMS ___.
Metastatic to brain, neck, mediastinum, hila, adrenals,
retroperitoneum, and right scapula per MRI and PET-CT. She was
admitted ___ for nausea, vomiting, cough, chest pain during
staging MRI. She was found to have airway obstruction and
underwent tumor ablation and L mainstem dilatation. She had
PET-CT on ___ and was transferred to the hematology/oncology
service to begin radiation therapy (both chest and whole brain).
She will establish care with Dr. ___ as an outpatient to
discuss systemic therapies.
#Chest tightness/cough - Likely secondary to tumor obstructing
the airway and underlying COPD. EKG, troponin & CK-MB x 2 were
negative. CTA was negative for PE. Given spiriva,
albuterol/ipratropium nebs, benzonatate,
chlorpheniramine-hydrocodone syrup, lidocaine nebs and
guaifenesin for symptomatic relief. Chest wall pain from cough
managed with tramadol and oxycodone.
#Brain metastases - Possibly contributing to nausea, vomiting,
headaches. Gave dexamethasone 4mg QID, which was then tapered,
as patient without any focal neurological symptoms. Patient
receiving whole brain radiation. | 158 | 190 |
12572856-DS-14 | 23,974,181 | Dear Ms. ___,
You were admitted to the gynecology service due to leg swelling
and vaginal bleeding. Your leg swelling was shown to be due to a
blood clot and you had a filter placed in your vein by Vascular
Surgery to prevent clots traveling to your lungs. Please follow
up with Dr. ___ in Vascular surgery for care of your IVC
filter, and at that visit, they will determine the optimal time
for removal.
While in the hospital you received anticoagulation treatment for
your clot. You are being discharged on a medication called
lovenox which you will administer to yourself daily to help
treat your clot.
For your vaginal bleeding, you had imaging performed which
showed masses. You were seen by the Gynecology Oncology service
who recommended biopsies of these masses but you had requested
time to think about it before pursuing further workup at this
time. We encourage you to have close follow up to complete
workup and diagnosis.
You will be discharged to the rehabilitation facility per the
recommendation of the physical therapy team.
Please call us at ___ if you have any additional
questions. | Ms. ___ is a ___ on ___ to the gynecology service for
workup of postmenopausal vaginal bleeding in the setting of
large occlusive LLE thrombus after placement of an IVC filter by
the vascular surgery service. Her vaginal bleeding improved
overnight and her hematocrit was trended.
On ___, Ms. ___ hematocrit remained stable at 34-35
and she was started on a heparin gtt for treatment of her LLE
thrombus and continued on pad counts. At this time she was
declining all workup and evaluation of her post-menopausal
bleeding. It was discussed with patient that her vaginal
bleeding may limit the ability to treat her LLE DVT and this
bleeding could have a serious underlying etiology and could
become lifethreatening in the setting of the anti-cogulation
needed to treat DVT.
Social work was also consulted at this point in her hospital
course for support. Given discomfort with ED exam, she was
recommended to undergo exam under anesthesia, possible
endometrial and cervical biospies as a definitive diagnostic
option of her vaginal bleeding, which she declined. She elected
to undergo CT scan with IV contrast but declined po contrast. CT
scan was highly concerning for endometrial malignancy showing:
Multiple retroperitoneal and pelvic lymphadenopathy suggestive
of metastatic disease. Markedly distended endometrial cavity
suggests a primary endometrial cancer. A dominant left external
iliac lymph node is invading the left external iliac vein, with
tumor thrombus extending into the common femoral vein,
associated with secondary subcutaneous edema within the superior
left thigh secondary to venous congestion.
On ___, Ms. ___ remained hemodynamically stable with
minimal vaginal bleeding on therapeutic heparin. The highly
concerning nature of her imaging results was discussed with the
patient and biopsy for definitive diagnosis was again
recommended. Gyn Oncology was consulted for further discussion
and recommendations, with patient continuing to decline any
additional workup of her imaging findings.
On ___, she was again HDS with minimal bleeding and the
decision was made to transition to therapeutic lovenox. Ms.
___ continued to decline additional workup of her vaginal
bleeding or imaging findings.
On ___, she remained HDS on lovenox. ___ was consulted for
limited mobility and recommended ___ rehab on discharge.
On ___, she again affirms that she would not like the primary
team to coordinate follow-up. The GYN team did offer to give her
a list of recommended providers, but the patient declined this
as well. At the time of discharge, we again discussed with the
patient that the recommended next step is an endometrial biopsy
for definitive diagnosis. In addition, she states that she will
set up follow-up herself. | 186 | 424 |
15256385-DS-11 | 24,552,874 | Dear Mr. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were feeling tired and not like yourself
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We did urine and blood tests. It looked like you may have had
a urinary tract infection and we started antibiotics, however
these were stopped because your urine did not grow any bacteria
- We consulted urology, they did not suggest any further testing
- We had our physical therapists evaluate you and they suggested
home physical therapy
- We had our wound care team evaluate you and they provided
recommendations for your groin wound.
- You reported that you were feeling better and were ready to go
home.
- We had our social worker help to work on reuniting you and
your service dog
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop a fever, groin pain, groin drainage, worsening
pain with urination or blood clots in your urine.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | Mr. ___ is a ___ yo M with a sig PMHx of bipolar disorder,
paroxysmal A. fib on Rivaroxaban, nephrolithiasis s/p multiple
ureteral stents, with recent admission at OSH for groin abscess
s/p I&D and urosepsis who presents with generalized malaise.
ACUTE/ACTIVE PROBLEMS:
# Fatigue
# Malaise: Patient reports generalized malaise since ___.
Suspect this is multifactorial in nature. Work up as an
outpatient showed iron deficiency anemia for which he was
started on supplementation. Other considerations include
worsening depression, given flat affect and states that he has
"a lot going on in his life." Denies any SI/HI. Further, he
endorses poor PO intake for the past few days, which may suggest
a component of orthostasis. No infectious etiology found this
admission (urine culture was negative). AM cortisol was WNL. TSH
& B12 WNL.
# Flank pain, hematuria: Patient has a history of
nephrolithiasis, ureteral strictures and a stable renal mass
(eventual plan for surgery). s/p ureteral stent. Pt states he
was treated for pyelonephritis at his recent hospital admission
to ___, s/p IV abx. He states he has persistent
dysuria and hematuria. There was initial c/f UTI given UA with
pyuria and hematuria. He was empirically started on CTX which
was subsequently stopped when urine culture was negative.
Urology was consulted given complicated hx and current urethral
stent. Urology recommended no further workup. Continued on home
Tamsulosin 0.4mg qhs and oxybutynin 5mg q8h prn bladder spasms.
#groin wound
Pt was supposed to be on a 10day course of doxycycline 100mg BID
with day ___. On admission pt reported that he picked up
medication but did not take it. Wound care evaluated him and
provided recommendations. Prior DC f/u was made with Dr.
___.
CHRONIC/STABLE PROBLEMS:
# Paroxysmal A fib: Recurrent episodes since ___. Rates
currently in ___. No rate control. Continued home Xarelto 20mg
daily.
# Bipolar Disorder
# Depression: Dx'ed in ___. Currently with generalized malaise,
c/f component of depression given that pt reports numerous life
stressors which has been aggravating his symptoms. No SI/HI.
Continued home divalproex ___ er qhs and escitalopram 5mg qhs.
# Anemia, Iron Deficiency
Continued home ferrous sulfate 325 qod (changed from qd).
Discharged on home daily iron supplementation. Labs: Iron30,
calTIBC 173, Transferritin 133, ferritin 163. Retic 2.2.
# GERD: EGD with chronic inactive gastritis in ___.
Continued pantoprazole 40mg qd and prn calcium carbonate qid.
#CODE: FC, presumed
#CONTACT: ___
Relationship: friend
Phone number: ___
TRANSITIONAL ISSUES:
==================
[] New Meds:
Benzonatate 100mg PO TID as needed for cough
Guaifenesin ___ PO every 6 hrs as needed for cough
[] Stopped/Held Meds: None
[] Changed Meds: None
[] follow up with Vascular Surgery with ___
on ___ 10:15 am
[] follow up with Urology with Dr. ___ on ___ at
8:00 AM | 243 | 455 |
12462977-DS-10 | 29,482,842 | Dear Mr. ___,
You came to the hospital because of cough and you were found to
have pneumonia and blood clots in your lungs. You were treated
with IV antibiotics and then transitioned to a pill form called
levofloxacin. You should make sure you continue all of this
medication until it is completed.
For the blood clots in your lungs, you were started on a
medication called warfarin. You were also started on a
medication called lovenox that you should take with the warfarin
until a lab test called the "INR" is within range. At that time
the lovenox will be stopped but the warfarin continued. ___
___ at ___ follow these results and be in
touch with you about how long to continue lovenox.
You also had an echocardiogram that showed slightly worsening
function of your prosthetic valve. For this you had a more
specialized echocardiogram that showed moderate to severe
backflow of blood across the mitral valve of your heart, the
valve which you had replaced in ___. The study also showed
increased narrowing of the valve. These findings should be
followed up with Dr. ___ as an outpatient. We did not think
you needed any acute intervention while in the hospital but you
should discuss this further with Dr. ___.
It was a pleasure being involved in your care.
Your ___ Team | ___ y/o M WITH h/o sCHF (EF ___, CAD w/ angina
pectoris (s/p CABG and tissue MVR, stent), HLD, HTN, and CKD
Stage III who presented with cough found to have bilateral PEs
and RLL PNA.
# Bilateral PEs:
Patient was transferred to ___ after bilateral PE's were noted
on CT at outside hospital showing bilateral PEs with pulmonary
infarcts involving right middle lobe and left lower lobe. EKG
showed no signs of RV strain, negative troponin, and patient
remained hemodynamically stable. Echo did show RV dilation but
not significantly changed from prior. Though CT showed evidence
of acute pulmonary emboli it was though that patient was very
well compensated and could have had a chronic to subacute
component to his pulmonary emboli. He was started on IV heparin.
He was discharged home on PO warfarin and lovenox dosing until
INR therapeutic at ___ range at which point lovenox should be
discontinued. Warfarin may be needed indefinitely given
possibility of acute on chronic pulmonary emboli. For this
reason NOAC was not used given possibility of chronic emboli.
Anticoagulation will be managed by ___ anticoagulation
by ___. It was thought that patient could undergo
hypercoagulable work up given bilateral pulmonary emboli and it
was suggested that he should have age appropriate colonoscopy.
#HCAP
Patient met sepsis criteria in setting of HCAP on admission and
was treated with IV vancomycin and cefepime. He showed gradual
clinical improvement and as transitioned to PO levofloxacin at
time of discharge to continue until ___.
# sCHF: EF ___
The patient's lisinopril and torsemide were initially held in
setting of sepsis above but restarted prior to discharge.
Digoxin and metoprolol also continued.
#Mitral Stenosis s/p MVR
The patient had echocardiogram to evaluate RV function in
setting of pulmonary emboli that incidentally showed worsening
pressure gradient of the mitral valve for which TEE was pursued
showing moderate to severe mitral regurgitation with mild mitral
stenosis. Plan for patient to discuss further management with
Dr. ___ worsening mitral valve function.
# Hyponatremia:
Hyponatremic to 126 on admission. This was felt to be due to a
combination of SIADH and hypovolemia. Sodium normalized prior to
discharge.
# Hiccups:
The patient was noted to have hiccups due possible diaphragmatic
irritation due to effusion. He was continued on thorazine PRN.
# CAD:
- Continued on home ASA, atorvastatin, and metoprolol.
# Psych:
- Continued home paroxetine | 222 | 387 |
10505380-DS-22 | 27,664,427 | Dear Ms. ___,
You came to the hospital with abdominal pain. We evaluated with
a scan of your abdomen that showed no acute process or surgical
emergency. Your lab work also showed some kidney injury from
dehydration that improved with hydration. Your pain improved and
you were eating and drinking normal before discharge.
We recommend that you continue to follow up with your primary
care physician when you leave the hospital as well as your
Gastroenterologist who you have an appointment with tomorrow.
It was a pleasure being involved in your care.
Your ___ Team | Ms. ___ is a ___ w/ Hx of HTN, GERD and SBO x 2 requiring
surgical lysis x 2, chronic pancreatitis, s/p cholecystectomy,
s/p appendectomy who presents with diffuse abdominal pain,
nausea, and vomiting and found to have ___ with negative CT
abdomen now admitted for further work up.
# Abdominal pain:
The patient presented with acute on chronic abdominal pain in
the context of her known prior surgical history. Evaluation
included CT scan that did not show evidence of bowel obstruction
or diverticulitis, or pancreatitis. LFT's and lipase were within
normal limits. The patient was noted to have planned endoscopy
on ___ by outpatient GI provider. Her abdominal pain and
nausea improved upon admission and patient was tolerating
regular diet and PO intake prior to discharge. Her symptoms were
thought to possibly be due to dyspepsia for which outpatient
work up is pending with plan for endoscopy on ___ with
outpatient GI provider. We also encouraged the patient to
discuss with her outpatient primary care provider other
underlying factors contributing to her chronic abdominal pain
including psychosocial factors and the role if any for ongoing
oxycodone as there was not a clear indication.
# ___ on CKD (baseline Cr 1.3):
The patient was noted to have acute kidney injury on
presentation with Cr of 2.0 that improved with IV hydration to
baseline of about 1.3 prior to discharge.
#Anemia:
Acute on chronic, Hgb has been 9s-10s over the past year and
remained stable while in the hospital.
CHRONIC ISSUES:
==========================
#Depression: continued bupropion
#Migraines:
-continued amitriptyline
-fioricet continued PRN
#Chronic pancreatitis: Presentation, imaging, and labs not
consistent with acute pancreatitis. Continued creon with meals.
# Chronic bursitis pain on oxycodone prescribed by PCP. ___
checked and patient receives prescriptions every 28 days
prescribed by PCP. Has outpatient pain management contract.
Continued oxycodone per outpatient regimen with bowel regimen
while in the hospital. Would like patient to have ongoing
discussions with PCP regarding potential weaning and
discontinuation of oxycodone with consideration of other pain
management regimens.
#HTN:
Lisinopril and HCTZ initially held in setting ___ and
restarted prior to discharge. Continued verapamil and atenolol.
#GERD: continued omeprazole 40 mg PO BID.
#Hypothyroidism: continued levothyroxine.
#Constipation: continued Miralax
#Insomnia: continued 100 mg trazodone QHS prn. | 91 | 371 |
11714752-DS-9 | 26,002,275 | Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
because you were feeling weak, and had a low blood pressure.
Your blood pressure improved with some fluids through the IV.
You were also seen by the physical therapists, and it was felt
that going to a rehab center would be helpful in improving your
strength and balance.
We held some of your blood pressure medications here because
your blood pressure was low. You should speak to your doctor
about the best time to restart these.
Again, it was very nice to meet you, and we wish you all the
best.
Sincerely,
Your ___ Care Team | ___ with history of Afib on apixaban who presents with weakness,
unstable gait, and hypotension.
===================================
ACUTE MEDICAL ISSUES ADDRESSED
===================================
#Weakness, gait imbalance: Patient reported gait disturbances,
and multiple recent falls that have been getting progressively
worse in the last 2 weeks to 1 month. She denied any syncope or
presyncope. She also reported multiple areas of pain, in
particular her left knee, though this was not new to prior. A CT
head and CT L-spine did not show any acute process. An x-ray of
the knee showed a moderate effusion with moderate-severe
degenerative changes. She was evaluated by physical therapy, and
it was recommended that the patient be discharged to rehab.
#Hypotension
___
#Hyponatremia:
Patient was found to be hypotensive to 84/36 in the ED after
receiving home blood pressure medications. She was asymptomatic,
and pressures improved with IVF. An infectious workup with a u/a
and chest x-ray was negative. She was also found to have ___
to 1.3 and hyponatremia to 130, suggesting that the patient was
somewhat volume depleted, possibly in the setting of poor PO
intake. The patient's blood pressure improved to the 130s with
IVF, and her Cr improved to 1.1 and sodium to 136. AM cortisol
found to be 10.1. On discharge her home amlodipine, lisinopril,
and HCTZ were held, to be restarted in the outpatient setting.
===================================
CHRONIC MEDICAL ISSUES ADDRESSED
===================================
#AFib: Fractionated home metop while in-house, discharged on
home dose. Continued home apixaban for anticoagulation.
___ disease: Continued home sinemet. Patient at
baseline MS per daughter.
#Hypothyroidism: Continued home levothyroxine, which patient
confirmed was 200mcg on ___, 100mcg every other day.
===================================
TRANSITIONAL ISSUES
===================================
[] Patient's home lisinopril, amlodipine, and HCTZ were held at
time of discharge. If SBP remains above 130, would restart
sequentially with close monitoring of blood pressures.
[] Of note, patient's medication list updated to include that
she takes 200mcg of levothyroxine on ___. TSH normal at
1.2.
[] Patient should have electrolytes checked in one week to
ensure that kidney function and electrolytes remain wnl.
[] Would continue to address code status at future primary care
appointments.
#CONTACT: ___ ___ | 118 | 339 |
12627613-DS-22 | 29,089,903 | Dear Ms. ___,
You were admitted to the hospital because of your
lightheadedness.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We treated your lightheadedness with medication
- We discovered that your oxygen levels were low and treated
that by stopping some medications and treating you with
different medications.
- We tracked your liver labs which became elevated but were
stable. We would like you to get this checked as an outpatient.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors and get
your liver labs redrawn and checked
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | Outpatient Providers: BRIEF HOSPITAL SUMMARY:
======================
Ms. ___ is a ___ year-old-woman status post kidney and
pancreas transplant ___ recent diagnosis mild non-humoral
pancreas rejection presenting with orthostasis, new hypoxemia
concerning for pulmonary embolism but found to have
methemoglobinemia likely ___omplicated by orthostatic hypotension and transaminitis
described below. | 202 | 46 |
15231087-DS-24 | 24,011,007 | You had an acute exacerbation of your congestive heart failure
because of an increased heart rate and pneumonia. We have
treated the pneumonia with an antibiotic pill and your heart
rate is normal now. It is very important that you limit the
amount of salt in your diet and educate yourself on foods that
are high in salt such as cheese, sausage and soups. Continue to
weigh yourself every morning, call Dr. ___ weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at
discharge is 223 pounds.
.
We made the following changes to your medicines:
1. STOP taking furosemide, take torsemide instead to get rid of
extra fluid
2. Discontinue Amlodipine
3. Use nitroglycerin as needed for chest pain, you can use one
tablet under your tongue, then wait 5 minutes and use another
tablet. Do not take more than 2 tablets and call Dr. ___
911 for any chest pain.
4. Start miralax to prevent constipation
5. START levofloxacin to treat your pneumonia, you need to take
this medicine every other day.
6. START taking tessilon perles for cough as needed.
7. Take Metolazone only if you see that your weight increases
more than 3 pounds in 1 day or 5 pounds in 3 days. You can take
two pills for a total of 5 mg. | Mr. ___ is a ___ year old man who presented with acute on
chronic diastolic HF thought to be due to secondary to
pneumonia.
.
#.DYSPNEA: likely multifactorial in the setting of pneumonia
with acute on chronic diastolic CHF exacerbation. Another
possibility is new atrial fibrillation with worsening CHF. On
admission, he was found to have bilateral crackles, elevated BNP
(althought not drastically above previous levels), lower
extremity and cardiac wheeze on exam which were consistent with
CHF exacerbation. The patient responded well to lasix 20mg IV
in ED (1L output in 6 hours), which is essentially was his home
dose. Diuresis was continued (approximately 2L/day net
negative). Besides new afib, another potential trigger for CHF
exacerbation is likely infection given PNA on CXR. Levofloxacin
ws started for planned 8 day course. In light of CHF
exacerbation and history of AS a repeat echo was obtained and
demonstrated normal cavity size and global systolic function (LV
> 55%) as well as minimal aortic stenosis with a peak gradient
of 21 torr. Mr. ___ was discharged on torsemide 40mg PO
daily and metolazone as needed (take 2 tabs if weight gain) as
well as metoprolol and nitroglycerin.
#.ATRIAL FIBRILLATION: New AF for patient. Given comorbidities
and CHADS2 score of 4, we initially elected to bridge with
heparin while coumadin became therapeutic but in light of prior
bleed decided to hold on anticoagulation. Rate control was
achieved with Metoprolol Tartrate 50mg BID. TSH was within
normal limits.
#.CAD: We doubted ischemia as a cause for the CHF exacerbation
as he denied chest pain, CE were negative, and EKG does not meet
Sgarbossa criteria. Patient on appropriate cardiac medications
except for a statin (as patient has had a low LDL off statins)
and ACE-I (no history of systolic dysfunction and CKD).
.
#.IDDM: Home insulin regimen was continued.
.
#.ESRD s/p TRANSPLANT: Cr 2.6 on admission which is close to
baseline for him. Home cellcept and prograf were continued as
was PCP prophylaxis with bactrim.
.
#.RIGHT INDEX FINGER PAIN: While admitted, Mr. ___
complained of right index finger pain secondary to presumed
gouty arthritis. He underwent surgery for this chronic index
finger pain in ___. He espoused decreased range of
motion and pain consistent with prior flares of arthritis. He
did not demonstrate any warmth or erythema concerning for
infection. Consideration for in house hand consultation was
made, but Mr. ___ insisted on outpatient management. | 222 | 403 |
16458312-DS-8 | 28,805,508 | Dear Mr. ___,
WHY DID I COME TO THE HOSPITAL:
-You came to the hospital because your legs were weaker than
before. You were also having more trouble breathing.
WHAT WAS DONE FOR ME IN THE HOSPITAL:
-You were found to have too much fluid in your body. This is
because of your weak heart (congestive heart failure). This was
a problem you have had for a long time.
-You were given medications to remove this fluid from your body
(diuretics) through your IV.
-You were also started on a medication to help with your
congestive heart failure
-You also had an MRI of your spine. This was to see why your
legs were weak. The MRI showed another meningioma in your spine.
You were seen by the neurologists and the neurosurgeons for this
meningioma.
-They recommended following up after leaving the hospital to
discuss a possible operation on this meningioma.
WHAT SHOULD I DO AFTER LEAVING THE HOSPITAL:
-Please continue to take your medications as prescribed
-Please follow-up with your doctors as ___
Thank you for allowing us to be a part of your care,
Your ___ Team | Mr. ___ is a ___ with PMH of meningioma ___ s/p resection,
with known parietal meningioma, CAD s/p PCI, HFrEF (EF 20%),
pulmonary HTN, h/o PE, PAD, thrombocytopenia, BPH and h/o C diff
who presents with dyspnea likely due to CHF exacerbation as well
as progressive leg weakness likely due to presence of newly
identified T5-5 spinal meningioma and deconditioning.
# ___ WEAKNESS:
# H/O NEUROPATHY:
# H/O C-SPINE MENINGIOMA S/P RESECTION:
# T ___ MENINGIOMA:
The patient at baseline has some ___ weakness, although the
distribution and extent of his weakness was unclear per prior
notes in the ___ system and per the patient (who has
dementia). Per discussion with his wife, he does have LLE > RLE
weakness ___ prior C-spine meningioma resection at baseline with
recent worsening over months of his right leg weakness. On
arrival, the patient's exam was notable for chronic urinary
incontinence (unchanged from baseline) and intact rectal tone
inconsistent with acute cord compression. He did undergo MRI of
his C, T, and L-spine on ___, which was notable for 1x0.9cm
intradural, extramedullary enhancing T5-6 lesion compatible with
meningioma resulting in moderate-to-severe canal stenosis with
compression of the adjacent spinal cord without any abnormal
cord signaling. He also was noted to have moderate to severe
spinal canal stenosis of the lumbar spine atL2-L3, L3-L4, and
L4-L5 with associated compression of the exiting cauda equina
nerve roots. Given these findings and his symptoms of worsening
weakness as well as ___ neuropathy (worse than prior per
patient's wife and review of ___ records), neurology and
neurosurgery were both consulted. Neurology recommended routine
serologic testing for neuropathy including TSH, B12, and
SPEP/UPEP, all of which was unremarkable. Neurosurgery
recommended initial initiation of dexamethasone and reviewed
imaging for consideration of operative intervention. After
discussion with neurosurgery, the patient (who does have
dementia, without capacity), and his wife (HCP), decision was
made not to intervene inpatient given no surgical emergency and
multiple other co-morbidities. Per discussion with neurosurgery
dexamethasone was stopped. He was planned to follow-up in clinic
with neurosurgery and after working with ___, planned for
discharge to rehab.
# DYSPNEA:
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
# H/O PE:
The patient has a known history of likely ischemic HFrEF, a mild
exacerbation of which was felt to be contributing to his
presenting symptoms. He appeared mildly volume overloaded rather
chronically without clear trigger on admission and was diuresed
with lasix 40mg boluses with good effect. There was minimal
concern, despite his history of multiple prior PE's and DVTs
that he was having acute PE given his response to diuresis. He
was started on captopril for afterload reduction and continued
on his home metoprolol 25mg XL PO daily. He was switched back to
his home dose of oral furosamide and remained clinically
euvolemic. His CAD was managed as below and he was also given
nebulizers for symptomatic relief. He was euvolemic at time of
discharge with weight of 97.5 kg (BEDWEIGHT). His captopril was
consolidated into Lisinopril 5 mg.
# NSTEMI/CAD:
The patient presented with weakness complaint at advice of his
PCP to ___. There, concern was raised about his ECG,
specifically regarding possible ST-elevations or new changes in
his inferior leads. Of note, the patient does have prior PCI to
his RCA many years ago. He had a mild troponin elevation to 0.03
(tropT) and was sent to ___ for further consideration of
catheterization. Of note, the patient was in CHF exacerbation
and had no signs of ischemic pain or angina equivalent. His ECGs
were reviewed on transfer to ___ and overall felt to be
similar with sub-mm changes that were not reflective of active
ischemia. His troponin leak was felt to be likely demand i/s/o
CHF exacerbation and poor clearance due to ___. He was treated
with diuresis as above and continued on home aspirin and
atorvastatin. His heparin gtt (started at ___ was stopped
on arrival. He did have nuclear stress test on ___ as part
risk stratification prior to potential surgery (discussed below)
showing a fixed large, severe perfusion defect involving the
RCA, fixed small severe perfusion defect involving the LAD,
increased LV cavity size. Moderate systolic dysfunction with
hypokinesis of the entire inferior wall and the mid-basal
inferolateral walls and apical akinesis.
# ELEVATED LFTs: The patient presented with elevated LFTs,
likely due to congestion from CHF exacerbation vs. mild
elevation in LFTs ___ myocardial damage. These improved with
diuresis and he did have RUQUS, which was unremarkable.
# THROMBOCYTOPENIA: The patient has baseline thrombocytopenia to
100-140k without clear etiology. The patient had no history of
cirrhosis and had RUQUS this admission to work-up elevated LFTs,
without any imaging findings compatible with liver disease
either. He should follow-up regarding work-up and management of
this condition, especially should he undergo surgery, as an
outpatient.
# DEMENTIA: The patient has a history of cognitive impairment
and per discussion with his wife carries diagnosis of dementia.
During this admission, he displayed (per apparent baseline),
lack of short term memory, to the degree of asking the same
questions multiple times during the same conversation. He was
continue ___ memantine and donepezil, home medications, during
this admission.
# H/O FE DEFICIENCY ANEMIA: continued Fe supplements
# BPH: Continued tamsulosin, finasteride and had foley placed
while diuresing, removed prior to discharge. | 176 | 875 |
11637393-DS-7 | 22,013,248 | Dear Mr. ___,
You were admitted to the hospital with fevers/left flank pain
and you were found to have multiple obstructing left ureteral
stones, causing a severe kidney infection and bacteremia due to
the blockage. You had a percutaneous nephrostomy tube placed to
decompress the kidneys and your symptoms improved. You have
been treated with IV antibiotics for kidney and bloodstream
infection. You will need to continue getting the IV antibiotic
at home for another 9 days and will keep the nephrostomy tube
until you see Dr. ___ in follow up. It important
for you to continue drinking lots of fluids and make sure to
follow up with your physicians as noted below.
In addition, you were found to have atrial fibrillation with a
rapid ventricular response which was likely caused by the
infection. This is much improved with an increased dose of
metoprolol (now ___ daily) to help control your heart rate.
We discussed starting anticoagulation instead of Aspirin alone
and you preferred to discuss this further with your primary
cardiologist. Please make sure to follow up with him in the
next ___ ___.
It was a pleasure taking care of you!
Sincerely,
Your ___ team
If you have any questions or concerns over the weekend, you can
call the ___ operator at ___ and ask to have Dr.
___ paged. | ___ man with a history of DMII, hypertension, atrial
fibrillation on ASA as AC, and renal calculi complicated by
multiple episodes of MDR UTIs who presents with complicated UTI
in the setting of left obstructing renal calculi s/p
percutaneous nephrostomy tube placement and atrial fibrillation
with RVR.
#Sepsis secondary to Obstructive Left Pyelonephritis
#Complicated by GNR blood stream infection.
Left kidney was decompressed with PCN and there was return of
purulent material. Pt was treated with IVF and meropenem given
hx of ESBL Coli. Pt rapidly improved with clearance of
leukocytosis and blood cultures remained negative at ___
though 2 blood Cx had been positive for E Coli and Proteus prior
to transfer. Pt had some intermittent Afib with RVR for ___
days post PCN placement. After 24hrs without fevers, pt had
foley removed and voided clear urine without difficulty. Pt had
a midline placed to complete a 14 day course of Abx for sepsis,
bacteremia and pyelo with Ertapenem to cover ESBL EColi and
Proteus. Last day of therapy ___ afterwhich the
midline should be removed. Pt was discharged with ___ to help
with IV Abx and PCN maintenance.
#Atrial fibrillation with RVR
Reported bursts of HRs into the 150s in the ED after perc
nephrostomy tube placement. Pt continued to have intermittent
Afib with RVR while on the floor after the procedure but
remained asymptomatic with normal BP, no CP, no SOB, LH or CHF.
He was rate controlled with increased doses of metoprolol and
by the time of discharge, his heart rate returned to ___. Pt
was instructed to resume his home regimen of Toprol 100mg daily.
Pt is presently on ASA alone for AFib though his CHADSVASC score
is 2 (age, DM) so guidelines would recommend anticoagulation.
We discussed initiation of anticoagulation with the patient and
discussed risk/benefits and he preferred to discuss further with
his primary cardiologist after discharge. He was continued on
full dose Aspirin and has close follow up scheduled.
#Hypertension - was previously on lisinopril, but his doctor
took him off this as he lost some weight and pressures
normalized. Discharged on home Toprol 100mg daily
#DMII: continued home metformin on discharge.
#Cardiac primary prevention: Continued atorvastatin and Aspirin.
Depression/Anxiety: continued Duloxetine
*** Transitional issue: Indeterminate lower pole right renal
lesion for which they
recommend a renal ultrasound for further characterization when
the
patient is stable" ___ official read of CT scan. *** | 223 | 419 |
17223574-DS-17 | 28,987,316 | Dear Mr. ___,
You were admitted for trouble with speech, numbness and
parasthesias along with focal weakness concerning for a multiple
sclerosis flare that is in the process of resolution as it has
been going on for quite some time. You have also had multiple
episodes of loss of consciousness and awareness. Your EEG did
not show any seizures. You did have multiple episodes of heart
sinus pauses that could be leading to this, or it may be that
you have sleep apnea causing you to have microsleeps throughout
the day leading to loss of consciousness and awareness. We
suggest that you follow up with your primary care physician. You
may need a sleep study as an outpatient if you do not already
have one.
Because of these spells, please do not drive until you are
re-evaluated as an outpatient by neurology at Dr. ___
___ vist on ___.
You had an MRI while you were in the hospital, and it did not
show any new lesions that are active. You also have a history of
a renal mass that still needs to be worked up as an outpatient.
Please follow up in neurology clinic. You will also need to see
your PCP for further workup of your renal mass. Please have your
PCP send your renal (kidney) workup to our office if they are
not within the ___ system. Our fax number is ___.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old gentleman with
obesity-hypoventilation syndrome and features concerning for MS
on MRI in ___ who presented from clinic with concern for a
recent exacerbation of MS. ___ recent symptoms of diplopia,
numbness/paresthesias, focal weakness, pain and bowel/bladder
dysfunction were thought to be consistent with an MS
exacerbation, particularly in the setting of a young gentleman
with prior MS lesions on imaging without follow-up/treatment. On
exam, Mr. ___ also had decreased pinprick, proprioception,
and light touch in his feet bilaterally. Though possible to be a
symptom of MS, it is also possible that this represents
peripheral neuropathy, particularly given bilateral "stocking
and glove" distribution. DM less likely given HbA1c of 6.4%.
Other etiologies (e.g. syphilis, B12 deficiency, hypothyroid)
are less likely given normal lab values. MRI head/C/T spine
negative for acute lesions.
He further endorses multiple episodes of loss of consciousness
over the past month. These are possibly consistent with seizures
given loss of awareness and increased likelihood of seizures in
the setting of MS. ___, he denies aura, post-ictal
confusion, loss of bowel/bladder function acutely, or
tongue-biting, and EEG did not demonstrate epileptiform
discharges. This is possibly cardiogenic in origin given risk
factors (obesity, hypertension) and sudden onset. This is less
likely vasovagal syncope given lack of prodrome and occurrence
of events while sitting. EEG was normal. He will need to obtain
a sleep study as outpatient. | 248 | 235 |
19170210-DS-22 | 29,661,464 | You presented to the hospital with fatigue and low-grade fevers.
We did not find a clear source of infection. You were noted to
have high heart rates / sinus tachycardia with minimal activity.
You had an echocardiogram which was unremarkable. Your thyroid
tests were normal. You were seen by the Rheumatologists and
they did not feel this was a manifestation of your autoimmune
disease. We had low suspicion for a blood clot in your lung
based on your blood test (D-dimer level) and ultrasound of your
legs, so we did not pursue a CT scan of your chest. You briefly
received stress dose steroids. You were noted to be anemic and
your B12 levels were also found to be low. We recommend that
you complete a course of injections for vitamin b12 supplements.
.
You should follow-up with your PCP, as well as Hematology.
.
You should keep any previously made physician ___.
.
Please take your medications as listed. | ___ yo F with PMH of autoimmune disease NOS, previously on
chronic immunosuppresion, complicated by chronic adrenal
insufficiency, who p/w fatigue and DOE, along with intermittent
low-grade fevers, found to have sinus tachycardia.
.
# Sinus tachycardia
Pt noted to be tachycardic to 150's with normal BP and normal O2
saturation. She was not symptomatic with CP or LH. She
received 3L of IVF in the ED for presumed volume depletion in
the setting of fever. Despite 3L of IVF, she remained
tachycardic with activity, but she was not orthostatic. Her
blood count did reveal a new anemia, with a Hgb of 10.6,
baseline Hgb (___), found to be vitamin B12 deficient (see
below). However, her anemia is likely chronic and the degree of
anemia was felt to be unlikely severe enough to account for her
degree of tachycardia, especially when considering her baseline
HR's are reported to be in the ___ - ___.
.
Further w/u of her onus tachycardia included unremarkable EKG
and normal troponin, making ACS unlikely. She had a
echocardiogram that showed no evidence of heart failure or
pericardial effusion. Her TSH, T3, T4 were all WNL. She had a
negative D-dimer and negative ___ ultrasound for DVT, making PE
unlikely, especially in the absence of hypoxia. Also wanted to
avoid radiation from CT, given that she had a CTA chest in ___. She denied pain or anxiety. Cross-sectional abdominal
imaging was not obtained to evaluate for pheochromocytoma but
she had normal blood pressures, absence of headache and absence
of sweating ,making pheochromocytoma less likely. Also
considered possibility of acute adrenal crisis, so she was
placed briefly on stress dose steroids, however, her AM cortisol
was not c/w acute adrenal crisis.
.
We also considered whether her symptoms could represent a flare
of her underlying autoimmune disease, so she was seen by the
Rheumatology consult service. Per their evaluation and based on
a normal ESR, CRP and negative ___, this was felt unlikely to
represent an active autoimmune disease.
.
Also considered the possibility of infection, especially viral
etiologies given low-grade intermittent fever. CMV serologies
negative; EBV and parvovirus B19 serologies still PENDING. Of
note, her IgG levels were WNL, making hypogammaglobulinemia less
likely. UA, UCx and CXR without evidence of infection. Blood
cultures still PENDING, but show NGTD.
.
# Anemia / # Vitamin B12 deficiency
As mentioned above, patient was found to have a new anemia.
There was no evidence of hemolysis based on T. bili, LDH and
haptoglobin levels. Her reticulocyte was inappropriately low,
c/w a more chronic process. Her WBC and platelet counts were
WNL, making marrow suppression less likely. Her B12 level was
indeed low, making B12 deficiency the most likely culprit. She
was started on Vit B12 supplementation. A MMA level was sent
and is PENDING. She should have repeat levels checked as an
outpatient. She was referred to ___.
.
# Chronic adrenal insufficiency
She had recently increased her hydrocortisone disease for
empiric rx of adrenal crisis. She was given IV stress dose
steroids, but her AM cortisol returned WNL and not c/w her
previous adrenal crisis episodes.
. | 164 | 534 |
12567919-DS-25 | 22,881,065 | Dear ___,
___ were admitted to the hospital due to fever and altered
mental status. ___ were diagnosed with Influenza B and are
receiving treatment for it with Tamiflu. ___ were confused due
to your acute medical illness and medications, that has
improved. ___ also needed oxygen due to your heart failure, your
Lasix was held while ___ were febrile and was then restarted
with significant improvement. ___ are now ready to continue
recovering in rehab.
We wish ___ a rapid recovery,
Your ___ Medicine Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mrs. ___ is an ___ year-old lady with a history significant for
AD, ___, Bipolar Disorder, dCHF and atrial fibrillation
presenting with fever and dyspnea.
#Influenza B: Patient presented with high grade fevers on
admission testing positive for influenza B PCR on nasopharyngeal
swab. Her chest X-ray was negative for consolidations She was
febrile to ___ and dyspneic during the first 48 hours of
her care receiving supportive care with acetaminophen and
supplemental oxygen. Her home metoprolol and furosemide were
held in setting of systemic inflammation and were restarted
during the last 48h of her admission during which she remained
afebrile.
#Encephalophathy: Patient with baseline dementia and bipolar
disorder. In the setting of high grade temperatures to ___,
new medications (___) she developed acute hypoactive
delirium during the first 24hours of her admission. Her home
aripiprazole was reduced to 0.5mg. After this she remained
intermittently confused with symptoms similar to her mania
prompting an evaluation by psychiatry. Psychiatry evaluation was
significant for delirium in setting of acute illness and
recommended aripiprazole 4mg on day 2, 3mg on day 3 to return to
home dose of 2mg on discharge. On discharge, she was alert and
oriented to self, ___ and ___.
#Diastolic Heart Failure: Received 2L NS in ED in setting of
systemic inflammatory response. Required 1 dose of furosemide
20mg iv due to hypoxia with resolution. Diuretics were held
during first 48h and home dose of furosemide was restarted
during last 48h. Upon discharge patient with JVP ~5cm, scant
bibasilar crackles, no pedal edema and weight 72kg.
#Atrial fibrillation: Not on anticoagulation. While febrile
having soft blood pressures prompting dose reduction and
fractioning of metoprolol with rates in the 120s. As she
defervesced her blood pressures improved, metoprolol was slowly
titrated back up to home dose.
# pre-admission medication list error: when patient was
admitted, had an error in her recorded aripiprazole dose taken
at home, possibly ___ records sent over from facility not being
available overnight at time of admission, with a lower dose
(0.5mg) listed instead of home dose (2mg) initially. There was
as well a wish on admission to dose reduce her medication due to
delirium and potentially ___ very high fever. When facility
called to confirm meds thereafter, PAML was corrected. As above,
her aripiprazole was then increased per psychiatry to higher
than previous dose temporarily, and then titrated down.
Patient's daughter became very upset with housestaff, staff
physicians, hospital, about this error, demanding that every
medication change be gone over with her. Multiple apologies were
made for this error. In addition to prolonged discussions with
team, during which multiple apologies were made, patient's
daughter has filed several complaints with several senior
members of hospital, emergency medicine, internal medicine, and
residency administration. Investigations into this error are
ongoing.
# Alzheimer's dementia: Continue Donepezil
# Bipolar disorder: Ariprazole and valproate as above.
# ___: On no medications per PAML.
TRANSITIONAL ISSUES:
-Patient being discharged having completed 7 doses of
___ need to complete 10 doses.
-Patient to go back to home dose of aripiprazole of 2mg daily
starting tomorrow.
-Please monitor weights and I/Os on furosemide. If gains or
loses more than 3lbs contact Dr. ___ to discuss dose
adjustment.
-Patient slightly below her baseline mobility level, will need
evaluation for physical therapy at ___
-Patient slightly below her baseline cognitive status please
enact standard delirium precautions
-Baseline WBC is ~3.0 after chemotherapy for Hodgkin's disease
in ___
# CODE STATUS: DNR/DNI, NO ICU TRANSFERS
# CONTACT: DAUGHTER/HCP ___, MD | ___ | 96 | 583 |
17805562-DS-11 | 24,936,630 | Dear Mr. ___,
You were admitted to ___ and
underwent left carotid endarterectomy. You have now recovered
from surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions | Mr. ___ is a ___ year old man with history of multiple
vascular risk factors and prior superior division left MCA
stroke s/p tPA with minimal residual deficit and questionable
seizure history who presented with a 4 minute episode of aphasia
followed by unresponsiveness. He was admitted to the neurology
service at ___ on ___ for
evaluation, where he was found to have severe left carotid
stenosis.
Vascular surgery was consulted. The patient was taken to the
operating room and underwent a left carotid endarterectomy on
___. For details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor.
On hospital day ___/post operative day 2, patient was noted to
have stridor with expanding neck hematoma, and so was taken
emergently to the operating room for left neck exploration,
hematoma evacuation, and trachea repair (performed by Acute Care
Surgery). Please see operative report for more details. He was
transferred to the CVICU postoperatively. He remained intubated
and sedated. Neuro checks were done with neurology consult. They
were initially concernred for a stroke episode, but once he was
fully off sedation, they confirmed that it was negative. He was
given fondaparinaux instead of heparin on hospital day 11 as his
platelet decreased from 180K to 90K with hematology consult.
Patient was extubated on hospital day 12. He had a bedside
speech and swallow that he had failed initially while he was in
the ICU and so was given tubefeeds via dobhoff. He tolerated it
well. His neck JP was removed prior to being transferred to the
floor on hospital day ___.
On hospital day ___, the patient was cleared for grounds and thin
liquids by speech and swallow, and his dobhoff tube was removed.
By hospital day 16, he was able to get out of bed and ambulate
with a walker and void without issues. His pain was well
controlled on minimal oral medications. He was deemed ready for
discharge to home with ___, physical therapy, and speech and
swallow services on ___, and was given the appropriate
discharge and follow-up instructions. | 423 | 370 |
13954367-DS-21 | 27,217,002 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came to the
hospital because of dizziness and shortness of breath. We found
that you had an abnormal heart rhythm, which can be very
dangerous if not fixed. We performed a permanent pacemaker
placement to help assist with your heart rhythm. This pacemaker
will kick in when it detects an abnormal rhythm. Otherwise, your
heart will beat on its own without any assistance.
You did well after the procedure and we did not detect any
further rhythm abnormalities.
IMPORTANT INSTRUCTIONS:
- Please take antibiotics for the next 2 days to prevent
infection
- No lifting the affected arm over your head on the side the
pacemaker was put in for 2 weeks. No lifting or pushing more
than 10 pounds for 6 weeks. No driving for 72 hours. Keep area
dry for 48 hours, then you may shower but do not scrub the area.
No submerging or swimming until a scar is formed.
- Please attend all follow-up appointments below
It was our pleasure caring for you. We wish you the best! | ___ female with CAD s/p DES x2 in ___ for NSTEMI, type 1
AV delay, hypertension, and DM presents with worsening episodes
of dizziness, fatigue and SOB likely due to sick sinus syndrome.
# Sick Sinus Syndrome/Type 1 AV delay:
Patient subacute history of worsening symptomatic bradycardia
prompting ED visit. ETT was notable for few beats of junctional
rhythm at 30 beats/min with retrograde conduction, and eventual
return to sinus rhythm. She augmented her HR to 86 and had 1:1
conduction. Given that symptoms correlated with episode of
junctional rhythm with sinus arrest, EP recommended PPM
placement. She underwent uncomplicated PPM placement on ___.
She was discharged on PO Keflex prophylaxis, with device clinic
f/u in 1 week.
# Positive UA: She had a moderately positive UA in the ED (few
bac, 5 WBC, trace leuk, neg nitr). Culture was negative. She
received 1 dose of Bactrim initially, and then this was
discontinued as she was asymptomatic.
# Anemia: the patient's hgb following PPM placement was below
baseline (8.9 from 10). There was no evidence of bleed. Iron
studies were unremarkable. Recommend monitoring and work-up as
outpatient.
# DM Type II: the patient was maintained on ISS.
# CAD s/p DES x2: she was maintained on home regimen with ASA,
Plavix, Metoprolol, Valsartan | 179 | 207 |
13516300-DS-20 | 22,564,204 | Dear ___,
It was a privilege caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
You came ___ because of shortness of breath.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
You had a chest tube placed to remove the fluid around your
lungs. After removal of the fluid your lung remained collapsed
and did not expand. To determine the cause of your collapsed
lung, we used a camera to look into your lungs, and made a small
incision ___ your chest to look at the area surrounding your
lungs. Small pieces of tissue and fluid collected from the
procedure were analyzed to determine the cause. We did not find
any evidence of infection, the final pathology of the tissue
showed scarring and no evidence of cancer. You were also given
medication through your IV ___ order to help remove extra fluid
from your body.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and ___
with your appointments as listed below.
-___ rehab continue to weigh yourself daily, call your primary
doctor if your weight increases by more than 1 pound ___ 1 day or
3 pounds ___ 1 week
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with history of HFpEF, AF not
on AC, CKD (baseline Cr 1.2), chronic R PLEFF follows with
outpatient IP, who initially presented as a transfer from
___ with worsening dyspnea and AF with
RVR requiring metop IV. ___ regards to his chronic R PLEFF of
unclear etiology, chest tube was placed ___. Followup CXRay
did not demonstrate re-expansion of lung consistent with trapped
lung. CT chest for further workup was unable to differentiate
between rounded atelectasis of RLL vs possible bronchogenic
mass. He therefore underwent bronchoscopy/thoracoscopy on ___.
Pleural fluid consistent with transudative effusion, and no
infection. Pleural biopsy showed fibrosis and no malignancy.
Tunneled pleurex catheter placed on day of procedure with plan
to be drained 3x/week (MWF). During admission patient was also
noted to be 5kg above dry weight and CXRay with pulmonary edema.
He was treated for acute on chronic HFpEF with lasix gtt,
trigger for his heart failure exacerbation thought to be due to
inadequate diuresis prior to presentation. He was transitioned
to Lasix 80mg PO daily on discharge also with cardiology and IP
___. | 214 | 187 |
12355847-DS-10 | 28,861,594 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for a facial droop, and you
were found to have a small stroke. We have restarted your
aspirin, and you should continue to take this to prevent stroke.
Your Echocardiogram showed improvement compared with your prior
study. Physical therapy worked with you while you were in the
hospital.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | The patient is a ___ year old woman with PMH diastolic and
systolic CHF, very refractory HTN, HLD, CAD, CKD, s/p meningioma
resection with resultant bitemporal field cuts, p/w L facial
droop and found to have a small subcortical stroke. MRI showed a
R periventricular coronal radiata white matter infarct, and a
questionable L pontine infarct. Etiology of the stroke
cardioembolic vs. small vessel disease from vascular risk
factors. The patient was started on ASA 81 on admission (not on
any antiplatelet therapy at home). LDL was found to be elevated
so she was started on a statin. The patient did well, and facial
droop gradually improved. She had an unsteady gait, and was
discharged to rehab for ___. UA and CXR negative.
# HTN: The patient has a history of very refractory HTN. We
checked a renal doppler US which showed no renal artery
stenosis. Her BP meds were initially held to allow her BP to
autoregulate, then they were gradually restarted. She was back
on her home regimin at discharge. At rehab, continue to monitor
BP and adjust medications as needed, goal normotension.
# Cards: Previously EF was ___, but repeat echo here her EF
has improved to > 55%. We continued furosemide. The patient will
follow up with cardiology at regularly scheduled appointment.
# ___: Baseline Cr 1.4. On admission creatinin was 1.5. She got
a small amount of IVF, and lasix was continued. Cr was ___
during hospital stay, and 1.6 at discharge. At rehab, continue
to trend creatinine twice per week, if elevated above 1.6,
consider gentle IVF or holding furosemide briefly.
TRANSITIONAL ISSUES
- ___ at rehab
- physical therapy for gait training
- At rehab please check her creatinine twice weekly to monitor,
if creatinine increases consider gentle IVF.
- At rehab please monitor her blood pressure and adjust
medications as needed, goal normotension.
- ___ with PCP
- ___ with neurology
- ___ with cardiology
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 =
119) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: LDL only mildly elevated, so
started atorva 20 for goal LDL < 100]
(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) ___ - () 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: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A | 91 | 567 |
13748151-DS-19 | 28,313,065 | Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you fell.
You were found to have a small bleed in your brain. The
neurosurgeons monitored you closely. Once your bleed was stable
you were transferred to the medicine service.
While on the medicine service, blood thinning medication was
restarted because of your mechanical heart valves. The
neurosurgeons continued to follow. Your area of blood enlarged
while on heparin, so your anticogulation was stopped and you
were sent to the neurology service.
You will also need to follow up with the neurosurgeon, Dr.
___ in 2 weeks. Please call ___ to arrange the
appointment, and to arrange for a repeat head CT.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
We made the following changes to your medications:
- We STARTED you on NIMODIPINE 60mg Q4H to help control your
blood pressure.
- We STARTED you on a LIDOCAINE PATCH once a day to help with
your hip pain.
- We STARTED you on ALBUTEROL NEBS every six hours as needed for
congestion, wheezing or shortness of breath
- We STARTED you on TYLENOL ___ every 6 hours as needed
for pain
- We STARTED you on a HEPARIN DRIP to help transition you back
to coumadin. We have a goal PTT of 50-70 for you, which your
rehab will check and monitor every 12 hours.
- We DECREASED your TRAZODONE to 100mg at night as needed, as we
felt you were too sleepy on your 200mg that you were taking
every night. | The patient is a ___ with history of hepatitis C, CKD, anemia,
on anticoagulation for mechanical AVR/MVR who was admitted after
mechanical fall with head strike on ___ and finding of small
left insular SAH with small IVH component. At that time INR
was 3.3. She was admitted to Neurosurgery and coumadin was held
without being actively reversed (approved by cardiology
consult). Serial NCHCTs were done which were stable until ___
when there was evidence of a small intraparenchymal hemorrhagic
contusion along with the SAH. This was felt to be a normal
sequelae of her head strike.
She was transferred to the medicine service on ___. Her INR
that day was 1.8 and she was started on a heparin gtt with
2900unit bolus as a bridge to coumadin given her mechanical
valves. Both the heparin with bolus was approved by the
neurosurgical team. The night of ___, she had one recorded
elevated PTT to 140s, but subsequent PTTs were in the goal range
of 60-80. That day she was also transfused 1 unit PRBC for
anemia.
The following day ___, her heparin gtt was transitioned to
lovenox 30mg SQ given the plan to discharge her home. Prior to
discharge, she was noted to be lethargic. Around 130pm, she was
even more lethargic and with slurred speech. NCHCT was done at
3pm which showed increasing left temporoparietal hemorrhage,
SAH, and mass effect on the left lateral ventricle.
Stroke neurology saw the patient urgently and found her
hypertensive to 190s/100s, lethargic yet responsive with a right
facial droop, left gaze preference, right sided weakness (right
arm ___, and right leg ___, bilateral upgoing toes. She was
urgently treated with Hydralazine and Labetalol IV doses while
urgently transfering to the NICU under the Neurology service.
BP was controlled (SBP<150) with a nicardipine gtt. No active
reversal was needed as INR was 1.1 and PTT was 34. Serial NCHCTs
were done to reevaluate her IPH and SAH. All anticoagulants were
stopped. Over several days, her exam improved, she became more
attentive, with no gaze preference, and improved strength on the
right.
On ___, she was transferred to the floor. However she
desaturated upon lying flat to the ___ and was placed on a
non-rebreather. Pulmonology performed an ultrasound which showed
atelectasis in the left lung, extensive, as seen on chest x ray
in the morning (likely due to mucus plugging). She was
transferred to the ICU. She was given incentive spirometry and
did well, by the end of the day she was saturating well on 3L
nasal cannula. By ___, her chest x ray was improved and she
saturated well on room air. She was then transferred back to the
floor.
On the floor she did well except that she wasn't taking adequate
oral intake. She was felt to be cachectic and had lost lots of
weight over the previous year. She had anemia persistently
throughout the hospital course which was likely in part due to
her chronic renal failure and hepatitis C, but otherwise was of
unclear etiology. We did a CT abdomen/pelvis to look for
malignancy as a possible cause but did not find anything
concerning for cancer. We had nutrition come see her and they
recommended Ensure shakes, which were not low potasssium.
Unfortunately, she became hyperkalemic, likely secondary to the
Ensure and her known chronic renal failure, with potassium
peaking at 7.0 on ___. She was given kayexalate, calcium
gluconate and insulin and her potassium decreased back to normal
levels. Her EKG done at the time of the hyperkalemia showed
peaked T-waves, which improved when her potassium improved. The
Ensure shakes were stopped.
She also became slightly more somnolent around this time, but
her UCx returned positive on ___, so she was put on a three day
course of ceftriaxone. Her mental status improved with
treatment of the UTI.
Of note, she was started on warfarin on ___ at a low dose of
2.5. After three days, her INR had still not gone above 1.0, so
she was also started on a heparin gtt on ___ to ensure
appropriate anticogulation given her two mechanical valves. Her
coumadin was increased until it was 7.5mg, which on ___ brought
her INR to 2.1. Her heparin gtt was continued as her goal INR
was 2.5-3.5. She had a NCHCT to ensure no increased bleeding
once her INR was above 2.0, which showed a stable appearance of
her hemorrhage. She was sent to rehab with a plan to continue
her bridge to warfarin with goal INR 2.5-3.5. She will need her
INR checked daily until it is in range. She will need her PTT
checked at least every 12 hours and adjusted to maintain goal
range of 50-70.
In addition, her BUN and Cr have fluctuated during this
admission. She has known CKD. At discharge her BUN was 43 and
creatinine was 1.5. These will need to be monitored at least
twice a week to ensure that she is not having worsening renal
failure.
====================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes after initial SAH, DVT ppx was restored, but after
admission to ICU, ppx was held off until ___ when SQ heparin
was restarted.
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. 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)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ] | 311 | 989 |
19454978-DS-12 | 28,903,611 | Dear Ms. ___,
You were admitted to ___ on ___ because you had shortness
of breath and altered mental status. We found that you had
pneumonia and were dehydrated so we treated you with IV
antibiotics and IV fluids. Your symptoms improved with this
treatment and you were discharged to rehab where you will
complete your IV antibiotics course.
It was a pleasure caring for you.
Best Wishes,
___ | Ms. ___ is a ___ year-old ___ speaking F with PMHx of Caroli
disease and recurrent pyogenic cholangitis and hepatic abscess
presenting with AMS, SOB, hypoxemia due to bilateral pneumonia.
# Pneumonia with hypoxemia: Patient presented from rehab with
desaturations to mid80s on RA secondary to bilateral multifocal
pneumonia on CXR and WBC 11.6. She was started on vanc and
cefepime for HCAP and O2 sats improved to mid90s with ___ NC.
Her WBC trended down to 4.5 and her O2 sats improved to high90s
RA on day of discharge. She had no cough and scant sputum
production for culture. Patient should be treated to complete
7-day course of HCAP via PICC access and repeat CXR after
resolution of symptoms.
# ___: On presentation, Cr of 1.9 from baseline of ~1.0, which
was thought pre-renal azotemia with BUN:Cr >20 and FENa 0.2%,
and poor PO intake in setting of infection. She was given IVF
and home lasix and maloxicam held with improvement of Cr to 0.6
at time of discharge.
# Hyponatremia: Na of 130 on presentation likely hypovolemic
hyponatremia which
resolved with IVF and PO hydration. At time of discharge Na was
136.
# AMS: Patient presented with AMS per family and was alert and
oriented to self and place (hospital) whereas usually is alert
and oriented to self, place, and date. Her neuro exam was
intact, and her waxing and waning mental status was consistent
with delirium, likely secondary to underlying infection as well
as pain and narcotics use due to her recent compression
fracture. Her TSH was normal and she was not B12 deficient.
With treatment of her pneumonia, her mental status improved but
continued to wax and wane. Patient needs frequent
reorientation, emphasis on sleep-wake cycle, and treatment of
her pain.
# L leg pain ___ compression fracture: Continued tylenol,
morphine SR, gabapentin and started lidocaine patch and
short-acting morphine PRN. She also had a left hip film to r/o
any underlying fractures as cause of her pain, other than
radicular pain from her compression fracture.
# Caroli disease s/p cholecystectomy w/recurrent pyogenic
cholangitis: Hepatic abscess ___ LFTs on admission were
within recent range and abdominal exam was unremarkable. She
was continued on suppressive doxycycline and ursodiol.
# Rheumatoid arthritis: Meloxicam initially held due to ___ and
restarted with resolution of ___.
# HTN: Held home BP meds amlodipine and losartan in setting of
infection initially; restarted at discharge.
# ___: Diet controlled
# GERD: Cont omeprazole
# Chronic thrombocytopenia: stable | 66 | 426 |
13312184-DS-18 | 20,473,324 | Ms. ___,
You were admitted with symptoms of walking instability, patchy
right sided sensory abnormalities, and intermittent vertical
double vision. An MRI of your brain, your current symptoms, and
your history of an episode of gait instability and vision
"darkening" with confusion, was consistent with a diagnosis of
multiple sclerosis. Your spinal fluid showed a high white blood
cell count with high lymphocytes (which could be consistent with
an MS flare). Another MS diagnostic test, oligoclonal bands, was
pending at the time of your discharge. Given your historical
intolerance of high dose steroids (hair loss and acne) and
historical improvement of symptoms on IVIG, we started IVIG for
you. After completion of 5 days of IVIG, your symptoms had
improved. You should follow up with one of our Multiple
Sclerosis neurologists to discuss a regular medication to help
decrease the progression of your disease. | Ms. ___ was admitted with symptoms of walking instability,
patchy right sided sensory abnormalities, and intermittent
vertical double vision. An MRI brain showed multiple FLAIR
hyperintense lesions in the cerebral white matter, corpus
callosum lesions, mild increase in the size of the frontal
lesions with new enhancement compared to the recent study of ___, no infratentorial lesions, and a T1 black hole in
the right occipital white matter. This MRI, the past medical
history of an episode of gait instability and vision "darkening"
with confusion originally diagnosed as ADEM, and lymphocytic
pleocytosis in the CSF were consistent with a diagnosis of
multiple sclerosis. Oligoclonal bands are pending at the time of
discharge. Given historical intolerance of high dose steroids
(hirsuitism and acne) and historical improvement of symptoms on
IVIG, we started IVIG (0.4 g/kg x 5 days). After completion of 5
days of IVIG, symptoms had improved. Ms. ___ will follow up
with one of our Multiple Sclerosis neurologists to discuss
selection of a disease modifying agent. | 143 | 170 |
19389735-DS-17 | 27,527,097 | Please keep left arm elevated as much as possible, avoid bending
left arm for a prolonged period of time, avoid sleeping on left
arm.
Use exercise ball to help mature the AV graft. Continue your
usual dialysis on ___ via the tunnel line (do not use graft
yet).
Please contact Dr. ___ if left arm is more swollen, feels
numb, cold, or painful. Call if incision appears bright red and
hurts or has drainage. | ___ male with a failed left upper arm fistula s/p left
upper arm loop AV graft ___ p/w LUE swelling, c/f graft
thrombosis on CT
Mr ___ history of ESRD on HD ___, diabetes mellitus,
presented after recent creation of LUE AV graft with left arm
pain and swelling.
He recently had creation of a left upper arm brachio-brachial
loop AV graft ___ with Dr ___. Without complications. On
___ he noted progressively worsening swelling in the left
arm, which also became painful. He had significant swelling from
the shoulder to the hand. Denies weakness, numbness,
paresthesias in the hand. No edema in the legs, and denies
dyspnea, abdominal pain/bloating, nausea, vomiting, fever, skin
erythema, any drainage from the surgical site.
On the first day of hospitalization an US revealed possible
thrombosis of left cephalic vein. On confirmation by CT scan the
following was found:
1. Near complete thrombosis of the venous graft extending from
the left
brachiocephalic vein to the left cephalic vein. The left
cephalic vein is
distended and minimally opacified, with surrounding stranding,
compatible with
recent ultrasound findings of cephalic vein thrombosis.
2. The left brachycephalic vein itself remains patent.
3. No additional areas of venous thrombosis are seen in the left
upper
extremity. The right brachiocephalic and subclavian veins are
patent.
4. Status post recent brachiocephalic artery to brachiocephalic
vein loop
graft, which appears patent. Postoperative changes are seen
surrounding the
surgical site.
The patient responded positively to non invasive interventions
(elevation) and electrolyte management. Graft had a bruit and
palpable thrill. He complained of residual mild numbness in left
index finger and thumb, had a small opening in antecubital area
left arm. Patient received last HD on ___ (UF 3L, BP 91/58)via
tunnel line without complications. Ready for discharge, in
stable conditions
Plan is to follow up with Dr. ___ out at ___. | 73 | 313 |
18056245-DS-36 | 25,527,483 | You were admitted to the hospital with abdominal pain. You were
found to have a small bowel obstruction on CT scan. You were
placed on bowel rest and given IV fluids for hydration. Now that
your symptoms have improved you were given food and have been
able to tolerate this. Your medications have been restarted
EXCEPT your coumadin.
However your INR has been elevated and is still elevated at 3.5
today on ___.
You will have your INR rechecked on ___.
Do NOT take ANY coumadin today or tomorrow ___ or ___. Take 1
mg of coumadin on ___ and ___ and ___. Your labs
will be checked on ___ and you will be contacted by the
___ clinic at that time with instructions on how
much coumadin to take.
You also were found to have a urinary tract infection and being
treated with antibiotics for a total of 5 days. Be sure to
finish the entire course.
You are being discharged home with the following instructions:
*Resume your home medications as prescribed except for the
Coumadin on ___ as discussed because of the elevated INR.
*Return to the Emergency room if you should experience the
symptoms that brought you into the hosptial or for any other
conerning symptoms.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Ms. ___ was admitted under the acute care service on ___
for management of her early small bowel obstruction. She was
kept on bowel rest and given IV fluids overnight. On the morning
___, her abdominal exam was much improved and she was without
pain or nausea. Her abdomen was soft and nontender, and her diet
was slowly advanced as tolerated.
Her vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. A foley was placed for
urine output monitoring. Of note, she had a positive u/a on
admission and was started on ceftriaxone, preliminary culture
with gram neg rods. She was therefore transitioned to bactrim
for a total course of 5 days. Her foley catheter was removed on
HD#2 and she voided without difficulty. Her INR was elevated at
3.6 on admission so her home coumadin was held. Her INR was
monitored daily and is 3.5 at discharge. She has been instructed
to hold her coumadin and is being followed by the
___ clinic at ___. Otherwise, her regular home
medications were restarted when she was tolerating PO's.
She was noted to be unsteady when ambulating by nursing and had
a physical therapy evaluation prior to discharge, who determined
the patient to be at her baseline mobility status.
On ___ she is afebrile and hemodynamically stable. She is at
her baseline mobility status. Her only complaints of pain are
her chronic chest pain for which she is being followed as an
outpatient. She is tolerating a regular diet without complaints
of abdominal pain or nausea. She is being discharged home with
services. | 216 | 265 |
18582343-DS-9 | 25,165,166 | You were admitted to the surgery service at ___ for evaluation
after MVA. You were found to have non operative rid, manubrium
and nasal bone fractures. Your were admitted for pain control
and ___ evaluation. You are now safe to return home to complete
your recovery with the following instructions:
.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
SINUS PRECAUTIONS
"1. Do not forcefully spit for several days.
2. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel "stuffy" or there may be some nasal
drainage.
3. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open." | Ms. ___ was admitted to the ICU for respiratory monitoring
after MVC in the setting of significant chest wall injury. Her
methadone dose was increased and she was given additional
oxycodone for breakthrough pain. VS remained stable, respiratory
status was stable, and she was doing well with pulmonary
toileting and incentive spirometry. She was stable x 36 hours
without evidence of respiratory distress. Mild LFT elevation on
admit was worked up with an abdominal ultrasound which showed
fatty liver but no evidence of trauma or gallbladder disease.
Plain films of the shoulder were negative. Tertiary exam did not
reveal additional injuries. Plastics will see the patient in
clinic to discuss management of the nasal bone fracture, but
nothing acute to do during this hospitalization. Physical
therapy evaluated the patient and cleared for home after ___ ___
visits. She was sent to the floor on HD2 with continuous 02
monitoring and ongoing pain control.
She was weaned off nasal cannula to room air. ___ worked with
the patient and recommended discharge home in ___ visits. The
patient was alert and oriented throughout hospitalization. She
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient tolerated a regular diet and intake
and output were closely monitored. The patient's fever curves
were closely watched for signs of infection, of which there were
none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with rolling walker, 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. | 336 | 328 |
18021108-DS-16 | 29,572,213 | YOU NEED TO HAVE A PNEUMOVAX AND INFLUENZA SHOT
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for shortness of breath and found to
have an exacerbation of your COPD and a possible pneumonia. You
were trated with steroids, antibiotics and nebulizers and your
breathing improved slightly. It will be very important for you
to go to pulmonary rehab after discharge to help your lungs get
stronger and improve your breathing. Please take all your
medications as prescribed and be sure to attend all followup
appointments as indicated. | Mr. ___ is an ___ man with multiple myeloma on
Revlimid and COPD who presents with acute on chronic SOB. He has
had several ED visits and hospitalizations over the past few
months for similar complaints, now with HCAP.
#. Pneumonia/COPD exacerbation: Patient presents with new CXR
findings of right middle lobe pneuamonia, shortness of breath
and cough. In the setting of recent hospitalizations and h/o
failed treatment with levaquin, he was seen by pulmonary and
treated for HCAP with vancomycin and cefepime. Pt. was recently
scanned, is off revlimid, Well's score is 1 at best, so CTA was
not obtained. The patient was started on an 8 day course of
vancomycin and cefepime as well as 60mg of prednisone with plan
for a slow taper. Echocardiogram was obtained to rule out
cardiac dysfunction which showed preserved EF. He had an episode
of acute shortness of breath on the morning of HD3. Chest xray
was unchanged and ABG showed some CO2 retention. The patient was
tripoding but breathing improved with supplemental O2 and
nebulizers. He received IVIG on ___ due to low immunoglobulin
levels and concern for pneumonia. During transfusion, he
developed tachycardia into the 160s but was asymptomatic. Blood
pressures were stable and EKG was consistent with either SVT or
MAT, though the baseline was poor. This episdoe resolved
spontaneously and the IVIG was continued without further
incident. He will be discharged to finish a 10 day course of
antibiotics with Levaquin.
#. Hyperthyroidism: Continued on home methimazole.
# Hypertension: Patient carries this diagnosis but blood
pressures were stable during admission and no intervention was
required.
#. Multiple myeloma: Revlimid was put on hold by outpatient
oncologist in anticipation of pulmonary evaluation. Revlimid was
held during hospitalization as protein levels were stable. | 97 | 293 |
19846637-DS-13 | 29,936,707 | You were admitted with worsening of you crampy chronic abdominal
pain. You received a CT scan with IV and PO contrast and also MR
___ which showed no evidence of pouchitis or source of
abdominal infection.
Per Dr. ___ caffeine in your diet as this can
exacerbate having loose stools. Also you should take Flagyl
until your follow up appointment with Dr. ___. | Mr. ___ was admitted to the ___ surgical service.
The gastroenterology team was consulted. He had a pouchoscopy
on HD 2 which demonstrated mild erosions in the pouch but
otherwise was normal. He had an MRE the same evening which was
normal -- no pouchitis or enteritis or abcess. He was started
on flagyl, hyosycamine, loperamide and creon supplementation.
His diarrhea and abdominal pain improved dramatically. On the
day prior to discharge he only had one bowel movement. Stool
studies were negative as of date of discharge.
He was counseled by both the surgical and GI teams to
decrease/eliminate his intake of high-caffeine sugar-free energy
drinks. The GI team recommended a two-week course of
ciprofloxacin in addition to the flagyl.
He is being discharged with followup with both GI and Dr.
___ on cipro/flagyl, creon, hyoscyamine and loperamide.
At time of discharge he is ambulating, tolerating a regular
diet, his pain is minimal and his diarrhea has resolved. | 63 | 166 |
16901627-DS-5 | 21,383,858 | Dear Ms. ___,
You were here for right leg pain. An MRI of your back showed a
lot of back disease as well as a 7 mm cyst pressing on your
spine. Please work with physical therapy. If you develop
uncontrolled pain, numbness, tingling, or weakness, you need to
come in immediately. If you develop weakness and do not get
evaluated, it could lead to permanent weakness or even
paralysis.
You also have some occasional tingling in your hands. Talk to
your primary care doctor about getting an MRI of your neck.
You have worsening of your kidney function and low sodium. Your
sodium was 122 on admission but was 134 on discharge. Your
creatinine was 6.0 on discharge. Please see your nephrologist on
___ at ___s your primary care doctor on ___
as scheduled. Have them both check your sodium and kidney
function.
You are leaving against medical advice because I would prefer to
watch your kidney function while you are here. Risks of leaving
include worsening kidney function or even a small risk of death.
All the best,
Dr. ___ | The pt is a pleasant ___ who is a poor historian. She was
transferred for possible aortic dissection. To me, she denies
chest pain, SOB, or dizziness. She was then admitted for
bilateral hand tingling and Hyponatremia. To me, she reports
longstanding Hyponatremia ___ SIADH. She reports that she
sometimes goes to an OSH ER, gets an IV infusion for her
Hyponatremia when it gets out of control, and is discharged the
same day. To me, she reports that her primary complaint is RLE
pain. She reports that the pain started in her right posterior
calf 15 days ago, and has now spread to her posterior thigh as
well. She reports mild bilateral ___ tingling without weakness.
She reports that her nausea present before admission has
resolved and she is eating well.
# Severe spinal cord stenosis:
The pt's primary complaint was RLE leg pain which sounded
radicular in nature. Her leg exam was normal. She had full
sensation, full ROM, no palpable abnormalities, and was not
tender on my exam. ___ doppler was negative for DVT. MRI ___
without contrast showed the following:
1. Grade 1 anterolisthesis at L4 upon L5 level as described
above, causing
severe spinal canal narrowing as well as crowding of the nerve
roots within
thecal sac.
2. Also at L4-5 level, there is a right articular joint facet
synovial cyst,
contributing to produce lateral thecal sac deformity at this
level.
3. Bilateral small kidneys with multiple numerous small renal
cysts.
The pt was neurologically intact with full strength, sensation,
no saddle anesthesia, and no bladder or bowel
incontinence/retention. Her pain significantly improved with ___
until it had almost fully resolved. She was able to ambulate
easily with ___. The risks vs benefits of surgical intervention
were discussed including the risk of spinal cord stenosis and
paralysis without surgery, and the high likelihood of becoming
dialysis dependent after a major operation. Pt opted to take a
conservative management approach. Neurosurgery was consulted and
agreed with conservative management. Home ___ was ordered. At the
time of discharge, pt was ambulating at her baseline level with
a walker. The red flags for spinal cord stenosis were reviewed
with her and her daughter, including numbness, tingling,
weakness, fecal incontinence/retention, and urinary
incontinence/retention. Pt was advised to come to the ER
IMMEDIATELY if she experienced these symptoms. She expressed
understanding.
# Acute on chronic renal failure
# Hyperphosphatemia
Pt's renal function is very poor at baseline and she has been
close to needing HD in the past with creatinine in the 5___.
Creatinine was 4.4 on admission, trended up to 5.9-6.0 with
fluid restriction. Her fluid restriction was therefore
liberalized. Her creatinine was 6.0 at the time of discharge
with elevated BUN but no signs of uremia or electrolyte
abnormalities. Sevelamer and calcitriol were continued. I
advised the pt to stay in the hospital until her renal function
improved. I advised her that leaving AMA would come with a risk
of worsening renal failure and electrolyte abnormalities leading
to cardiac death. She understood these risks but hated being in
the hospital and elected to leave AMA. She has an appointment to
see her PCP on ___ for a BMP, and I set up an appointment for
her to see her nephrologist on ___. I updated her
nephrologist by phone.
# Hyponatremia: baseline NA 130 with hx SIADH. Urine Osms less
consistent with SIADH, likely due to high free water intake, low
solute I/s/o poor renal function and difficulty with water
excretion. Her hyponatremia improved with free water restriction
at an appropriate rate and her sodium level was at baseline when
the pt left AMA.
# Parasthesias: per pts daughter, in upper extremities,
positional, only started since arrival in the hospital. Most
likely due to positional nerve compression. Normal neurologic
exam. On ___, pt denied any UE symptoms including no
numbness,
tingling, or weakness. I advised her daughter to follow up with
PCP regarding an MRI neck.
# Concern for aortic dissection: Resolved.
This was the initial reason for xfer however pt is comfortable,
denies any CP, no focal neurologic deficits, no murmur on my
exam. Low suspicion for aortic dissection. TTE did not show any
significant abnormalities.
# elevated trop: mild, stable, ___ CKD. No chest pain.
# microcytic anemia: with no e/o active bleeding, unclear ___,
likely ___ CKD.
# gout: cont home allopurinol
# glaucoma: cont home eye drops
# HTN: cont home amlodipine | 177 | 719 |
17467916-DS-6 | 22,227,850 | It was a pleasure taking care of you at ___
___. You were admitted to the hospital for
evaluation of your leg pain. You received blood thinners and
underwent a thorough work up of this pain. You are now scheduled
to return ___, for your angiogram to help with the
pain in your left leg. This surgery may improve blood flow to
your leg.
Vascular Leg Discharge Instructions
WHAT TO EXPECT AFTER YOUR ANGIOGRAM NEXT WEEK:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes
within a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will likely receive a visit from a
Visiting Nurse ___. Members of your health care team will
discuss this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon. You may be instructed to use special elastic
bandages or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches or
staples. This is normal.
It is normal to have a small amount of clear or light red
fluid coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician. | Ms. ___ presented to the emergency department at ___ on
___ for left lower extremity pain. She was started on a
therapeutic heparin drip, and underwent testing to assess the
extent of her lower extremity vascular disease with plans for
intervention, possibly this admission.
She underwent noninvasive vascular studies and carotid
ultrasound. The heparin drip did not improve her symptoms.
Subsequently, she was scheduled for a left lower extremity
angiogram ___, and was appropriate for discharge without
anticoagulation. At the time of discharge, she was doing well,
afebrile with stable vital signs. She was tolerating a regular
diet, ambulating, voiding without assistance, and her pain was
well controlled on oral medications. She was deemed ready for
discharge, and was given the appropriate discharge and follow-up
instructions. | 890 | 125 |
10681517-DS-15 | 25,590,198 | Dear Ms. ___,
You were hospitalized due to symptoms of left weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-high blood pressure
-high cholesterol
-uncontrolled diabetes
-chronic kidney disease
-obstructive sleep apnea
-obesity
We are changing your medications as follows:
-Take Plavix in addition to Aspirin for the next three months.
Keep take aspirin only after this
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911).
In particular, since stroke can recur, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Neurology Team | Ms. ___ came into the ED at ___ on ___ due to L
hemibody weakness and dysarthria. She underwent a CTA head and
neck which showed Sequela of chronic bilateral occipital lobe
(left greater than right), left parietal lobe, and right corona
radiata and posterior limb of the right internal capsule
infarcts.
#Right anterior choroidal infarct: CT head with hypodensity in
right coronal radiate and posterior limb of internal capsule.
CTA without evidence of large vessel occlusion. Therefore given
unclear last known well and evidence of possibly completed
infarct on CT without LVO she was not candidate for thrombectomy
or tpa. MRI showed multiple chronic infarcts, notably several
large territory infarctions in the territories of bilateral
PCAs. Of note she does have bilateral fetal PCAs. MRI also
showed new right anterior choroidal artery distribution infarct,
responsible for her presentation. Given pattern of chronic
infarcts and current anterior choroidal artery infarct, highest
suspicion is for cardioembolic etiology vs atheroembolic though
there was not a large amount of extracranial atherosclerotid
disease on CTA. She has multiple vascular risk factors and
evidence of white matter disease on MRI therefore, small vessel
disease cannot be excluded. She was started on aspirin and
Plavix. TTE was showed moderate symmetric LVH but no
cardioembolic source. Risk factors were notable for HgbA1c 9.2
and LDL 44. She was continued on her home rosuvastatin.
She was discharged with zio patch for outpatient telemetry
monitoring.
#ESRD, on HD ___: she was continued on her home ESRD
medications and followed by renal. She received HD on ___ on
admission, ___. She was continued on her home torsemide during
admission.
#Chronic back pain: her pain was managed with tylenol and
lidocaine patch.
#Calf pain: during admission she developed new left calf pain to
palpation. Lower extremity ultrasound was negative for DVT.
#Diabetes: ___ was consulted to assist with management of
diabetes. HgbA1C 9.2. Her home insulin 70/30 was increased
slightly to 34 units BID.
#HTN: iso acute stroke her blood pressure was allowed to
autoregulate and her home antihypertensive medications were
held. She was continued on her home Carvedilol but at half dose.
amlodipine 10/valsartan 320 daily**
#GERD: her home esomeprazole was replaced with pantoprazole due
to interaction with Plavix.
Transitional Issues
====================
[] insulin increased slightly to 34 units BID per ___ for
better BG control
[] She was discharged with outpatient telemetry with Zio patch
to monitor for A fib
[] Neurology: Discharged on DAPT (aspirin, Plavix) for 3 months,
will continue aspirin thereafter
[] HD ___
[] Follow up with Neurology
[] Neurology: Noted to have fetal PCAs on CTA
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?
() Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 44 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (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 pharm___
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () 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 | 314 | 736 |
17079153-DS-15 | 27,029,710 | You were admitted for a bloodstream infection from your right
groin tunneled HD catheter. The line was removed, and we treated
you with antibiotics to cover the infection. We also accessed
your new left arm graft during your hospitalization, and it was
irreversibly damaged, so you had to undergo surgery to place a
new graft. In addition, we placed another HD catheter in your
right groin again to perform dialysis until your new graft has
matured. | This is a ___ M PMhx ESRD on HD presenting with fever,
hypotension and leukocytosis in the setting of hemodialysis, now
s/p left groin line removal, placement and exchange of right
groin tunneled line, and thrombectomy/hematoma evacuation of
left upper extremity AV graft.
# Sepsis from pseudomonas and achromobacter bacteremia: Patient
a/w fever, hypotension and leukocytosis. Hypotension was volume
responsive in the ICU. Source was felt to be HD line given lack
of focal findings on exam and history. Left groin tunneled line
was pulled and broad spectrum coverage was continued with
vancomycin and cefepime. Gentamycin (given prior to admission)
levels remained therapeutic. ___ blood cultures grew
GNRs which were pan sensitive pseudomonas. Pt was initially on
vanc-cefepime, after GNRs were identified, vanc was stopped but
cipro was added. Ultimately, catheter tip grew achromobacter
which was insensitive to cefepime and cipro, but both
psuedomonas and achromobacter were senstiive to meropenem. ___
was started on meropenem for planned 14 d course (___).
The patient remained hemodynamically stable and afebrile. The
plan is to continue Meropenem via peripheral iv until ___. On
hemodialysis days, Meropenem should be given after hemodialysis.
# ESRD: Patient required removal of his left groin tunneled HD
catheter ___ concerns regarding infection. Patient on HD
(___) and was able to dialyze via recently
placed LUE HD graft until ___ when AV graft was dissected by
needle and hematoma developed in his upper arm. Pt received a
second tunneled HD line in right groin for temporary access on
___. On ___, pt went to surgery for thrombectomy with
evacuation of hematoma. Fistula cannot be used for 3 weeks. He
continued to receive HD on his scheduled days via right groin
tunneled line, which was exchanged for longer tunneled line on
___. The axillary incision had small amount of serous drainage
on ___, but has remained free of drainage or redness. At time
of discharge, the LUE AVG had a bruit/thrill and 2+ left radial
pulse. Patient had mild pain in LUE. He denied numbness/tingling
in left hand. He will continue on HD via R tunnelled femoral
line.
# Axillary vein stent: Pt was on heparin drip and warfarin -
goal INR ___ for axillary vein stent. Heparin drip was stopped
just prior to discharge to ___.
___ coumadin 8, ___ coumadin 8, ___ coumadin 4mg, ___
coumadin 4, ___ coumadin 8mg. INR 1.8 on ___.
Anti-hypertensives (amlodipine and hydralazine were held upon
admission due to hypotension/sepsis). SBP averaged 120s to 140
with HRs in ___ to 90 range the day prior to discharge.
Amlodipine 5mg was started on ___. Please monitor for need to
increase amlodipine and restart hydralazine.
TRANSITION ISSUES
- Full Code
- Complete meropenem on ___ for pseudomonas and achromobacter
bacteremia
- Left upper extremity graft cannot be used until ___ at
the earliest. Continue HD through R groin line.
- Ft ___ contact information (___)
- Restart antihypertensives PRN | 76 | 489 |
14214341-DS-47 | 27,564,804 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for chest pain.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You had an EGD which showed gastritis which is inflammation of
the lining of the stomach. We think this may be a cause of your
pain.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below, and
in particular:
STOP leflunomide.
STOP gabapentin if you want to see how if affects your fatigue.
START pantoprazole 1 pill per day (take 30 minutes before your
largest meal).
YOU CAN CONTINUE famotidine but pantoprazole will help with acid
in your stomach as well.
- Get labs drawn on ___ and have them faxed to your
Transplant Surgery team.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY FOR ADMISSION:
===============================
Mr. ___ is a ___ male with past medical history
significant for ESRD ___ diabetic nephropathy s/p failed LRRT in
___ and active DDRT in ___ with progressive kidney failure
secondary to hypertension, diabetic calciphylaxis requiring
lower extremity BKA, OSA, PVD s/p revascularization, HTN, CAD,
who presented with subacute worsening of chronic chest pain. | 161 | 58 |
18425118-DS-10 | 29,587,829 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing exploratory laparotomy and then drain placement
by Interventional Radiology for an infected pancreatic cyst
complicated by peritonitis. You have recovered from surgery and
are now ready to be discharged to home with ___ services for
drain care and INR checks, with a follow-up CT w/ IV contrast
and clinic visit in two weeks. Please follow the recommendations
below to ensure a speedy and uneventful recovery.
Please call Dr. ___ office at ___ if you have any
questions or concerns about your recovery process. You have a CT
with IV contrast scheduled for ___ to evaluate
the pancreatic abscess and fluid collections. You have a
___ clinic visit with him scheduled for ___. Both appointments are in the ___ building.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
- Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | On ___, the patient was admitted to the ___ Surgery
Service through the Emergency department for acute abdomen and
peritonitis due to an infected pancreatic head cyst. The patient
was afebrile and hemodynamically stable in the ED, but
diaphoretic and in clear discomfort with a rigid and guarded
abdomen. He had a supratherapeutic INR of 5.0 and was given IV
vitamin K and K-centra, which brought his INR down to 1.6 in
preparation for the operating room. He had rectus sheath
catheters placed by Acute Pain Service for pain control, as well
as an NGT, and was taken to the OR for exploratory laparotomy
with unroofing of the pancreatic cyst and placement of JP drain.
For full details of the procedure please see the operative
report. The patient tolerated the procedure well and was taken
to the PACU in stable condition. | 891 | 142 |
13389993-DS-4 | 26,602,964 | Dear Ms. ___,
You were admitted to the hospital with a community-acquired
pneumonia. We initially treated you with an oral antibiotic
regimen, but you failed to improve significantly, so you were
switched to IV antibiotics and started on an oral steroid
regimen. You were also sent for a CT scan of your chest to rule
out a blood clot in the lungs, which was negative. By ___ you
were starting to feel a bit better and we felt safe discharging
you home from the hospital.
Instructions for Prednisone taper:
- Take 4 pills (40mg) daily for 3 more days, from ___
- Take 3 pills (30mg) daily for 5 days, from ___
- Take 2 pills (20mg) daily for 5 days, from ___ - ___
- Take 1 pill (10mg) daily for 5 days, from ___ - ___
- After this, you can stop
- Take 5 more days of antibiotics (Levofloxacin 500mg)
- Use the Albuterol inhaler with spacer every ___ hours as
needed for shortness of breath. | Assessment: ___ yo female with hx well controlled Asthma admitted
with shortness of breath and fevers secondary to
community-acquired pneumonia. | 163 | 21 |
13931815-DS-26 | 26,847,293 | Dear Ms. ___,
You were admitted to the ___ stroke service for an acute
confusional episode concerning for stroke. Your CT and MRI were
negative for an acute stroke, therefore, none of your
medications were changed. Your symptoms prior to admission may
have been related to your chronic pain medications or recurrence
of symptoms related to your previous old strokes, however, there
was no identifiable trigger. As you may already be aware, an
ACUTE ISCHEMIC STROKE, is 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, your current risk factors
include:
High cholesterol
Hypertension
Tobacco use | Ms. ___ was admitted to the ___ stroke service on ___ after an acute confusional episode concerning for stroke
given her previous history of CVA and multiple other risk
factors. CT/CTA demonstrated no acute hemorrhage. Small
chronic infarction in the right occipital pole as well as small
focus of volume loss uncertain etiology in the left superior
parietal lobe. Moderate-sized hypodensity in the right
cerebellar hemisphere that was relatively well-defined and most
likely chronic. CT perfusion study demonstrated no
abnormalities. Three mm aneurysm of the left cavernous internal
carotid artery was noted, which has been present on previous
studies. There was no evidence for flow-limiting stenosis in
the cervical or major intracranial arteries.
MRI Brain the following day showed stable areas of
encephalomalacia in the cerebellum on the right and left
parietal lobe likely sequela of prior infarcts. There was no
evidence of new infarct or hemorrhage. Basic labs including
CBC, Chem, LFTs, Coags were unremarkable. Urine/Serum tox were
positive for Tylenol/Opiates as would be expected given her home
medications. HgA1c was 6.2 and LDL was 86. Echocardiogram was
performed with no evidence of cardiac embolus seen. A single
bubble crossed at rest within 4 beats of full opacification of
the right ventricle during saline injection. No other bubbles
were seen both during cough and Valsalva. This does not make the
cut off for a PFO requiring 3 bubbles within 4 beats of
opacification. There was mild regional LV systolic dysfunction
of the apical myocardium not following a coronary
distribution.Compared with the prior study (images reviewed) of
___ systolic function has slightly improved.
The etiology of Ms. ___ symptoms remains unclear but may
have been related to use of pain medications (opiates) vs.
recrudescence of previous stroke symptoms, however, there was no
identifiable trigger for this. No changes were made to her
medications. She was evaluated by ___ who recommended ongoing
outpatient ___. Ms. ___ was noted to have a fluctuating exam
with concerns for functional overlay. Her mental status
remained stable without further concerns for acute alterations
in mental status, therefore, she is planned to follow up with
her primary neurologist as previously scheduled. | 173 | 371 |
10766542-DS-9 | 21,202,882 | Mrs. ___,
___ were admitted to the Internal Medicine service at ___
___ on ___ 7 regarding management
of your left lower extremity deep venous thrombosis (DVT) and
pulmonary embolism. Your oxygen saturations improved once your
started anticoagulation. ___ received injectable enoxaparin and
on discharge were transitioned to oral rivaroxaban. This
medication needs to be continued at 15 mg by mouth twice daily
for ___, and then 20 mg by mouth daily thereafter. Take the
medication with food. ___ should talk with your primary care
doctor about testing for inherited clotting disorders and
testing for these conditions. Please wear ___ compression
stockings going forward to prevent further clotting.
___ should also have a right upper quadrant ultrasound to
evaluate the small lesions in your liver that were noted on your
chest imaging. These are likely benign hemangiomas or vascular
lesions. The number to schedule the imaging study is listed
below.
Please call your doctor or go to the emergency department if:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* ___ develop new or worsening cough, shortness of breath, or
wheezing.
* ___ are vomiting and cannot keep down fluids, or your
medications.
* If ___ are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit, or have a
bowel movement.
* ___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* ___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* ___ develop any other concerning symptoms. | ___ with PMH significant for anxiety disorder, history of
recurrent urinary tract infections (on chronic ___
antibiotics) and ___ nighttime asthma who presents
with left lower extremity pain and swelling with exertional
shortness of breath found to have likely provoked left lower
extremity DVT and evidence of bilateral pulmonary embolism.
# Pulmonary embolism- Her EKG with poor ___ progression and
exertional dyspnea made pulmonary embolism a serious concern.
CTA indeed demonstrated bilateral pulmonary emboli. No evidence
of right heart strain. She was initially given LMWH with 60 mg
SC Q12 hours and then per patient preference, we agreed to dose
her with rivaroxaban 15 mg PO BID for ___ and transition to
20 mg PO daily for the remainder of ___. BNP flat and
troponin negative which is prognostically favorable. Discharge
ambulatory oxygen saturations were normal.
# Deep venous thrombosis - Recent travel history with period of
immobilization noted, suggesting provoked event. No prior VTE
disease history. Family history mildly concerning given father's
DVT history. She was initially given LMWH with 60 mg SC Q12
hours and the after a discussion with the anticoagulation
pharmacist and the patient, we agreed to dose her with
rivaroxaban 15 mg PO BID for ___ and transition to 20 mg PO
daily for the remainder of ___.
# Liver hemangiomas - Incidental finding on CT chest imaging. No
symptoms. Will obtain outpatient RUQ US to confirm finding.
Study ordered and patient given contact number for radiology.
# Anxiety disorder - Stable. Continued SSRI treatment.
# History of recurrent UTIs - No current symptoms. U/A negative
in ED.
# ___ nighttime asthma - Stable symptoms.
Continued rescue albuterol inhaler. | 291 | 269 |
12843152-DS-33 | 24,529,379 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with cough and chest
discomfort and found to have a pneumonia. You were treated with
antibiotics that you will need to continue at home.
Medication changes:
Please take levofloxacin 750 mg daily for 4 more days
Please take Guaifenisin-codeine ___ every 6 hours as needed
for cough, do not operate machinery while using | ___ yo F with PMH sig for ulcerative colitis s/p TAC/ileostomy,
seizure disorder presenting with cough and pleuritic chest pain.
# Community acquired pneumonia- Patient presenting with symptoms
consistent with pneumonia. She endorses typical symptoms of
pneumonia including cough, pleuritic chest pain, and sputum
production. She does not have dyspnea or objective fever. The
presence of an infiltrate on plain chest radiograph is
considered the gold standard for diagnosing pneumonia when
clinical and microbiologic features are supportive. CXR did not
show a pneumonia however CT performed to rule out a pulmonary
embolism showed a multifocal bronchopneumonia in the right
middle/lower lobes and lingula. CURB65 score of 1 for low blood
pressure, which is close to her baseline. Patient does not have
an elevated WBC. A d-dimer was elevated at 515, CT negative for
pulmonary embolism. Acute coronary syndrome highly unlikely
given atypical pleuritic chest pain and other symptoms
consistent with pneumonia along with normal EKG. The patient
was treated with one day of levofloxacin and monitored
overnight. She was discharged with another 4 days of
levofloxacin 750mg. | 65 | 187 |
15317980-DS-24 | 28,643,550 | Ms. ___,
It was a pleasure taking care of you at the ___! You were
admitted on ___ for worsening glucose control and fatigue. You
had some skin lesions that may have been contributing to your
poor glucose control so you were started on antibiotics and
Surgery opened and drained one of your new abscesses. ___
diabetes recommended some changes to your insulin regimen to
help better control your sugars. You did have some low blood
sugars while you were here, and you insulin regimen was modified
by ___.
You also had decreased appetite and diarrhea after eating. A
gastric emptying study showed that this was not gastroparesis.
In fact, your stomach was emptying quickly. You were evaluated
by Gastroenterology who looked into your esophagus, stomach and
small bowel and took biopsy samples. The biopsy samples showed
inflammation in the first part of your small intestine, but the
rest of the intestine looked normal. You also had a MRI of your
intestines with barium contrast. All of the findings suggest
that the diarrhea is likely from the Celiac's disease and we
wondered if you may be exposed to trace gluten in one of your
medications. This is something to discuss with your pharmacist
after discharge.
You were started on anti-diarrheals and by the time of discharge
you were feeling more able to eat and only having diarrhea with
kayexelate. We encourage you to continue the loperamide to help
reduce diarrhea.
During your hospitalization, we also noted that your potassium
was often elevated. This can be concerning and can cause
problems with the conduction in your heart. We gave you
kayexelate when your potassium was high, and it did cause the
potassium to drop to normal temporarily, but it also gave you
diarrhea. We switched your dietary supplement from Glucerna to
Nepro, which has less potassium too. We recommend you have your
potassium and electrolytes rechecked within a day or two of
discharge. If your potassium continues to be high, you may need
to take kayexelate regularly.
Prior to your admission, you recently had retinal thromboses and
were started on Coumadin for anticoagulation. We noticed that
the effect of the Coumadin was too low. We increased your dose
of Coumadin, but have had some difficulty getting you
therapeutic. We restarted the Lovenox medication in the mean
time to prevent anymore clots. If the dose of coumadin is too
high, there is a risk of bleeding, but if it is too low, there
is the risk of clotting. It will be very important that you get
your blood test to check on the dose tomorrow. The clinic will
be expecting you.
During your stay here you did have some episodes of worse chest
pain. We checked your EKG and blood tests for a problem with
your heart and everything looked OK during this hospitalization.
However, since you have the history of heart problems, it is
very important to keep taking your medications.
It will be important for you to closely monitor your blood
sugars at home and follow up at ___ (as detailed below) in
order to establish a good longterm insulin regimen and discuss
getting an insulin pump again.
You are also scheduled to follow up with your gastroenterologist
at ___ to discuss management of your Celiac disease.
Again, it was our pleasure participating in your care.
We wish you the best,
- Your ___ Team - | PRIMARY REASON FOR ADMISSION:
Ms. ___ is a ___ yo woman with history of T1DM, CAD s/p PCI,
dCHF, Celiac disease and gastroparesis who was admitted with
fatigue, diarrhea, and poor PO intake for four days in the
setting of hyperglycemia to 500s with no evidence of DKA. | 559 | 48 |
11873714-DS-14 | 22,144,724 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for worsening shortness of
breath and chest discomfort. We gave you IV medication to
diurese you (make you pee off excess fluid). You had a right
heart catheterization that showed you have very high blood
pressure in your lungs. We suspect that this is because of your
sleep apnea, and is causing your symptoms. You will need a sleep
study as an out patient to further evaluate this. You will need
a repeat CT Scan in ___ weeks so it is important that you
follow up with the pulmonologist.
Please make the following changes to your medications:
.
1. STOP taking lasix. Instead, START torsemide 40 mg daily
2. DECREASE valsartan to 160 mg daily
3. START Imdur 60 mg by mouth daily
4. START Atorvastatin 20mg by mouth daily
5. STOP taking Metformin until told it is okay to do so by your
outpatient doctors ___ will monitor your kidney function and
re-start it when it stabilizes)
-Continue taking your other home medications as directed
It is critical that you follow-up with the appointments listed
below. | Patient is a ___ yo male with w/COPD, HTN, DMII who presents with
increased DOE, chest discomfort with exertion and found to have
signs of volume overload on CXR and pulmonary hypertension on
ECHO. Right heart cath revealled extremely elevated systolic
pulmonary pressure.
. | 186 | 45 |
19914314-DS-9 | 23,447,403 | Dear ___,
___ was a pleasure participating in your care while you were
inpatient at ___. You came back to us after you had another
episode of chest pain and suffered a second heart attack. You
had a stent placed to open up a blockage in the vessels of your
heart; this blockage was the cause of your heart attack. You did
very well afterwards and are being discharged to home with
visiting nursing services.
You will have a few new medications that must be taken every
day. These are shown below, but include aspirin and plavix.
Best Wishes,
Your ___ Team | ___ h/o of significant GIB ___ years ago at ___, HTN,
breast cancer s/p mastectomy and tamoxifen, recent BI admission
for V5-v6 STEMI (during which pt declined cath), who presented
with recurrent nausea and chest pain found to have ST elevations
of V5, V6, with ST depressions in III, AVR, V1, V2. She was
taken to the cath lab where she was found to have complete
occlusion of the first OM s/p bare metal stent.
#) ACUTE CORONARY SYNDROME: The patient presented with recurrent
chest pain and nausea found to have ST elevations in V5-V6 and
ST depressions in III, AVR, V1, and V2. The patient was amenable
to catheterization during this admission where she was found to
have complete occlusion of ___ s/p bare metal stent. All other
coronaries were clean. Following the procedure, the patient's
chest pain and EKG changes resolved. TTE on ___ showed LVEF
50-55% with hypokinesis of the basal-distal lateral wall
consistent with TTE on ___. She was started on Plavix 75mg
daily and continued on her home Aspirin 81mg and statin. Her
metoprolol was down-titrated to 12.5mg daily in the setting of
low blood pressures. Plan to follow-up as an ___ to
adjust her metoprolol dose and determine if an ___ needed
(not started given low BPs). Repeat TTE in ___
#) Severe aortic stenosis: TTE ___ showed severe aortic
stenosis with valve area 0.9, peak velocity 4.0 m/sec, peak
gradient 65 mm hg, mean gradient of 40mmHg and LVEF 50-55%.
After extensive conversation with the patient during her
previous and current admission, she declined further evaluation
for TAVR or SAVR.
#)History of GIB: The patient has a history of GIB in ___
Dieulafoy's lesion treated at ___. Required MICU stay and
intubation, however, no bleeding episodes since then. She was
continued on her home protonix and her CBC remained stable. The
patient experienced bleeding from her hemorrhoids for which we
recommended stool softeners, high fiber diet, and hemorrhoid
creams for symptomatic management with plans to follow-up with
her PCP as an ___.
#) Hypotension: The patient was mildly hypotensive with SBPs ___
on admission. Her home spironolactone was held and her
Metoprolol was decreased to 12.5mg daily. She was not started on
an ACE-inhibitor during this admission given her soft BPs. Plan
to follow-up with ___ cardiologist for further
medication adjustments as needed.
CHRONIC ISSUES:
================
#) Hypertension: Patient mainly hypotensive on admission.
Discontinued home Spironolactone and decreased metoprolol dose
as above. Continue to monitor as an ___.
#) Vertigo: Continued on home meclizine.
#) Arthritis: Managed w/Tylenol prn. | 100 | 424 |
10882916-DS-67 | 21,645,650 | Mrs. ___ was a pleasure taking care of you during your stay at ___.
You presented to the emergency room on ___ for abdominal
pain and generalized malaise. This is likely an acute
exacerbation of pain.
A CT Scan revealed no abnormalities. The MRE was not able to be
done as an inpatient. We will communicate with your outpatient
providers to have the imaging study done after you leave the
hospital.
Your pain was controlled with your home dose of Dilaudid and you
received medication for anxiety and PTSD.
Appointments have been provided for you for your GI doctor and
your primary care physician.
We wish you the best of luck,
Your team at ___ | ___ year old F with PMH of crohns, short bowel syndrome, hx of
superior vena cava collapse on anticoagulation who presents with
abominal pain in right upper quadrant pain for the last 2 weeks.
Patient presented to the ED where a CT scan was performed
revealing no acute intra-abdominal processes. She was then
transferred to the medical floor for further management and pain
control.
#Right Upper Quadrant Pain: A broad differential diagnosis was
entertained on admission including adhesions, intermittent
obstruction, hepatobiliary pathology, pancreatitis,
nephrolithiasis, pyelonephritis, crohns flare, viral gastro. CT
scan was performed revealing no acute intra-abdominal processes.
UA negative. LFTs without clear pathology. Per patient not
similar to previous crohns flare. No true dermatomal pattern of
pain or rash that would indicate Zoster. MRE was requested to
rule out intra-abdominal adhesions vs intermittent obstruction.
However, this was not performed, as it would not be able to be
performed until ___ and patient requested to go home
as pain had returnred to baseline.
___: Pre-renal due to decreased PO intake and emesis. Patients
baseline creatining ~.7, and 1.2 upon admission. Patient
received IVF and creatinine returned to baseline.
# Hypovolemic Hyponatremia. NA on admission was 127 and upon
receiving fluids, became 135.
# Crohns: Patient kept on a gluten free diet
# History of SVC Syndrome: Continued on home fondaparinux
# Depression: Patient relays an increase in depression symptoms
in the past few weeks, likely related to increasing GI symptoms.
Denied SI. Remained on home citalopram.
# PTSD, Anxiety: Particular attention was placed to avoid male
transporters, only males in the room and ensuring that the
entire team was rounding on the patient as a team.Valium was
utilized as needed for anxiety. | 113 | 280 |
15868868-DS-15 | 25,643,089 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hospital because you were experiencing shaking chills. You were
found to have fever, a low oxygen level in the blood, and a
chest x-ray showed evidence of a possible pneumonia. You
received support for breathing with a machine called BiPAP but
only required this for less than one day. You received IV
antibiotics and then you were transitioned to oral antibiotics.
You experienced a small amount of hemoptysis. A chest CT was
completed to evaluate your symptoms, which did not show a
specific cause for your symptoms.
It is important to complete the full course of antibiotics as
prescribed.
Again, it was a pleasure to take care of you at ___
-Your ___ team | Mr. ___ is an ___ year-old gentleman with a history of atrial
fibrillation (on Coumadin), diastolic heart failure and small
bowel AVMs who presented with chills, fever and hypoxia.
#Community acquired pneumonia: Patient was originally on BiPAP
for hypoxia in ED then transitioned to nasal cannula in less
than 24 hours which was felt to be most consistent with
aspiration pneumonitis. Given concern for possible underlying
pneumonia based on radiologic findings and high fever on
admission, as well as patient's advanced age and comorbidities,
he was treated for CAP (last admission >90d prior) initially
with ceftriaxone and azithromycin followed by transition to
amoxicillin-clavulanic acid/Azithromycin, which was well
tolerated, with course to end ___. Pt tolerated room air
well and had an ambulatory saturation of 93%.
# Hemoptysis/History of recurrent pneumonias: Per pt, has had
multiple recurrent pneumonias over last year and a few episodes
of very small volume hemoptysis (on ___, and about 2 weeks
prior). Given speech/swallow findings, likely mechanical
disfunction leading to aspiration with PNA-related hemoptysis as
etiology. However, differential would include malignancy with
post-obstructive pneumonia. A chest CT was completed, and did
not find any evidence of an endobronchial lesion to explain
either recurrent pneumonia or hemoptysis. Recommend ongoing
outpatient follow up.
#Diastolic heart failure: Pt received furosemide in ED given
concern for possible hypervolemia, and responded by voiding
1.5L. Patient subsequently had low BPs and was given back ___.
Most likely etiology for hypotension was overdiuresis. Home
furosemide was initially held but later restarted. At discharge
he appeared euvolemic with trace lower extremity edema.
# Dysphagia: Unclear etiology. Per speech/swallow may benefit
from outpatient neurology follow up. Patient does have some
resting tremor and question mild underlying dementia as well. He
was continued on dysphagia diet with nectar thick liquids in
house.
#Atrial fibrillation: At home, patient was rate controlled.
Initially with supratherapeutic INR, and coumadin was held; this
was restarted with INR therapeutic at discharge. Patient had HRs
in the ___ so home metoprolol was held. Consider restarting if
tolerated as outpatient. | 127 | 334 |
15935768-DS-13 | 29,824,916 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came with vomiting and blood in your vomit.
While you were here, we made sure your blood level remained
stable and that you did not continue to bleed. You underwent an
EGD that looked at your esophagus, stomach, and duodenum. We
found some gastritis and duodenitis, meaning that parts of your
stomach and intestine are very irritated and inflamed. This
may be due to h. pylori infection that you were diagnosed with
in ___, especially since you did not finish your entire 7 day
course of antibiotics. Part of your stomach was also biopsied
during your procedure, and you will need to follow up with a
doctor to get the results of this biopsy.
We understand you are not interested in alcohol rehab at this
time, but strongly recommend you keep considering this option
for the future, as alcohol abuse has severe consequences on your
health.
Please note that the following changes have been made to your
medications:
- Please take thiamine, folic acid, and multivitamin every day
- Please take omeprazole 20mg twice/day to protect your stomach
- Please take clarithromycin and amoxicillin, both twice/day,
for 7 days to treat your h. pylori infection | PRIMARY REASON FOR HOSPITALIZATION:
___ male with recent admission for hematemesis, alcohol
intoxication, and H. pylori presents after vomiting blood x2. | 210 | 23 |
10556108-DS-11 | 21,699,228 | Dear,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for gastrointestinal bleeding.
What was done for me while I was in the hospital?
- Your liver failure led to worsening kidney failure and your
kidneys stopped working.
- You, with your family, came to accept that ultimately you did
not have much time left to live.
- We transitioned our focus from extending your life, to
optimizing the time you have left
- We placed a catheter in your belly to help remove the excess
fluid
What should I do when I leave the hospital?
- Enjoy the time you have left with your loved ones
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ w/ PMH of alcoholic cirrhosis (Child
Class C) c/b recurrent ascites, hepatic encephalopathy and
varices, not a transplant candidate as he is actively drinking,
who presented in the setting of an acute GI bleed, shock, and
___ on CKD, intubated iso hematemesis and admitted to the MICU.
He became anuric without evidence of renal recovery and was not
started on dialysis given his ultimate prognosis and likely
inability to tolerate HD from a hemodynamic standpoint. After
some days of goals of care discussions, the decision was made
for ___ to be transferred home with hospice.
Transitional Issues
===================
**Patient is CMO**
[] Drain pleurX catheter regularly and ensure patient and family
understands how to use it.
[] Patient discharged on short course of oxycodone until IV
morphine is delivered
[] MOLST filled out DNR/DNI/Do no transfer to hospital
ACUTE ISSUES
===============
#Goals of care discussions
The patient and family have had multiple conversations regarding
his goals of care with his primary hepatologist. With ___
liver failure and subsequent renal failure without hope of
curative intervention, ___ prognosis is poor. Ultimately,
palliative care was consulted and after some days of thinking
and in-depth discussion with family, patient was transitioned to
___ focused care, though with continued lab draws and
midodrine. He is being transferred home with hospice.
# Hematemesis:
# c/f UGIB
# Esophagitis
# Acute on chronic normocytic anemia:
Hb 9 at baseline. On admission ___ s/p 1 episode of hematemesis.
EGD notable for grade D esophagitis, likely ___ tear
at GEJ, with large grade ___ varices. Mild Hb drop ___ requiring
1U PRBC without HD instability or active extravasation, possibly
___ mild oozing from severe esophagitis. Started sucralfate
x14d, ___, octreotide drip, IV PPI which was transitioned to
PO.
# Shock:
Initially hypotensive required pressors. Weaned off quickly.
Differential included distributive ___ sepsis but infectious
workup was unrevealing. Ceftazidime was continued empirically
for possible pulmonary or intra-andominal source. Home midodrine
was continued.
# Respiratory Failure:
The patient was intubated in the setting of airway protection
after an episode of hematemesis. There was no evidence of
hypoxemia that was contributing prior to intubation.
Successfully extubated ___.
# ___ on CKD
# Hepatorenal syndrome:
Baseline Cr ~2.2 elevated to 4.0 on admission. The patient has a
history of hepatorenal syndrome. He was recently managed with
diuretics in ___, though currently off diuretics given HRS. Has
had recurrent ascites, requiring multiple therapeutic
paracenteses. In the past, has had unsuccessful responses to
challenge or terlipressin, though has responded to octreotide
and midodrine. Other contributions include intravascular volume
depletion. Renal consulted and determined he was not ___ candidate
for RRT given his liver transplant candidacy. He received
albumin challenge, then continue midodrine/octreotide. He
remained anuric without any evidence of renal recovery.
# Decompensated alcohol cirrhosis (MELD 32, CHILDS C):
Patient with h/o alcohol cirrhosis complicated by refractory
ascites. He is not a transplant candidate as he is actively
drinking. Last EGD in ___ showed 3 cords of grade 2 varices.
Also complicated by HE and HRS, with multiple recent admissions
for renal failure. He had multiple paras and ultimately had a
pleurX placed for management of his ascites.
- HE prophylaxis: no evidence of HE, remained on lactulose PRN.
- Varices: Severe esophagitis and large grade ___ varices
- SBP: s/p diagnostic para ___ negative for SBP. On ceftazidime
given concern for sepsis for 7 day course to finish ___, then
switch to SBP ppx with ciprofloxacin
- Nutrition: tube feeds and regular/thin diet
# Hydrocele
# c/f cellulitis:
The patient has had baseline scrotal edema, with an acute
worsening. CT A/P on admission with large resultant hydrocele.
No subcutaneous gas identified. Per ACS, consulted in ED, low
c/f ___ so recommended d/c'ing clinda which he received
briefly on admission.
# Traumatic fall
# Left Sided Rib Fractures:
Patient stated he had a mechanical fall 3 days prior to
presentation. CT head neg for any acute intracranial process. CT
Abd/Pelvis reporting multiple rib fractures. Encouraged
incentive spirometer.
# Thrombocytopenia
# Coagulopathy:
Likely in the setting of his underlying liver dysfunction. Of
note, his platelet count acutely worsened from baseline,
possible reactive ___ acute infection resulting in marrow
suppression. Ongoing bleed likely exacerbated by his elevated
INR. Trended fibrinogen, CBC, platelets. Had oozing from his
neck after discontinuing the MAC line, improved with FFP.
# Portal Vein thrombus:
Documented on prior CT during last hospitalization.
# AGMA
# Lactic Acidosis:
Lactate elevated to 17 initially on admission, improved
substantially with blood resuscitation and pressure support.
# Hyponatremia:
Presented with Na 125-126. Likely hypervolemic hyponatremia in
the setting of liver cirrhosis. Clinically volume overloaded
with significant ascites. Na improved to 130s.
CHRONIC ISSUES
==============
# Alcohol use disorder:
Current ETOH use with longstanding etoh use disorder.
# GERD
- discharged on omeprazole 20mg daily | 132 | 773 |
13428695-DS-20 | 28,135,034 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You presented with chest pain and pressure. You
received an EKG and blood work that were negative for a heart
attack. Based on review of your symptoms, it seems unlikely that
your pain is related to your heart and we did not feel you
needed stress test or an echocardiogram to look at the heart.
When you came to the hospital, you had high blood pressures at
more than 170/80. You were given Carvedilol and Lisinopril. Your
blood pressures at the time of discharge were in better control
at 140/50. You were discharged with carvedilol 12.5 mg twice a
day and lisinopril 40 mg Daily.
Please make sure to continue taking your blood pressure
medications as they are written so that you do not experience
the consequences of high blood pressure, which can include
stroke, heart attack, and fluid in your lungs.
You were continued on your furosemide for heart failure and you
did not experience any difficulty with breathing. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
We have scheduled a primary care doctor visit and a visit with
your cardiologist. Please make sure to attend those clinics at
the times listed below.
IT was a pleasure taking care of you.
Your ___ Care Team | Mr. ___ is a ___ M with PMHx of CHF (EF 50%), HTN, and
smoking who presented with negative trp x2 and EKG unchanged
from prior, and had atypical chest pain.
# Chest pain
He described the pain as pressure-like, intense, constant, and
improved with mild exertion. Sometimes associated with headache.
Negative trp x2 in the ED with EKG changes similar to prior.
Given the story, this was thought unlikely to be ACS. CXR
negative for PNA. This was thought due to anxiety from social
stresses. Social work was consulted to provide resources for
financial and social worries. At discharge, he was on Aspirin 81
and Atorvastatin 40mg.
# HTN:
At admission, Mr. ___ had blood pressures in 170s-180s. He did
not have any signs of end organ damage. He noted that he had not
taken his lisinopril for >1 week. At discharge, his systolic
blood pressures were 130s-140s/60s-70s. He was discharged on
Carvedilol 6.25mg BID and Lisinopril 40mg twice a day.
# Heart Failure with reduced ejection fraction:
Previously, Mr. ___ had an ejection fraction of 20%, which had
improved to EF of 50% on an ECHO in ___. He appeared
euvolemic on exam. At discharge, continued Lasix 40mg twice a
day, and Lisinopril 40mg daily.
# Substance Use Disorder:
Mr. ___ noted that he drinks ___ pint/day and smokes ___ ppd.
He occasionally uses heroin, but no cocaine. Social work was
consulted, who provided resources. He did not have any
signs/symptoms of withdrawal during the admission, and at
discharge, appeared to be at his baseline. | 222 | 253 |
12647636-DS-9 | 26,591,786 | Dear Ms. ___,
You were admitted to the gynecologic oncology service after
presenting with a small bowel obstruction likely due to a lupus
flair. You have recovered well after your operation, and the
team feels that you are safe to be discharged home. Please
follow these instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat a regular diet.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing | Ms. ___ was admitted to the gynecology oncology service
after presenting with abdominal pain. CT abdomen/pelvis revealed
a likely partial small bowel obstruction. There was an
ill-definied soft tissue density in the pelvis that was
nonspecific. Pelvic ultrasound revealed normal ovaries.
Her small bowel obstruction was managed conservatively. She was
made NPO with IV fluids. A nasogastric tube was placed to low
intermittent suction. Interval assessment with MRI revealed
improvement in small bowel obstruction with nasogastric tube
decompression.
Tumor markers were reassuring.
Colorectal Surgery, GI, and Rheumatology were consulted.
On ___, she underwent MR enterography revealing no evidence
of bowel obstruction. The bowel was normal with decreased
ascites. Debris in the cul-de-sac was thought to be possibly
likely to a ruptured ovarian cyst.
Her NG tube was then clamped with minimal residuals. Therefore,
her NG tube was removed.
On ___, her diet was advanced and she tolerated a regular
diet.
On hospital day #4, ___, she was tolerating a regular diet
without nausea or vomiting. She was ambulating, voiding and
denied pain. She was then discharged in stable condition without
outpatient follow-up scheduled. | 155 | 177 |
11389640-DS-16 | 28,038,867 | It was a pleasure to participate in your care. You were admitted
with nausea and vomiting. You were evaluated by the
gastrointestinology service and underwent an upper endoscopy
(EGD). You were found to have inflammation in your esophagitis.
You were started on a medication to reduce stomach acid
(omeprazole). You should avoid spicy foods, acidic foods,
alcohol, NSAIDS (ibuprofen, naproxen). You should also avoid
smoking as this will make your stomach and esophageal upset
worse.
You also had a headache. A CT scan of your head was normal.
Please continue your home medications with the following
changes:
1. START taking omeprazole
2. STOP taking Ibuprofen, naproxen
3. START taking maalox/lidocaine/diphenhydramine as needed
4. STOP taking steroids
5. START taking zofran (ondansetron) as needed for nausea | ___ y/o female with depression/dysthymia, lumbar radiculopathy,
morbid obesity, and endometriosis who was admitted on ___
with nausea and vomiting and a syncopal episode.
.
#NAUSEA/VOMITING: Patient presented w/ nausea, vomiting and mild
epigastric pain in the setting of increased NSAID use and
steroid use for new headache. Patient reported some coffee
ground/blood-streaked emesis prior to arrival and had one
episode of coffee-ground emesis here. CT Abdomen was negative
for acute pathology. Patient underwent EGD which showed no
active bleeding, only gastritis/esophagitis. Her Hct and vital
signs remained stable. H.pylori was negative. She was started on
a PPI and symptoms were managed with anti-emetics and IVF. Her
solumedrol dose pack was discontinued and she was told to avoid
NSAIDs as these medications likely contributed to her
presentation. By discharge, she was tolerating a regular diet.
She will continue on a PPI, zofran, and magic mouthwash. She
will follow-up with GI as an outpatient for repeat EGD as her
stomach was incompletely visualized.
.
#SYNCOPAL EVENT: Patient had one reported episode in the
bathroom of the emergency department felt to be vasovagal in
setting of nausea/vomiting. She was monitored on telemetry and
had no further events.
.
#HEADACHE: Patient initially presented with global headache
without neck stiffness, fevers, or chills. Headache had been
ongoing since steroid injection a few weeks prior. She had been
started on NSAIDs and steroids for the headache but this was
discontinued during this admission given her
gastritis/esophagitis. CT Head was negative for acute process.
Headache gradually resolved so felt to be likely related to
dehydration in setting of nausea and vomiting. She was continued
on tylenol for pain.
.
CHRONIC ISSUES
#. Depression/Dysthymia/Anxiety: Continued trazodone,
clonazepam, sertraline, risperidone
.
#. Asthma: Currently well-controlled. Continued fluticasone,
albuterol
.
TRANSITIONAL ISSUES
-Follow-up with GI this week to arrange for repeat EGD under MAC
to evaluate extent of esophagitis/gastritis | 125 | 307 |
18845096-DS-9 | 27,223,840 | You came to the hospital for evaluation of right leg pain and
urinary retention. A foley catheter was inserted to drain your
urine. This also helped your leg pain. A CT scan was done to
evaluate the cause of your right leg pain. This CT scan showed a
pseudo-aneurysm in the left groin. You had a thrombin injection
procedure to correct the pseudo-aneurysm today. The procedure
was successful and uncomplicated. Your right leg pain is
probably related to nerve irritation from your TAVR procedure.
This should improve with time. Your hemoglobin blood level
improved during your stay.
You had a low grade fever and a cough, and a chest x-ray shows
pneumonia. You will need to take antibiotics for this pneumonia.
You are already taking antibiotics for prostatitis
(ciprofloxacin). You should stop taking ciprofloxacin, and
instead take levofloxacin for 2 weeks. Levofloxacin will treat
both prostatitis and pneumonia. You received your first dose of
Levofloxacin in the hospital this evening. Continue taking it
each evening for an additional 13 days.
You will be discharged with the foley catheter in place. We
discussed this plan with Dr. ___ who is covering for your
usual urologist. You should make an appointment with your
urologist office to be seen in about 1 week. They will decide
when to remove the foley catheter.
Please call ___ HeartLine at ___ if you have any
follow-up questions or concerns. A nurse practitioner or
cardiologist ___ return your call the same day. However, if you
have a medical emergency you should call ___.
While you are staying in ___ with your son, you need access
to your medicines. ___ on ___ in ___ is filling
your Levofloxacin prescription and re-filling your Eliquis and
Flomax prescriptions. They are also going to provide you with a
short supply of amlodipine and hydrochlorothiazide. Please pick
these up today and take all of your usual medicines as
prescribed. | Mr. ___ was initially transferred to the emergency department
on ___. His presenting complaints included right lower
extremity pain and urinary retention causing him to strain to
urinate.
#RIGHT lower extremity pain:
The RLE was imaged via ultrasound and there was no evidence of
DVT, and only a slight irregularity of the anterior wall of the
right common femoral artery but no obvious pseudo aneurysm was
seen. After a foley catheter was placed and his bladder was
emptied, his RLE pain improved and had virtually resolved
completely by the next day.
#LEFT groin pseudo aneurysm:
Although his presenting complaint was RIGHT leg pain, he had a
CT showing a 1.4 by 1.9 cm pseudo aneurysm in the LEFT groin. He
underwent successful embolization procedure/injection of the
left common femoral artery pseudo aneurysm in interventional
radiology the next day without complications.
#Urinary Retention:
He was started on Cipro 250mg BID by his urologist prior to
coming in for presumed prostatitis given his significant history
of this issue. His outpatient urologist was contacted prior to
discharge and the foley catheter was left in place upon d/c home
with the plan for the patient to follow up with urology next
week for trial of removal of catheter. The patient has had foley
catheters at home in the past and is comfortable with managing
it at home.
#Pneumonia:
On physical exam in the AM of ___, the patient was noted to
have abnormal lung sounds. Given the low-grade temp of 100.4
earlier that morning, he was sent for a chest x-ray which
demonstrated a possible right sided pneumonia as noted in the
report. After discussion with urology, his Cipro was changed to
Levofloxacin in order to cover both pneumonia and prostatitis.
His dose was adjusted based on his creatinine clearance and he
was put on a renal dose of 250mg daily for a 2-week course.
The results and plan of care were discussed extensively with the
patient and family (wife and son) by Dr. ___ they
verbalized understanding and agreement with the plan.
The patient plans to stay with his son in ___ for a few days
before returning home to ___, ___. He did not have his
medications with him, and therefore some refills were sent to
the local ___ in order for him to have access to his
medications. These included Eliquis, Amlodipine,
Hydrochlorothiazide, and Tamsulosin.
Home ___ services were arranged for him as well. | 315 | 405 |
10643286-DS-17 | 24,693,844 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You came into the hospital because you face and lips were
swollen and you had trouble breathing and speaking.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
- Because you had trouble breathing and speaking, we performed a
procedure to open up your airway to help you breath. We then
inserted a tube into your neck (tracheostomy), that made sure
your airway remained open. We gave you medications to treat your
allergic reaction. You improved and we were able to take the
tube out. You are now breathing normally on your own.
- You had a tube placed down your nose into your stomach to help
feed you when you were unable to eat. Your diet was slowly
advanced and you slowly ate more food. You are now eating normal
meals.
WHAT SHOULD I DO WHEN I GO HOME?
=================================
- Please continue to take all of your medications as directed.
- Please follow up with all the appointments scheduled with your
doctor.
- Please go to the Emergency Room immediately if you experience:
* face/neck swelling
* difficulty breathing or speaking
* worsening pain or difficulty with swallowing
* chest pain/palpitations
* bleeding or drainage from your stoma site
* any other new or concerning symptoms
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team | TRANSITIONAL ISSUES:
====================
[ ] OUTPATIENT FOLLOWUP: The patient has appointments with a
newly established PCP, ___, and Allergy clinic. Consider
sending RAST allergy testing though this may be difficult if
patient does not have insurance.
[ ] Please have patient follow up with patient financial
services and social work for ongoing help obtaining resources.
[ ] The patient's new PCP is ___, who is a resident
and works under Dr. ___. For billing purposes,
insurance needs to name ___ as the Primary Care
Physician. Please do this before the PCP appointment or this can
incur out of pocket costs.
[ ] The patient may also benefit from an outpatient sleep study
(CO2 retention during sleep) though this is not an urgent issue.
[ ] The patient should have LFTs repeated at PCP follow up as
she had transaminitis that resolved during admission. | 247 | 140 |
11250729-DS-16 | 28,370,665 | Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
___ medicines such as Motrin, Aspirin, Advil, or
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 ___.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain. You should take your pain medicine as 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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Clavicular fracture - you may use a sling for comfort. Call
your doctor or return to the emergency department if you have
any numbness, tingling, or weakness in your affected hand.
Have your staples removed in the acute care ___ clinic in 7
days at your appointment. | Patient was admitted to the ICU on ___ and discharged on
___, the day he was transfered to the floor.
Neuro: On admission to the TSICU, the patient was
intermittently moving bilateral upper extremities and the left
lower extremity and was poorly responsive. Initial head ct
showed a sub-arachnoid hemorrhage as well as a L temporoparietal
skull fracture with pneumocephalus and associated sub-dural
hemotoma. He was dilantin loaded and put on a 7 day course.
Repeat head CT on HD 2 showed evolution of the sub arachnoid but
no midline shift. At this point, he was moving all four
extremities and intermittently following commands but was still
not fully alert. On the floor, he was evaluated by ___ and
cleared to be discharged with outpatient OT. HIs mental status
was normal and was able to ambulate without assistance. He will
follow up with NS in ___ weeks for repeat head CT. The scalp
laceration was repaired with staples which will be removed in
ACS clnic.
CV: Initially hypotensive poorly responsive to fluids, was on
neosynepherine for several hours but SBP came back into
acceptable ranges shortly. Hemodynamically stable as of HD 2.
R: L chest tube placed for pneuothorax which was self dc'd on
HD 1. Post-pull film showed no reaccumulation of pneumothorax.
Satting well on room air.
Abd/GI: Made NPO initially due to intubation, kept NPO on HD 2
due to poor mental status. Received h2 prophylaxis while NPO.
On the floor he tolerated a regular diet without abdominal pain,
nuasea, or vomiting.
MSK: The patient suffered left sided rib fractures and left
clavicle fracture. THese fractures were non-operative and given
a sling for comfort.
GU: A foley was placed in the trauma bay and urine output was
monitored. He was able to urinate without difficulty after the
foley was removed. Electrolytes were repleted as appropriate.
Endo: The patients blood sugars were monitored while in the ICU
and were appropriate.
ID: The patient's temperature was monitored during his stay in
the ICU. He was afebrile. | 438 | 357 |
17331657-DS-6 | 26,922,726 | Dear Ms. ___,
You were admitted to ___ because you were having chest pain.
You had a cardiac catheterization which showed a narrow coronary
artery, and you had a stent placed. Since you are still having
occasional chest pain, we recommend that you be evaluated by the
thoracic surgery service for a possible procedure that may stop
your vasospasm. Please see below for your appointment time.
We made the following changes to your medications:
-STOP doxazosin
-INCREASE isosorbide mononitrate to twice daily: 60mg in the
morning and 120mg at night
-INCREASE nifedipine to 90mg at bedtime
-START aspirin 325mg daily
-START prasugrel 10mg daily
You should also have a repeat echocardiogram in ___ weeks as an
outpatient. Please call ___ to schedule this exam.
Please update Dr. ___ the frequency of your chest pain
either by phone or email. Follow up with him in clinic as
previously scheduled.
Books to consider:
___ "The Relaxation Response" (cheap on ___
A video from his center:
___
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery. | Primary Reason for Hospitalization:
___ with coronary vasospasm with history of vfib arrest ___
s/p ICD placement, acquired long QT syndrome, paroxysmal afib
presenting with chest pain | 188 | 27 |
17500922-DS-12 | 27,305,131 | Dear Mr. ___,
You were found to have a displaced sternal (breast bone)
fracture after a car crash and you were admitted to the hospital
for pain control and to monitor your breathing. Your pain is
managed with pain medication and your breathing has remained
stable. You were evaluated by physical therapy and...
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
* Your injury caused a sternal 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 sternal fractures. In order to
decrease your risk you must use your incentive spirometer 10
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 sternum 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 sternum or ribs (crepitus). | Mr. ___ is an ___ male with a history of bladder
cancer who presented to the hospital after a MVC. Upon
admission, the patient was made NPO, given intravenous fluids
and underwent imaging. Imaging was significant for a displaced
manubrial fracture. The patient was noted to have chronic T4
vertebral body consistent with a compression fracture.
Neurosurgery was consulted and evaluated the patient and no
surgical intervention was indicated. The patient was admitted
to the Acute Care Surgery/Trauma service for pain control and
for pulmonary toilet.
The patient's pain was managed with acetaminophen and tramadol.
The patient was weaned off O2 and was stable on room air. He
remained stable from a pulmonary standpoint and was instructed
in the use of the incentive spirometer. His vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
In preparation for discharge, the patient was evaluated by
physical and occupational therapy. Recommendations were made for
discharge to a rehabilitation facility to further regain
strength and mobility.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with the use of a walker and assistance of one,
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. A follow-up appointment was made with his primary care
provider. | 315 | 251 |
18715623-DS-11 | 27,071,806 | Dear Mr. ___,
You were diagnosed with an ACUTE HEMORRHAGIC STROKE, a condition
from bleeding into 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 or
bleeding 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:
[] arterial hypertension
[] anticoagulation use
We are changing your medications as follows: Your beta blocker
dose was reduced to half (25 mg) for blood pressure control. We
are also holding your anticoagulant, warfarin. Please take your
other medications as prescribed. Please follow up with Neurology
as listed below. Please follow up with your regular doctor
within 14 days of 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 ___ yr M w/ hx of prior stroke attributed to
basilar artery clot on Warfarin, Afib, HLD, COPD, and SCLC s/p
chemo/XRT and prophylactic Brain XRT who presented from OSH with
L subcortical IPH. Etiology of the ICH indicated hypertensive
etiology vs less likely brain met in setting of prior SCLC given
bleed not located at G-W differentiation and SCLC lesions not
known to be particularly hemorrhagic vs spontaneous complication
___ to elevated INR from anticoagulant therapy (warfarin for
afib).
#Left Basal Ganglia Intraparenchymal Hemorrhage
Patient presented from OSH with L basal ganglia IPH. Admission
exam with significant dysarthria and subtle R facial
droop/pronator drift, but no other concerning findings. L basal
ganglia IPH was confirmed on review of NCHCT from OSH. Likely
hypertensive etiology versus less likely met vs complication
from anticoagulation. MRI brain w/wo contrast confirmed acute
intraparenchymal hemorrhage centered within the left lenticular
nucleus, most likely hypertensive related hemorrhage. Blood
pressure control was obtained by using IV labetalol and
hydralazine PRN with goal of SBP<150. ASA, NSAIDs and all
antiplatelet agents were held. Patient was also evaluated by S&S
and at time of discharge was on a puree and nectar prethickened
diet. He should resume anticoagulation with warfarin on ___.
#Afib
Patient was continued on half dose of home beta blocker (25 mg
Lopressor).
Home atorvastatin was continued, while warfarin was held i/s/o
IPH.
Transitional Issues
====================
- Please, maintain goal SBP<150 for patient.
- Patient's dose of Lopressor was reduced to half (25 mg) during
this admission, please, consider increasing to full dose as
needed.
- Please, resume anticoagulation with warfarin from ___.
- Follow up MRI brain w/wo contrast in 3 months to evaluate IPH
- Neurology follow up appointment in 3 months
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No | 265 | 380 |
14813528-DS-18 | 23,171,242 | Dear Ms. ___,
It was a pleasure to take care of you here at ___. You were
were admitted for left leg fracture and found to have a cancer
in your bone called B cell lymphoma. You will have an
appointment with oncology to further discuss management options.
You were also found to have a clot in your left leg which could
be due to the cancer or decreased movement in your leg in the
months leading up to your fracture because of the pain.
Nevertheless, we started you on a blood thinner called lovenox
to help treat this clot. You should continue this medication
until your doctor tells you otherwise. During your stay, the
orthopedic surgery repaired your femur/left leg by placing a
nail across it. Physical therapy worked with you throughout your
hospital stay in order to help you regain your strength. We also
noted that you had a rash on your belly which may have been due
to antibiotics you received during your hospitalization. The
antibiotic called ancef will be added as a possible allergy to
your medical records. We wish you all the best.
Sincerely,
Your ___ team | ___ F w osteoporosis, ___ transferred from ___
with initial c/o of ___ days of LLE pain, found to have closed
left distal pathological femur fracture with bone biopsy
consistent with B cell lymphoma and found to have left peroneal
vein DVT.
# Pathological closed left distal femur fracture: Patient was
found to have subacute left distal femur fracture (possibly 10
days prior to presentation) and then underwent L distal femur
ORIF on ___ with open bone biopsy and retrograde nail
placement. See below for orthopedics course. Patient is to
follow up at the orthopedics clinic in 2 weeks for further
evaluation and imaging. Pathology was consistent with atypical B
cell dominate lymphoid infiltrate with a MIB fraction of 45-50%.
Patient was followed by hematology-oncology service while in the
hospital and decision was made that chemotherapy/xrt could be
safely delivered in the community. Patient will be staying with
family in ___ after rehab and will be connected with
oncologist in the area at that time. If at any time,
chemotherapy is not felt to be tolerated, it would be stopped
and xrt alone would be pursued. Malignancy would be restaged
after 2 cycles. Baseline TTE was obtained in anticipation of
chemotherapy. Radiology oncology is to evaluate patient
outpatient for further determination of treatment. Of note, CT
chest had no evidence of primary intrathoracic tumor. CT
abdomen/pelvis was unrevealing for other LAD though there was
evidence of uterine leiomyomas. SPEP/UPEP were not consistent
with multiple myeloma.
# LLE infrapopliteal DVT: Unclear if provoked in the setting of
decreased mobility secondary to pain or due to malignancy, more
likely the latter. Treatment dose was not initially started
because DVT was below knee. Immediately after patient underwent
ORIF of distal femur, she was started on therapeutic lovenox
dose. This should be continued unless specified otherwise by
primary hematologist-oncologist.
# Abdominal rash: Of note, patient was also noted to have
erythematous pruritic rash on abdomen 4 days after operation -
thought to be reaction to ancef given perioperatively. Ancef was
added to allergy list with "uncertainty." There is also a
possibility that rash is a manifestation of malignancy. She was
started on hydrocortisone cream and loratidine. Rash should
continue to be monitored and evaluated daily on discharge.
Hydrocortisone cream should be continued only until ___, and
loratidine should not be continued indefinitely either. Consider
symptomatic treatment.
# Uterine leiomyomas: patient asymptomatic with no spotting or
abdominal pain. Further evaluation was deferred pending
treatment of malignancy.
# Hypertension: Lisinopril and amlodopine were restarted at
lowest doses and should be titrated up as needed. It is unclear
what doses patient was on since she was not compliant with these
medications at home.
# Osteoporosis: Held on restarting alendronate in the setting of
acute illness
TRANSITIONAL ISSUES
# Continue therapeutic lovenox for left peroneal DVT until
specified otherwise by hematologist-oncologist
# Patient is to f/u with Orthopedics clinic in 2 weeks for
post-op evaluation with repeat XRAY (Xray imaging is walk-in and
patient does not need to schedule appt - she should have this
imaging done prior to her appt in the afternoon). At her appt,
she can have suture removed.
# Patient is to be connected with outpatient
hematologist-oncologist after rehab for further management of
cancer with chemo/xrt
# Patient noted to have possible drug reaction with erythematous
rash on abdomen secondary to ancef given intra-operatively
(ancef has been added to allergy list as possibly allergy) - she
was treated with hydrocortisone cream and loratidine with good
effect. Both of these medications should be discontinued once
abdominal rash has resolved or within the next week. Last dose
of hydortisone cream is evening of ___.
# Alendronate was held during hospitalization and discharge in
anticipation of chemo/xrt in the near future
# Statin, lisinopril, and hctz were restarted at lowest doses.
Consider uptitrating as tolerated.
# The patient would benefit from follow-up after Cycle 2 ___ and Dr. ___, who specializes in
lymphoma and has managed several similar cases (___).
# Monitor multiple intramural uterine leiomyomas, the largest
measuring 5.6 x 4.7 x 4.5 cm seen on MR pelvis
# Patient was retaining urine on evening prior to discharge. She
was started on tamsulosin. Foley should remain for an additional
3 days (foley placed on ___- and patient should have an
attempted voiding trial after 5 days. At that time, removal of
foley can be considered if patient passes voiding trial.
================================================================
ORTHOPEDIC COURSE
The patient is an ___ female who was transferred to the
___ emergency department on ___ and was evaluated by the
orthopedic surgery team. The patient was found to have a left
distal femur pathologic fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left femur retrograde nail, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from
the OR to the PACU in stable condition and after recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed
to a regular diet and oral medications by POD#1. The patient was
given perioperative antibiotics and anticoagulation per routine.
The patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to a rehab facility was appropriate. The hematology/
oncology service was consulted on POD#1 for work up and
management of her unknown primary malignancy. On POD#3, the
patient was transferred to the medical service for continued
oncologic work up and treatment.
At the present time, the patient in stable from an orthopaedic
stand point. The patient's pain is well controlled with oral
medications and incisions are clean/dry/intact. A thorough
discussion was had with the patient and her son ___ regarding
the diagnosis and expected post-discharge course, and all
questions were answered.
1. The patient is PWB in the left lower extremity, with range of
motion as tolerated.
2. The patient should remain on chemical DVT prophylaxis for two
weeks post-operatively. We recommend Lovenox 40mg SC QPM
3. Pain control
4. Mobilize with physical therapy
5. The patient should follow up in 2 weeks with ___ or
___. Call ___ to schedule an appointment.
6. If the patient is still in house on POD#14 (___) we will
obtain repeat imaging of her left femur and remove staples/
sutures.
7. Please page ___ with any questions or concerns. | 189 | 1,025 |
18426170-DS-10 | 22,229,213 | Dear Mr. ___,
You came in with hand pain, and were concerned you had an
infection. You were started on antibiotics, however on your
second day in the hospital you decided to leave, against medical
advice. We recommended out of concern for infection that you
stay to evaluate your need for antibiotics, and we explained
this to you, however you still decided you would rather leave.
It is important to follow up with your primary care doctor, to
evaluate your hand for potential infection, as progression of an
infection can lead to worse illness and ultimately death. | ___ yo M with PMHx of substance abuse (including recent heroin
and EtOH use) presents with right hand pain initially c/f
recurrent cellulitis s/p 10 days of cephalexin (should have
completed course on ___.
# Hand pain:
Patient initially presented with hand pain reportedly in the
same area/distribution as prior cellulitis (in dorsal hand
involving ___ and ___ digits and web space), with trace edema on
exam of the affected hand, no increased warmth, some ttp, no
erythema. Hand radiographs with some edema c/w his hx of
cellulitis. Patient reports never injecting into his hands
before. Given 1 dose of IV vancomycin in the ED, held off on
additional antibiotics given patient without obvious signs of
cellulitis, and afebrile, without leukocytosis, continued
monitoring in case of early infection. Patient left AMA on day
after admission, continued afebrile. Blood cultures pending at
time of patient leaving AMA.
# Cough:
Patient complaining of a cough on admission, that has been
worsening recently. Notes it is productive of thick yellow-green
sputum that is new and worsening, however visualized sputum and
looked clear. CXR without evidence of acute process, patient
afebrile without leukocytosis per above, deferred starting any
antibiotics. Patient left AMA on day after admission, continued
afebrile. | 95 | 202 |
18981355-DS-18 | 22,666,889 | Dear Ms. ___,
You were admitted to ___ for
evaluation after your fell. You were followed by the trauma team
and were evaluated by the cardiology team who recommended
decreasing your torsemide to 60mg daily and 7mg warfarin daily
until you follow up with primary care on ___. You are
otherwise recovering well and are now ready for discharge.
Please follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Patient is a ___ year old female with past medical history
significant for CAD, HFrEF (last EF 35%), hx of mechanical MVR
on LVX/warfarin that presented s/p fall with complaints of RUE
hematoma, L hemothympanum, and chronic melena. The patient was
hemodynamically stable and was admitted for observation given
multi-system trauma while on anticoagulation. Imaging was
completed and no acute fractures or acute injury were noted.
Serial hematocrits were monitored to assess for bleeding and
once stable, she was started on a regular diet which she
tolerated well. Elevation of RUE on a pillow was encouraged
however patient refused to comply and continued to report severe
pain. Therefore PO tramadol was added to home regimen of norco
(10mg TID) which was initiated on admission.
On HD2, ENT was consulted for evaluation of L hemotympanum and
suggested outpatient audiogram in ___esired.
Medicine and Cardiology were also consulted for management of
anticoagulation. At baseline, patient has INR goal of 2.5-3.5
given hx of mechanical MVR, therefore it was suggested she
receive 7mg Coumadin for INR 2.4 from ___ and outpatient
follow up scheduled with primary care on ___. However on ___
patient refused discharge stating she preferred to wait until
the am of ___ to go home when her husband would be available to
care for her.
On morning of ___ patient received additional warfarin dose of
7mg, therefore management of anticoagulation schedule was
re-discussed with cardiology team. The cardiology team suggested
patient receive 1 time dose of lovenox 60mg sc prior to
discharge on ___ and hold Coumadin dose until PCP follow up
appointment which was scheduled for ___. On ___, patient also
experienced fever of 101.3 which improved to 98.8 after 650mg
Tylenol. urinalysis, urine culture, and chest xray obtained to
ensure no infectious process prior to discharge home. Urinalysis
was positive, therefore she was started on course of macrobid
and prescription given.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and actively
participated in the plan of care. 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 and follow up with primary
care scheduled on ___ for INR follow up. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 297 | 404 |
16461238-DS-6 | 22,155,944 | Dear Ms. ___,
You were hospitalized due to symptoms of acute onset left sided
weakness resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
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:
- prior stroke
We are changing your medications as follows:
- plavix 75mg po daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ woman with prior CVA in ___ and
traumatic SAH who was admitted ___ with acute onset left
sided weakness. On exam, she had trace LUE/LLE weakness in UMN
pattern and a minor L facial droop. NCHCT showed R subcortical
hypodensity in area of prior infarct. MRI head showed acute
ischemic infarct in R thalamus. ___ recommends acute
rehab.
She was transitioned from Aspirin to Clopidogrel 75mg.
Of note, also had UTI on admission, started on ceftriaxone. WBC
continued to rise, transitioned to cefepime. Urine culture
showed sensitivity to ceftriaxone and cefepime, transitioned to
po cefopodoxime. | 271 | 101 |
18305480-DS-19 | 28,119,297 | You were admitted to the hospital after surgery to address a
blockage in your carotid artery.
You have begun coumadin (a blood thinner), and need a lab test
done every ___ days to adjust your dose as necessary. We also
started you on lovenox injections which you should continue
twice daily until your coumadin is in range. Dr. ___ is
responsibile for further directions on the coumadin and lovenox
dosing.
Division of Vascular and Endovascular Surgery
Carotid Stent Discharge Instructions
Medications:
Take Aspirin 325mg (enteric coated), Plavix (Clopidogrel) 75mg
and Coumadin (as directed by your PCP) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
You should not have an MRI scan within the first 4 weeks after
carotid stenting
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions. | The patient was admitted to the hospital on ___ after 2
episodes of amaurosis fugax in the setting of known right
carotid artery stenosis. He was brought to the operating room
on ___ and underwent a right carotid artery cutdown and
stenting. The procedure was without complications. He was
closely monitored in the PACU and then transferred to the floor
in stable condition. On POD 1, he developed R eye diplopia,
for which he was evaluated by the neurology service. A CTA
showed a large thrombus within the petrous segment of the right
internal carotid and narrow flow channel in the ICA stent with
possible thrombus. The right anterior circulation is likely
receiving blood from collateralflow from the left anterior
circulation. He was started on heparin and transitioned to
coumadin. He did develop a small right neck hematoma which was
managed conservatively. The diplopia has since resolved and he
is neurologically intact. Other issues that required attention
while in the hospital included:
1.Aspiration
Significant signs of aspiration became evidence as po intake was
increased on POD #3. Speech and swallow was consulted.
Aspiration and pharyngeal residue was noted with all
consistencies trialed during evaluation. He was made NPO. A
video swallow performed ___ showed moderate oral and
pharyngeal dysphagia. His dysphagia is likely acute on chronic
with components associated both with his post-esophageal ca
dysphagia (documented in ___ as well as swelling from his
right carotid endarterectomy. Repeat study on ___ showed
improvement but there was continued mild aspiration. He was
discharge to home on nectar thick liquids and moist, ground
solids. We have done diet teaching and set him up for home
suction for oral care. He is scheduled for an outpatient repeat
video swallow study on ___.
2.Vocal Cord Paralysis
Worsening hoarseness was noted on POD #4 and ENT was consulted.
Exam showed evidence of moderate supraglottic and laryngeal
edema, likely associated with the hematoma, as well as right
true vocal cord paralysis. He was started on decadron 10mg
three times daily with taper which was completed by ___. His
voice has improved and is nearly back to baseline. Follow up
with ENT has been arranged.
3.Pneumonia
Chest Xray on POD 3 showed evidence of infiltrate in left lower
lobe and right base with fever to 101.6 felt to be secondary to
aspiration. He was started on vanco and cefepime and received
an 8 day course. He is now afebrile with a normal white blood
cell count and breath sounds.
4. Carotid Thrombus
The plan is for anticoagulation with coumadin with goal INR ___.
As his INR was subtheraputic today, he will be discharged on a
lovenox bridge until INR is checked on ___. Anticoagulation
is being followed by his PCP, ___. Follow-up has been
arranged with Dr. ___ in one month with surveillance
carotid duplex.
He was discharged to home on POD # 11 in stable condition with
home services. | 328 | 499 |
14045846-DS-18 | 23,931,034 | ___ were admitted to the hospital with a small bowel obstruction
and ___ underwent an ileocecetomy with formation of a diverting
loop ileostomy. ___ were taken back to the operating room due to
a post-operative bleed. ___ have now recovered from this
procedure well and ___ are now ready to be discharged to rehab.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. Your ileostomy has
high output, we are sending ___ to a rehabilitation hospital to
continue to recieve IV fluids as needed to prevent ___ from
being dehydrated. ___ should continue to take in foods that are
thickening like bannana, rice, mashed potato to help to thicken
the output, however ___ will continue to have high output. ___
will recieve TPN for nutrition. Please monitor yourself for
signs and symptoms of dehydration including: dizziness
(especially upon standing), weakness, dry mouth, headache, or
fatigue. If ___ notice these symptoms please call the office or
have the rehab hospital callour office. ___ are being discharged
on total parenteral nutrition through your PICC line. Please
restrict your oral intake to less than 250 cc per day. Stick to
foods/liquids that will thicken the ostomy output as suggested
to ___ by the ostomy nurses in the hospital.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. The
rehab will continue to give ___ the medications like imodium,
opium tincture, and metamucil wafers to slow the output.
Please monitor your incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ may gradually increase
your activity as tolerated but clear heavy exercise with your
surgeon.
___ will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car or drink alcohol while taking narcotic pain medication.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck! | The patient was evaluated by the colorectal surgery team in the
emergency department (see consult H&P for further details). His
emergency department course was notable for increasing abdominal
pain and worsening leukocytosis, thus the patient was taken
urgently to the operating room for exploratory laparotomy with
resection of prior ileocolonic anastomosis (see operative report
for further details). Following the procedure, the patient was
taken to the PACU where he was persistently hypotensive despite
resuscitation with 5L crystalloid and 750cc 5% albumin. In
consideration of patient's longstanding steroid usage, stress
dose steroids were administered for possible adrenal
insufficiency. Vasopressor support with neosynephrine was
initiated. ABG demonstrated increasing lactate and worsening
acidosis. He was transfused 4 units of RBC and ___ FFP without
appropriate response. Taken to OR for re-exploration with
evacuation of clot and over-sewing of small mesenteric bleed
(See op report for further details). Patient maintained on
pressor support, intubated postop and admitted to the SICU for
further care.
Neuro: Post-operatively, the patient admitted to SICU intubated,
sedated and paralyzed to facilitate hemodynamic and ventilatory
support. Paralysis was discontinued on ___. He was weaned
off all sedation on POD#3. As the patient regained alertness,
propofol was started on POD#4. received Dilaudid IV/PCA with
good effect and adequate pain control. When tolerating oral
intake,
the patient was transitioned to oral pain medications.
CV: Patient admitted to SICU on levophed and vasopressin for
hemodynamic support. Weaned pressors ___. Developed atrial
fibrillation w RVR POD#5 which was controlled w IV lopressor.
Converted to NSR POD#6. The patient was stable from a
cardiovascular standpoint; vital signs were routinely monitored.
As the admission progressed the patient was occationally
hypotensive related to dehydration and required intermittent
intravenous fluid boluses based on ileostomy output. While
recovreing there was a fine blance between keeping the patient
hydrated and not having pumonary edema. He required intravenous
lasixX2 with good affect. His lung sounds remained clear for
several days prior to discharge. On the day of discharge the
patient was noted to have intermittent hypotension which was
likely related to hypovolemia. He was given intravenous fluid
and the dose of the colinidine patch was decreased. This
requires further monitoring at rehab.
Pulmonary: Admitted to SICU intubated on APRV ventilatory mode.
Failed CPAP trials ___. POD#5 bronchoscopy performed.
Tolerated CPAP ___. Desaturations POD#8 prompting bronch w
purulent secretions c/w VAP.
Pulmonary toilet including incentive spirometry and early
ambulation were encouraged. The patient was stable from a
pulmonary standpoint; vital signs were routinely monitored.
GI/GU: Patient initially NPO with IVF resuscitation. Started
tube feeds on POD#4 and advanced POD#5. Started on banana
flakes, imodium and DTO for high ostomy output. Given refractory
high ostomy output, tube feeds d/c'd POD#7 and TPN initiated.
Throughout the remainder of Mr. ___ admission, the
patient had issues with high ostomy output. He was started on
opium tincture, imodium, octreotide, metamucil wafers, and
protonix. These medications helped some, however, he continued
to require repleations with intravenous fluids to prevent
dehydration. This unfortunately made it difficult to place the
patient in a rehabilitation facility. The patient was tolerating
a regular diet throughout this time with occational nausea in
the morning.
HEME: Patient transfused 4 RBC, ___ FFP prior to takeback.
Received additional transfusion after takeback for hemodynamic
support. Given vitamin K for coagulopathy.
ID: Patient febrile on POD#0 and maintained on broad spectrum
antibiotics for five days due to concern of initial
contamination. Blood cultures sent on POD#0. CT scan abd/pelvis
performed POD#6 w result showing free fluid though no abscess or
other acute process. Full infectious workup also sent including
BCx, UCx, mini-BAL and C-diff. Purulent secretions on bronch
prompted initiation VAP protocol POD#8.
ENDO: In addition to stress dose steroids following first
operation. Patient given methylpred at near home dose equivalent
following this. He will continue on a prednisone taper as
follows: 15mg daily for 4 more days, 10mg daily x2 weeks, 5mg
daily x2 weeks, 5mg every other day.
Prophylaxis: The patient received subcutaneous heparin during
this
stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge to rehab, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. | 595 | 701 |
18513809-DS-50 | 25,567,426 | Dear Ms. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- for abdominal pain, diarrhea, headache
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We did imaging of your abdomen which did not show any
inflammation.
- You underwent an upper endoscopy and colonoscopy which was
normal. Samples/biopsies were done which were also normal
- We also did an ultrasound of your heart which showed normal
heart function
- Your blood pressure was low so you gave you steroids
- We looked at your lungs which was did not show a clot or an
infection.
- We tested you for viruses and found that you had the flu, we
started medication to treat your flu.
- You were briefly on antibiotics because you had fevers.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop shortness of breath, chest pain, fever/chills, or
worsening cough.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | Ms. ___ is a ___ female with complicated PMH
including CML s/p allo BMT, DM, SIBO, latent TB, chronic GVHD,
pancreatic IPMN, IgA deficiency, H. pylori s/p treatment, left
atrial appendage thrombus, recurrent DVT/PE on , and
hypogammaglobulinemia receiving IVIG q4-6wks, who is admitted
from the ED with acute on chronic abdominal pain and diarrhea.
She was found to have influenza, now s/p Tamiflu course, as well
as active C Diff infection for which she was started on a 2 week
vancomycin course. | 231 | 79 |
14269614-DS-14 | 24,612,496 | You were admitted with an ongoing infection at the site of your
prior amputation. You had an MRI performed that did not show any
evidence of bone infection. You were started on antibiotics and
your symptoms improved. You will continue the antibiotics for a
total of 10 days. You were also given topical antibiotics to
place on the wound.
It was a pleasure taking part in your medical care. | ___ yo w/extensive psych history, prior osteo s/p BKA presents
with pain and drainage from stump concerning for recurrent
osteo.
# Cellulitis: Pt presenting with small area of erythema and
drainage on R BKA stump. Initial concern for osteomyelitis;
however, x-ray and MRI performed which did not show any evidence
of osteomyelitis. Wound culture with MRSA from PCP's office. Pt
was started on doxycycline based off sensitivies from that
culture. Will continue antibiotics for 10 days. Pt was also
started on topical bacitracin. Pt remained afebrile and w/o
leukocytosis throughout admission. On the day of discharge,
reported that pain and drainage from area was improving.
# BiPolar/Depression: continued psych regimen per recent
discharge summary
# Seizure d/o: continued Keppra
# Heroin Dependence: continued methadone | 68 | 120 |
11723732-DS-14 | 21,191,421 | Dear Mr. ___,
It was a pleasure caring for you. You were admitted after a fall
and feeling weak. You were found to probably have a urinary
tract infection for which you were started on antibiotics with
improvements in your symptoms. You should complete the course of
antibiotics as prescribed. Given your goals, you and your family
opted to take you home rather than to rehabilitation, which is
reasonable. We also had you seen by the swallowing experts who
recommended a pureed diet with all meals taken sitting upright
to prevent aspiration (choking on food). You will also have a
visiting swallowing nurse at home. Please take it easy for a few
days and rest/recover.
We wish you the best in your health. | Mr. ___ is an ___ year old gentleman with a history of
dementia, atrial fibrillation, GERD, aspiration who presents s/p
fall with concern for possible UTI.
# ? UTI: The patient has a history of UTIs in the past, most
recently in ___. He presents with leukocytosis and foul
smelling urine. Unfortunately, urine sample could not be
successfully obtained in ED and he received antibiotics prior to
arrival to the floor. Has only grown pan sensitive E coli in
past ___ years in our system. A UA and UCx was finally obtained as
above, but this was after at least ___ of antibiotics
(negative culture). Was started on CTX (___) and
transitioned to ciprofloxacin on ___, with plan to complete 7d
course for complicated UTI. His improving MS and WBCs suggested
significant treatment response. He also received about 3L of
fluid over the course of his hospitalization, which likely also
helped with UTI management.
# aspiration pneumonitis: admit CXR with evidence of a right
basilar opacity that could reflect atelectasis but infection or
aspiration is not excluded. Of note, according to his daughter
the patient has a chronic cough at baseline. Given lack of
change in respiratory symptoms, did not broaden coverage to
treat for pneumonia (briefly trialed one dose of doxycycline but
then stopped as this was deemed unnecessary). Repeat CXR on
___ without infiltrate/change, suggesting just aspiration
pneumonitis. Discussed with daughter who agrees that
thoracentesis not within goals of care/indicated. He was seen to
be aspirating more than normal and as such had an evaluation by
the speech pathologist on ___ (delayed due to holiday). At
that time, he was clinically much improved, and was recommended
to have a pureed diet with thin liquids, always sitting up with
meals. He was noted to have a poor oral phase but good likely
pharyngeal phase. Explained to pt's wife importance of following
appropriate swallowing recommendations, though not clear she
understood completely. Explained also to both daughters, and
patient will also have speech services at home. Recommend that
if swallowing worsens, could consider video swallow.
# S/P Fall: The patient requires assistance from his home health
aide with ambulation at baseline. He has a history of recurrent
falls secondary to underlying dementia, though on admit ay was
noted to be off his baseline mental status. Concern for possible
infection as contributing etiology. No evidence of acute
pathology on CT neck, CT head, Pelvic Xray. ___ consult was
deferred given patient is known to require full assist with
ambulation/transfer at home and family not
interested in rehab.
# Atrial fibrillation: Rate controlled without medications. Per
PCP notes the patient is a poor candidate for anticoagulation
given prior bleeding history in the setting of fall and fall
risk. This was discussed with the family in the outpatient
setting who were in agreement.
# Dementia: Continued citalopram. The patient requires 24 hour
care.
# Goals of care: ___ MD discussed ___ code status
overnight with the ___ daughter, ___, who is also a
physician. ___ is in favor of changing the ___ code
status to DNR/DNI, however her sister is the official HCP. After
discussion with her mother, HCP favors full code. Sisters will
continue to discuss. | 122 | 526 |
10685197-DS-18 | 24,323,791 | You were admitted to the hospital with abdominal pain. You were
found to have "sludge" in your bile duct for which you underwent
a procedure called an ERCP. | ___ with h/o CAD s/p CABG x 1 vessel, HTN, HLD who presents with
fevers, abdominal pain and elevated LFTS consistent with
cholangitis.
.
# Bile Duct Obstructition with Ascending Cholangitis: Pt
presented with RUQ pain, fever and found to have elevated
bilirubin to 5. The patient underwent ERCP on ___ during which
a sphincterotomy was performed and biliary sludge and pus
drained. The patient was initially placed on Unasyn and did not
have any fevers. The morning after, she had no abdominal pain,
and her diet was advanced to regular, again without any
complications. I spoke with the ERCP attending who agreed she
can be seen by surgery as an outpatient. Her PCP should draw
her LFTs within ___ weeks of discharge, and if normal, can
restart her statin, and if they have not normalized, can refer
her back to the ERCP program at ___.
..
# HTN: Pt was initially just continued on her beta-blocker in
the setting of SIRS. Her antihypertensives were slowly added
back after she had a max inpatient SBP of 165.
.
# GERD: continue PPI bid
.
#Diarrhea - patient has functional diarrhea in the setting of
IBD which has been chronic for years. She reports having
episodes of loose stools which coincide with her receiving
Ampicillin, an ABX that she has an explicit reaction of diarrhea
to in the past. On the afternoon of ___, she was switched to
oral Cipro which she reportedly had no problems with in the
past. She states that this diarrhea is not significantly
different from functional diarrhea episodes in the past; it is
non-bloody. She was told that if her diarrhea worsens or
accompanied with pain, she will need to seek immediate medical
condition.
.
# HLD: Held statin in setting of elevated transaminases
.
# ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
.
# CAD: Held ASA in setting of ERCP but restarted on discharge. | 28 | 322 |
17825687-DS-12 | 22,067,688 | Dear Ms. ___,
It was a pleasure taking care of you. You were admitted to the
gyn/onc service with a small bowel obstruction. Your obstruction
was managed with a NG tube and pain medication.
We discussed your care with the medical oncology team, who does
not feel that any further chemotherapy would improve your health
or extend your life. You met with the palliative care team who
recommended hospice care for support and symptom control. We
then started medications to keep you comfortable. You were
started on Tylenol and morphine for pain control and Zofran to
help with any nausea.
We wish you the best!
Your ___ Oncology Care Team | ####################GYNECOLOGY-ONCOLOGY
COURSE#########################
Ms. ___ was evaluated in the ED and diagnosed with a high
grade small bowel obstruction. An NG tube was placed for
decompression. IVF were started. A foley catheter was placed for
urinary retention. She was admitted to the gyn/onc service.
When admitted, her mental status was noted to be waxing and
waning and she could not clearly articulate her desires about
goals of care. Review of outside records indicated she had
previously discussed not desiring invasive measures with her
outpatient providers and had completed a MOLST form. Med onc
was consulted and recommended hospice care and no further
treatment. Palliative care was consulted for further discussion
of goals of care and symptom control. Discussions were had with
the patient and her family (husband, son) confirming the goals
outlined in her MOLST form (DNR/DNI, no artificial nutrition).
Her family felt she would not want any IV hydration or
medication such her anti-coagulation medication continued and
these were discontinued.
On hospital day 2, she pulled out her NGT. After discussion with
her HCP, it was agreed that this would not be in line with goals
of care to replace this. Her pain was managed with IV morphine.
She had no nausea or vomiting after removal of NGT tube.
####################ONCOLOGY COURSE#########################
___ year old female with history of CAD s/p CABG, DM2, and
recurrent fallopian tube adenocarcinoma admitted with high grade
SBO with goals of care transitioned to ___ focused care, at
which point she was transferred to the Oncology service. | 108 | 249 |
17362900-DS-12 | 29,258,112 | Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Non weight bearing left lower extremity
Non weight bearing left upper extremity
Non weight bearing right upper extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Physical Therapy:
nonweight bearing on LLE, LUE, RUE.
full weight bearing on RLE
Passive and active range of motion in LLE
Passive and active assist in LUE
Treatments Frequency:
Site: Right arm stump
Description: Incision approximated w/sutures
Care: DSD daily and prn drainage/displacement
Site: LLE
Description: Surgical incision
Care: DSD/Ace wrap; ___ brace in unlocked position | The patient was admitted to the Orthopaedic Trauma Service on
___ for repair of a right upper extremity amputation, Left
tibial plateau fx, Left calcaneus fx, Left supracondylar humerus
fx. The patient was taken to the OR and underwent an
uncomplicated open reduction internal fixation Left humerus,
ORIF Left tibial plateau fracture, closed treatment Left
calcaneus fracture, revision stump closure right upper
extremity. The patient tolerated the procedures without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
The patient was transfused 6 units of blood for acute blood loss
anemia during his hospital course.
Weight bearing status: nonweightbearing on all extremities.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 196 | 215 |
17507320-DS-21 | 20,429,889 | Dear Ms. ___,
It was a pleasure taking care of you. You were admitted to the
___ because your blood sugars
were very high causing you to be very tired and dehydrated. You
were initially admitted to the intensive care unit for close
monitoring and you were treated with inulin and IV fluids and
you improved rapidly. Your kidney function was also slightly
worse that your baseline, but this improved after you were given
fluids.
While you were in the hospital, you were also treated for a
urinary tract infection. You should continue taking your
antibiotic (ciprofloxacin) for 1 day after leaving the hospital
to complete the required course (last day = ___.
We also found that your body is not producing the steroids it
usually needs, likely because of the prednisone that you have
been on which replaces your body's own production. You should
continue taking
You should follow-up with
We wish you a speedy recovery,
Your ___ Care Team | Ms. ___ is a ___ woman with history of chronic
kidney injury (baseline creatinine 2.16 in ___,
___-type diabetes mellitus (diet-controlled; last A1C 6.9%
in ___, hypertension, seronegative RA, and systolic HF (25%)
who presents with fatigue and polyuria, found to have
hyperglycemia to >800, anion gap acidosis, and renal failure
concerning for diabetic ketoacidosis. Patient initially admitted
to the medical ICU and improved rapidly with IV fluids and
aggressive blood glucose control. Patient also found to have a
prerenal acute-on-chronic kidney injury that resovled after IV
fluids, with creatinine returning to baseline of 2.1 at
discharge. She also was found to have a complicated cystitis
that was treated with 7-day course of ciprofloxacin (last day -
___, as well as iatrogenic adrenal insufficiency in the
setting of chronic prednisone use. She was restarted on
prednisone 5mg PO daily.
BY PROBLEM
# Acute-on-chronic gap acidosis | Diabetic ketoacidosis: Likely
triggered by viral illness, last A1c in ___ system from ___
at 6.9%. She was admitted initially to the medical ICU due to
presenting glucose of 859, with gap acidosis and low
bicarbonate, normalized pH now. This may be more of a chronic
acidosis, now with exacerbation by prerenal azotemia. She was
maintained initially on an insulin drip per protocol, goal FSG
140-180. She also was given fluid resuscitation with NS +KCl.
When her plasma glucose reached 250, fluids were switched from
___ NS to ___ NS. The ___ diabetes service was consulted
for insulin management. Unclear if ketoacidosis as ketones were
not checked on arrival. She received a total of 4.5L of IV
fluids. Her gap acidosis continued to improve and resolved at
discharge with a HCO3 of 24 and a gap of 12.
# Ketosis-Prone Diabetes Mellitus:
Patient with known ketosis-prone type 2 diabetes
(___-type). She presented with hyperglycemia to 800s, along
with anion gap acidosis. Last A1C 6.9% in ___, but now 13.0%
this admission. It is unclear if she was truly in DKA as her
anion gap may be due to uremia, and ketones were not tested
until after her gap had closed. Regardless, she was initially
admitted to the medical ICU for insulin drip in addition to IV
fluids, her anion gap closed, and she was transitioned to SC
insulin. She was followed by the ___ service from the time of
admission. Insulin regimen adjusted daily, and at discharge,
___ recommended glargine 30 units QAM and Humalog 10 units
TID with meals.
# Acute-on-chronic kidney injury:
Admission Cr of 3.0. Likely pre-renal in the setting of DKA.
Patient with stage III CKI, baseline Cr. 2.0 - 2.1. No obvious
obstruction. She was given hydration as above. Her Cr improved
and was back at baseline of 2.1 at the time of discharge.
# Iatrogenic adrenal insufficiency:
Patient known to be hypertensive, now with soft blood pressures
in the ___, despite being off antihypertensive therapy.
Also reports lightheadedness. Recently on 5mg prednisone PO
daily, which was held without taper on admission due to
hyperglycemia. She was found to have low morning cortisol and
underwent cosyntropin testing with low-normal physiological
response. In discussion with the ___ diabetes service,
prednisone was resumed due to concern for adrenal insufficiency,
and insulin regimen was adjusted accordingly prior to discharge.
# Pansensitive E. coli complicated Cystitis:
UA grossly positive with WBC and nitrite. No dysuria, but has
had increased urinary frequency, likely due to urinary tract
infection or hyperglycemia. She remained afebrile, but was found
to have leukocytosis to 11. She was started on ciprofloxacin
250mg PO Q12H (___) for acute complicated cystitis and
received a 7-day course for pansensitive E. coli, with
improvement in leukocytosis and urinary symptoms.
# Systolic HF:
Chronic. Thought to be mixed ischemic and Takatsubo. Has an ICD
in place. LVEF 25% when last checked. She was
hypovolemic-appearing on admission. Losartan and furosemide held
during hospital stay. Furosemide was restarted at discharge due
to euvolemic appearance in the setting of hydration. Dry weight
91kg. Losartan was held at discharge, given soft blood
pressures, to be restarted by PCP or cardiologist when
appropriate.
# Hx of CAD, s/p ___ ___:
DES x1 to obtuse marginal and DES x1 to circumflex, had
presentation then with chest pain, EKG then with submm STE II,
III, avF, V5, V6. Cardiac enzymes negative here, reassuring
against ACS. Her home aspirin, ticagrelor, and atorvastatin were
continued. Metoprolol was held on admission and restarted prior
to discharge.
# Arthritis:
Continued home hydroxychloroquine. Resumed prednisone as above.
# Depression:
Continued duloxetine. Initially held doxepin, given renal
dysfunction, restarted prior to discharge, given return in renal
function to baseline.
# Chronic Pain:
Held home gabapentin in the setting of renal dysfunction,
restarted prior to discharge, given return in renal function to
baseline.
# Gout:
Held home allopurinol in the setting of renal dysfunction,
restarted prior to discharge, given return in renal function to
baseline. | 159 | 801 |
17059566-DS-24 | 25,491,129 | Dear ___,
___ was a pleasure to take care of you during your stay at ___
___.
You were admitted to ___ for worsening difficulty speaking as
well as lightheadedness in the setting of nausea/vomiting and
loose stools for several days. You underwent EEG which did not
show any signs of seizures. Your symptoms improved and you
should follow up with your neurologist within 1 month.
You were also noticed to have elevated blood pressure
contributing to an acute kidney injury so we optimized your
blood pressure medication. You should take them as prescribed.
You are being discharged to a rehab facility.
Please take your medications as instructed. You have follow up
appointments as mentioned below.
It was a pleasure taking care of you.
Best,
Your ___ team. | ___ is a ___ hx seizure disorder on Trileptal, right
frontal AVM s/p rupture with resulting seizure disorder (___),
R frontoparietal AVM s/p coiling (___) with baseline
dysarthria and left-sided weakness, who initially presented with
worsening dysarthria and lightheadedness in the setting of
nausea/vomiting and loose stools for several days. She was
transferred from neurology to medicine service on ___ for ___
and hypertension.
#Neuro:
Patient presented with worsening dysarthria and lightheadedness.
She underwent stroke work up including CTA head and neck which
was stable and did not show any acute intracranial abnormality
that could explain her symptoms. She also under went an EEG
which did not show any epileptiform form activity. She was
maintained on her home AED's. Her symptoms were thought to be
due to viral illness given her hx of several days of
nausea/vomiting and loose stools prior to presentation. She
improved back to her baseline. She was evaluated by ___ who
recommended rehab. Her oxcarbazepine level was mildly elevated
at 36 and per neurology service no need to change her AED
regimen. Should ___ with Dr. ___ 1 month of
discharge.
#HTN:
Patient has hx of htn and is on losartan, amlodipine, metoprolol
at home. Previously on HCTZ but had been stopped as an outpt
prior to admission. Home anti hypertensive medication was
initially held as patient had a mild ___ ___ contrast induced
nephropathy form dye during CTA. She was maintained on IV
hydralazine and Lopressor. Patient was noted to be increasingly
hypertensive throughout admission despite
restarting home meds. Medicine was consulted and recommended
transitioning metoprolol to labetalol 200 TID. On ___ patient
was noted to have SBP in 200's and was transferred to ___. On
the evening of ___ she was noted to be tachypnic and
diaphoretic. Also with new O2 requirement of 2L after desatting
to 89%. EKG showed anterior ST elevations. Cardiology was called
and performed bedside echo which did not show decreased anterior
wall motion suggestive of infarction. In addition,
given elevated BP's bilateral UE were checked to see if there
was a pressure difference suggestive of dissection. RUE 138/85
and LUE 139/76. Troponin, CKMB, BMP were sent. Troponin was
negative. Mg 1.4 and K 3.1. She received 80meq total K (40 IV,
40 po). CXR showed new consolidation vs atelectasis in RLL,
given lack of elevated WBC, no left shift, and no fever, more
likely atelectasis. The following morning patient was
transferred to medicine service. While on medicine, her blood
pressures were kept in the goal rage of 140 < SBP < 180 with
amlodipine 10 daily and labetalol which was titrated to 200 mg
TID. She was discharged on this regimen and will need close
follow up and transition off of labetalol for long term HTN
management
# ___
Initially most likely due to contrast induced nephropathy from
dye during CTA head and neck. Cr on admission 0.8 rose to 1.2
after CTA. Pt received IVF with improvement of Cr to 0.7.
However, after restarting home losartan Cr again rose to 1.7.
Losartan was discontinued and pt received IVF. Cr remained
elevated in the setting of SBP > 200. Overall her ___ was felt
to be multifactorial from contrast, ___, and hypertension. UA
and sediment not c/f ATN. Her Cr stabilized at 1.5 and she was
discharged with plan for close outpt ___.
#Asymptomatic bacteriuria: urine culture from ___ resulted
with e. coli 100k cfu however contaminated with mixed
skin/genital flora. She was not treated for this as she was not
symptomatic. However if she becomes symptomatic with UTI,
culture results below for reference.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
# Anxiety: pt was maintained on her home Escitalopram Oxalate 20
mg daily
#HYPOXIA: Overnight into ___ became acutely hypoxemic. CXR
showed RLL consolidation c/f aspiration vs atelectasis vs pna on
CXR however no fevers or leukocytosis. Her respiratory distress
resolved quickly without intervention and she was stable on room
air for the rest of her admission. currently doing well on RA.
CPAP was continued and incentive spirometer given.
#Normocytic Anemia: Hb on admission 10.6 drifted down to 8s and
then stabilized ___ range. No clear source of bleeding. Did not
have large amounts of fluid resuscitation although some fluids
for ___. Hemolysis was ruled out, iron labs unremarkable, folate
and b12 normal. Retic index was low. SPEP/UPEP pending on
discharge. She may need outpatient hematology ___ if her anemia
continues given concurrent leukopenia. This may also be side
effect of AEDs.
#DM: SSI. home colesevalam and gemfibrozil held
Code status: full confirmed
==========================================
# Transitional issues
==========================================
- VALIUM: pt was on valium prior to admission. For unclear
reason pt was started on valium 10mg QAM and 15mg QPM on
admission. Per most recent discharge documentation should be
valium 10mg qpm only. Unclear if she is on valium for seizures
or anxiety. Valium is not usually prescribed to control
seizures. We are trying to wean her down to her home dose. Her
valium dose was decreased from 15mg qpm and 10 mg qam to 15 mg
qpm and 5mg qam on ___ and then to 10mg qpm and 5mg prn per
her home regimen.
- Blood pressure regimen:
- home losartan and HCTZ stopped for ___
- discharged on amlodipine 10 mg daily and labetalol 200 mg
tid
- Please adjust blood pressure regimen as necessary. Would
suggest transitioning off of labetalol to more easily taken
medication after ___ resolves.
- Renal function: will require close PCP ___ and BMP check for
return of renal function
- if does not improve can consider outpt nephrology referral
-Anemia and leukopenia: if persistent should consider outpatient
hematology referral for possible bone marrow biopsy
-Seizure disorder: continue oxcarbazepine at current dose. ___
with Dr. ___ 1 month of discharge.
-Asymptomatic bacteriuria: culture from ___ resulted w/ e coli
but also contaminated w/ skin and genital flora. pt not
symptomatic but sensitivities below for reference if pt becomes
symptomatic.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
-HCP: patient has not identified a health care proxy. please
discuss this with her | 125 | 1,319 |
16433543-DS-9 | 22,953,760 | Dear Dr. ___,
___ was a pleasure participating in your care during your
admission to ___. As you know,
you were admitted for low-grade fevers and constitutional
symptoms and found to have methicillin-sensitive Staph aureus
bacteremia. MRI of your lumbar spine showed abscesses in the
soft tissues near the spine, and CT showed possible screw
loosening. You were treated with nafcillin and taken to the
operating room for incision and drainage of abscesses and
hardware removal.
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace from your previous surgery.
This brace is to be worn for comfort when you are walking. You
may take it off when sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
As tolerated
Treatments Frequency:
Please continue to evaluate the incision | Dr. ___ is a ___ with h/o L3-S1 lumbar fusion in ___ c/b MSSA
abscess who p/w fevers to 100.3 and diffuse muscle
aches/stiffness x5 days, now with MSSA bacteremia, fevers
(resolved), and paraspinal soft tissue abscesses with apparent
hardware involvement, s/p incision and drainage of abscesses
with hardware removal on nafcillin.
#MSSA bacteremia: Despite benign p/w low-grade fevers and
constitutional symptoms, patient was found to have MSSA
bacteremia in ___ bottles obtained on admission, with transition
from empiric vancomycin to nafcillin upon speciation. He was
intermittently febrile with subsequently positive BCx x1 on
vancomycin, but defervesced on nafcillin and remained HD stable
without leukocytosis and with back pain only minimally increased
from baseline, no new paresthesias or urinary/fecal
incontinence, and nonfocal neurologic exam throughout. L-spine
MRI revealed paraspinal soft tissue abscesses, with possibility
of small epidural abscess, while L-spine CT suggested screw
loosening. TTE was negative for obvious vegetations, though the
study was technically limited. Purulent material drained from a
paraspinal soft tissue abscess at the beside grew out coagulase+
S. aureus, c/w BCx. He was taken to the OR for incision and
drainage of abscesses and hardware removal, with subsequent
transfer from medicine to orthopedics for continued management.
#Microcytic anemia: Hct of 29.2 on admission with MCV 85, c/w
post-operative baseline of ___, remained stable throughout
admission to the medicine service. He denied ischemic symptoms,
though baseline anemia likely contributed to overall malaise.
There was no e/o active bleeding by history or on exam, and
active hemolysis was precluded by normal tbili. Fe (11) was
found to be low with otherwise normal Fe panel. Vitamin B12
supplementation was initiated for low B12 (198). Primary
hematologic process could not be excluded.
___: Cr of 1.3 on admission, likely prerenal due
to poor PO intake, improved with IVF. Na remained stably low,
131-133, throughout admission, c/w baseline, initially perhaps
in the setting of hypovolemia, though he later appeared
euvolemic, suggesting some component of SIADH, as supported by
elevated urine osms (459 on ___.
#Hypertension: He remained normotensive on home amlodipine and
metoprolol, with ACE inhibitor held in the setting ___ on
admission.
#GERD: Home omeprazole was continued.
#BPH: Home Flomax was continued.
#Insomnia: Home trazodone was continued, with Ambien as needed. | 421 | 374 |
16775973-DS-16 | 25,284,809 | You were admitted to the hospital due to concern for infection
and diarrhea. Blood cultures were checked and they have been
negative, C diff also was negative. You had some bacteria in
the urine but not an urinary tract infection. On discharge,
your WBC has returned to normal and you did not have any fever
while inpatient so you will not be on any antibiotics. It was
noted you had an elevation in your liver function, which was
decreasing by discharge, this will be followed as an outpatient. | ___ year old female with recurrent pancreatic cancer s/p first
cycle of FOLFOX ___ and h/o ovarian cancer on suppressive
anastrazole who presents with fever, diarrhea and weakness.
#. Diarrhea: Chronic diarrhea from pancreatic insufficiency but
also had been concerned for recurrent Cdiff.
-Initially treated empirically for Cdiff, but stopped Vanco once
C diff came back negative. Pending other stool cultures, but
likelihood of other infectious causes is low, could also be
slight worsening from side effect from chemo.
-cont prn immodium
-Continued home Creon while in house.
# Leukocytosis: Has resolved,ddx included C. diff colitis, port
infection.
-BCx neg to date, Ucx grew only ___ Klebsiella with U/A
<10 WBC so will not treat given suscpetibility for Cdiff
-neg Cdiff
.
# Pancreatic cancer: Her chemo was 2 weeks ago, now due but will
hold.
-will f/u next ___
.
#. Ovarian cancer: Has been on suppressive anastrozole.
- Continued on home anastrozole
#. Type 1 DM: Due to pancreatic cancer. Patient not on diabetic
diet and manages own novolog sliding scale while in hospital.
- pt monitored own sugars and ISS as she had done in previous
stays
.
#. Hypertension, benign: Stable, continue home atenolol
.
# GERD: Continued home omeprazole | 92 | 189 |
10666610-DS-12 | 21,110,018 | Dear Mr. ___,
You came to ___ because you were bleeding from your rectum.
Please see more details listed below about what happened while
you were in the hospital and your instructions for what to do
after leaving the hospital.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- Your bleeding was concerning for a bleed in your intestines.
- You had a colonoscopy which showed that you have
diverticulosis, which is an outpouching of your colon, as well
as hemorrhoids.
- Your blood counts also were normal which was reassuring. You
were recommended to restart your blood thinners. Your blood
counts did not drop after restarting them.
- You also had a fast irregular heart rate which was corrected
by fluids. This happened because you were bleeding from your
rectum
- Finally, you had tenderness in your scrotum. You had a scan
which showed that you have a hernia. The surgery team was
consulted and you did not need surgery for this. Your pain also
improved.
- You improved considerably and were ready to leave the
hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see
below).
- Seek medical attention if you have a lot of bleeding from
your rectum, have chest pain or palpitations, feel dizzy, or
other symptoms of concern.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | Mr. ___ is an ___ M with a history of Afib on dabigatran,
advanced dementia, and bipolar disorder who presented from his
nursing home with bright red blood per rectum. | 273 | 30 |
13282748-DS-14 | 28,521,621 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized here because of
a severe infection of your gallbladder. You became very sick and
your heart went into an abnormal rhythm. You had a procedure .
Because of this probklem with your heart, you. After you were
revived from this rhythm, you underwent a procedure to place a
plastic tube in your gallbladder ducts to open up the
obstruction. This tube will have to be removed (see information
below). Secondary to your infection and arrhythmia, you also
developed kidney insufficiency, which has since recovered. You
received antibiotics for the gallbladder infection and recovered
well. | ___ with a history of DM, CHF (EF ___, Afib on coumadin who
presented to the ED with a 4 day history of progressively severe
epigastric pain found to have likely acute cholangitis, who is
transferred to the MICU for management of septic shock.
#Acute Cholangitis:
On presentation, pt had septic shock thought to be due to acute
cholangitis, evidenced by fever, RUQ pain, transaminitis,
hyperbilirubinemia, and imaging findings demonstrating common
bile duct dilatation and stone in gall bladder neck. Blood
cultures were obtained, and ampicillin-sulbactam was given to
cover enteric flora. Urgent ERCP was performed with removal of
an ampullary stone, placement of a stent, and drainage of a
large quantity of frank pus on ___. After this procedure, LFTs
continued to uptrend, which could occur due to instrumentation
of biliary tree vs incomplete decompression. Unasyn was
broadened to meropenem for pseudomonal coverage starting on ___.
Per hepatology, an uptrend in LFTs was to be expected and a
repeat ERCP was not indicated, as abnormalities in LFTs and INR
were likely related to liver shock. His LFTs uptrended but then
began to downtrend, and at the time of transfer, were all
trending down.
#Septic shock: Pt's hemodynamic instability was consistent with
septic shock given fevers, leukocytosis, evidence of end-organ
hypoperfusion (lactate 2.2, altered mental status), and
persistence of same despite aggressive fluid resuscitation. In
the ED, a central venous catheter was placed, and he was started
on a norepinephrine drip for hemodynamic support; given hx of
CHF, fluid boluses were carefully administered, with CVP and
clinical exam of volume status trended. Home antihypertensives
were held. He ultimately required blood pressure support with
two agents, norepinephrine and vasopressin. These were
discontinued on ___, and he maintained adequate blood pressure
on his own thereafter.
#Airway instability/Respiratory failure:
Pt was initially intubated for AMS in the setting of acute
hypotension. He had multiple causes for AMS during his
hospitalization, including infection, septic shock, uremia.
Acute intracranial process was considered, and noncontrast CT
head was obtained, showing only a subtle fluid collection over R
frontoparietal lobes thought to represent an old SDH. Extubated
without complication on ___. He developed some focal atelectasis
in the LLL after extubation, which was resolved at the time of
discharge
#Troponinemia/Type II NSTEMI:
Pt found to have elevated Tns on laboratory evaluation. Tns
continued to trend upwards in the setting of septic shock,
thought to represent demand-type NSTEMI. This problem was
managed by treating septic shock as above, and has resolved at
the time of discharge.
#Ventricular tachycardia:
On ___, pt had an episode of ventricular tachycardia prior to
ERCP procedure. He was coded and required shock therapy x1, and
resolved thereafter. Started on amiodarone drip; this was
transitioned to PO amiodarone on ___. No other episodes of VT
during his course. Cardiology evaluated and recommended an
amiodarone gtt; no other episodes. His home digoxin was not
re-started per ___ cardiologist. Amiodarone gtt. was
transitioned to po amiodarone at 400 po bid, then after 1 week
to his maintenance dose of 200 mg po daily (to be started on
___.
___:
The pt's historical baseline renal function was found to be
~2.0. His Cr continued to trend upwards to 6.9 in the setting of
septic shock (as above), as well as contrast nephropathy after
getting his CTA. Ultimately, he required placement of a
temporary HD catheter and the initiation of CVVH to treat his
acute on chronic kidney disease. This was discontinued ___ ___
as his renal function improved significantly. On the day of
transfer his creatinine was stable at 2.7, and he was making
about 0.5cc/kg/hr of urine for the past 36hours. Per renal
recommendations, the dialysis catheter was kept in for one more
day. After arrival on the medical floors, the dialysis catheter
was removed without complication as Mr. ___ continued to make
adequate urine.
#CHF: Has baseline systolic heart failure, with EF ___
--All home antihypertensives and diuretics were held in the
setting of septic shock. After transfer to the floor, he was
diuresed with incrementally increasing doses of lasix, and then
transitioned to his home dose of torsemide, 150 mg po bid,
however metolazone, irbesartan and spironolactone were held. On
discharge, he was sent with his home doses of torsemide and
spironolactone.
#Transitional Issues:
--The amiodarone dose which Mr. ___ is currently on is 400mg
PO BID, which was started on ___. On ___, he is to transition
to his maintenance dose of 200 mg PO daily. Digoxin can continue
to be held until he follows up with cardiology as
outpatient.
--Coumadin/INR management in the setting of new amiodarone use
--Follow up LFTs to ensure resolution
--On the AM of discharge, the patient's TSH came back 8.8. Free
T4 pending. | 112 | 779 |
18000437-DS-17 | 22,974,863 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
-You had a serious infection of your foot
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
-You were seen by the vascular surgeons and the foot surgeons
-You were given IV antibiotics
-You had two angiograms, and an angioplasty which was successful
WHAT SHOULD I DO WHEN I GO HOME?
-You should continue to take your antibiotics
-You should see the podiatrists and vascular surgeons
Be well!
Your ___ Care Team | ___ w/ AF, CAD, and PAD s/p many interventions (left lower
extremity arteriogram with atherectomy and angioplasty, R iliac
stent, angioplasty and stent of R SFA/AK pop occlusion) with
chronic non-healing wounds of lower extremities presenting with
concern for left foot cellulitis vs. osteomyelitis, admitted to
general medicine for further management of her left foot
infection. Podiatry did not recommend any surgical intervention.
Vascular surgery evaled w NIAS and angiogram x2, and she
underwent successful angioplasty. She improved clinically and
was transitioned to po antibiotics. She developed diarrhea
likely related to antibiotics and c diff testing was sent to r/o
c diff colitis which was pending at d/c. | 81 | 108 |
16752897-DS-12 | 26,242,701 | You were admitted for left leg and arm weakness. You had a head
CT which showed two areas of subacute strokes. You then had an
MRI of the head which showed an acute stroke on the right side.
We think the cause of these strokes is small vessel disease from
diabetes and cholesterol. We checked your stroke risk factors.
A1c revealed very poor diabetes control. ___ has recommended
a new regimen for your insulin because of this. Your cholesterol
was also too high (LDL 127). You are on the maximum dose of
atorvastatin. You should take this faithfully and maintain a low
cholesterol diet.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Transition of Care Issues: Titrate up amlodipine and lisinorpil
as needed. Strict diabetic diet with insulin sliding scale as
below. Neurology follow up as below.
This is a ___ RH man with a history of HTN, HL, poorly
controled DM type II, LVH with depressed systolic function (EF
___, and stage III CKD who presents with a 2 day history of
left leg pain progressing to left arm and leg weakness and
numbness. CT head shows a likely subacute R basal ganglia
infarct, in addition to more chronic appearing R frontal
infarct, neither of which were present on previous imaging in
___. The etiology is most likely related to small vessel
disease, given his multiple poorly controlled risk factors.
Neuro: The patient was admitted to the stroke service. He had an
MRI which showed infarcts in the lateral aspect of the right
thalamus and the posterior limb of the internal capsule. Stroke
risk factors were checked. A1c was very high at 12.2 and his
morning glucose was 400. LDL was also elevated at 127. He was
continued on his home statin and his aspirin was increased to
325mg.
CARDS: The patient has known systolic heart disease. Though the
strokes are most likely from small vessel disease an echo was
done to evaluated for an embolic source. This was essentially
unchanged from prior echos with an EF around 30% and no thrombus
seen. He was monitored on telemetry with no events noted. Blood
pressure was allowed to autoregulate initially and the home
antihypertensives were restarted at half the home dosages. His
blood pressure was very well controlled on this regimen which
suggests that he was not taking all of his medications properly
at home.
ENDO: The patient has a history of poorly controlled diabetes.
On presentation his A1c was again very high at 12.2 and his
morning glucose was 400. ___ was consulted for
recommendations and they changed his insulin regimen to include
a long acting insulin in the evenings as well as an augmented
sliding scale. | 118 | 335 |
12532356-DS-23 | 21,723,331 | Please call Dr. ___ office at ___ for fever > 101,
chills, dizziness, nausea, vomiting, feeding tube clogs,
jaundice, diarrhea, constipation, increased abdominal pain,
abdomen distension, biliary drain or abscess drain output
increases significantlyl or stops, or abdominal drain insertion
sites appear red or have drainage, picc line site appears red or
has drainage, edema, cloudy urine, decreased urine output
Keep Roux drain uncapped to gravity drainage. change dry gauze
to site daily and as needed. Check insertion site for redness,
drainage or bleeding, assure suture in place.
If biliary drain or abscess drain dislodges, call immediately to
Dr ___ office at ___.
Please give tube feeds via PEG feeding tube. Keep HOB at 30
degrees for aspiration precautions as the tube is in stomach | ___ y/o female admitted from rehab with altered mental status and
abdominal pain.
On admission the existing Roux tube was placed to gravity
drainage. There was minimal output. Blood and urine cultures
were obtained, and Vanco and Zosyn were started. On ___, a
cholangiogram was done via the Roux tube which noted the
indwelling Silastic tube had slipped out of the common bile duct
and was lying within the bowel. Initially this appeared to be
plugged, which on gentle manipulation was cleared. The Roux tube
was removed at the bedside.
An MRCP was then done on ___ multifocal cholangitis, with
multiple small hepatic abscesses, including a 2.1 cm dominant
abscess in segment VIII. The remainder of the hepatic abscesses
measured less than a centimeter. No biliary dilation was seen.
On ___, blood culture isolated enterococcus faecium. Daptomycin
was started on ___ and given for 2 days then antibiotics were
switched to Linezolid and Meropenem on ___ when blood culture
isolated 2 morphologies of E.Coli and Klebsiella.
On ___, cholangiogram was done noting non dilated intrahepatic
biliary ductal system with brisk emptying of contrast through
the patent hepaticojejunostomy. There was communication of the
right and left biliary ductal systems with a small
common hepatic duct. A 10 ___ modified APD drain was placed
via the right posterior ductal system with bag left to gravity
drainage. A 2.4 cm complex collection in the right posterior
lobe was aspirated to completion (~5 cc purulent blood tinged
fluid). Sample was sent for microbiology and culture. This
culture isolated mixed bacteria. On ___, a new right brachial
POWER PICC was placed with tip in mid to lower SVC for IV
antibiotics.
She remained afebrile with serum WBC WNL until ___ when WBC
started to increase to as high as 14 on ___. Surveillance blood
cultures were negative up until ___ when she was febrile to 102
and serum WBC increased to 31.5. Blood culture from ___
isolated Klebsiella Pneumoniae resistant to multiple drugs.
Daptomycin was started on ___. ID had been consulted and
recommended adding Tigecycline which was started on ___. WBC
decreased and she remained afebrile.
On ___, a non-IV contrast CT was done of her chest and abdomen
showing enlarged dominant abscess in segment VIII of the liver
(from 2.1 x 1.9 cm to 3.0 x 2.5 cm). The previously seen small
abscesses in segment V/VI was noted again. There was new mild
to moderate ductal dilatation. She was then sent to
interventional radiology and underwent exchange of existing
percutaneous transhepatic biliary drainage
catheters with new 10 ___ catheters as well as aspiration of
a 3 cm segment 6 hepatic abscess with 8 ___ drain placement.
Fluid aspirated was sent for culture and isolated 2 morphologies
of MDR Klebsiella and Enterococcus (VRE)sensitive to Daptomycin.
Subsequent surveillance blood cultures from ___ were
negative. Blood cultures from ___ and ___ were negative to
date and pending. Biliary drain remained to gravity drainage and
abscess drain to JP bulb suction. The biliary drain output
averaged 400-600 cc/day and the JP 40 cc/day. LFTs were
relatively stable despite cholangitis and need for biliary drain
exchange. Alk Phos had increased to 190s just prior to last
biliary drain exchange on ___. Alk Phos decreased to 130-140s
post procedure.
She experienced ___ while bacteremic after treatment with
vancomycin and after MRCP contrast despite protocol to minimize
dye effect with creatinine increase (beginning on ___ as high
as 6.0 around ___. IV fluid management and volume overload were
managed with daily Lasix. Nephrology was consulted and made
daily recommendations. With improved renal function, IV Lasix
was switched to Torsemide 60 mg iv daily on ___. This dose was
decreased on ___ when weight was closer to her baseline and
creatinine was down to 3.3.
She required 4 liters of nasal cannula O2 as well as scheduled
neb treatments in addition to fluticasone MDI. She had episode
of desat's to low to mid ___ the week of ___. Overall
respiratory status improved as renal function returned closer to
her baseline. It should be noted that her home dose of
theophylline was held throughout this hospital stay due to
aspiration precautions. This med can not be crushed and put thru
the PEG.
Her nutritional status was poor on admission and she was noted
to cough when taking any po's. She failed a video swallow on ___
and had a post pyloric feeding tube placed. However, she did not
tolerate this experiencing persistent nausea and vomiting. On
___, a PEG tube was placed by Dr. ___. Tube feeds were started
and formula adjusted to Nepro at 40cc/hr continuous. Of note,
the biliary drain was noted to have the color of tube feeds
periodically given the h/o Roux en y hepaticojejunostomy.
Hospital course was long and complicated. She was depressed and
became increasingly despondent. ___ felt that she had a
hypoactive delerium. Zoloft was continued. Geriatrics was
consulted. TSH was wnl, and Fentanyl patch was recommended for
pain medication with break thru oxycodone which did improve her
pain control (pain at ___ drain and abscess drain site).
Mood improved as her kidneys were recovering and antibiotic
coverage was targeted to infections.
She had persistent yeast in urine and the foley catheter was
changed on ___ and ___. Urine culture was positive for
yeast on ___ and ___.
___ followed her and assisted to get her out of bed using the
hoyer as she was too debilitated to participate. Rehab was
recommended and ___ was contacted. A bed at ___
was available on ___. The plan was to transfer her to ___
with continuation of her antibiotics as followed:
Daptomycin 500 mg IV Q 48 hours (last administered
___ 50 mg IV q 12 hours, and Meropenem 500 mg IV
Q12 hours(infused over 3 hours). Start date was ___ of
drain placement and PTBD/biliary drain exchange). Stop date ___
(minimum, pending resolution of abscesses).
She was transferred to ___ on ___. She will f/u with
Dr. ___ on ___ on ___.
Code status: DNR/DNI
Daughter ___ ___ | 123 | 1,007 |
13410908-DS-6 | 27,231,669 | 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:
-Touchdown weightbearing 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 ___ regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open distal tibia and fibula fractures and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ORIF, IM nail right lower
extremity for open right distal tibia and fibula fractures,
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 to his
hospitalization. The patient worked with ___ who determined that
discharge to extended care facility 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
touchdown weightbearing next field right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 502 | 269 |
17826217-DS-21 | 29,619,450 | Dear Mr. ___,
You were admitted to ___ and
underwent Transcervical ORIF (open reduction, internal
fixation) of right comminuted mandible angled fracture. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | The patient presented to Emergency Department on ___,
transferred from ___ after an MVC for treatment of
mandible fracture. Pt was evaluated by ACS and ___ upon arrival
to ED. Given findings, the patient was taken to the operating
room for ORIF of the mandible by OMFS. There were no adverse
events in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with liquid oxycodone,
tylenol, and ibuprofen.
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. Postoperative,
the diet was advanced sequentially to a liquids, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. At the request of ___,
the patient was maintained on cefazolin IV while inpatient and
discharged to complete a course of Keflex.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 422 | 294 |
15925803-DS-11 | 26,505,090 | Mr. ___,
It was a pleasure treating you during this hospitalization. You
were admitted because of abdominal distension and feeling tired.
You were found to have an infection in your ascites fluid for
which you received antibiotics. You were also found to have mild
renal failure which improved after receiving albumin. Your
sodium was slightly low, this may be the result of diuretics.
You should discuss with your Hepatologist about reducing or
discontinuing your diuretics all together.
The following changes to your medications were made:
- START Ciprofloxacin 500mg once daily
- START Lactulose up to three times per day, make sure you are
having ___ BMs per day
- No other changes were made, please continue taking your home
medications as previously prescribed. | ___ yo M with NASH cirrhosis complicated by diuretic refractory
ascites s/p TIPS procedure and recent hospital discharge after
TIPS revision that represented to ED with 8lb weight gain,
confusion, and abdominal pain. Treated for HE and SBP with
subsequent development ___ and electrolyte abnormalities.
Discharged home off of diuretics.
. | 123 | 50 |
10253803-DS-16 | 29,975,375 | Dear Mr. ___,
It was very nice to meet you and to be a part of your care team
at ___. You came to the
Emergency Room to be admitted for a cardiac catheterization, but
we found that you do not have enough red blood cells (anemia),
and so you were admitted to the Medicine Service. We gave you
some blood, and your anemia got better. We also gave you some
iron to take, and you should continue to take this at home as
instructed below. We know that your anemia is because of low
iron, but we did not discover why your iron is so low.
We would like for you to have a colonoscopy and EGD to look for
possible reasons for your anemia. This will be scheduled by your
primary care provider. When you take the bowel prep for your
colonoscopy, be sure to carefully follow the instructions for
fluid repletion and on the final day of the prep (when you drink
the Mag Citrate), take a half dose of your Lasix.
As you know, your heart is not working as well as it used to,
and so you should weigh yourself every day, and call Dr. ___
___ your weight increases by more than 3 pounds.
We were not able to schedule you an appointment with Dr. ___
___ enough for you to see after your hospitalization. Instead
you will be seeing Dr. ___, who is also an excellent
physician. Please see below for the details.
We were glad to see you breathing better when you left us, and
we wish you the best of luck!
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ yo male with a hx CABG, COPD, and
AICD/Pacemaker coming in with worsening exertional dyspnea and
b/l leg pain for the past week, found to be anemic with a Hgb of
6.1
===================
ACTIVE ISSUES
===================
#Iron deficiency anemia:
In the ED, the patient was found to have a Hgb of 6.1. He was
guaiac negative. He was transfered to the Medicine service, and
was transfused a unit of PRBCs over 4 hours. He was monitored on
tele during the transfusion to assess oxygenation status. The
patient tolerated the transfusion well. Further labs showed TIBC
503 Hapto 227 Ferritin 5.5 TRF 387. He was started on PO iron
supplements. A repeat h/h on ___ showed a Hgb of 7.1. The
patient received a second unit of PRBCS, which he again
tolerated well. On discharge, the patient reported that his
breathing was much improved, and that he was able to walk around
the unit without feeling short of breath.
#Dyspnea:
Though initially thought to be due to CHF, on exam the patient
did not exhibit signs of being fluid overloaded and a CXR showed
no pulmonary edema. The patient's symptoms improved after
receiving transfusions of PRBCs. He was also continued on his
home fluticasone and albuterol.
#Bilat leg pain:
The patient initally presented with bilateral leg pain of
unclear etiology, with recent vascular studies that did not show
signs of arterial disease. He did not experience this pain
during his hospitalization.
# Chronic Systolic CHF:
Secondary to ischemic cardiomyopathy with last known LVEF
___. The patient was continued on his home medication
regimen, which includes lasix 40mg daily, imdur 30mg daily,
losartan 50 mg daily, simvastatin 20 mg daily, and metoprolol
100mg daily. He received his PRBCs over 4 hours, as discussed
above, and did not experience increased dyspnea.
===================
CHRONIC ISSUES
===================
#CAD - s/p CABG ___:
The patient was continued on his home aspirin 81mg daily, as he
was guaiac negative and had no symptoms associated with an
active GI bleed. His other cardiac medication were continued as
above.
#OSA - The patient was continued on his home CPAP.
#Hypertension - Patient's home medications were continued as
above
#Hyperlipidemia- Home ezetimide was continued
#GERD - The patient's home pantoprazole 40mg BID was continued
#Insomnia - Patient was continued on his home lorazepam 1mg QHS
===================
TRANSITIONAL ISSUES
===================
- The patient does not currently have a PCP, and should
follow-up with his new PCP, ___.
- The patient will have an h/h done on ___, with results faxed
to ___.
- The patient's PCP should ___ the need for his high dose of
pantoprazole, considering that PPIs may contribute to poor iron
absorption.
- The patient's PCP should schedule him for an outpatient
colonoscopy and EGD (previously saw ___ to assess for a GI
bleed as the cause of his iron deficiency. | 268 | 453 |
12036892-DS-13 | 22,801,963 | You were admitted to ___ with abdominal pain and were found to
have acute appendicitis. You were treated with IV antibiotics
and bowel rest. Your pain has resolved and you are now
tolerating a regular diet. You are ready to be discontinued home
to continue your recovery. You will need to follow-up in clinic
to discuss having your appendix removed once all the
inflammation subsides. Please note the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | The patient presented to the ___ ED on ___. Pt was
evaluated upon arrival to ED. Given findings, the patient was
seen by ACS and admitted to the floor for medical management of
appendicitis.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV and then
transitioned to oral medications once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. The diet was
advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
Patient abdominal exam was conducted at least daily, with a
benign abdominal exam by time of discharge.
ID: The patient's fever curves were closely watched for signs of
infection. Patient was started on a course of antibiotics for
management of appendicitis.
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 on ___, 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 was discharged home with a 2 week
course of antibiotics. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 266 | 268 |
16279137-DS-24 | 21,880,201 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for back and flank pain.
What was done for me while I was in the hospital?
- You were found to have a malfunction of the tubes draining
your urine.
- Because of the malfunction, you developed a urinary infection.
- Your tubes were exchanged and your pain improved.
- You completed a course of antibiotics; your urine cultures
grew broadly sensitive Proteus.
What should I do when I leave the hospital?
- Continue to take all medications as prescribed. In particular,
please take Fosfomycin upon discharge from the hospital.
- Please go to all of your doctors ___ as listed below.
- If you have any recurrence of your symptoms, please let your
doctors know immediately.
Sincerely,
Your ___ Care Team | ___ yo F with PMH uterine cancer in infancy, s/p hysterectomy and
radiation therapy to pelvis resulting in radiation colitis s/p
bowel resection, IBD, recurrent pyelonephritis, with recent
admission for ___ ___ requiring bilateral PCNU
placement and balloon ureteroplasty who presents with bilateral
flank pain and ___ ___ urinary obstruction. S/p ___ PCN
replacement on ___ with improvement in pain, completed 6 days
of zosyn and 1 dose of fosfomycin for pan-sensitive Proteus UTI.
TRANSITIONAL ISSUES
====================
New Medications: None
Changed Medications: None
Stopped/Held Medications: None
[ ] Assess resolution of diarrhea after finishing antibiotics at
outpatient follow-up. | 148 | 92 |
11432819-DS-5 | 29,167,571 | Dear Ms. ___,
You were admitted to ___ because you were having worsening
abdominal pain, nausea, and vomiting.
You were found to have inflammation of your pancreas (Acute
Pancreatitis) based on your symptoms, blood tests, and imaging
tests. You were treated with hydration through your IV and with
medications to address your pain. You were monitored closely
until you were able to eat and your pain improved.
Unfortunately, we do not know why you developed Acute
Pancreatitis. But to prevent future episodes, please avoid any
alcohol and eat a healthy diet.
It is also incredibly important for you to continue taking your
medications to prevent rejection of your liver transplant and to
follow up closely with your outpatient doctors!
Please do not take ranitidine any more, as this can make you
more likely to have further pancreatitis. We will replace it
with a similar medication called "famotidine," which does not
have these risks.
Thank you for allowing us to be a part of your care,
Your ___ Team | Ms. ___ is a ___ yo woman with PMHx of PSC s/p liver tx in
___ c/b acute moderate allograft rejection on triple
immunosuppression, untreated HCV, CKD who was transferred for
abdominal pain found to have pancreatitis. | 164 | 37 |
10150423-DS-3 | 29,203,506 | Dear Mr. ___,
WHAT BROUGHT YOU TO THE HOSPITAL?
You came in with fever and several episodes of vomiting.
WHAT WAS DONE IN THE HOSPITAL?
You were found to have a pneumonia. You were treated with
antibiotics. We held your blood pressure medications, as your
blood pressure was on the lower range while in the hospital.
Your liver enzymes were found to be elevated.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You should continue your antibiotics as prescribed.
-You should follow-up with your primary care provider.
-You should get your liver enzymes checked within one week.
-Weigh yourself every morning.
-Call a physician if your weight goes up more than 3 lbs in one
day or more than 5 lbs in one week.
We wish you the very best. It was a pleasure taking care of you
in the hospital.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with CAD s/p NSTEMI ___, DES
to LAD (c/b ICU stay with Impella, vaspopressors, and
intubation), HFrEF (EF 45% ___, HTN, DM2, who presented for
fever and vomiting for 2 days and found to have right lower lobe
consolidation on CXR concerning for community-acquired
pneumonia. | 132 | 54 |
12189469-DS-17 | 24,293,553 | YOU ARE LEAVING AGAINST MEDICAL ADVICE DESPITE A THROUGH
DISCUSSION REGARDING THE RISKS. OUR RECOMMENDATION IS REHAB. YOU
ARE BEING DISCHARGED HOME AGAINST MEDICAL ADVICE.
BELOW ARE INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY FOR A SAFE
DISCHARGE:
- 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 right lower extremity
- Aircast boot for ambulation
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Weight bearing as tolerated right lower extremity
Aircast boot for ambulation
Treatments Frequency:
Dry sterile dressing changes as needed
Aircast boot for ambulation | YOU ARE LEAVING AGAINST MEDICAL ADVICE DESPITE A THROUGH
DISCUSSION REGARDING THE RISKS. OUR RECOMMENDATION IS REHAB. YOU
ARE BEING DISCHARGED HOME AGAINST MEDICAL ADVICE.
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibia intramedually nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. However, the patient refused
rehab and left against medical advice despite a thorough
discussion regarding the risks. He was discharged home with
services against medical advice. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 313 | 307 |
18785721-DS-13 | 25,125,958 | You were admitted with fainting episodes. This is likely due to
blood pressure changes that develop when you eat large meals,
urinate, defecate and wake up in the morning. You need to be
very careful when you eat to have small frequent meals. You can
also buy compression stockings.
Normally, for the irregular heart rate that you have, you would
be started on anticoagulation. However, because of your risk of
falls and the anticipated carotid surgery that you are going to
have, blood thinners (anticoagulation) were not started. You can
discuss this further with your primary care doctor. | The patient is an ___ year old male with a history including CKD
and hypertension and recently found to have severe left carotid
stenosis who presents with syncope.
#SYNCOPE: He was recently hosptalized at ___
___ after presenting there with multiple episodes of syncope,
one of which caused clavicular fracture. The work-up there
included CT head (no acute process), TTE with bubble study
(normal EF, no significant valvular disease), and carotid
ultrasound (left 80-99% stenosis). He left prior to completion
of evaluation (AMA). He returned home and experienced another
episode of syncope (no prodrome, sitting in chair at time, slow
return to baseline over 20minutes). During this admission he
experienced an episode of syncope while on telemetry. This
occurred 30min after eating breakfast, no prodrome, while
sitting in a chair, slow return to baseline alertness over
20minutes. Telemetry showed atrial fibrillation at a rate in
___ without conversion pause or malignant arrhythmia.
MRI/MRA brain did not demonstrate a vascular or cerebral
abnormality. EEG was obtained and was unremarkable.
Orthostatics were normal. Labetalol was held. He was evaluted
by neurology and cardiology. The most likely etiologies
included neurogenic syncope and post-prandial orthostatic
hypotension. He was encouraged to eat small meals, stay
hydrated, and change positions slowly.
#PAROXYSMAL ATRIAL FIBRILLATION: He denied history of atrial
fibrillation. The labetalol was stopped and he was started on
metoprolol for rate control. His CHADS2 score is two (age, HTN)
and thus he would benefit from systemic anticoagulation. He
decided not to start anticoagulation in the hospital and said he
would think about it. The risks and benefits of systemic
anticoagulation were discussed with him.
#CAROTID STENOSIS: He was found to have left carotid stenosis of
80-99% at ___. This was repeated at ___ and
confirmed. He was evaluated by vascular surgery. He was started
on aspirin. He was continued on atorvastatin. Vascular surgery
will call the patient to arrange follow up and surgery.
#CKD: He was found to have a creatinine of ~3.0 with an unknown
baseline. The etiology may be due to hypertension. He has a
follow up appointment arranged at ___ to follow up
with nephrology for further evaluation.
#HYPERTENSION: Labetalol was stopped. He was started on
metoprolol.
#PULMONARY NODULE: He was found to have a "vague 2cm pulmonary
opacity" with radiology recommending non-urgent CT chest to
further evaluate.
TRANSITIONAL:
[ ] non-urgent CT chest to evaluate pulmonary opacity | 97 | 407 |
19713100-DS-79 | 26,548,607 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted with confusion and
weakness and found to have a recurrent urinary tract infection
and heart failure. You were treated with antibiotics and
improved. You also had a bladder catheter for a short time. This
was removed prior to discharge.
For your heart failure, you were treated with IV furosemide. You
no longer need oxygen and you should take the same dose of
furosemide you were taking prior to admission.
You will need to take 2 additional days of antibiotics after
discharge. | The patient is a complicated ___ year old male with multiple
medical problems including CAD s/p CABG x 2, s/p bioprosthetic
AVR, incomplete bladder emptying who presented with malaise,
leukocytosis and UTI and also new oxygen requirement concerning
for acute diastolic heart failure, confirmed on CXR. Given IV
lasix and Cipro-> to Meropenem empirically due to myoclonic
jerking previously described. Transitioned back to Ciprofloxacin
with improvement in myoclonus. Also with troponin leak and
stable EKG consistent with demand ischemia from CHF. Also
concerns for dementia and night terrors. Followed by geriatrics
and started on low dose olanzipine for agitation.
#Acute encephalopathy/Malaise:
Likely related to recurrent bacterial UTI, hypernatremia and
diastolic CHF (see below). Also with report of months of
insomnia and shouting at night. Daughter concerned for
underlying dementia, psych condition, or ? PTSD. Consulted
Geriatrics. Geriatric depression screen was negative. His mental
status began to improve begining ___ as his tremors resolved
and his Na improved to the 130s. The patient would benefit from
futher evaulation and work up of his subacute change in mental
status once his urinary tract infection has been treated. He
remains oriented x2-3 with intermittent periods of agitation and
confusion.
#Klebsiella UTI: Positive UA and similar presentation to prior.
Was started on Cipro at first given recent sensitive urine
cultures. However, has h/o ESBL organisms. Per previous neuro
note, cipro increased myoclonic jerking, so changed to Meropenem
pending urine culture. Also monitoring PVR given known
retention, currently in the 200s. The culture was later Cipro
sensitive and was switched back (following discussion with the
patients daughter that stated she believes it was the UTI and
not the cipro that makes him jerking more pronounced). The
patient has no further episodes of myoclonic jerking. He was
discharged on oral Cipro to complete a ___cute diastolic CHF:
CXR with pulmonary edema and troponin leak. Continued on BB and
statin. Given IV lasix with good results. The patient was
resumed on his home dose of Lasix 20mg daily on discharge.
Weight is 185.
# Hypernatremia: In the setting of diruresis and poor water
intake the pts Na went up to 147. He became increasingly
lethargic. He was given 2L of free water and his Na and mental
status appeared to improve over the same time course. Sodium on
discharge is 141.
# Myoclonic jerking: Of hands, neck, and face. Discussed with
daughter and this increases with UTI. Has been seen by neuro in
the past for this. Although prior notes have recommended
avoiding Fluoroquinolones the patients jerking appeared to
improve in the setting of UTI tx and free water correction. No
further episodes of myoclnic jerking on discharge.
# Urinary Retention: The pt was noted to have cloudy urine. A
foley was attempted by nursing but unsuccesful. Urology was
consulted on ___ and a foley was placed for acute urinary
retention. The patient has a history of increased urinary tract
infections when he had a chronic foley catheter therefore the
decision had been made in ___ to discontinue the ___. The
patient had his foley removed this admission and had post void
residuals checked which were less than 200cc. He was discharged
home WITHOUT a foley in place.
#Depression and anxiety:
Severe per prior notes and geriatrics. The patient continued to
express depressive symptoms while hospitalized. He continued
mirtazapine and duloxetine and may benefit from further
psychiatric evaulation as an outpatient. | 97 | 571 |
12156613-DS-20 | 26,169,533 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or 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). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
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 | ___ year old male with a known left sided subdural hematoma.
#Left Sided Subdural Hematoma
Patient went to the operating room on ___ for a left sided
craniotomy for subdural hematoma evacuation. The procedure was
uncomplicated. Please see separately dictated operative report
by Dr. ___ further details. Two surgical drains (both
___ left in place postoperatively. Patient was
extubated in the operating room and recovered in the post
anesthesia care unit. He was then transferred to the step down
unit for close neurologic monitoring. He was continued on Keppra
postoperatively for seizure prophylaxis. Postoperative CT of the
head showed no acute intracranial hemorrhage and improvement in
the size of the left sided subdural hematoma. Patient was placed
on flat bed rest and instructed to lay on his right side with
his left side up to encourage drainage. On ___, a repeat CT
scan was grossly stable. The surgical drains were removed, and
the drain sites closed with ___ silk sutures. The patient
remained neurologically stable.
#Polycystic Kidney Disease
Patient is status post kidney transplant for his polycystic
kidney disease. Transplant Nephrology was consulted for
recommendations. Patient was continued on his home mycophenolate
mofetil and tacrolimus. Daily tacrolimus levels were drawn for a
goal of ___.
#Bradycardia
Patient had an episode of bradycardia. A formal cardiology
consult was ordered. Cardiology recommended an ECHO for further
evaluation, which showed low-normal left ventricular function,
but was otherwise normal. Outpatient cardiology follow up
appointment was requested via OMR.
#Urinary Retention
Patient experienced urinary retention and required straight
catheterization intermittently. On ___, a foley catheter was
placed and the patient was started on Flomax. He was advised to
follow up with his PCP regarding continuation of this
medication.
#Disposition
On ___, the patient ambulated well with nursing, carried out
all ADLs and was discharged home without incident. | 595 | 292 |
18555110-DS-5 | 27,844,746 | Dear Mr. ___,
you presented to the emergency room due to a prolonged episode
of vertigo and blurry vision. You had an MRI of brain which did
not show any strokes. This episode may have been a type of
migraine.
However, when we checked your stroke risk factors, you were
found to have high LDL (bad cholesterol) and you have been
started on a medication to control your cholesterol. Please
continue with a baby aspirin as well.
Your creatinine (measure of your kidney function) was also found
to be high. Please follow up with Dr. ___ these issues. | Mr. ___ is a ___ yo man without significant PMH who presented
with an episode of vertigo as well as blurry vision. Upon
further history taking, he complained of more of lights in his
vision instead of blurry; no double vision. His symptoms did not
recur during the hospitalization. On the day of admission, he
had Unterberger sign (turning to left while marching in place)
which resolved by the day of discharge.
His MRI/MRA did not show any stroke or other abnormalities. The
episode was thought to be more consistent with complex/basilar
type of migraine. His stroke lab showed elevated LDL to 189
(triglyceride also high but non-fasting sample), so he was
started on aspirin and atorvastatin for primary stroke
prevention. | 97 | 122 |
11042045-DS-17 | 25,833,141 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because you presented with abdominal
pain which may have been concerning for many different causes
given your history of pancreatitis flares in addition to
pseudocyst formation and gastrointestinal bleed.
What was done while I was in the hospital?
- Pictures were taken that showed that you had a small
increase in the size of your pancreas pseudocyst in the time
interval since your drainage and last scan.
- These pictures also did not show strong evidence to suggest
that you were having an acute pancreatitis attack, which was
also reflected by some of your lab markers, although these may
be diminished in chronic pancreatitis states.
- Your case was reviewed by the ___ pancreas team here who
determined that your new pseudocyst size was incompatible with
physical intervention and manipulation, especially since the
risks may outweigh the benefit given you had a previous bleeding
complication.
- You were started on medications to help control your
abdominal pains and the subsequent nausea which followed.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have any signs of bleeding through vomiting or bowel
movement or sudden worsening abdominal pains, please tell your
primary doctor or go to the emergency room.
Best wishes,
Your ___ team | ___ hx familial hyperTG c/b pancreatitis/pseudocyst and recent
advanced endoscopic procedures, known chronic splenic vein
thrombosis, who presents with abdominal pain admitted for
pancreatitis and inability to take PO. | 257 | 26 |
15287471-DS-18 | 22,836,422 | Ms. ___,
You were admitted to the hospital after you experience chest
pain at rehab. Your blood pressure was extremely elevated at the
time. This is thought to be the most likely cause of your chest
pain. Your EKG and blood tests were reassuring. We also obtained
an echocardiogram of your heart, which was regularly scheduled
given your history of heart valve infection.
Please see the medication reconcilliation page for your complete
medication regimen. Please ensure you take the metoprolol as
directed as this will prevent high blood pressure.
It is important that you receive kidney dialysis on a regular
schedule. You are currently receiving it on a
___ schedule. Please continue this
schedule unless directed by a physician.
An appointment has been made with your Infectious Disease
doctors, the details are below. | The patient is a ___ yo with recent hospitalization for MSSA
endocarditis, septic shock, renal failure, lumbar osteomyelitis
complicated by respiratory failure s/p intubation followed by w/
trach and PEG, recently discharged from ___) and
transferred to ___, admitted with chest pain in setting of
hypertensive emergency, with resolution of chest pain with
normalization of blood pressure.
.
ACTIVE ISSUES
#Chest pain:
Patient with substernal chest pain/pressure day before admission
in setting of hypertension to 240s SBP (reported). Per history,
patient had not received HD yesterday and had missed doses of
metoprolol. Initial troponins are mildly elevated, but patient
on dialysis. MB component normal and unchanged at 3. Her CXR was
not suggestive of intrapulmonary or acute aortic process. EKG
was without changes other than rate. Given hypertension to 240s,
patient most likely with some demand ischemia, especially since
chest pain and symptoms resolved completely once pressures
reduced. CAD less likely given no EKG changes and no elevation
of MB component. Troponins were not of diagnostic quality given
the patient's renal disease. A stress echo was considered, but
given no further symptoms (and given symptoms occurred
originally in sleep), thought unlikely to be exertional.
.
# Hypertension:
Likely hypertensive in setting of missed HD and held metoprolol
dosing since patient was likely well-controlled prior to
discharge from ___. Meds were restarted and pressures have
decreased to 120s systolic.
.
# Renal failure:
Thought to be secondary to hypotension during episode of septic
shock during last admission. Also question of AIN from
previously antibiotic use. Recently switched from ___ to TTS
dialysis schedule.
.
# h/o MSSA mitral valve endocarditis:
Antibiotic course completed in ___ with follow-up in ___
clinic. No episodes of fever. Patient has been getting TEEs,
last ___ without vegetations. Patient was expecting to get
TTE per ___ clinic note now. An echo was obtained which did not
demonstrate any vegetations.
.
#Osteomyelitis:
Patient with history of osteomyelitis, with antibiotic regimen
completed in ___. A follow-up MRI was obtained prior to
hospitalization without indication of osteomyelitis.
Inflammatory markers were obtained in the ER which showing a CRP
trending downwards, but elevated ESR compared to recent trend. A
follow-up appointment has been made with Infectious Disease.
.
TRANSITIONAL ISSUES
#Patient should continue on metoprolol dosing as specified in
medication reconcilliation.
#A stress test can be considered as an outpatient.
#Patient should receive hemodialysis on new ___,
___ schedule unless otherwise directed by physician.
#Patient should follow-up with Infectious Disease to review
results of imaging and lab work.
#Patient should receive physical rehab. | 129 | 406 |
11764279-DS-18 | 27,362,844 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with pneumonia and were found to be in heart failure, as well.
We treated you with IV antibiotics to treat the infection and
diuretics (lasix) to get rid of extra fluid. In addition, our
interventional radiology team exchanged and finally pulled your
biliary drain. You also had an octreotide scan, which showed
that your cancer is stable and unchanged from prior scans. Your
symptoms gradually improved and we discharged you to rehab so
that you can regain your strength.
Please follow-up at the appointments below that have been
scheduled for you.
On behalf of your ___ team, we wish you all the best! | Ms. ___ is a ___ with COPD (on nighttime O2), HTN, and
metastatic abdominal neuroendocrine cancer who was sent in from
rehab for fever, cough and CXR findings c/f pneumonia.
# HCAP: History and exam findings consistent with pneumonia. CXR
with ?lower lobe opacities (vs irregular diaphragm seen on
previous CTs). Given increased work of breathing, fever to
101.7, WBC 14, and CXR showing multifocal rounded opacities in
lower lungs, as well as rehab/recent admnission, she was treated
for HCAP with vancomycin and cefepim (note she has listed CTX
allergy but has tolerated Cefepime in the past) for a total of 7
days. Later azithromycin was added (5 days total) for atypical
coverage given her slow recovery. She was continued on nebulizer
treatments (albuterol and ipratropium). Her symptoms were
continuing to improve, albeit slowly, on discharge. She had a
repeat CXR on ___ due to her persistently high O2 requirement
(4L), which showed interval improvement compared to prior films.
Her slow improvement is most likely due to poor baseline lung
parenchyma due to COPD and component of volume overload from
decompensated heart failure. She was discharged with uptrending
O2 requirements.
# Hyponatremia: At admission, sodium was 129, but increased to
133 following additional 60 mg IV lasix. Most likely
hypervolemic hyponatremia given response to diuresis. Continued
to appear hypervolemic on physical exam. . We continued to
provide additional IV diuresis as needed and she needs
outpatient f/u of cardiac status and diuretic regimen. She was
discharged on a lasix dose of 100 mg PO daily.
# Acute on chronic dCHF exacerbation: Cardiac echo from ___
showed nl LVEF but mod pulmonary artery HTN and mod-severe
tricuspid regurgitation. New worsening PASP and 3+TR may be due
to OSA, kyphosis, CTEPH or even malignant spread of her
neuroendocrine tumor. Fortunately, ocreotide scan showed no
progression of her disease. Elevated alk phos most likely
secondary to right-sided heart failure. She was diuresed with IV
lasix while inpatient, but discharged on 100 mg PO lasix. Her
home dose is 60 mg daily, however, she still appeared volume
overloaded on discharge and will require further diuresis at
rehab. Etiology of heart failure should be followed-up as an
outpatient.
# Biliary leak s/p Biliary drain: Patient with biliary drain
placed ___ in the setting of biliary leak s/p TACE.
Currently, Alk Phos elevated at 284 but is lower than prior
admisison ___ AP 690). The patient did not have TBili
elevation or abdominal pain. She is due for reimaging of the
drain and potential removal. The drain was replaced on ___ and
was removed on ___. Initially there was lots of drainage
requiring ostomy bag for collection, however, this subsided.
# Afib with RVR: Patient had history of paroxysmal afib in the
past but had never been symptomatic. Her metoprolol succinate
50mg qday was held due to soft pressures from aggressive
diuresis. On ___, patient had central chest pain radiating to
her left shoulder and was noted to be in afib with RVR with
heart rates in the 150s-160s. 5mg IV metoprolol was given with
blood pressures decreasing to the high ___. She was bolused
IVF with mild improvement in blood pressures and was transferred
to the MICU. She spontaneously converted with increasing doses
of metoprolol tartrate and was briefly on a phenylephrine gtt.
She was transferred back to the floor on ___. Patient
remained in rate-controlled, sinus rhythm for the remainder of
her stay. Discharged on metoprolol 50 mg succinate daily (home
dose) and aspirin 81 mg. Outpatient discussion of
anti-coagulation is warranted, as her CHADs2vasc is 3 now with
new diagnosis of diastolic CHF.
# Constipation/Abdominal discomfort: Patient had required
disimpaction prior to her hospital stay and was significantly
constipated upon arrival. She was having pain from straining. An
aggressive bowel regimen was started that resulted in copious
bowel movements. Her bowel regimen was downtitrated at
discharge.
# HLD: Stable. She continued simvastatin 10 mg PO QPM and
aspirin 81 mg daily
# Rib fractures: Stable. She continud home pain regimen with
Tylenol, PO diluadid, oxycontin, and fentanyl patch.
# Hypothyrodisim: Stable. She continued home Levothyroxine
Sodium 75 mcg PO DAILY.
# Code: Full
# Emergency Contact: ___ (daughter) ___ | 116 | 691 |
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