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18249057-DS-4 | 22,038,389 | You were admitted to the hospital with abdominal pain, nausea
and vomiting which contained blood. Your pain is likely
attributable to an ulcer in your gastric remnant for which you
received intravenous antacid, with subsequent improvement of
your symptoms. You are now prepared for discharge with the
following instructions:
Please call your surgeon or return to the emergency department
if you experience emesis of blood or bloody bowel movements.
develop a fever greater than 101.5, chest pain, shortness of
breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, or any other symptoms which
are concerning to you.
Please take omeprazole 40 mg twice a day, for 6 months. | The patient was admitted to the Bariatric Surgery service at
___ for abdominal pain. He underwent an abdominal CT scan,
EGD, and abdominal ultrasound in evaluation of his pain. His
abdominal pain improved, and he denied any hematemesis or blood
per rectum. Below is a hospital course by systems.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intermittent
narcotics and IV tylenol and then transitioned to oral Roxicet
once tolerating a stage 2 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 Bariatric Stage 3 diet, 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.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and abdominal pain
resolved. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 122 | 258 |
13131177-DS-10 | 20,651,719 | Dear Ms. ___,
You were admitted to the hospital with abdominal pain and
inflammation of your pancreas due to an obstructing gallstone.
It is believed that this gallstone passed on its own. To
prevent further gallstone disease, you were taken to the
operating room and had your gallbladder removed
laparoscopically. This procedure went well. You are now
tolerating a regular diet and your pain is better controlled.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ is a ___ year old female with no significant past
medical history, who presented to ___ with approximately 2
days of diffuse abdominal pain. She had an elevated WBC(14.5)
and elevated lipase. Liver enzymes were normal without typical
signs of either cholecystitis or gallstone pancreatitis.
Gallbladder US showed cholelithiasis without cholecystitis. The
patient was admitted to the Acute Care Surgery service for
further care.
On ___, the patient underwent laparoscopic cholecystectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor on IV fluids, and
acetaminophen and oxycodone for pain control. The patient was
hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge on ___, 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 was given a prescription
for the pain medication Tramadol. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 778 | 244 |
10113036-DS-15 | 20,558,872 | Please take KEFLEX (cephalexin) to continue treatment of your
cellulitis. Please take this right up until you return for your
procedure in four days time. Otherwise your meds are the same as
prior to admission.
On the morning of your surgery (___), make the following
changes to your meds:
- HOLD metformin
- HOLD furosemide (Lasix)
- HOLD apixaban (Eliquis)
- decrease your long-acting insulin dose by 25%
(If plastic surgery give you recommendations on what to do with
your meds, that supersedes my recommendations as above.)
For wound care, soak a non-adherent dressing in Betadine
(iodine-based antiseptic), cover with gauze, and wrap in an ACE
wrap. Do this daily (or more frequently as needed if the
dressing gets soaked or dirty).
Use your crutches and try not to bear weight on the foot. If you
do need to take a couple steps, try to walk on the heel or toe,
rather than step flat. | ___ a-flutter (on Eliquis), HFpEF, HTN, DM2 (c/b CKD III,
neuropathy w/ R Charcot foot), R foot abscess (s/p operative
debridement, split-thickness skin graft; now w/ chronic
non-healing R plantar wound), admitted w/ recurrent RLE
cellulitis.
#RLE Cellulitis:
Patient initially had a superficial spreading bright-red
erythema around his calf, shin, and dorsomedial foot. The
plantar wound itself did not appear purulent, and as the
erythema receded with treatment, the affected area was clearly
not contiguous with the wound (although it was still the likely
site of entry). Based on this clinical appearance (and him
having no history of MRSA), he was de-escalated from vanc/Zosyn
to just Ancef 2g TID. Over four total days of antibiotics, the
erythema resolved, leaving only venous stasis changes. He is
discharged on Keflex, which he will take for four more days.
#NON-HEALING R PLANTAR WOUND
This did not appear clinically infected, although it is the
likely entry site for the causative pathogen of his cellulitis.
Recent angiogram showed good blood flow to the foot. Plan is for
upcoming free tissue transfer with plastics. He is on the OR
schedule for ___. Until then, he will continue
wound-care with a non-adherent betadine-soaked dressing and
compressive ACE wrap.
#HTN:
-Continue home labetalol
-Continue home diltiazem in fractionated doses
#Atrial Flutter:
- Continue home Eliquis
#Chronic diastolic HF
Currently euvolemic. JVP is low, but no exam findings to suggest
hypovolemia either.
-Continue home lasix 40 mg daily
#Diabetes: A1c 7.5
- Continued home glargine/meal time Humalog and SSI
- continue metformin; note that his renal function is BORDERLINE
for this med and it may soon need to be stopped.
#Hypothyroidism:
-Continued home levothyroxine
#Gout
-Continued home allopurinol
#ASYMPTOMATIC BACTERURIA
UA showed few bacteria and no pyuria. Urine culture was sent in
the ED, although he has no lower tract symptoms; this grew a
very nasty ESBL Klebsiella, sensitive only to amikacin. If he
ever does develop a UTI, note that he would need empiric
amikacin.
#MICROSCOPIC HEMATURIA
This non-smoking patient under ___ is probably at low enough risk
for bladder cancer that cystoscopy would not be needed, unless
the finding is persistent. No mass on ___ renal US.
***TRANSITIONAL ISSUES***
BP was slightly high (systolic intermittently around 160). If
this persists at clinic follow up, would increase
antihypertensives.
Note that his renal function is BORDERLINE for metformin and
this med may soon need to be stopped.
Repeat UA to make sure microscopic hematuria is not persistent. | 148 | 392 |
11793360-DS-28 | 24,774,465 | Dear ___ was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you were confused
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you had lots of tests and
imaging but no new changes were found
- Your thinking cleared
- You started methadone for pain
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team | Summary:
----------
Mr. ___ is a ___ year-old man with multifactorial
dementia ___ TBI, CVA, polysubstance use, MDD with psychotic
features, numerous readmissions for AMS and SI, admitted again
for the same in addition to question of acute on chronic toxic
metabolic encephalopathy with negative workup for acute process.
Medically stable for discharge. | 100 | 51 |
16428221-DS-28 | 29,883,182 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came to the
hospital with bloody stools. You required blood transfusions
and you had an endoscopy that did not show a clear source of
bleeding. You also became very sleepy during your hospital
course, but you recovered. Your pain medications and gabapentin
have been decreased and your ambien has been stopped to avoid
confusion. Please follow up with your gastroenterologist.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | MEDICAL FLOOR COURSE
# Encephalopathy: The pt was taken for EGD on ___, requiring
general anesthesia and intubation. Following extubation, the pt
was somnolent. Initially, this was felt to be related to
anesthetic effect. However, the pt's mental status did not
improve. On ___, she was too somnolent to be consented for
her colonoscopy. The pt continued to be A&O x 2, inattentive,
easily agitated, and perseverative throughout the morning of
___. At around 12:30 ___ on ___, the pt triggered for
altered mental status. She was not tachycardic, hypotensive,
febrile, or hypoxic. Her work up was notable for ___, but
otherwise was unrevealing. All of her sedating medications
(oxycodone, zolpidem, gabapentin) were stopped. The pt
continued to be somnolent and at around 5 ___ on ___ a VBG
showed CO2 retention. The medical ICU was consulted given
concern for hypercarbic respiratory failure. Nalaxone was
administered and produced a short-lived response, but repeat VBG
continued to show CO2 retention and the pt was transferred to
the medical ICU for naloxone drip and possible BiPAP on ___
in the setting of hyerpcarbic respiratory failure. She improved
and was transferred back to the floor.
# Gastrointestinal Bleed in the Setting of Hereditary
Hemorrhagic Telangiectasias (HHT): The pt presented to the ED
with bloody BMs. She has a history of multiple prior GIBs from
HHT requiring blood tranasfusions. Her hgb was 4.4 on admission
and she ultimately received 3 U pRBC on ___. Her hgb
stabilized by ___. She had EGD on ___ showing multiple
AVMs without a clear culprit lesion. She had 8 AVMs treated.
She was scheduled to undergo colonoscopy on ___, but this
was aborted due to encephalopathy. She remained on a BID PPI.
The gastroenterology service was following throughout the
medical floor course.
# Acute Kidney Injury: The pt's creatinine was 0.9 on admission
and increased to 1.7 by ___. This was likely related to
volume overload. The pt's ___ likely decreased renal clearance
of sedating medications and may have contributed to the pt's
development of encephalopathy.
# Diastolic CHF from pulmonary HTN with right to left shunting
via PFO vs proximal intrapulmonary shunting from HHT with
chronic hypoxemia: Dry weight is approximately 185 pounds. Pt
did not feel volume overloaded and had no ___ edema, JVD, or
crackles on admission. Her furosemide was held in the setting
of GI bleed, in holding became volume overloaded requiring
diuresis with IV Lasix. She improved and was transitioned to
home PO Lasix.
# DM II: Followed by ___. On Glargine 18 U QAM and 22 U QHS
with Humalog SS at home. Decreased insulin dose while on clear
liquid diet and NPO.
# HTN: Held lisinopril in setting of GIB, resumed on discharge.
# OSA: Continued CPAP
# Asthma: Continued supplemental O2 and albuterol
# Gout: Continued home colchicine
# Chronic pain: Continued gabapentin, oxycodone on admission.
These medications were stopped on ___ in the setting of
altered mental status. Ultimately restarted home oxycodone as
her mental status improved since it seemed she was having opioid
withdrawal, but her oxycontin was held, Neurontin dose was
decreased.
#Insomnia: On discharge encouraged pt to stop zolpidem, although
pt resistant. Discharged with instruction to take half her usual
dose (5mg) given concern for use of higher dose in women.
# HLD: Continued simvastatin
MICU COURSE: ___
On evening of ___, patient was noted to be less responsive. Out
of concern for decreased responsiveness this evening, a venous
blood gas was obtained which was 7.18/___, with physical
examination notable for pinpoint pupils and bilateral pulmonary
crackles. The patient was administered Narcan with improvement
in mental status, and gradual improvement in her blood gas to
7.19/69, and 1 hour later 7.24/___ after administration of second
dose of Narcan. The decision was made to transfer the patient to
the MICU for closer observation and management of hypercarbic
respiratory failure resulting in respiratory acidosis.
#Hypercarbic respiratory failure: Likely secondary to opiate
administration in the setting of ___, as the patient improved
after administration of narcan x2 on the floor. Also likely
component of volume overload, as patient with trace edema and
bilateral crackles on physical examination. Patient started on
narcan gtt in the MICU with return to baseline mental status.
She also received IV diuresis with lasix with improvement in her
respiratory status
#Fever: Patient febrile to 101.4 prior to transfer to MICU, no
localizing symptoms at that time. Given normal WBC and absence
of clear infectious source, antibiotics was held. Infectious
workup was repeated upon arrival.
# Acute blood loss anemia: Pt has history of multiple GI bleeds
in the past from HHT and has required transfusions in the past
and during this admission. On transfer to MICU, Hgb noted to be
6.9 and she received 1U PRBC. No frank bleeding during MICU
stay.
MEDICAL FLOOR COURSE 2
# Encephalopathy: On return to the floor, the pt's was improved,
but she remained encephalopathic. She was inattentive and
responded to questions inappropriate. She also remained
disoriented. On ___, her mental status was greatly
improved. She was discharged on Percocet 5 mg Q6H PRN pain,
gabapentin 100 mg TID (down from 800 mg TID), and zolpidem
decreased from 10mg to 5mg to minimize sedating medications.
# Acute Blood Loss Anemia from GI Bleed in the setting of HHT:
Last transfusion was ___. Her hgb remained stable during
her second medical floor course. Deferred further intervention
given concern for encephalopathy.
# ___: Her ___ was likely related to volume overload, resolved
with diuresis. Anemia may also have contributed. Her
creatinine returned to baseline and was 0.9 on discharge.
# Diastolic CHF from pulmonary HTN with right to left shunting
via PFO vs proximal intrapulmonary shunting from HHT with
chronic hypoxemia: On return to the floor, was found to be
volume overloaded in setting of holding home furosemide. She
received 40 mg IV furosemide on ___ and was restrated on her
home 40 mg PO furosemide per day on ___. She is on
supplemental O2 at home at baseline.
# DM II: Followed by ___. On Glargine 18 U QAM and 22 U QHS
with Humalog SS at home. Halved insulin dose while on clear
liquid diet and NPO. Blood sugars continued to be well
controlled on this decreased regimen in hospital after diet was
advanced, so was continued on discharge.
# HTN: Held lisinopril in setting of GIB, resumed on discharge.
# OSA: Continued CPAP
# Asthma: Continued supplemental O2 and albuterol
# Gout: Restarted home colchicine when ___ resolved
# Chronic pain: Decreased doses of gabapentin and oxycodone as
above
# HLD: Continued simvastatin | 90 | 1,123 |
13352668-DS-6 | 28,762,495 | You presented with acute worsening of your chronic abdominal
pain. You had a CAT scan of your abdomen and pelvis which did
not show any acute issues. You also had lab work, which was
normal. Of note, you did have 1 fever on the day of admission,
but then you had no fevers after that.
You were seen by the endocrinologists. You were also seen by the
gynecologists. It seems that your pain is most likely related to
your long-standing endometriosis. You were given the name of ___
gynecologist who specializes in treatment of this.
Finally, when you were seen by the endocrinologists, you
mentioned concerns over your lack of menstrual cycles. You
should have some hormonal studies sent as an outpatient. You
should discuss this with your PCP as well as at your gynecology
follow up appointment. | ___ y/o F with PMHx of endometriosis, presenting with acute on
chronic R-sided abdominal pain.
# Acute on Chronic Abdominal Pain, N/V
# Endometriosis
The patient reported long-standing ___ year) chronic abdominal
pain, for which she was most recently on suboxone.
Unfortunately, attempts to reach her suboxone provider or former
PCP were unsuccessful. CT A/P without acute process. Initially,
there was concern that symptoms could be related to narcotic
withdrawal, given that she recently self-tapered suboxone.
However, ultimately the time course was not felt to be
consistent with this. The patient reported a long-standing
history of endometriosis, for which she states she had 1 ovary
removed. She feels that this is the etiology of her s/s. Of
note, she did have a fever on initial presentation to the floor
but had no further fevers. There was initial concern for
Addisonian crisis given her reported history of Addison's;
however, she was ultimately felt to not have Addison's (see
below). GYN was consulted and performed pelvic exam, which did
not reveal any clear acute process. Pelvic ultrasound was also
unremarkable. GYN recommended pain control, pelvic floor ___, and
outpt f/u for consideration of TAH.
# Concerns for Narcotic-Seeking Behavior
Of note, during admission, the pt did exhibit some some
concerning behaviors regarding her pain control. She demanded IV
meds over PO's; and, per RN's, asked that her doses be given by
push. When switched to PO pain meds and told that she couldn't
get an IV dose because she had just gotten a PO dose, she asked
about inducing vomiting so that she could get an IV dose.
Furthermore, despite reports of ___ pain and writhing in her
bed with pain, her HR remained in the 40's-50's. Nevertheless,
given her prior oophorectomy as well as prior suboxone therapy,
it was felt that the patient does likely real disease / pain. In
the end, her pain is likely multifactorial, including organic
disease (endometriosis) as well as psychosomatic issues. Given
significant discomfort and distress on exam, she was initially
treated with IV pain medications. However, given her stated goal
of getting home ASAP as well as her ability to tolerate clears,
she was transitioned to PO pain medications. While she stated
that PO meds did not help, she appeared much more comfortable on
exam. She was able to sit up and hold a complete conversation,
only expressing discomfort intermittently during discussion.
Ultimately, the patient reported that, given no acute issue seen
on labs or imaging, she would rather go home because she feels
that she would be more comfortable there. She plans to call
___ and ___ tomorrow AM to make follow up
appointments. She was discharged with a small amount of PO pain
medications with instructions to follow up closely at ___
___ for referral to a pain specialist.
# Amenorrhea:
Given amenorrhea > ___ year, endocrine recommended bHCG, FSH, LH,
prolactin. This can be done as an outpatient. Encouraged patient
to discuss having this lab work done when she follows up with
her PCP.
# Prior Diagnosis of Addisons:
Cortisol 45 during this admission. Not consistent with Addison's
per endocrine assessment. | 136 | 513 |
10833322-DS-19 | 21,829,601 | Dear Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you were not yourself
at the nursing home you were in, and were found to have the flu
and pneumonia.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were started on anti-viral medication and antibiotics to
treat your infections. Y
- While you were in the hospital, you developed some loose
stools caused by an infection called C. Dificile. We gave you an
antibiotic for this.
- You had some episodes of low blood pressure which were related
to dehydration from your diarrhea. We gave you fluids for this.
- Our physical therapists worked with you and did not feel that
you would be safe at home without people to help you ___. We
discussed this with you and with ___ and ___. You
declined to go to rehab, so we worked to have as many extra
supports as possible at home.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team | ___ presents from rehab with agitation, found to have influenza,
community acquired pneumonia. He recovered with Tamiflu and
antibiotics but developed c dificile in house. On discharge he
was recommended to go to rehab, but patient adamantly refused.
After substantial discussion of risks and benefits from the
patient's healthcare proxy ___ and ___, the
plan was made to discharge home with ___, homemaker, as well as
some home visits through friends, meals on wheels and ___
services.
#Toxic metabolic encephalopathy/ Possible underlying dementia
#Refusal of rehab
#Discharge planning
#Change of healthcare proxy
His prior HCP and niece ___ reported that he was
previously living at home, had an admission to ___
___ with discharge to rehab at that time. Per Ms.
___ while in rehab he was angry, agitated and combative
with staff. The patient reports that he was trying to get out of
rehab. He was brought back to the hospital for agitation. While
in house he was initially agitated but rapidly cleared with
administration of IVF, and abx for infection as below. ___
evaluated him and recommended discharge to rehab, however the
patient repeatedly and adamantly declined. He remained calm and
did not become agitated unless we discussed possible rehab
placement with him. At baseline he was AAOx3, but did
demonstrate tangential speech. Per family he has difficulty with
dressing and feeding himself due to hand arthritis, and
consistently demonstrated unsteady gate. His understanding of
his strength and ability to care for himself at home were felt
to be poor. This was discussed with his initial healthcare
proxy, his niece ___. The patient changed his
healthcare proxy halfway through the admission to ___ and
___, close family friends. After extensive discussion
regarding the risks and benefits, ultimately the decision was
made to discharge the patient home. We recommended 24 hour care
at home, but unfortunately for financial reasons this was not
feasible. Mr. ___ worked with our case manager and social
worker to increase care for Mr. ___ to include ___,
homemaker several times per week with companion service for
appointments, visits through the ___, meals on wheels, and family
to check in on him. While Ms. ___ Mr. ___ demonstrated an
understanding of the risks of discharging Mr. ___ home, his
consistent and adamant refusal to participate in rehab, and
demonstration of acute agitation on discussion of the topic, he
was ultimately discharged home with services.
#Influenza:
#Community Acquired Pneumonia:
Infiltrate on XR, and productive cough. Treated for CAP with
CTX/azithromycin x5d ___ well as for influenza with
Tamiflu (started on ___. He was afebrile throughout his
admission and his cough resolved with treatment.
#C Diff Colitis
Started having multipel watery stools on ___. C dif positive.
Started on vancomycin ___ to continue through ___ for 10d
course. He did have 2 episodes of hypotension thought related to
dehydration from his stool output. He was given IVF with
improvement with stable blood pressure at discharge. Oral intake
should be emphasized. His metoprolol was held but should be
restarted at discharge.
#COPD: No hypoxia or wheezing on exam. Home medications
monteleukast, advair, and fluticasone were continued.
#Atrial Tachycardia: Rates mildly tachycardic in sinus. BP
stable. Digoxin recently discontinued in the setting of concern
for amyloidosis. Home metoprolol and ASA were continued at
discharge.
#Positive blood culture
Blood cultures positive on ___. Speciated to micrococcus on ___
suggesting contaminant. Started empirically on Vanc on ___,
discontinued on ___ after speciation results. | 218 | 566 |
16813920-DS-18 | 23,412,803 | Dear ___,
___ was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had nausea,
vomiting, headache, and vision changes with extremely high blood
pressure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were found to have a hypertensive
emergency due to extremely high blood pressure. You were given
IV medications to help control your blood pressure in the
emergency department. Following this, you were given your home
medications. However your blood pressure became very low
following administration of these medications, this is likely
because you are not consistently taking all of your blood
pressure medications while you are at home. Over the next few
days, your blood pressure medications were adjusted to an
appropriate regimen. You should continue follow-up with your
cardiologist and primary care physician for further adjustment
of these medications.
- You were evaluated by rehab services here and they recommended
that you go to a rehab facility to regain strength and function
and prevent future falls.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
___ female with history of hypertension, diabetes, ESRD
on ___ dialysis who presented with
hypertensive emergency (nausea, vomiting, headache, vision
changes) requiring nicardipine drip in the emergency department
subsequently switched to home antihypertensive regimen. She was
found to be acutely hypotensive after taking all of her home
meds which indicated that she likely was not adherent, which she
also endorsed. She was restarted on part of her home medication
regimen and discharged to rehab with a plan to further adjust
medications as an outpatient. | 212 | 87 |
10221634-DS-4 | 27,654,198 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital after having a
seizure at work. You were initially intubated, but extubated
soon and you remained stable. You were started back on your
previous dose of Keppra (1000 mg twice a day), to be continued
indefinently to prevent future seizures.
It is improtant that you do not drive after a seizure for 6
months. Stay away from any activity that could be dangerous if
you were to have another seizure, including climbing on ladders,
heights, swimming, bathing in a bathtub, mowing the lawn or
operating other heavy machinery. Limit alcoholic drinks to a
maximum of two per day, and avoid any flashing lights/strobe
lights as these may precipitate seizures.
It is important that you continue to take all your medications
as prescribed and keep your follow up appointmens. | Neuro:
The patient presents via EMS from work as a ___
where he was witnessed to have a generalized clonic seizure c/b
impact to the left forehead s/p intubation. The duration was
unknown, and the patient was unresponsive after the event.
Intubation was attempted in transport but was unable to be
achieved. Upon arrival at ___, the patient was successfully
intubated upon ABG findings of severe acidosis (pH 7.1, HCO3 -
9). Of note, the patient had an almost exactly similar event in
___ at the same place at work at which time his meningioma
was identified. ___ demonstrated no acute process,
identifying the left frontal cortex s/p resection. In the ED
the patient was loaded with Keppra, started on continuous EEG
monitoring, and admitted to Neurology.
The patient was transferred from the ED after stabilization to
the NICU for further management, where repeat ABG showed
resolution of his acidosis. Of note, his responsiveness
significantly improved and after EEG evaluation revealed no
epileptiform activity, the patient was successfully extubated.
On examination after extubation the patient had no focal
deficits, although his exam was complicated by pain in the left
shoulder and thigh where he impacted upon falling after the
onset of his seizure. He also complained of swelling on the
left eye which made his lid feel heavier, although no visual
deficit was noted.
On the morning after admission, the patient reported feeling
better and was looking forward to eating. He again noted no
deficits, and the exam was unchanged from the previous night.
Per the EEG fellow, the study of Mr. ___ continuous
monitoring revealed no epileptiform activity. He was loaded on
Keppra with 1800 mg IV, and was continued on Keppra 1000 mg BID
(to be continued indefinently after discharge). The patient had
some injuries with his fall and GTC. A L shoulder fracture was
suspected and ortho was called, but CT L shoulder showed no
evidence of fracture. The patient was discharged on Keppra with
follow up with his neuro oncologist. He was re-educated about
seizure precautions including no driving x 6 months after a
seizure, no climbing ladders, no swimming or baths, no operating
standing machinery. He was educated to limit alcohol intake to a
maximum of 2 drinks per day and avoid flashing lights to avoid
other seizure triggers. | 144 | 392 |
10922118-DS-26 | 25,156,678 | You were admitted for evaluation of coughing, fever and
shortness of breath. Your symptoms are likely related to
pneumonia. Your symptoms improved with antibiotic therapy.
Please continue to take your antibiotics for the remainder of
their course.
You are taking narcotic medication for pain as previously
prescribed. Take only as directed, keep the medication safe,
take with stool softeners, do not drive when taking this
medication, do not take this medication with benzodiazepine
medication for anxiety such as your lorazepam/Ativan as it could
cause you to stop breathing. | ___ y/o M with PMHx of severe COPD on home O2
(2L), borderline, DM, HLD, GERD, known lung nodules, as well as
oropharyngeal SCC with recent RLL wedge resection for concerning
lung nodule with path consistent with metastatic SCC, who
presented with 5 days of worsening cough productive of
white/yellow sputum, DOE, pleuritic R-sided chest pain, and
fevers, c/w pneumonia.
#pneumonia with fever, cough
#pleuritic post op chest pain
The patient presents with several days of fever (none during
admission), worsening cough and DOE. CXR with no clear
infiltrate, CTA with concern for PNA and emphysema, no PE. Pt
reports only having surgical site related pain that has improved
compared to prior. He was started on a course of ceftriaxone and
azithromycin with marked improvement in his symptoms. Sputum cx
x 2 contaminated. 02 weaned to 2L upon admission and pt was
actually requiring 1L at the time of DC. Pt advised to continue
his 5 total course of abx therapy on discharge,
cefpodoxime/azithromycin. Tylenol and oxycodone provided for
pain relief as per outpt regimen. Thoracic surgery saw the pt
and signed off during admission.
#epistaxis: Likely related to continuous O2 use. none during
admission. Stable h/h during admission.
#severe COPD: On home O2. No wheezing on exam to suggest acute
exacerbation during admission .
Continued home meds- home Advair, Spiriva, Mucinex
# METASTATIC OROPHARYNGEAL SCC: Pt recently underwent wedge
resection with pathology consistent with metastatic
oropharyngeal
SCC. He has been referred for f/u with his outpatient
oncologist.
Given presentation with fevers, he was seen by thoracics in the
ED, who felt that surgical site was healing well with no
concerns. Pt will f/u with his outpt oncologist as scheduled to
discuss next steps in tx plan.
# BORDERLINE DM: Pt not currently on any medications. Monitored
___ and remained acceptable during admission.
# HLD: continued home statin
# GERD: continued home PPI | 90 | 293 |
10709096-DS-7 | 20,869,326 | * Your injury caused pelvic and spine fractures
* 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.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves. | (c/s) ___ early Alzheimers s/p mechanical fall ___ stairs with L
sup/inf pubic rami fx, left sacral fx with assoc pre-sacral
hematoma, T11 compression fx. Orthopedics was consulted and
recommended WBAT to LLE, f/u w ortho trauma in 4 weeks Dr.
___. Serial crits were checked and they have been stable.
___ Serial H/H: 00 am. (33.3) 4am (31.8)--> 5pm ( 31.5). On
___, ___ and OT saw patient and recommended rehab.
Neurosurgery was consulted and they rec. TLSO brace worn when
OOB. On ___, the patient was tolerating a regular diet, pain
was controlled, having abdominal function, and was ready for
rehab disposition. | 156 | 106 |
17129167-DS-23 | 29,760,143 | Dear Mr. ___,
You were admitted to the ___
for feeling weak. You had studies of your heart and lung that
did not show anything was worse. You likely have "bronchiolitis"
or inflammation in your lungs. You got better with antibiotics.
It was a pleasure taking care of you at ___. We wish you well
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | In brief this is a ___ with CAD s/p CABG ___ (left axillary ->
LAD using R thigh SVG), PCI with BMS to ___ ___, multiple
PTCA and stents after CABG done at ___, chronic
systolic HF (LVEF 30%) pAF and dementia who presented with 2
weeks of weakness, fatigue and SOB as well as 4 days of cough.
Referred to ED after outpatient visit, where he desatted to the
___ with ambulation. In the ED had stable VS, EKG in sinus
rhythm with prior anterior infarct and no change. Labs notable
for WBC 12.1, trop negative x2, BNP 1225 (baseline unknown),
d-dimer 654. Exam not consistent with volume overload. Had CT-A
chest negative for PE but that was concerning for infectious
bronchiolitis. Patient placed on ceftriaxone and azithromycin
overnight with improvement in symptoms. | 67 | 135 |
13787489-DS-13 | 22,774,737 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were treated for an ulcerative colitis flare
after you symptoms worsened and persisted after attempted
outpatient management of your symptoms. You were given IV
steroids and a new medication called infliximab, with
improvement in your symptoms.
Dr. ___ will call you in approximately ___ days
regarding an earlier follow-up appointment (within ___ weeks).
If you do not hear from his office by ___, please call
___.
It is important that you take all of your medications as
prescribed, and that you attend all of your outpatient
appointments as scheduled, in order to ensure safe follow-up. At
your follow-up appointments, your health care providers ___
help develop a plan to prevent future ulcerative colitis flares.
We wish you the best in health,
Your Care Team at ___ | Ms. ___ is a ___ year old woman with history of ulcerative
colitis who presents with two weeks of worsening abdominal pain,
painful bloody bowel movements, elevated CRP and sigmoidoscopy
findings consistent with ulcerative colitis flare.
ACTIVE ISSUES
# Ulcerative Colitis (Flare):
Patient presented with worsening abdominal pain with passage of
blood and clots; she had attempted outpatient management of
suspected ulcerative colitis flare with asacol, azathioprine,
rowasa, and cortifoam, but symptoms progressively worsened. She
was admitted to the medicine service, where she was evaluated by
GI. A sigmoidoscopy and biopsy were consistent with an acute
flare of ulcerative colitis. She had no fevers, chills or travel
history prior to presentation, making an infectious etiology
less likely, and assays on ___ for pathogens including C. Diff
were negative. She was started on IV Solumedrol 20mg Q8H, and
received infliximab 10mg/kg on ___. Her symptoms improved upon
starting IV steroids, and further improved following infliximab
infusion (as TB and Hep B serologies were negative). At the time
of discharge the patient only experienced abdominal pain with
bowel movements and the stool was well formed. The need for
further infusions of infliximab will be determined on an
outpatient basis during follow-up with Dr. ___ and Dr.
___. | 137 | 204 |
15881002-DS-8 | 20,373,079 | Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You had a heart attack because the stent in your heart from
your prior heart attack got clogged with a clot. This can happen
if you do not take the medications that protect your stent every
day.
WHAT HAPPENED IN THE HOSPITAL?
- You had a cardiac catheterization ("cath") and the clog in the
stent was cleared.
WHAT SHOULD I DO WHEN I GO HOME?
- Take your medicine as prescribed.
*** It is very important that you take your ticagrelor
("Brillinta") twice every day (one in the morning, one in the
evening). Do not skip doses. This will prevent clots from
forming in your stent and having another heart attack***
- Follow up with your cardiologist at the ___ within 1 week.
We wish you the best!
-Your Care Team at ___ | Mr. ___ is a ___ year old gentleman with history of CAD s/p
MI x2 with multiple DES to LAD, HTN, HLD, HFrEF (EF ___
___, ischemic stroke, prostate cancer, and dementia presenting
with chest pain found to have anterior STEMI with in stent
thrombosis of LAD, s/p cardiac catheterization with angioplasty
and restoration of flow.
#Anterior STEMI:
The patient was found to have anterior STEMI secondary to
in-stent thrombosis. Possible causes include decreased
antiplatelet therapy with ticagrelor 60 BID to 60 once daily vs.
failure of Plavix. The patient underwent balloon angioplasty of
the LAD with restoration of flow. He was chest pain-free
subsequently. He should continue on home aspirin and
atorvastatin. He was started on ticagrelor 90mg BID and should
stay on this regimen as long as possible if he can manage BID
dosing. He was not initiated on ACEi or B-blocker because he did
not tolerate these medications in the past. His atorvastatin was
kept at 20 mg daily rather than increasing to 80 mg daily due to
concern regarding his dementia and attempting to prevent changes
in medication that could lead to medication non-compliance.
#Post-catheterization Hematoma:
The patient developed a hematoma post-cardiac catheterization
which was stable in size after direct pressure was applied to
the site. He maintained a stable CBC and was hemodynamically
stable. Ultrasound was performed which showed no evidence of AV
fistula or pseudoanerusym. Recommend repeat CBC at clinic
follow-up.
#Heart Failure with Reduced Ejection Fraction without acute
exacerbation:
The patient presented without acute exacerbation of heart
failure, felt to be euvolemic. He should continue on his home
Lasix dosing.
#GERD: Continued home omeprazole 20mg
#Psych: Continued home sertraline 50mg po daily
#Dementia: Continued home donepezil 5mg PO daily
#Supplements: Continue home MVI
===================
TRANSITIONAL ISSUES
===================
- Follow-up with cardiology (at ___ within 1 week post discharge
for in-stent thrombosis s/p revascularization
- Recommend repeat CBC at clinic follow-up for
post-catheterization hematoma
- He was started on ticagrelor 90mg BID and should stay on this
regimen as long as possible if he can manage BID dosing
- Not started on ACEi or B-blocker because he did not tolerate
these medications in the past.
- Code Status: Full in periprocedural period, otherwise DNR/DNI
and would not want invasive procedures to save his life
- Contact Information: (son) ___ HCP ___ | 154 | 370 |
14244279-DS-10 | 21,461,661 | Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization for shortness of breath and chest tightness.
You did not appear to have any emergent heart problems causing
these symptoms, but given your history of cardiac disease, we
recommend getting a pharmacologic stress test as an outpatient
then following up with your outpatient cardiologist.
Please also restrict your water intake to 1.5 L a day if
possible. Feel free to liberalize your salt intake as long as
your shortness of breath does not get worse and you do not
develop swelling or weight gain. This should help with your low
sodiums.
TRANSITION OF CARE ISSUES
- Discuss with your PCP how to optimize your treatment of COPD,
which may include starting a long-acting inhaled medication
- You should have the levels of sodium and potassium in your
blood checked and followed by your PCP.
- You are scheduled for a pharmacologic stress test on ___,
___, at 9:20. Please attend the appointment listed
below. You will discuss the results of the stress test with
your outpatient cardiologist
MEDICATION CHANGES
- STOP lisinopril for now - this medication can cause high
potassium levels. Discuss with your PCP whether you should
restart this medication | ___ yo male with h/o CAD (DES to mid-LAD and distal RCA on
___, hypertension, mild aortic regurgitation, chronic
kidney disease, HIV, HCV cirrhosis, COPD, presents with dyspnea
and left-sided chest tightness starting at 7am morning of
admission that woke him from sleep.
# Chest pain - has known history of NSTEMI, but per pt this pain
is more consistent with COPD exacerbation than NSTEMI pain.
- ACS ruled out with 3 neg cardiac enzymes, EKG unchanged from
prior
- P-MIBI as outpatient later this week, then follow-up with Dr.
___
- cont home plavix, lisinopril, isosorbide mononitrate, aspirin,
metoprolol
- cont Albuterol-Ipratropium 2 PUFF IH TID, recommend optimizing
COPD medications to include long-acting medication, at next PCP
___.
# Hyponatremia - Na on admission was 121, improved with fluid
restriction to Na 126. Urine lytes consistent with SIADH. Has
history of SIADH with no clear precipitant (no evidence of
malignancy or medications that typically cause SIADH).
Asymptomatic. Appears euvolemic.
- fluid restrict 1L, liberalize salt intake
- F/U Na as outpatient
# Hyperkalemia - improved after receiving kayexelate, insulin,
and glucose in ED. no EKG changes concerning for cardiac
membrane instability
- Hold lisinopril, PCP may restart if K normalizes
- F/U K as outpatient
# Pancytopenia - chronic pancytopenia likely related to HIV &
Hep C infection, unremarkable diff, no sign of acute infection
# COPD: exacerbation likely caused his current presentation
- Continue home albuterol-ipratroprium
- Outpatient follow-up with Dr. ___ for COPD
management, recommend long-acting inhaled medication
CHRONIC MEDICAL PROBLEMS
# HIV, asymptomatic: Most recent CD4 is 481 (___). per
patient well controlled with no evidence of opportunistic
infections.
- Cont efavirenz, lamivudine, abacavir
# HCV cirrhosis: followed by liver unit at ___. pt opted to
hold on therapy for HCV. has liver follow-up later this week.
# HTN: hold lisinopril for now given hyperkalemia, defer to PCP
whether to restart
# CODE- confirmed full | 207 | 321 |
19538920-DS-49 | 26,062,626 | Dear ___,
___ was a pleasure taking care of you during your hospital stay.
You came to the hospital for pain control after a fall on the
ice. We scanned your head and spine and that did not show any
fractures. You were given pain medication and you felt better.
You were also constipated and this was relieved with a
suppository. In addition, you had one session of dialysis while
in house. Physical therapy recommended home physical therapy,
you did not feel this was necessary, however. Please take your
full course of antibiotics.
Your discharge appointments and medications are detailed bellow.
Please call Dr. ___ you continue to have urinary symptoms
or symptoms of a yeast infection.
We wish you the best!
-Your ___ care team | ___ h/o ESRD, DM2, HTN, CAD s/p CABG, HFpEF and recurrent UTI
presented to the emergency room after a mechanical fall on ice.
Her CT head and spine showed no fractures. Her pain was
controlled with Dilaudid PO. Her course was complicated by
constipation and brief acute encephalopathy on admission likely
secondary to opioids.
ACTIVE ISSUES:
#Severe Back Pain s/p mechanical fall: She had severe back pain
after a mechanical fall on ice. CT head, C,T and L spine all
negative. She received fentanyl and morphine while in ED which
made her somnolent but did not improve her pain. Her pain was
subsequently well controlled with PO Dilaudid and standing
Tylenol and she improved until her discharge at which point she
denied any pain. Physical therapy was consulted who recommended
home physical therapy--the patient and her husband declined
physical therapy as they felt she could ambulate safely without
it.
#Altered Mental Status: She was altered briefly on admission,
given both fentanyl and morphine in emergency department. ___
was negative. She had some desaturations but with time this
improved.
#UTI: Treated with 10 day course of Augmentin for prior UTI
(missed dose on ___. Last day ___. | 125 | 197 |
13890436-DS-23 | 28,087,711 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow an
extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks
to help prevent deep vein thrombosis (blood clots). If you were
taking Aspirin prior to your surgery, you should hold this
medication while on the one-month course of anticoagulation
medication.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
after aqaucel is removed each day if there is drainage,
otherwise leave it open to air. Check wound regularly for signs
of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches. Wean assistive device as able. Posterior precautions.
No strenuous exercise or heavy lifting until follow up
appointment. Mobilize frequently.
Physical Therapy:
WBAT RLE
Posterior hip precautions x 3 months
Mobilize frequently
Wean assistive devices as able (i.e., 2 crutches, walker)
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed | The patient was admitted to the Orthopedic Trauma Surgery
service and was taken to the operating room for above described
procedure on hospital day #1 with the Arthroplasty service.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
POD#1, due to her low iron count, she was started on iron
tablets.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox for DVT
prophylaxis starting on the morning of POD#1. The surgical
dressing will remain on until POD#7 after surgery. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the dressing was intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Walker or two crutches, wean as able.
Ms. ___ is discharged to home with services in stable
condition. | 494 | 215 |
16567081-DS-22 | 23,824,369 | -You were admitted with a dignosis of KIDNEY STONE
(NEPHROLITHIASIS) and ACUTE RENAL INJURY. You have passed the
obstructing stone and this has been sent out for analysis.
-It is imperative that you follow with Dr. ___ repeat
LAB work to monitor your renal function (acute renal injury).
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house. | Mr. ___ was initially admitted to urology for nephrolithiasis
under Dr. ___ for Dr. ___. He was admitted through
the ED for a trial of passage to include aggressive IVF, flomax
and pain control. Foley catheter was refused but urine was
strained for stone capture and Mr. ___ was prepped for
possible intervention in AM if renal function not improving and
if pain persisted.
Overnight, Mr. ___ was hydrated with intravenous fluids and
received appropriate pain control but nephrotoxic agents were
avoided given his acute kidney injury (creatinine up to 3.2-->
3.5). Flomax was given to help facilitate passage of stone. On
hospital day two, while NPO on IVF, he passed a large stone that
was captured and sent to pathology for analysis. He delightfully
reported near resolution of his pain with only minimal flank
tenderness. Repeat KUB obtained and no stone was seen. Repeat
basic metabolic panel was obtained without significant downward
trend in creatinine (only to 3.4). Surgical intervention was
deferred and Mr. ___ opted for discharge home and follow up
with PCP ___ repeat labs and creatinine monitoring.
He was thus discharged home with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty. Mr. ___ was explicitly advised to
follow up as directed with Dr. ___ his lab work and to
follow up with Dr. ___ as well. | 462 | 228 |
17970081-DS-15 | 24,035,894 | You were seen in the hospital for pain in your side, which was
most likely related to a urinary tract infection
(pyelonephritis). This improved with IV antibiotics, which we
changed to Bactrim, an antibiotic pill since this was shown in
the laboratory to treat your infection. The last day of
antibiotics is ___
Changes to your medications:
START taking Bactrim twice a day. Start this tomorrow morning
and take until ___. | This is a ___ y/o female with a past medical history of IDDM,
hypertension, hypercholesterolemia, reflux, anxiety and on a
narcotics agreement who presents with L flank pain and acidic,
fruity smelling urine for the past couple days.
# Pyelonephritis: In the ED an ultrasound was performed which
demonstarted an nonobstructive interpolar nephrolithiasis. This
may have been the cause of the pts. flank pain. The patient also
had a urinalysis performed, which demonstrated a urinary tract
infection. She was started on Cefepime empirically due to a past
resistant E.coli strain. The following day the patient stated
that her pain did not get any better, despite the down trend in
___. A CT abdominal scan was ordered to rule out hydro and
nephrolithiasis within the ureteres. No such blockages were
discovered. The following day her WBC continued to down trend
and patient relates that she was feeling better in the morning.
The patient was informed of an incidental finding on the CT
report of an area in the superior mesenteric vein which may
represent non-occlusive thrombus or flow artifact. The patient
was made aware of this and was told that if she begins to have
symptoms she should follow up with her PCP and consider being
further evaluated with a doppler abdominal ultrasound.
# Diabetes: Patient has an insulin pump and was seen by the
___ DM. She should follow up her diabteic treatment with
___.
.
# Transitional Issues:
-Pt. was given a Rx for Bactrim which she will take twice a day
untill the ___.
-Pt. will follow up with PCP ___ ___ weeks | 73 | 261 |
17159404-DS-14 | 21,740,093 | 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 to the left lower extremity, in the
locked ___ brace at all times
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add Dilaudid as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take subcutaneous heparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Touchdown weightbearing on left lower extremity in locked
___ brace at all times
Treatments Frequency:
Please follow up in clinic for wound check, postop visit, and
staple removal in two weeks. | The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for left
knee I&D, explantation of components, and antibiotic spacer,
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 ___ rehabilitation 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 on the left lower extremity in a locked
___ brace at all times, and will be discharged on
subcutaneous heparin 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. | 542 | 246 |
13669315-DS-16 | 23,770,593 | 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?
- You were vomiting and were unable to eat
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We treated your nausea and vomiting with medications
- You occasionally had high heart rates, we monitored this and
were reassured that your heart rate would come down with time.
You do not need any treatment for this.
- We discussed the connection between your brain and gut. It may
be that your stress is associated with the symptoms you have
been experiencing. For this we started Lexapro.
- We will be in touch with your outpatient providers to help you
get involved with therapy to help you manage and process
stressors.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Please continue to eat small meals to help your stomach adjust
to food.
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team | PATIENT SUMMARY:
================
___ with prior hx of pneumomediastinum, eating disorder,
unexplained bouts of nausea/emesis (?functional), who presented
with 1 week of emesis and inability to tolerate PO. Found to
have recurrence of pneumomediastinum, although CT showed no
extravasion of oral contrast from the esophagus, and per
thoracic surgery, no intervention was required. She slowly
improved with supportive care, and after a few days, was
tolerating POs without nausea, vomiting, or pain.
TRANSITIONAL ISSUES:
==================
[] Started on PPI and famotidine, for suspected gastritis
component. Can taper these off again in about four weeks.
[] Discharged on zofran to help with nausea
[] Started Lexapro to help with anxiety, which seemed to drive a
vicious cycle of vomiting and escalating distress. Counseled
need for adherence for at least 4 wks for most benefit
[] Discussed association between mind/brain and GI, which pt
seemed to be responsive to. Pt is motivated to improve stress
management and is open to group therapy. Pts biggest stressors
are fear of losing her job and caring for her ___ daughter.
[] Encouraged use of fiber when better able to tolerate food to
help with regular BMs
[] Filled out work leave paperwork until ___, may need an
extension | 228 | 198 |
17640969-DS-16 | 25,176,733 | Dear Ms ___,
It was a great pleasure taking care of you as your doctor. As
you know you were admitted to ___
___ after a mechanical fall. It was found that you have a
fracture in your pelvic bone that did not need intervetion
according to the bone doctors' evaluation. We gave you pain
killers that helped to control your pain and have physical
therapy evaluation.
We made the following changes in your medication list:
- Please START tylenol 1 gram three times daily to control your
pelvic fracture pain
- If tylenol doesn't help, please take OxycoDONE (Immediate
Release) 2.5 mg tablet every 4 hour as needed for breakthrough
pain.
Please continue taking the rest of your home medications the way
you were taking them at home prior to admission.
Please follow with your appointments as illustrated below. | ___ year old woman with history of CAD, hypertension & left hip
fracture s/p pinning admitted after mechanical fall complicated
by minimally displaced left pubic ramus fracture, evaluated by
orthopedics who recommended no surgical intervention. Discharged
in stable condition.
.
# Left PUBIC RAMUS FRACTURES: Traumatic secondary to witnessed
fall. Seen by orthopedics in the ED and thought to be
non-operative. She was given standing 1000 mg tylenol TID which
resulted in good control over pain. She is provided with
oxycodone 2.5 mg every 4 hour as needed only for breakthrough
pain. She had physical therapy evaluation and will be discharged
to ___ rehab. She will follow with Dr ___ in 4 weeks
(ortho). She can do weight bearing on her left lower extremity
as tolerated.
.
# Fall: Recent fall in ___ as well. Likely mechanical per
daughter's history, no LOC, normal mentation. However, history
is limited given patient's underlying dementia. Based on
observation, possibly mechanical as she is on minimal
medications that could potentially lead to falls. Could be
orthostasis as she appeared dry on exam at admission. She was
given IVF with improvement in volume status. We continued her
aspirin.
.
# Bacteriuria: given patient can not give accurate history and
UA significant for bacteriuria, we initiated course of
ciprofloxacin 250 mg daily for 3 days for presumed UTI. Urine
cultures are added and pending prior to discharge.
.
# Chronic Renal Insufficiency: Baseline around 1.5. Her Cr
during her stay was at her baseline. Remained stable.
.
# Anemia, normocytic. Remained stable. B12 and folate greater
than assay. Retic 1.3%. No known baseline (called PCP from PA
but they had no documented HCT/Hg).
.
# Hypertension: We continued home metoprolol 12.5 mg twice
daily.
.
# Depression: We continued lexapro 10 mg daily.
.
# Dementia: at baseline.
.
# GERD: continued PPI as inpatient.
. | 137 | 321 |
16081055-DS-21 | 27,803,093 | Dear Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted with two episodes of fainting, but we found no evidence
of a heart-related cause of your episodes on EKG or heart
monitor. Please follow-up with Dr. ___
(___) for further workup. | ___ h/o recurrent syncope of unclear etiology, palpitations,
congenital mitral regurgitation, fibromyalgia, and mixed
headache disorder presents after 2 episodes of recurrent syncope
on the morning of admission.
# Recurrent syncope: Pt has strong family history of arrythmias,
but no QT prolongation on EKG and no evidence of ischemia or
decompensated valvular disease (normal EKGs and stable echos in
past). Has had extensive cardiac evaluation which has been
unrevealing, including normal 24-hour Holter. Less likely
neurologic etiology or orthostatic hypotension (orthostatics
negative, which they have also been per patient), though drop
attacks / narcolepsy is possible. ___ have component
somatization and/or anxiety. Overnight, there were no EKG
changes (normal QTc) or events on telemetry, though she becomes
bradycardic to ___ overnight (asymptomatic). Per e-mail
communication with Dr. ___ further ___ indicated
in-house.
# Headaches: chronic, stable, continue home topamax, fiorcet
# Fibromyalgia: chronic, stable, continue home Vicodin
# Anxiety: chronic, stable, continue home clonazepam
# Smoking: continue home Wellbutrin; smoking cessation advised
# HLD: continue home simvastatin | 48 | 166 |
11391144-DS-6 | 22,583,419 | Your large dressing may be removed the second day after
surgery.
You have steri-strips in place, you must keep them dry for 72
hours. Do not pull them off. They will fall off on their own or
be taken off in the office. You may trim the edges if they
begin to curl.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit. | On ___ the patient was admitted to the floor via the
emergency room after presenting with subjective feves, fatigue,
malaise after a L4-L5 foraminotomy and microdiskectomy on
___. He did not have an elevated WBC. On exam, the patient
had no fluctuance and scant drainage from the post pole of the
incision. He did have erythema which was noted and marked by
the ED. He was continued on IV ancef and the erythema improved
significantly.The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incision was clean/dry/intact
with minimal erythema/no fluctuance/no drainage, the patient was
ambulating safely, was voiding and moving bowels spontaneously,
and the patient's neurological exam was stable/improved. The
patient was discharged with a prescription for 1 week of PO
keflex, and will follow up with Dr. ___ in ___ days
for a wound check. A thorough discussion was had with the
patient regarding the diagnosis/surgery and expected
post-discharge course, and all questions were answered. | 216 | 180 |
18932912-DS-12 | 25,724,682 | You were admitted to ___ for treatment of your left frontal
wound infection. You were found to have a MRSA infection and
were started on IV antibiotics. You are now being dischared
with a PICC (IV) line for long-term antibiotics. You will be
followed by the Infectious Disease service for management of
your infection.
Please follow up with your primary care team this week for your
GOUT in the left knee and ankle.
Please follow up with your oncology team in 1 month.
Please follow up in the ___ in 14 days from the
date of your surgery. On ___ at 0900.
PLEASE wear your helmet at all times when out of bed.
· You underwent surgery to wash out your wound
· Please keep your incision dry until your sutures&staples
are removed.
· You may shower at this time but keep your incision dry.
· 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.
· 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
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
This will be discussed at the TIME OF YOUR SUTURE/STAPLE removal
in the Neurosurgery office
you have been cleared by Dr ___ to resume your aspirin on the
day of discharge ___.
·· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
YOU NEED to WEAR YOUR HELMET at all times while OUT of
BED.Alternatively you may wear a baseball hat with hard piece
of plastic over left frontal portion
What You ___ Experience:
· You may experience headaches and incisional pain.
· 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.
· Feeling more tired or restlessness is also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
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 | ___ ___ gentleman with DM, HTN, CAD (s/p BMS x1 in ___,
Stage IV NSCLC with mets to brain on alectinib as part of a
study, s/p right and left craniotomies (on ___ and ___
for resection of mets) presenting with scalp and facial swelling
found to have late wound infection.
#Late surgical wound infection: Patient with fluctance pain
edema and erythema on presentation. CT w/ evidence of fluid
collection directly over surgical plates. NSG aspirated fluid
collection which revealed MRSA. Pateint was taken to the OR
___ LEFT CRANIOTOMY FOR WOUND EXPLORATION AND WASH OUT;
drain implant. IV antibiotics (Vancomycin ___.
# Lung cancer: Stage IV NSCLC with mets to brain s/p whole brain
XRT and resection via craniotomy ___. Currently on alectinib
(ALK inhibitor) as part of a study at the ___ for anaplastic
lymphoma kinase (ALK) fusion oncogene positive non-small cell
lung cancer. - Last dose alectinib ___ will hold for now while
going to OR
- Continue namenda for post XRT cognitive impairment if able to
confirm on med rec tomorrow
- Continue mirtazapine for appetite
On ___, Mr. ___ was transferred from the ___ to ___
___ for a left wound exploration and washout. He tolerated
the procedure well and there were no intraoperative
complications. He was transferred to the inpatient ward for
mangement and observation. Mr. ___ was continued on
vancomycin. Infectious Disease continued to follow the patient
during this time.
On ___, Mr. ___ was having new left ankle pain, erythema
and swelling. Orthopedics was consulted for aspiration, which
was conducted at the bedside. Fluid was sent for analysis. An
x-ray of the ankle was taken to rule out infection or fracture.
The patient was started on indocin for a (likely) gouty
flair-up. He was also started on his home anti-hypertensives
and metformin. A physical therapy consult was placed as well.
Mr. ___ continued to recover well. Although Indocin was
started for his possible gout flair-up to his left ankle and
knee, he continued to have pain with little improvement in the
swelling. on ___, colchicine was started to aid in his
symptoms. On this day, a PICC line was inserted in preparation
for discharge on IV vancomycin. His vanco trough was 18.
On ___, The patient's left foot and ankle exhibited
edema/erythema. The patient reported left lateral foot pain.
Oncology medicine recommended that the patient begin a 7 day
course of prednisone. And recommended that the patient
discontinue use of the naproxen and colchiine. The serum
magnesium and potassium were low and repleated. The patient
denied headache. A vancomycin trough was 19.4. Dr ___,
___ recommended transfusion with 2 units PRBC for a
heatocrit of 19.8. The post transfusion hct was 24.
On ___ Oncology cleared the patient for home. The patient was
restarted on his home dose of aspirin. The plavix will be held
until discussed in follow up in ___ Neurosurgery office. The
patient was noted by nursing staff to pick at his inciison
frequesntly and there was a scant amount of drainage noted in
the middle of the incision. The incision was well approximated
with sutures and staples.
___, the patient was neurologically stable and discharged to
rehab | 723 | 549 |
13550987-DS-7 | 23,925,905 | Dear Mr. ___,
You were admitted ___ for
observation after exploration and repair of your left forearm
laceration by the plastic surgery team. You have done well and
are now ready to be discharged to home. Please follow the
instructions below to continue your recovery:
- Elevate left upper extremity, to remain in splint
- Ok to perform active and passive range of motion of your
fingers
- Aspirin 325 x 1 month
- Continue all your home medications
- Resume your home diet and activities.
- Observe for fever > 101, chills, redness that is spreading
from your wound, foul smellin drainage, numbness or tingling of
the fingers that does not go away
- If you have any concerns or questions, please call
___.
Thank you for allowing us to participate in youre care.
___ Team | Mr. ___ was admitted after repair of his left forearm injury.
He was taken to the operating room and underwent left forearm
exploration and repair of radial artery. A thumb spica splint
with wrist neutral was applied after the surgery. He tolerated
the procedure well without complications. For details of the
procedure, please see the operative report. He was admitted
briefly for observation and to await his ride. He was discharged
in good condition with discharge and follow-up instructions. | 128 | 79 |
18702117-DS-14 | 25,540,420 | Dear ___,
___ came to the hospital because your blood sugar was high and
___ did not feel good.
___ had a very serious illness called Diabetic Ketoacidosis,
which is caused by uncontrolled diabetes. It caused ___ to
become very dehydrated and the acid level in your blood was way
too high. This affected your whole body. ___ started insulin and
got lots of fluids and ___ got better.
___ also had many fevers. We did not find an infection that was
causing these fevers despite a thorough evaluation.
When ___ go home, it is very important that ___ take insulin as
directed by your diabetes doctors. ___ allow your husband to
help ___ with this! Please remember that insulin is a
___ medicine for ___.
Please take:
Glargine 40 Units before Breakfast
Humalog 16 Units before Breakfast
Humalog 12 Units before Lunch
Humalog 12 Units before Dinner
Also when ___ go home:
- pick up your prescriptions for test strips and meter at your
local ___ pharmacy (information provided from Walgreens
bedside delivery)
- check your blood sugar 4 times per day and record the number
in a notebook to take with ___ to diabetes appointments
- please call your primary care doctor if ___ are concerned
about your blood sugar
- eat a meal promptly after taking Humalog, avoid snacking
throughout the day as it will affect your blood sugar
- take lisinopril and pravastatin to help with your blood
pressure and cholesterol, to help prevent problems with your
heart related to diabetes
- please call your doctor if ___ notice any more fevers or any
symptoms that worry ___
It was a pleasure caring for ___ and we wish ___ the best!
Your ___ Team | Ms. ___ is a ___ y/o F w/ bipolar disorder, HTN, HLD,
and uncontrolled diabetes, who presented with DKA in the setting
of not taking insulin, course complicated by fevers. | 271 | 30 |
12975145-DS-20 | 22,853,963 | Ms. ___,
You were admitted to the hospital, because there was a concern
that have an infection in your heart and you needed to be
watched closely. While in the hospital, you did not have a fever
and your lab work showed that you did not have an infection. We
were also concerned that you are at increased risk for an
overdose given that you recently experienced a relapse while
taking methadone. You met with the addiction psych team to
discuss treatment options. While in the hospital, you were also
monitored for seizures since you have recently been an
increasing number of seizures. You were seen by the neurology
team who recommended that you continue your home dose of 400 mg
Zonisamide daily. Since there was an outbreak of the flu on the
medical floor, you were discharge with Tamiflu to help prevent
you from catching the flu.
It was a pleasure caring for you,
Your Medical Team | Ms. ___ is a ___ female with a history of
complicated seizure disorder (currently on zonisamide), opiate
use disorder c/b by recent intravenous heroin use (currently on
methadone), prior history of endocarditis, chronic hepatitis C
infection, bipolar disorder, irritable bowel syndrome, and
fibromyalgia. She presents with increased seizure frequency over
the last 2 months and had one fever in the setting of active
IVDU. | 158 | 64 |
17972281-DS-12 | 29,832,793 | Dear Ms. ___,
You were admitted to the hospital after having an episode of
vertigo and vomiting. We obtained a brain MRI to look for a
stroke as the cause of your vertigo. It did not show a stroke.
While in the hospital, we discussed your memory problems as
well. We tested your B12 level and it was in the low-normal
range so started you on a B12 supplement since low B12 levels
can affect memory. Depression, anxiety, and sleep problems also
affect memory so it is important to address these things as well
with your other doctors. ___ recommend you see a neurologist for
your memory problems. To help investigate further, your
outpatient doctors ___ refer ___ for neurocognitive testing as
well.
Sincerely,
Your ___ Neurology Team | ___ female admitted with unsteady gait and vertigo with
concerns of posterior circulation stroke vs. BPPV. CTA
Head/neck and MRI head were negative for stroke. Pt's cognitive
function is significantly decreased with ___ on MOCA. Pt would
benefit from close follow-up with a Cognitive Neurologist.
Additionally her B12 level was decreased, so she was started on
B12 1000mcg daily.
MRI Head ___
IMPRESSION: Unremarkable contrast-enhanced brain MRI aside from
a few punctate scattered white matter FLAIR hyperintensities
that likely reflect chronic small vessel ischemic changes.
___________________________________ | 124 | 88 |
19160437-DS-15 | 27,045,528 | Dear ___,
___ was a pleasure caring for you at ___.
Why was I admitted to the hospital?
You were admitted to the hospital because you sodium was low.
This was likely due to some dietary indiscretion while you were
on vacation in ___.
What did we do for you in the hospital?
-We gave you some albumin and restricted your fluids in order to
improve your sodium. We also looked for infection which we did
not find.
-We continued your steroids and your liver function tests
improved.
-We noted your red blood cells were low. There was some concern
that your body was breaking down your red blood cells, but your
tests are reassuring. Your blood levels remained stable and your
primary care doctor can follow up on this issue.
Please make sure to take all of your medications and keep your
follow-up appointments.
We wish you all the best,
-Your ___ Team | Mrs. ___ is a ___ with PMH of PBC/cirrhosis who presented
with worsening ___ edema in the setting of dietary non-compliance
with hyponatremia to 123.
#Hypervolemic hyponatremia. 123 on admission with spontaneous
improvement to 126. Likely due to dietary indiscretion prior to
admission. Treated with albumin and fluid restriction. Improved
to 134 on discharge.
#Autoimmune Cirrhosis/PBC. MELD 22 on admission. Labs notable
for a very low albumin. Nutrition was consulted in this setting.
AST/ALT were downtrending in the context of recent steroid
taper. Her decompensation was likely due to dietary indiscretion
as above. Per outpatient liver attending, patient's dry eyes and
mouth
could be ___ Sicca syndrome (30% prevalence in those with PBC).
Recently started on hydroxizine at night for pruritis. Ursodiol
and hydroxizine were continued. Requires HCC screening by u/s
and alpha fetoprotein every 6 months. U/S completed in house, no
lesions seen, notable for perihepatic ascites.
#Anemia: Hb 10.3 on admission after volume repletion. Baseline
~13.8. Ferritin was normal, but haptoglobin was low and indirect
bili was elevated, concerning for hemolysis. Smear showed no
schistocytes and Coombs test was negative. Hb remained stable
throughout admission and should be followed up as outpatient.
#Isolated ST segment ~1mm elevation. Sub MM ST elevations in
V2-V3 on admission. She was asymptomatic. No
chest pain, SOB, or lightheadedness. Trop neg x 2.
#Hypertension. Labile blood pressures during admission. Patient
with hypertensive urgency initially to 210s. No
CP, headache, change in vision or SOB. Her BP then dropped to
100/50's over 12 hours. No clear inciting event. Home
anti-hypertensives were held in the setting of lower BPs but
then resumed, along with diuretics and patient remained
normotensive. | 154 | 271 |
19378187-DS-20 | 23,378,172 | Dear Mr ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You had difficulty breathing and weakness.
What happened while I was in the hospital?
- You had a tracheostomy placed so that you would be able to
breathe better with the help of a ventilator.
- You were seen by the neurologists and diagnosed with an
atypical form of ALS (amyotrophic lateral sclerosis) that mostly
affects your
breathing muscles.
- You were seen by speech and swallow specialists, who
determined that it is very dangerous for you to eat and drink by
mouth, as you have a high risk for aspirating and developing a
serious lung infection, for this reason it was determined that
you need a tube placed in your stomach to give you adequate
nutrition. This tube was placed before you left the hospital.
-The swallow specialists re-evaluated you before you left the
hospital and found that while you were still having difficulty
with some consistencies of food and drink you would be safe to
resume a modified diet.
-You were diagnosed with an infection in your colon called C.
diff. This was treated with antibiotics and testing confirmed
successful treatment prior to you leaving the hospital.
-You had a tube placed in your stomach to provide you with more
nutrition.
What should I do once I leave the hospital?
- Take medications as prescribed and follow up with your
neurologists and primary care physician.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES:
=======================
[] Before advancing diet, would need speech and swallow
reevaluation.
[] if he needs antibiotics in the future, would consider
prophylactic PO vanc given Cdiff infection this hospitalization
[] discontinued alprazolam and started clonazepam this
hospitalization
[] Required intermittent low doses of insulin this
hospitalizations, however fBGs WNL prior to dc so held, restart
ISS as needed outpatient.
[] Please check weekly CMP for renal funtion, potassium
[] Noted to be severely and persistently hypokalemic this
hospitalization, started on spironolactone and standing K
repletion. Will likely require ongoing titration of K repletion
as stool output normalizes
[] Check weekly EKG for QTc while requiring multiple
QT-prolonging medications
[] Held atorvastatin during this hospitalization while working
up his muscle weakness. Consider restarting as outpatient. | 266 | 119 |
10305245-DS-11 | 21,127,077 | Ms. ___,
You came to the hospital for a sore throat, fever, weakness and
some numbness. We determined that this was not due to
meningitis or a primary problem with the brain or the spinal
cord. We found that your tonsils were inflamed and that you had
a very small pocket of infection near your right tonsil. We
treated you with antibiotics and you improved. Neurology
recommended follow-up as an outpatient since your neurological
findings resolved.
The ear, nose, throat doctors recommended follow-up in ___
weeks. You should follow-up with your primary care physician
and they ___ refer you to the ear-nose-throat doctor as well as
the neurologist.
It was a pleasure taking care of you,
-Your ___ Team | ___ is a ___ year old woman who presents with neck
stiffness, fevers, generalized weakness (near quadriplegia) and
numbness. Brain imaging showed small non-enhancing white matter
lesions, spine imaging wnl, with normal LP. CT showed very small
peritonsilar abscess and tonsillitis and she was started on
Unasyn. Her neurological exam normalized over time. Her CSF
studies showed were mostly pending at discharge, but HSV was
negative. She was treated with Unasyn and Switched to
Amoxicillin for a 10 day course.
# Neurological Findings: Initially concern for meningitis given
stiff neck. She received brief treatment for meningitis.
However, CSF was bland and meningitis coverage was discontinued.
MRI of the C-T spine without acute findings. MRI brain with
scattered nonspecific T2 white matter foci, which may be due to
demyelination, prior infectious or inflammatory etiologies,
vasculitis, postmigraine changes or be idiopathic. She was
evaluated by neurology in the ED though the etiology of her
findings remains unclear. Per neuro, resolving weakness in the
setting of fever may be due to radiologically isolated syndrome.
She will be seen in neurology clinic as outpatient. HIV
negative. ___, ESR, CRP, Quant ___, Sjogren, ANCA,
ESR, SLE antibodies, ACE, ACHR, MS panel ___ bands)
were all negative.
# Tonsillitis with small right peritonsillar abscess: Patient
presented with sore throat and neck pain as well as painful
cervical adenopathy. Patient reports long history of
tonsillitis. Initially treated for meningitis coverage, found to
have pus in tonsils on closer examination. CT Neck on ___ shows
bilateral peritonsillar inflammation associated with
tonsilliths, possibly early phlegmon, and a discrete 5 mm right
peritonsillar abscess. On exam, patient is breathing
comfortably, with no stridor and uvula midline. Per ENT, there
is no discrete drainable collection at this time given size and
position. She was treated with Unasyn while inpatient with a
plan for oral amoxicillin for 10 day course (D1: ___.
Right tonsil culture did not grow GAS. She will follow-up with
ENT.
# Fever: resolved. The etiology is most likely secondary to
tonsillitis. CSF not consistent with meningitis as above. CT
neck with evidence of RUL consolidation, though clinically and
per history she does not have signs/symptoms of pneumonia. UA
bland. Abdominal exam benign. She was treated as above.
# Neck Stiffness: Initially concerning for meningitis, though as
noted above CSF is not consistent. She has chronic neck pain at
baseline. Multiple CSF studies are pending. Conservative
treatment was done for neck pain including Tylenol and tramadol.
# Dizziness: resolved. Patient noted dizziness, lightheadedness,
with dull headache. Per patient, presentation consistent with
symptoms when her diastolic BP at home <50. Concern for
pre-syncope and orthostatic hypotension given history of
hypotension and dizziness. Patient states she is baseline
hypotensive, with undetermined etiology. Her orthostatics were
negative and her dizziness resolved with eating (initially NPO).
#Anemia: Patient presented with normocytic anemia at 10.6. Her
iron studies significant for low reticulocyte index. A poor
bone marrow response who be evaluated further.
Transitional Issues:
[ ] F/u pending CSF studies
[ ] Anemia: inadequate bone marrow response with RI of 0.7,
ferritin wnl, iron wnl--may need further work-up to evaluate
inadequate bone marrow response.
[ ] 10 day course of Antibiotics (Unasyn switched to
Amoxicillin) Last day: ___
[ ] PCP to refer for ENT Follow-up
[ ] PCP to refer for Neurology follow-up
# CODE: Full
# CONTACT: Husband ___ | 122 | 566 |
15691899-DS-21 | 25,922,204 | Dear Mr. ___:
You were hospitalized for an asthma exacerbation likely worsened
by your viral URI. You were treated with steroids and
nebulizers. Your PEF increased from 150 on admission to 270 on
discharge. You required O2 transiently during your admission but
no other more invasive ventilation techniques. You were
discharged on a steroid taper.
Thanks for choosing ___! All
the best for the future!
Sincerely,
___ Treatment Team | ___ year old man with complex psychiatric and social history
presenting with asthma exacerbation | 66 | 14 |
17767034-DS-5 | 28,784,838 | You were transferred to ___ for a trauma evaluation after a
mechanical fall. CT scan showed a pelvic fracture and was
concerning for a large hematoma (collection of blood) in the
pelvis that was still bleeding. You were taken to Interventional
Radiology and underwent an embolization of the pelvic arteries
that may have been attributing to the bleed. You tolerated this
procedure well.
Orthopedics was consulted, and felt the pelvic fracture would
heal with nonoperative management. You can ambulate and bear
weight as tolerated. You have worked with Physical Therapy and
you are now medically cleared for discharge to rehab to continue
your recovery. 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 | ___ PMH of HTN s/p fall from standing transferred to ___ with
right pubic ramus fracture and pelvic hematoma with active
extravasation on CT scan. The patient became hypotensive in the
ED and received 1 unit of PRBC with good response. Orthopedics
and Interventional radiology was consulted. The patient was
taken to ___ for pelvic angiogram with gel embolization of the
anterior branches of the internal iliac artery. CT Cystogram was
obtained to rule out bladder injury, which was negative. Per
Orthopedics, lateral compression pelvic fracture can be treated
in a non operative manner without manipulation. She can be WBAT
with a walker as able and should follow-up in clinic in 4 weeks.
The patient was admitted to the TICO for serial hematocrits and
close monitoring.
On HD2, troponins were cycled due to tachycardia and concern for
heart strain on EKG. Hematocrit went from 35 to 31. The patient
was given 500cc LR bolus for soft blood pressure. Intermittently
tachycardic to 140s, EKG sinus tach, resolves spontaneously.
HD3 patient started bactrim for increased frequency and positive
UA, for which she completed a 3-day course of. Also resumed home
Lopressor XR. Left femoral ___ angiogram site intact and distal
___ pulses intact. The patient was overall hemodynamically stable
and hematocrit stable so she was called out to the floor.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
was adherent with respiratory toilet and incentive spirometry,
and actively participated in the plan of care. The patient was
seen and evaluated by Physical therapy, who recommended rehab
once medically clear. The patient received subcutaneous heparin
and venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs and hematocrit. The patient was
tolerating a regular diet, ambulating with assistance, voiding
without assistance, and pain was well controlled. The patient
was discharged to rehab. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan | 307 | 348 |
19100978-DS-14 | 23,123,890 | You were admitted with fever and cough and we found you had a
virus called parainfluenza. It is similar to the flu. This
explains your symptoms. You improved with some fluids and rest
and treatment of the cough.
You will follow up with Dr. ___. make sure you get your
labs/bloodwork drawn on ___ when you go for your CT scan
as below, she wants to see them because your counts are low.
FOr now, please stop taking your aspirin because your blood
platelets are low and this could cause you to have bleeding. You
will need to restart it when Dr. ___ you to do so. | ___ w/ metastatic pancreatic cancer presenting with cough,
dehydration, low grade fever.
# Fever/Parainfluenza infection: patient had fever to 100.7 at
home but none in ED. Only symptom was generalized weakness and
cough. CXR showed no pna but did have crackles on LLL on exam.
Flu -ve but resp culture came back positive for paraflu. He had
no further fevers during the admission and was never started on
antibiotics (ANC ___ throughout) as not neutropenic. Urine
and blood cultures showed no growth and he denied dysuria,
nausea/vomiting/diarrhea.
# Anemia - Hct drop after aggressive IVF resuscitation in ED and
on arrival to the floor, likely hemodilutional compounded by
recent chemotherapy and malignancy. Smear in ED not suggestive
of hemolysis. No hematuria or bloody stools/melena. Hemodynamics
stable. Counts check soon as outpt.
# Thrombocytopenia - likely ___ chemotherapy but worsening on
this admission though stable at the time of discharge. His
aspirin was held and this can be resumed as an outpatient when
his platelets improve (pt without major cardiac history). Counts
check soon as outpt.
# Leukopenia/borderline neutropenia - pt trending towards
neutropenia and
technically meets criteria for mild neutropenia with ANC nadir
>1200 and ANC of ___ at the time of discharge. Some of this
was likely dilutional as other labs reflect this and pt s/p 2L
IVF. No fevers during the admission.
# Back pain - chronic, seems to be over the right SI joint, full
ROM without pain on exam, no vertebral point tenderness, no
weakness/incontinence, seems c/w musculoskeletal etiology
nothing to suggest vertebral mets or cord compromise. Oxycodone
worked very well and he had no pain at the time of discharge and
was fully ambulatory.
# ___: on arrival likely due to hypovolemia, resolved
immediately after IVF.
# Pancreatic Cancer: patient was due for next dose of
gemcitabine abraxane on ___ but was hospitalized as above.
This was skipped. He will follow with his primary oncologist, he
has plans for staging scans on ___.
# HTN: cont home metop and lisinopril on DC
# DM2: cont home antihyperglycemics on DC
# HLD: continue home atorvastatin, holding asa pending plt trend
# GERD: continued home rantidine
# Hypothyroid: continued home levothyroxine
# IV access - pt has port placed from another hospital, ___
___ evaluated and we requested records from that hospital
regarding type of port and placement | 106 | 384 |
15904840-DS-21 | 29,193,559 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight-bearing as tolerated in bilateral arms.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
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 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have bilateral forearm abscesses and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___, and ___ for serial
irrigation and debridement and eventual closure of bilateral
upper extremity incisions, which the patient tolerated well. For
full details of the procedures please see the separately
dictated operative report. After each procedure, the patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The patient's wound cultures grew mixed bacterial
flora and the ID team was consulted for antibiotic guidance. A
regimen of 12 days of O Augmentin 875mg Q12H was recommended.
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 bilateral upper extremities,
and will be discharged on Aspirin 325mg QD for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis, antibiotic course, 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. | 253 | 293 |
17838522-DS-12 | 22,817,935 | You were admitted to ___ and
underwent laparoscopic appendectomy. 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. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
obtain x-ray in the event that root is retained , needs
extraction and plan on getting tooth replaced on outpatient
bases. Also comprehensive dental treatment is required. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed
Dilation of the appendix up to 12 mm suggests appendicitis.
WBC was elevated at 16.7. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating regular diet, on IV fluids, and dilauded and tylenol
for pain control. The patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 346 | 217 |
17739472-DS-20 | 21,529,328 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to heart failure and were found to
have severe narrowing of one of your heart valves (aortic
stenosis). You were treated with diuretic medications and were
evaluated by the cardiac surgery team. A cardiac catheterization
showed no need for CABG surgery. Plans were made to repair your
malfunctioning heart valve.
After discharge, please return to the hospital as scheduled for
your upcoming surgery.
Please weigh yourself every day. If your weight goes up by more
than 3 lbs take a dose of furosemide. If you are having chest
pain or shortness of breath, please seek medical attention.
Thank you for allowing us to participate in your care,
Your ___ cardiology team | ___ with pmhx of HTN, HL, mild MR and SVT who presents with 2
days of chest tightness and dyspnea on exertion and found to
have severe AS.
# Severe aortic stenosis
# Acute congestive heart failure with preserved ejection
fraction:
Pt presented w/new onset symptomatic heart failure. His symptoms
improved with diuresis. He had a TTE which showed severe AS and
an EF of 45%. He was seen by the cardiac surgery team, who
agreed to proceed with surgical AVR. He underwent diagnostic
coronary cath without occlusive disease (70% occlusion in first
diagonal). Pt is being discharged today with plan for AVR on
___.
___: Cr 1.5 on presentation from recent baseline 1.0-1.1.
Downtrended to baseline with diuresis. Most likely ___
cardiorenal. | 130 | 123 |
19113038-DS-13 | 23,469,429 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
your word finding difficulties and some weakness on the right
side. On the scan of your brain, it was noted that there was a
large area of decreased blood flow, indicating that you had a
stroke.
If you have the similar symptoms of difficulty speaking,
weakness, facial droop or numbness/tingling, please come back to
emergency room as this can be an indication of another stroke.
Some of your blood pressure medications were changed during this
hospitalization as you had a recent stroke. Please check your
blood pressures at home and increase metoprolol to 50 mg twice
daily if it remains higher than 140. Please call your primary
care physician if it is higher than 160.
We also stopped your aspirin and restarted your plavix. Dr.
___ about this change and he is okay with it. | TRANSITIONAL ISSUE:
[] ?Chest CT to better evaluate the paratracheal nodule seen on
CT/CTA of head/neck.
[] blood pressure monitoring (metoprolol decreased,
lisinopril/isosorbide dinitrate/furosemide stopped during this
hospitalization)
============================
[ 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? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 70) - () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes (continued on home dose of Lipitor 40 mg daily) - () No (if
LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
=============================
___ yo RH man with PMH of CAD s/p CABG and stent placement
(previously on ASA and plavix, but plavix was stopped for a
recent episode of epistaxix requiring ED visit), HTN, HL and PVD
who presents with word-finding difficulties. Found to have L MCA
stroke on CT/CTP, but given his NIHSS of 4 and the timing of the
event he was not given tPA. He was admitted to stroke service
for clinical monitoring given the large deficit on CT perfusion
study, and he was laid flat and his blood pressure was monitored
to optimize cerebral perfusion. Patient's symptoms improved
during this hospitalization, and he was evaluated and cleared by
both physical therapy and speech therapy. His other modifiable
risk factors were checked and found to be all well controlled.
Telemetry did not show atrial fibrillation, and his
echocardiogram did not show an evidence of thrombus, though it
did show decreased left ventricular EF since his last
echocardiogram.
# NEURO: Found to have L MCA stroke with some word finding
difficult and mild distal RUE weakness, but patient clinically
improved during this hospitalization. His antiplatelet therapy
was changed to plavix 75 mg daily given his history of bad
epistaxis when he was on both full dose aspirin and plavix. A1C
and lipid panel were checked and were found to be under good
control, so he was continued on home dose of lipitor 40 mg
daily. His home antihypertensives were held and metoprolol was
decreased to half dose, and patient's SBP remained in 110-130
ranges.
# CV: last echo with EF of 40% in ___, HTN, HLD and CAD s/p
CABG and stents. Patient's repeat echocardiogram showed
decreased EF% from last echocardiogram. His lisinopril was held
during this hospitalization given normotension and attempts to
maximize to cerebral perfusion, but will need to be restarted
later for his systolic heart failure. He was continued on half
dose of metoprolol (25mg BID) during this hospitalization. He
was also continued on home dose of lipitor as lipid was well
controlled. He was discharged on plavix for antiplatelet therapy
as he had episodes of bad nose bleeds requiring visits to ED and
cauterizations when he was on both plavix and aspirin.
# ENDO: HgA1C 5.9, no diabetes. Lipids: Cholesterol:139,
Triglyc: 118, HDL: 45 and LDLcalc: 70, so continued on home dose
of Lipitor. TSH wnl.
# PULM: No respiratory issues during this hospitalization, but
patient had incidental finding of paratracheal soft tissue on
CT/CTA of head/neck. Will likely need repeat CT chest to better
characterize the finding.
# PPx: SQ heparin TID, bowel regimen.
# CODE/CONTACT: Full Code, discussed with patient and wife, ___
___ ___ | 157 | 628 |
15575815-DS-9 | 26,746,725 | Dear Ms. ___,
You were admitted to ___ for abdominal pain and underwent
removal of your gallbladder which you tolerated very well.
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 as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
All the Best,
The ___ Surgery Team | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain. The
patient underwent laparoscopic cholecystectomy, which went well
without complication (See Operative Note for details). However,
there was evidence of retained 7mm stone in the CBD that would
not clear with glucagon. After a brief, uneventful stay in the
PACU, the patient arrived on the floor tolerating CLD, on IV
fluids, and oxycodone with IV morphine for breakthrough for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirrometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
Because of the retained stone, she had an ERCP on ___ which
showed 4mm retained CBD stone. She tolerated the procedure well.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 175 | 220 |
14417835-DS-19 | 28,551,272 | Dear Mr. ___,
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were passing
bloody bowel movements.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your blood counts were low due to bleeding so we gave you
extra blood.
- We used a CT, or CAT Scan, to take pictures of your abdomen to
look for problems in your gastrointestinal tract.
- We used a camera to check the inside of your gastrointestinal
tract (colonoscopy) for bleeding. There were no signs of active
bleeding and during the procedure a small polyp was removed.
- You have bleeding from a condition called "diverticulosis" -
small outpouchings in your colon contain fragile blood vessels
that can bleed.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medications
- Follow up with you primary care provider
- ___ return to the hospital if you notice recurrent bright
red blood in your poop or black poop.
We wish you the best!
Your ___ Team | Mr. ___ is a ___ year old male with a history of HTN, OSA,
___, diverticulosis who presented with hematochezia and acute
anemia (Hbg downtrend from 14 -> ~7).
ED Course:
Pt was hypotensive and tachycardic, responded appropriately to
1L NS. Anoscopy demonstrated no internal hemorrhoids. A CTA
Abdomen Pelvis was obtained which showed no evidence of acute
intraluminal extravasation. Mild stenosis of the rectosigmoid
and mild mesenteric fat stranding with few reactive lymph nodes,
likely due to mesenteric panniculitis.
Admission:
Pt was admitted to the floor on ___, started on a PPI,
monitored on telemetry and prepped for a colonoscopy. The GI
suite was not available the following day. The patient continued
to have hematochezia with straining and bowel movements
___ but remained hemodynamically stable. A colonoscopy was
performed ___ which demonstrated: 1. Severe
diverticulosis of the whole colon. 2. Polyp (2mm) in the
ascending colon (Polypectomy) 3. Slight blood tinge to the colon
fluid, but no signs of active bleeding. After the colonoscopy
the patient was transfused with 1 unit of pRBCs for a Hb of 7.0.
Discharge Hbg was 8.6. Regarding his history of hypertension,
HCTZ was held for acute blood loss/hypotension but patient was
instructed to restart day following discharge.
TRANSITIONAL ISSUES
==================
#Hiatal hernia- Noted on CT Abdomen/Pelvis: ___
hiatal hernia, increased in size since prior CT in ___.
#Renal Cyst- Noted on CT Abdomen/Pelvis: Increase in size of the
right lower pole simple renal cyst now measuring up to 8 cm.
#Patient is on aspirin for primary prevention but given GI
bleeding this was stopped this admission.
#If he continues to have recurrent bleeds, please consider
evaluation for partial colectomy if the site of the bleeding is
able to be identified and is recurrent in nature. | 166 | 292 |
10104012-DS-20 | 23,867,813 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non-weight bearing right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin daily for 2 weeks
WOUND CARE:
- Please wear your ___ brace/knee immobilizer locked in
extension at all times | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was
initially admitted to the Trauma Surgery Intensive Care Unit for
altered mental status requiring intubation. The patient was
subsequently extubated on hospital day one. Sedation was lifted
and his mental status normalized. On hospital day 2 he was
determined to no longer require ICUlevel care and was
transferred to the orthopaedic surgery service. His fracture was
subsequently determined to be non-operative. He was evaluated by
physical therapy who felt that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications and the patient was voiding/moving bowels
spontaneously. The patient is non-weight bearing in the right
lower extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 148 | 200 |
12035353-DS-24 | 22,524,595 | It was a pleasure taking care of you here at ___. You were
admitted because of your confusion. You were found to have a
urinary tract infection and a new bleed in your brain. Your
confusion, hallucinations, and dilirium are likely due to your
urinary tract infection and not the head bleed. The bleed in
your head was seen on CT scan and found to be stable (not
increasing in size). Please come back to the emergency
department if you develop any other concerning neurologic
symptoms such as increased confusion, sleepiness, or severe
headache. Please stop taking your aspirin as this can increase
your risk of bleeding.
You have a follow up visit with Dr. ___ on ___.
Please see below for details. | ___ year old woman who presented with progressive confusion with
delusions, hallucinations, and tremulousness and found to have a
small left anterior frontal hemorrhage and urinary tract
infection. | 122 | 28 |
15352391-DS-7 | 28,639,279 | Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ with concern for an infection in
your lungs called tuberculosis. Your sputum was tested for this
and returned negative. The x-ray and CT scans of your chest were
normal. Your trouble swallowing will be looked into further
outside of the hospital.
If you have any fevers, chills, difficult swallowing or any
other concerning symptom, please let your doctor know.
Again, it was our pleasure participating in your care.
- Your ___ Medicine Team - | PRIMARY REASON FOR ADMISSION
Mr. ___ is a ___ ___ male with no PMH who presents
with blood in the oral cavity in the setting of cough. | 89 | 26 |
19866267-DS-20 | 23,331,401 | Dear Ms. ___,
You were admitted to ___ and
underwent a below the knee amputation. You have now recovered
from surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site. | ___ is a patient that was admitted to the vascular surgery
service for a heel ulcer. In the ED the patient had an Xray that
showed a heel fracture. Initially ortho was consulted however
the patient requested a BKA. The patient was started on
Vancomycin ciprofloxacin and flagyl. The patient tolerated the
procedure well. Post operatively the patient was found to be
hyperkalemic and slightly hyponatremic. She was fluid restricted
to 1.5L which seem to improve the hyponatremia and she was given
Lasix to resolve the hyperkalemia. Her pain was controlled with
PO dilaudid. On the day of discharge, she was well appearing and
her pain was well controlled. | 293 | 110 |
13383248-DS-17 | 25,547,604 | Dear Mr. ___,
You were admitted to ___ and found to have a severe
electrolyte disturbance. The level of sodium in your blood was
extremely low, a condition called 'hyponatremia'. You were
initially treated for this in the intensive care unit and later
on the general medicine service.
In order to prevent this issue from recurring you will need to
limit your intake of fluid to 1 liter daily. You will also need
to take 'salt tablets' four times a day (one with every meal as
well as one before going to sleep at night). This is extremely
important to prevent life-threatening electrolyte imbalances.
You will also need to have your electrolyte levels checked on
___ at your primary care doctor's office. This
appointment has already been scheduled for you (see below).
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team | ___ with PMH of pancreatic CA, CLL, warm autoimmune hemolytic
anemia, HTN, HL, CAD, and chronic constipation presenting with
complaints of constipation and urinary retention, found to have
severe hyponatremia.
# Hyponatremia: Patient with sodium of ~125-135 over the past
year but acutely worse, as low as 113 during this
hospitalization. Patient appeared euvolemic on exam, but
received 2L of IVF in the emergency room. Cortisol and TSH were
WNL. Most likely etiology was thought to be SIADH. Patient was
placed on hypertonic saline at ___, with gradual
improvement of his Na. He was transitioned from hypertonic
saline to salt tabs only on ___. Doxycycline was also stopped
(can be associated with hyponatremia and patient was on this
medication for unclear reasons). At time of discharge, sodium
was stable at 128. He was therefore discharged on a regimen of
2g of salt tabs QIDACHS and a 1L fluid restriction. He will
follow-up within 4 days with his PCP and have ___ repeat Chem-7
drawn at that time (this appointment was scheduled prior to
discharge and included in discharge documentation).
# Leukocytosis: Marked increase in WBC over the past week was
concerning for infectious etiologies vs progression of CLL. UA
negative, CXR and abdominal CT without clear evidence of
pneumonia, abdominal CT without evidence of pancreatitis or
colitis. His only localizing symptoms were a non-productive
cough of several days duration with associated mild dyspnea,
however this was thought to be more consistent with URI. Empiric
levofloxacin was given for 48 hours but discontinued after
cultures showed no growth.
==== TRANSITIONAL ISSUES ====
# Severe Hyponatremia: Na stable at 128 on ___.
- PCP follow up appt on ___
- Please recheck Chem-7 on ___
- Please ensure patient is taking salt tabs as prescribed and
adhering to 1L fluid restriction
Code Status: Full Code (confirmed) | 143 | 296 |
19305757-DS-5 | 24,065,070 | Dear Mr. ___,
It was a pleasure participating in your care while you were
inpatient at ___. You came in because you were coughing up
blood after your biopsy. Fortunately this has stopped, and you
did not require any procedures. You will have follow-up with Dr.
___ in thoracic surgery early this coming week to discuss your
biopsy results and next steps.
If you have further episodes of coughing up blood, please call
either Dr. ___ or the office of your primary care
doctor, or come to the Emergency Department for further
evaluation.
We wish you the best.
Your ___ | ___ ___ M smoker with history of hypertension, chronic
kidney disease, polycystic kidney disease, cerebral infarct and
history of intracranial aneurysm, seizure, status post recent
bronchoscopy with biopsy performed by Interventional Pulmonology
Service for calcific growth in his chest with on ___, found to
have low grade neuroendocrine tumor, most consistent with
typical carcinoid, who presented with a six-hour history of
coughing up small clots, chest discomfort, and nausea.
# Hemoptysis: Resolved soon after admission with no persistent
cough, hypoxia or hemodynamic instability. CT chest revealed
post-biopsy changes consistent with hemorrhage. Interventional
pulmonary was consulted, but given stability, bronchoscopy was
deferred. Patient wished to be discharged home from the ICU,
deferring further monitoring. Given stability and patient's
understanding of risk and benefit, this was done. Patient did
have some intermittent chest discomfort in setting of coughing
that was not reproducible or otherwise pleuritic. No hypoxia.
Pulmonary embolism felt unlikely.
#Neuroendocrine tumor: Patient underwent recent bronchoscopy
with biopsy performed by Interventional Pulmonology Service for
calcific growth in his chest with on ___. Discussion of biopsy
results deferred to follow-up in thoracic surgery clinic.
# Tobacco use: Patient quit smoking the week prior and did not
have any cravings. | 97 | 197 |
15313106-DS-4 | 23,232,056 | You were admitted due to change in mental status, lack of diet,
fatigue.
You began to recover after getting fluids and antibiotics were
also given. Studies and a scope showed that you had narrowing
and diverticula in the area of the outlet that delivers bile and
pancreatic enzymes into the intestine. This area was cleaned out
and opened up and since the procedure you've been doing well.
Antibiotics were stopped since there was not clear evidence of
infection.
Please continue all your home medications as you were taking
them before. And please follow up with your primary care doctor
___ scheduled). Please also continue your scheduled follow
up with your kidney cancer doctor at ___. You don't need follow
up with the GI doctors at this ___.
If you develop worsening appetite, abdominal pain,
nausea/vomiting, fevers/chills, please call your doctor or come
back to the emergency room for further evaluation.
Sincerely,
Your ___ Team | Ms. ___ is a ___ female with the past medical
history of localized left renal cell carcinoma s/p RFA at ___ on
___, CAD s/p open-heart bypass with concurrent AVR with
porcine valve in ___, Grave's disease s/p thyroidectomy on
Synthroid, depression, HTN, HLD, DM2 on oral meds, GERD, COPD,
and s/p cholecystectomy decades before presentation who presents
with fatigue, anorexia, weakness, shaking chills, and
encephalopathy. | 150 | 67 |
16658369-DS-13 | 25,694,688 | Mr. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ with abdominal pain, found to have acute
pancreatitis. You were treated with nothing by mouth, IVFs and
pain control. GI was consulted and agreed with our plan.
Eventually your diet was advanced and the pancreatitis resolved.
You were also found to have a clot in the veins behind your
pancreas, called portal and splenic vein thrombosis. You were
started on a blood thinner called Coumadin which you should
continue for ___ months. You will also be given Lovenox until
your coumadin levels are therapeutic.
You should avoid high fat foots and alcohol which can worsen the
pancreatitis.
Please be sure to continue taking coumadin. You can discuss with
your PCP regarding the ultimate duration. | ___ M with history of HTN and heavy alcohol use admitted with
abdominal pain found to have acute complicated pancreatitis and
splenic vein thrombosis.
# Pancreatitis: Complicated pancreatitis with imaging findings
concerning for necrosis of pancreatic tail. Complicated by
splenic vein and portal veing thrombosis. BISAP score during
admission 0. Most likely alcohol related given history and
macrocytosis on CBC. No medications to invoke and no history of
gallstones or evidence on CT or RUQ U/S. He was treated with
NPO, IVFs and pain management. Diet was slowly advanced until he
tolerated a regular low fat diet. GI and surgery were consulted
given concern for necrosis, and did not feel there was any
indication for intervention.
# Splenic Vein Thrombosis: Most likely a sequalae of
pancreatitis. Patient was treated with a Heparin drip initially
and then transitioned to Lovenox and Warfarin. Coumadin to
continue for ___ months. Would repeat abdominal imaging in 3
months.
# Macrocytic anemia: ___ be an indicator of chornic heavy
alcohol use. B12 level normal.
# HTN: Chronic, stable. Continued Atenolol once tolerting POs | 129 | 201 |
11347465-DS-25 | 27,233,868 | You presented to the hospital with symptoms of an ear infection
after your symptoms did not improve with oral antibiotics. You
were treated with a different IV antibiotic with significant
improvement in your symptoms. You have now been transitioned to
oral antibiotics, which you will take for a total of 10 days. It
is very important that you follow up with your primary care
physician ___ 1 week to evaluate for further improvement in
your symptoms. | ___ y/o M with PMHx of HIV, HCV, DM2, CKD, as well as recent
diagnosis of L-sided OM s/p course of amoxicillin, who presents
with persistent symptoms. CT scan showed findings consistent
with OM as well as possible developing mastoiditis.
# ACUTE OTITIS MEDIA
# POSSIBLE DEVELOPING MASTOIDITIS
Persistent symptoms on presentation likely represent expected
recovery from recent OM vs. treatment failure of amoxicillin.
Lack of systemic symptoms is reassuring against worsening
mastoiditis. Pt reports significant improvement in symptoms on
CTX. He was transitioned to cefpodoxime for planned 10 day
course. He will also continue Cipro ear drops twice daily x 10
days as well.
# HIV: Well-controlled.
-Continue Etravirine 200 mg PO BID
-Continue Raltegravir 400 mg PO BID
-Continue Lamivudine 150 mg PO BID
# DM2:
- 40 units lantus
- Humalog with meals + correction dose
- Held jardiance while inpatient, restarted at discharge
- Fingersticks qACHS
# CAD:
- Continue atorvastatin
- Continue ASA/Plavix
- Continue zetia
- Continue metoprolol
- Continue Lisinopril
#Insomnia:
- Continue seroquel
TRANSITIONAL ISSUES
- Pt will continue cefpodoxime and cipro ear drops x 10 days
- Pt will f/u with PCP to ensure resolution of symptoms
- Please note the following incidental imaging finding: "Soft
tissue density masslike area in the left lung apex likely
represents scarring with adjacent atelectasis. Follow-up chest
CT in 3 months is recommended to evaluate for stability." | 76 | 220 |
10398209-DS-19 | 26,551,658 | Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having a fast heart rate at
your rehab. You were found to have an irregular heart rhythm and
were started on a new medication called amiodarone. You also had
a bad cough and were started on IV antibiotics for a pneumonia.
If you have fevers, chills, chest pain, palpitations, shortness
of breath, burning with urination, or any other concerning
symptom, please let your doctors ___.
Again, it was our pleasure participating in your care.
We wish you the best! | PRIMARY REASON FOR ADMISSION:
Mr. ___ is a ___ h/o DM II, with CAD and larrge R MCA
stroke with hemorrhagic conversion following an elective left
heart cath with placement of DES to LCx who presented from ___
with tachycardia and found to have afib with RVR in ED. | 96 | 48 |
19601656-DS-10 | 26,400,308 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You came in due to a urinary tract infection and confusion. We
treated you with antibiotics for your infection and your
infection improved. We also gave you some medication to help
reduce your confusion.
Though your confusion has not totally resolved, we discussed
with your family that being at home would be a more stable
environment for you as you get better. | ___ yo F with bipolar disorder, frequent UTIs, presenting with
altered mental status for the past week per family
# Delirium: Patient was brought in by her family after becoming
agitated and confused at home and for treatment of UTI. Patient
had seen her urologist Dr. ___ earlier in the week and culture
has shown Pseudomonas. On presentation the patient was very
confused and agitated, refusing to work with medical staff.
Delirium was most likely secondary to UTI given history of
confusion with previous UTIs and know positive UC. A depakote
level, TSH, and RPR were negative. She was started on Meropenem
as patient has many known drug allergies. Olanzipine was used
PRN for agitation and she received several doses. Delirium
failed to resolve with antibiotics and patient continued to be
agitated. She pulled out several IVs and a PICC line. Psych was
consulted for refractory delirium and recommended haldol .___.
A qt interval was normal. 3 days following treatment with
haldol, the patient developed a tremor in all 4 extremities
thought to be from EPS. Delirium moderately improved and family
expressed wish to bring her home. Medical staff felt it was in
patient's best interest to be in a more familiar environment. A
head CT was not ordered as the patient had a similar admission
this ___ at which time a head CT was unremarkable. The
family was instructed with clear instructions to bring the
patient back to the hospital if her mental status did not
improve in the next ___ hours upon returning to home.
# Recurrent Urinary tract infections: UCx was positive for
pseudomonas as an outpatient but she required meropenem due to
many drug allergies. Pt had been put on Tigecycline on previous
admission this ___ after failing nitrofuritonin. A repeat UA
and culture at admission was positive and culture grew E.Coli
sensitive to meropenem. The treatment was complicated by
delirium which resulted in the patient not receiving several
doses. She completed a ___t which time a UA was
negative and a UC showed no growth. She will continue
methenamine as an outpatient. Her urologist was informed of
admission and did not believe additional work up was warranted.
# Hypothyroidism: Patient has normal TSH. Continued with home
synthroid dose.
.
# Glaucoma: Continued Combigan, daily to right eye.
.
# Bipolar disorder: Psych saw patient but could not confirm
this diagnosis. She as kept on her home dose of depakote
.
#HTN: Patient did not come with diagnosis but was persistently
hypertensive throughout stay. She was started on lisinopril and
responded well. Cr was normal at initiation and repeat labs
showed no increase. She will follow up with PCP.
.
# Hyperlipidemia: Continued simvastatin.
. | 76 | 447 |
10839217-DS-21 | 23,110,547 | Dear Ms. ___,
You were admitted to ___ for
evaluation of weakness, difficulty breathing, right eyelid
droop, and difficulty speaking. Testing of your nerves and
muscles (EMG) as well as blood tests showed that your weakness
was due to myasthenia ___, a condition where your immune
system attacks the connection between your nerves and muscles.
Despite starting treatment for your myasthenia, your weakness
continued to worsen, so you required intubation to help support
your breathing. You were briefly weaned off the ventilator twice
before being able to breathe comfortably without the assistance
of the ventilator. Your swallowing function also improved prior
to discharge and you did not need the assistance of tube
feeding. You were started on medications to treat your
myasthenia (azathioprine, prednisone, and pyridostigmine). You
were also started on an antibiotic (Bactrim) to prevent
infections while on prednisone and azathioprine.
During your stay, you were also found to have atrial
fibrillation, an abnormal heart rhythm that increases your risk
of stroke. You were started on a medication to prevent blood
clots and strokes (apixaban), as well as medications to control
your heart rate (amiodarone and diltiazem).
You also developed a urinary tract infection during your stay
that was treated. You were also found to have slightly low
platelet levels that can be followed up by your primary care
provider.
Please attend your follow up appointments listed below.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___ | Ms. ___ is an ___ woman with history notable for
hypertension admitted with ptosis, dysarthria, and generalized
weakness. Examination at time of admission was notable for
fatigability concerning for myasthenia ___, which was
subsequently confirmed on EMG as well as with AChR antibody
testing. Chest CT was negative for thymoma, and brain MRI was
unremarkable. Treatment was initiated with IVIG, but initial
treatment course was complicated by disease progression
resulting in hypercarbic respiratory failure requiring
intubation and ventilation (___). Respiratory
improvement was noted upon completion of IVIG, prompting a trial
of extubation that was ultimately unsuccessful, requiring
elective reintubation on ___. During this time, therapy
with prednisone was initiated in consultation with the
Neuromuscular service, and a second trial of extubation was
attempted following clinical improvement on ___. This
course was complicated by pulmonary edema (felt to be related to
oncotic load from IVIG as well as IV fluids) requiring a third
elective intubation from ___, during which time
Ms. ___ respiratory status improved with aggressive diuresis.
As respiratory support with ventilation was available, a second
course of IVIG was completed in consultation with the
Neuromuscular service. Ms. ___ was then started on
azathioprine (with TMP-SMX for PJP prophylaxis) and continued on
prednisone with plan for outpatient taper.
Of note, Ms. ___ had recently been noted to have new atrial
fibrillation just prior to admission, also confirmed during her
hospital stay. Echocardiogram obtained during the admission was
notable for mild pulmonary hypertension. Ms. ___ was started
on apixaban for anticoagulation as well as diltiazem (selected
over beta blockers in setting of myasthenia) and amiodarone for
her heart rate.
Incidental note was made of pseudothrombocytopenia during the
admission (for which future hematology studies should be
obtained in a citrated tube) as well as mild asymptomatic true
thrombocytopenia. An E. coli urinary tract infection was also
treated during the admission.
TRANSITIONAL ISSUES
1. Continue prednisone 60 mg daily until follow up with Dr.
___.
2. Outpatient speech and swallow follow-up.
3. Follow up platelets as outpatient.
4. Please monitor serum potassium periodically while on TMP-SMX
and lisinopril.
5. Avoid medications known to worsen myasthenia ___, such as
aminoglycosides, fluoroquinolones, and beta blockers, when
feasible.
6. Avoid EDTA tubes for future hematology laboratory draws.
7. ___ consider follow-up CT for incidentally detected 3 mm
pulmonary nodule 12 months. | 236 | 375 |
18536023-DS-13 | 20,958,867 | Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Mr ___ is a ___ with PMH of HTN and intermittent LLQ pain who
presents with a recurrent episode of LLQ abdominal pain and OSH
imaging concerning for possible SBO. Mr. ___ presented to the
ED on
Mr ___ has been in ___ since last ___, at which
point he started having abdominal pain. He was unable to
tolerate PO, and on ___ had episodes of vomiting and cramping
LLQ abdominal pain associated with darkened urine. He presented
to a hospital and had a CT scan done with PO contrast that
showed concern for SBO. He has never had any prior surgeries on
his abdomen. His last colonoscopy was done in ___ and one
benign polyp was removed. Mr ___ decided to come to the ___
for further evaluation, especially if he needs potential
surgical intervention.
Upon review in the ___ ED, he reports that his pain has
improved since returning to the ___. He has been able to
tolerate water and gingerale without nausea and vomiting, though
he has not attempted solid food. He had an episode of diarrhea
and a solid BM yesterday, and last passed flatus this morning.
He says his darkened urine has now resolved. He is tender in the
LLQ on exam. He denies fevers, chills, nausea, chest pain, or
SOB.
After this, he was admitted to the acute care surgery service
for conservative management with bowel rest, IVF, serial exams.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with oral pain
medication
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 with IV Fluids.
After improvement in abdominal exam, the diet was advanced
sequentially to a Regular diet, 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.
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. | 293 | 433 |
10181426-DS-14 | 29,600,070 | Dear Mr. ___,
You were admitted to ___ after you had right flank pain and
blood in your urine. We are treating you for a possible
infection. You should take your antibiotics for two weeks. It
could be that you had a cyst in your kidneys that ruptured that
could cause pain and is common and not dangerous.
You should hear from the ___ about an appointment
with Dr. ___ will be within the next two weeks.
Please call if you do not hear from them this week. You should
have your blood tests repeated this ___. You should also
ask you neurologist if it's ok to stop aspirin as you have had
some blood in the urine. | Mr. ___ is a ___ with w/ PCKD s/p LUR kidney
transplant in ___ presenting to the ED with hematuria and right
flank pain.
#Flank Pain/Hematuria: The differential included nephrolithiasis
(given gross hematuria and lack of dysuria, fever, leukocytosis)
vs rupture of a cyst vs pyelonephritis, given similar
presentation to ___ admission. Although hemorrhage into a
cyst can lead to hematuria, the typical presentation may be pain
as in this case, since many cysts do not communicate with the
collecting system. He has had at least two E. coli UTIs in the
last year (one in OMR ___ UCx, the other from ___
admission for pyelo), both pan-sensitive. Other differential for
hematuria includes other renal structural disease.
hypercalciuria, malignant HTN, renal vein thrombosis, renal
infarct being very unlikely. He may have ureteral or bladder
obstruction, appears less likely given patient currently
minimally symptomatic. Sediment was not consistent with
glomerular pathology. CT Abdomen/Pelvis without contrast did not
show any clear anomaly. He was continued on ceftriaxone and then
switched to cipro for a two week course. He was given IV fluids
for renal dysfunction and Tylenol for pain.
___: Cr was 1.3 from baseline 0.9-1.0, resolved with IV fluids.
This was likely pre-renal given likely infection and
concentrated urine (Sp ___ 1.022). Post-renal unlikely given
renal transplant ultrasound w/o hydronephrosis.
#Pyuria/Hematuria: Pyuria has been present on the last 5 UAs in
the system going back to ___. He has also had microscopic
hematuria dating back to that time, but gross hematuria was new.
BK PCR in the urine negative last week. Normal prostate exam
without evidence of BPH or prostatitis. He has had at least two
E. coli UTIs as above. This may have been be due to
pyelonephritis vs cyst rupture. It was unlikely to be glomerular
given minimal proteinuria on dipstick. Urine culture was pending
at discharge.
#S/p LURT, Polycystic kidney disease: Transplant on ___, was on dialysis for about 8 months prior. We continued
immunosuppression at home doses.
#HTN: Enalapril was held initially due to ___ and restarted at
discharge
#GERD: Continued omeprazole
#Osteoporosis: diagnosed on BMD ___, was briefly on
alendronate. Continued vitamin D ___ units/daily). | 119 | 362 |
10082662-DS-10 | 22,060,359 | You presented to the hospital after routine staging scans showed
a blood clot in your lungs. Follow up ultrasound imaging also
showed a blood clot in your left leg (likely the source of the
blood clot in your lung).
You were started on Lovenox, and your dose was adjusted based
off of your Lovenox levels.
You are now being discharged home. It is very important that you
follow up with your doctors as ___. | ___ y/o F with PMHx of metastatic melanoma, pulmonary
aspergillosis, CKD IV, HLD, who was referred to the ED after
routine staging CT showed PE. Imaging also notable for LLE DVT.
She was started on Lovenox, with doses adjusted to get levels in
therapeutic range.
# DVT/PE: Pt was only minimally symptomatic (endorsed several
months of mild progressive DOE). No evidence of right heart
strain on lab work (BNP and Tn not elevated); however, ECG did
show TWI in III. She was started on Lovenox at once daily dosing
given renal function. However, renal function subsequently
improved on HD2, and dosing was increased to BID per discussion
with pharmacy. Levels were followed and were therapeutic at the
time of discharge. Would continue to monitor renal function in
the outpatient setting and consider rechecking LMWH levels if Cr
increases.
# CKD STAGE IV: Cr appears to generally range 1.5 to 1.8 over
the past year in OMR. Cr was 1.8 on presentation but has
improved to 1.5 at the time of discharge.
# CHRONIC DIASTOLIC HEART FAILURE: No evidence of volume
overload on exam. Continued home metoprolol and Lasix.
# METASTATIC MELANOMA: Home Dabrafebib/Trametinib held while
patient in house and restarted at discharge.
# ANEMIA: H/H below recent baseline, but no clear evidence of
bleeding. ?possibly related to recent chemotherapy. Remained
stable throughout hospital course.
TRANSITIONAL ISSUES
- Pt will need to remain on Lovenox indefinitely given
concurrent malignancy diagnosis.
- Would continue to trend Cr in the outpatient setting and
consider rechecking LMWH levels if there were a change in renal
function. | 72 | 254 |
11128372-DS-17 | 28,072,785 | You have undergone the following operation: Thoracic Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without getting up and
walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit 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. This brace
is to be worn at all times.
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.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in 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.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Lumbar decompression without fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit 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 may have been given a brace. This
brace is to be worn when you are walking. You may take it off
when sitting in a chair or 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 and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in 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.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
TLSO at all times. No lifting greater than 10 lbs. No
significant twisting or bending.
Treatments Frequency:
Daily dry gauze dressing change to thoracic spine. When dry x
48h, may leave open to air. When dry x 48h, may shower. No tub
baths or soaking incision | Patient was admitted to the general surgery trauma service. In
addition to his thoracic spine fractures, he was found to have a
R rib fractures, a small L pneumothorax and a sternal fracture.
The pneumothorax was stable to serial chest x-rays, his rib
fractures were treated with pain control and chest physical
therapy.
He was taken to the operating room on ___ for treatment of
an unstable spine fracture at the T7 level with a T6-8 posterior
spinal fusion with instrumentation. He received ancef for
perioperative antibiotics, and ___ hose/pneumoboots ___
operatively for DVT prophylaxis. He was globally neurologically
intact before and after the operation. He also has a T4
compression fracture. ___ operatively he was fitted for a TLSO
brace, which he is to wear at all times.
On POD 1 he was tachypneic and hypoxic on RA, and had a chest CT
scan to r/o pulmonary embolism. The scan was negative for PE,
but did show a questionable small pneumonia which the medical
service recommended treatment with Levaquin for a total of 5
days ending ___. He is maintained on ___ nasal cannula
O2 to keep sats >92%, and requires chest pt and incentive
spirometer to continue encouragement of deep breaths and
clerance of ___ operative atelectasis, as well as adequate pain
control for his rib fractures.
He had slight low urine output the evening prior to discharge,
which responded well to a fluid bolus. He had the foley
catheter removed prior to discharge to rehab facility.
He was managed while in house on a CIWA protocol with diazepam
for potential alcohol withdrawl, and was treated with folate and
thiamine for his likely alcohol related deficiencies.
He was seen by physical therapy, and found to have significant
limitations in mobility that would benefit from a rehabilitation
facility. He was afebrile with stable vital signs and a
clean/dry wound at the time of discharge.
He was seen by physical | 1,267 | 325 |
18102889-DS-5 | 26,105,790 | Dear Ms. ___,
It was a pleasure caring for you here at ___
___!
WHY WAS I IN THE HOSPITAL?
=================================
- You had repeated bouts of diarrhea and abdominal pain.
WHAT HAPPENED IN THE HOSPITAL?
=================================
- Tests were performed that showed that you had some
inflammation of your bowels.
- You were started on antibiotics to help with the inflammation
in your abdomen.
- Some of your medications were not given to you in order to
help with your inflammation.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
=================================
- You will be going to an extended care facility in order to
best recover from your hospitalization.
We wish you all the best!
Your ___ care team. | PATIENT SUMMARY
================
This is an ___ female with advanced dementia who
presented to ___ with abdominal pain and emesis,
transferred with concern for ischemic vs infectious colitis on
CT A/P. She was evaluated by surgery, admitted to ___ for close
monitoring and medical management. Her lactate down-trended with
IVF and bowel rest, she was treated with a 5 day course of
ceftriaxone and metronidazole for sepsis. She was called out to
the floor, hemodynamically stable with no clinical symptoms.
Elevated MAP maintained iso question of ischemic colitis. She
completed Abx course on ___. Symptoms improved with holding
home antihypertensives and increased hydration
TRANSITIONAL ISSUES
=======================
[] Please evaluate for re-start of her home anti-hypertensives.
Currently held iso possible ischemic colitis with permissive
hypertension
[] Please evaluate for re-start of her home pain medications as
held during this admission.
[] Noted discussions regarding placement of long-term care in a
memory unit.
[] If within goals of care, would need sigmoidoscopy as an
outpatient
[] Repeat CBC in 1 week
[] readdress code status, was previously DNR/DNI
Code Status: Full (limited trial)
Contact: ___ ___
ACUTE ISSUES
============
# Undifferentiated Colitis
Ms. ___ presented with severe abdominal pain with n/v/d. CT
A/P at OSH was concerning for colitis of the sigmoid/descending
colon. Given her tenuous vitals and elevated lactate there was
concern for septis iso infectious colitis. She was started on
broad spectrum Abx, however, iso diarrhea and vomiting also coud
have been ischemic in nature. Given acuity and high lactate,
sigmoidoscopy was deferred. Surgery followed along, but patient
did well with conservative management; lactate normalized with
IVF, and she received a 5 day course of
ceftriaxone/metronidazole for sepsis. Elevated MAPs were
maintained iso presumed ischemic colitis.
# Elevated lactate
# Leukocytosis
# GPC bacteremia
She had an elevated WBC to 24.9 on ___ which was suspected
secondary to critical illness vs infectious colitis. CXR was
without infiltrate, urine was bland. She was started on
ceftriaxone/flagyl/vanc. She had ___ BCx pos for GPC which
speciated to staph saprophyticus, thought to be contaminate.
Vancomycin was discontinued on ___. Repeat BCxs were negative.
She completed 5 day course of ceftriaxone/flagyl. Her WBCs
returned to ~11 upon discharge.
CHRONIC ISSUES
===============
#CAD primary prevention
Held home ASA.
#HTN
Held her home enalapril and felodipine iso possible ischemic
colitis.
#Hyperlipidemia
Continued home Pravastatin 40mg
#Depression
Continued home fluoxetine 60 mg
#Chronic pain
Given home gabapentin 100mg daily, Tylenol prn. Held home
oxycodone.
#Severe Dementia
-Stable, continue to monitor | 106 | 388 |
18056245-DS-47 | 21,540,273 | Dear Ms. ___,
It was a pleasure taking care of you during you stay at ___.
You were admitted for worsening left breast/chest pain. You
were found to have a low oxygen level, likely caused by not
taking your water pill (torsemide). Torsemide was restarted and
your oxygen level improved. Your breast pain improved with
medications and a Lidocaine patch. Please continue to take your
medications as prescribed and keep your follow-up appointments.
For your diarrheal infection, we switched metronidazole to oral
vancomycin. The vancomycin had to be sent to a particular
pharmacy. Please pick it up at:
___ Pharmacy
___, ___
Phone: ___
We hope you continue to feel better.
Sincerely,
Your ___ Team | Ms. ___ is a ___ ___-speaking woman with past
medical history significant for C. diff colitis on
metronidazole, chronic arthritic chest wall pain, chronic
abdominal pain, recurrent DVT/PE on Coumadin, and diastolic
heart failure who presents with left breast pain and medication
non-adherence.
# Acute exacerbation of diastolic heart failure: Per the
patient's son, patient has been refusing to take her PO
medications, including torsemide. On admission, she had
symptoms of mild volume overload (bibasilar crackles, bilateral
___ edema, hypoxia). She was given 20 mg IV furosemide and
restarted on torsemide 40 mg daily. On discharge, she denied
shortness of breath and did not require oxygen.
# Diarrhea c/b hypokalemia: Patient was hospitalized last month
for C. diff infection. Per the patient's son, she has been
refusing to take her PO meds, including metronidazole and K+
supplement. She has had ongoing diarrhea and her potassium on
admission was 2.7. As the patient prefers liquid medications to
pills, we have called a script into an apothecary to compound
liquid vancomycin for a 14-d course to treat continued C. diff.
# Left breast/chest pain: Chronic in nature, but worse on
presentation. Son previously declined further work up. At time
of discharge, pain had returned to baseline.
# Thrush: Likely from chronic steroid use, although patient's
son reports that she has not been taking prednisone for weeks.
She was started on Nystatin S&S QID, which she should continue
for 21 days.
# Sub-therapeutic INR: Patient is on lifelong anticoagulation
for recurrent DVT/PE. INR on admission was 1.8 but was
supratherapeutic at last admission. Patient's son reports that
he does not allow his mother to refuse to take this pill.
Possible dietary indiscretion may have contributed to
subtherapeutic INR. She was continued on home Coumadin and was
not bridged. | 114 | 311 |
14021375-DS-6 | 23,657,284 | Dear Ms ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came in because your sugars were very high because you
missed taking your insulin
What happened while you were in the hospital?
- You were give insulin through your IV. When your sugars came
down, you then got the insulin injections under your skin.
- The ___ Diabetes team helped adjust your insulin dosing
What should you do once you leave the hospital?
- Take your insulin with each meal.
- Follow up with your primary care team including Dr. ___ at
___ as scheduled
We wish you all the best!
- Your ___ Care Team | ___ non-domiciled woman with T1DM c/b neuropathy and
recurrent admissions for DKA, history of seizure d/o, and PTSD
who presents with DKA in the setting of insulin omission.
Patient initially presented with metabolic acidosis 7.16 with
bicarb 8, ketonuria, and beta hydroxybutyrate 14.7 in the
setting of sleeping through meals/insulin administration while
on the train. She was placed on an insulin drip overnight, and
transitioned to subq insulin when her anion gap closed. Due to
her frequent admissions for DKA in the setting of housing
insecurity, psych was consulted to ensure that there were no
underlying psych disorder also detracting from access to care.
They deemed that she did not have any psychosis, delusions,
suicidality or other overt psychiatric pathology to explain her
inadherence to insulin despite the serious consequences she has
experienced (multiple ICU admissions, diabetic neuropathy,
etc.). ___ team was involved and adjusted her insulin
regimen while she was inpatient. Her discharge insulin regimen
was 28 units at night, and 10 units with meals. She previously
took long-acting insulin in the morning, but understands to take
it at night going forward to coincide with how it was given in
the hospital.
Regarding insulin adherence, Ms. ___ did not demonstrate
much interest in behavior change and though she was able to
identify some barriers to insulin administration, she was unable
to identify any new strategies for increasing adherence to
insulin regimen. Discussed her case with her primary care
physician (Dr. ___ of ___ to try to troubleshoot &
strategize ways to help the patient take her insulin and avoid
recurrent DKA. Plan is that Dr. ___ team is going to be
very actively involved with the patient in the coming days and
weeks, and the patient is scheduled to be seen by a new [to her]
diabetes educator.
#Anemia - she had Hgb of 13.2 on admission, which was
hemoconcentrated, and when given adequate hydration this was
9.9. There was no evidence of GI bleeding. MCV was 89 which
likely represents chronic malnutrition. She was given Rx for
iron and multivitamins with minerals on discharge (60 day
supply), and will follow-up with her primary providers to see if
she would benefit from any additional testing. | 110 | 375 |
19670384-DS-47 | 29,678,917 | Dear Ms. ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with abdominal pain and
diarrhea. You were found to have infection of your bladder. We
evaluated your transplanted kidney with an ultrasound and it was
found to be normal. You were also evaluated with stool studies
which showed that you do not have C. diff. We started you on an
antibiotics, cefpodoxime. You should continue this antibiotic
through ___.
We wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with history of ESRD from FSGS
s/p LURT in ___, baseline Cr 1.7, CAD s/p NSTEMI, hypertension,
previous C. diff infection in ___ s/p augmentin presents with
fever and diarrhea found to have complicated cystitis.
# Complicated cystitis: The patient presented with fevers and
diarrhea. Though her history was initially concerning for C.
diff infection given her recent history of antibiotic use, the
patient was found to have pyuria with urine culture growing E
coli sensitive to cephalosporins and ciprofloxacin and negative
C diff stool antigen. The patient was evaluated with stool
studies which were normal and CXR which was normal. The patient
was evaluated with CMV viral load which was negative. Ova and
parasites were negative. The patient was started on ceftriaxone
transitioned to cefpodoxime to complete a 14 day course though
___. The patient was evaluated with a renal transplant
ultrasound which was normal.
# ESRD s/p LURT ___ on immunosuppression: The patient's
creatinine was found to be at baseline. The patient's tacrolimus
and sirolimus levels were monitored throughout her admission and
she was discharged on her home regimen. The patient's furosemide
was held initially given her infection. This medication was
restarted on discharge.
# HTN: The patient was continued on her home metoprolol
succinate 75mg PO qday.
# Hyperparathyroidism: continued calcitriol
# CAD s/p NSTEMI: The patient was continued on her home aspirin
81mg PO qday, clopidogrel 75 mg PO daily, atoravastatin 80mg PO
qPM, and nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain. The
patient had a recent admission for chest pain which was thought
to be GI in origin. She was continued on her home famotidine 20
mg PO DAILY:PRN nausea, abdominal pain, and pantoprazole 40 mg
PO Q24H
# Depression/anxiety: continued citalopram 40 mg PO DAILY
# Insomnia: continued zolpidem 10mg PO qHS PRN
# Pain management: continued hydrocodone-Acetaminophen
(5mg-325mg) 1 TAB PO Q6H:PRN pain
# Vitamin deficiency: continued folic acid 1mg PO qday
# Gout: continued febuxostat 120mg PO qday
Transitional Issues:
- Continue cefpodoxime 400mg PO q12hours through ___ for
complicated cystitis | 89 | 353 |
13206852-DS-18 | 24,339,560 | ANTICOAGULATION:
- Please take lovenox 60mg every 12 hours x 1 week, then change
to lovenox 40mg daily x 2 weeks.
.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get your left leg splint or your left hand splint wet.
.
-You should keep your left lower extremity elevated when you are
not dangling or walking (you may use pillows) to help with
swelling and drainage.
-You should continue to walk around with platform walker but do
not weight bear on your left leg.
-Report any change in color of your flap area including
increased redness and/or any dusky or darkened appearance to the
office.
-use gauze, as needed, to help absorb any drainage from flap.
-Your left lower extremity graft sites, wounds and flap incision
should be dressed with Adaptic and bacitracin ointment dressings
daily and then left lower extremity should be wrapped with clean
ace wrap daily from your foot to just over your knee and you
should wear your bi-valve splint at all times.
-Your right thigh incision can be left open to air, without a
dressing.
-You may shower but you will need to cover your left lower
extremity where your flap and skin grafts are with plastic
wrap/bag to shield from moisture. You may leave your left thigh
skin graft donor site and right thigh incision open to let warm
water run over it. Pat dry with soft towel and re-apply ace
wrap. No tub baths until directed by your doctor.
-___ your skin graft donor site open to air to dry out.
-You may continue to dangle and walk around according to the
protocol which you started in the hospital. You reached 30
minutes, three times a day in the hospital. You should increase
dangles to 60 minutes, three times/day x 2 days and if you
tolerate this well, increase to 90 minutes, three times/day x 2
days. After that, you can dangle and walk around like you would
normally do (except no weight bearing on left leg).
-Keep your left hand splint in place.
.
Diet/Activity:
1. You may resume your regular diet.
2. Avoid heavy lifting and do not engage in strenuous activity
until instructed by your doctor.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol. These narcotic medication will be weaned off going
forward, as discussed with you in the hospital. As you continue
to heal, the need for narcotic pain control should dissipate.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
NARCOTIC WEANING SCHEDULE:
Week 1 start ___
MS ___ 30mg po Q12H
Oxycodone ___ po Q3H prn
.
Week 2 start ___
MS ___ 15 po Q12H
Oxycodone ___ po Q3H prn
.
Week 3 start ___
MS ___ 15 po QAM
Oxycodone ___ po Q3H prn
.
Week 4 start ___
Oxycodone ___ po Q3H prn
.
Week 5 start ___
oxycodone ___ po Q4H prn
.
Week 6 start ___
oxycodone ___ po Q4H prn | Mr. ___ presented to the ___ Trauma ___ in hemorrhagic
shock, with GCS score of 15, and was found to have splenic
laceration, left open tib/fib fractures, and bleeding from
paravertebral artery. His vitals responded well to fluid
resuscitation and blood transfusion.
.
On ___, he was taken to the OR with by orthopedic surgery
for I&D and application of an external fixator for temporary
stabilization of the fractures and stemming of the bleeding. He
tolerated the procedure well.
.
Given his injuries, he was transferred to the Orthopedic Service
for management of his fractures. On ___, the patient was
taken to the OR for I&D, tibial IMN, ABx spacer, and VAC of the
wounds. VAC were exchanged ___ and ___. On secondary
survey, the patient was found to have left fifth metacarpal neck
fracture, which was managed by an ulnar gutter splint and
converted to an orthoplast splint.
.
On ___, the patient had SOB and left chest pain, so we did
a cardiac and pulmonary workup for PE. Cardiac markers were
negative, and CTPE was normal.
.
Given the patient's history of self reported bipolar disorder
with ? suicidal ideation, Psych was consulted, who recommended
decrease in ativan with weaning off prior to discharge, seroquel
as necessary, and confirmed that there were no psychiatric
contraindictations to discharge to rehab. Please psych note for
further details on history and recommendations. Also, please see
Social Work note for additional history and recommendations.
.
On ___, he was taken to the OR by plastic surgery for wound
coverage. He had a R ALT free flap to the L tibial wound, as
well as split thickness skin graft from L thigh to the L knee
wound and the muscle adjacent to the free flap. Anastomosis
end-to-end into the AT artery was challenging due to extensive
vasospasm and clot, requiring multiple revisions. Otherwise, the
patient tolerated the procedure well.
.
Following the free flap, he was transferred to the Plastic
Surgery service for the remainder of the hospitalisation.
Hospital course by system while on the plastic surgery service:
.
- Free flap management/Activity: He was placed on bedrest for 5
days, then changed to OOB to chair with assist, with keeping the
LLE elevated. The LLE remained NWB. He initially had a plaster
posterior splint placed in the OR, then changed to a custom
bivalved fiberglass splint. He was started on a dangling
protocol on POD#5, starting with 5 min TID, then 10, 15, 30, 60
minutes TID each successive day. Tissue perfusion was monitored
with flap checks and continuous Vioptix monitoring, which was
stable. The vioptix monitoring was discontinued prior to
discharge.
.
- GI: He was kept NPO for at least 24 hours following the free
flap. He received IVF during that time. After 24 hours, he was
transitioned to a regular diet excluding caffeine and chocolate,
which he tolerated well.
.
- GU: His Foley catheter was removed on POD#5 after the
procedure. Intake and output were closely monitored.
.
- Neuro: An epidural catheter w/ bupivicaine was placed
pre-operatively for pain control. Acute pain service was
consulted. The epidural was discontinued on POD#2 and his pain
was managed on MS ___ and oxycodone with plans to wean off
both drugs post-operatively.
.
- CV/Pulm: Stable, vitals monitored.
.
- ID: Post-operatively, the patient was on IV cefazolin, then
switched to PO cefadroxil x 7 days for discharge home. The
patient's temperature was closely watched for signs of
infection.
.
- Heme: Following the free flap, he was therapeutically
anticoagulated. He was initially on heparin drip but due to
difficulty with obtaining a therapeutic anticoagulation level,
on POD#2 he was changed to weight-based Lovenox with plans to
continue weight-based Lovenox for a 2-week course
post-operatively, then therapeutic Lovenox for a further 2
weeks. He was also started on a 1-month course of Aspirin.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, voiding
without assistance, and pain was well controlled. His left
lower extremity flap was warm and viable with good doppler
pulse, incision intact without signs of infection, skin graft
sites healing in and bi-valve splint in place. Left thigh STSG
donor site with dry xeroform in place. Right thigh flap donor
site incision intact without signs of infection. | 737 | 710 |
19173798-DS-16 | 23,022,057 | Dear Mr. ___,
You came to the hospital with an episode of dizziness, sweating
and clamminess that improved in the emergency department.
However, you also seemed to be having some difficulty
recalling the events of the day. We think this may have been a
phenomenon called transient global amnesia, though your
presentation is not quite typical as you still seemed to have
some recall of events.
As the name suggests, this was short lived and your memory
improved within a few hours of being in the hospital. We are not
entirely sure why this occurred, but it is often related to
ongoing stress.
We obtained an MRI of your brain which was normal. You were
feeling much better and we discharged you home without making
any changes to your medications.
If you have a recurrence of any similar events you should call
the office at ___ or come in to the emergency room so
you can be evaluated.
- Your ___ neurology team | SUMMARY
=========
This is a ___ man, with no prior neurologic history with
the exception of a diagnosis of migraines, who was brought to
the emergency department after a somewhat vague episode of
dizziness, diaphoresis, and general malaise, subsequently with a
few hours of partial anterograde amnesia.
Transitional Issues
====================
[ ] Pt still having some mild cognitive fogginess, please
follow-up his mental status examination at follow-up to ensure
this has resolved
This is a ___ man, with no prior neurologic history with
the exception of a diagnosis of migraines, who was brought to
the emergency department after a somewhat vague episode of
dizziness, diaphoresis, and general malaise, subsequently with a
few hours of partial anterograde amnesia. He was clearly having
some difficulties w/ memory, however he does not appear to have
had a dense amnesia, as he is able to recall some vague portions
of the events from yesterday evening. For example he remembers
making phone calls but has no recollection of the content of
those calls. He reports the he returned to baseline in the
evening of ___ after admission. He underwent a brain MRI which
was normal. The morning following admission he still
demonstrates some difficulty w/ remote recall tasks such as
listing serial presidents, however his exam is much improved. We
obtained collateral from his husband who agrees that he is at or
very near his baseline at this time. We gave Mr. ___ strict
return precautions, he is aware that he will need to be further
evaluated if he has another such event. While the events in
question are not ___ typical for transient global amnesia, he
seems to at least have had a brief episode of partial
anterograde amnesia. He did nor does he currently appear
encephalopathic. He has never experienced an event such as this
previously. If it were to recur we could consider seizure,
although this currently seems unlikely. | 165 | 317 |
14814421-DS-14 | 26,423,533 | Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
Here in the hospital because you had a cough, fever, diarrhea,
and abdominal pain at home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
In the hospital you had a chest x-ray which is normal. You had
an ultrasound of your liver which showed stones in her
gallbladder which may be normal. You had no fever.
WHAT SHOULD I DO WHEN I GO HOME?
-You should continue taking medications as prescribed
-You should follow-up with your primary care doctor to get
treatment for your HIV
-You should follow-up with your primary care doctor to get
treatment for hepatitis C and cirrhosis.
It was a pleasure taking care if you!
Your ___ Care Team | Mr. ___ is a ___ with h/o untreated HIV and HCV cirrhosis
who presents for cough, fever, and abdominal pain, now afebrile
and with resolving abdominal pain and diarrhea.
ACUTE ISSUES:
==============
# Fever
Patient reports fever at home, with associated symptoms of cough
and abdominal pain. Last fever ___ per patient, with none noted
here. Localizing symptoms include cough and abdominal pain with
diarrhea, as discussed below. Pt was not treated empirically
with
antibiotics because he felt so well and was afebrile by the time
he was admitted.
# Abdominal pain
# Diarrhea
Patient reports several days of abdominal pain associated with
diarrhea and fever after eating and points to the outline of his
liver. Resolved without intervention. Described the pain as
wrenching. Found cholelithiasis on RUQUS. Suspect biliary colic
with inflammatory response, now resolved. Pt advised to avoid
fatty foods and follow up with surgery as an outpatient. Patient
remains at higher risk of bacterial GI infections due to HIV.
However, diarrhea and fever had resolved prior to admission. Did
not treat empirically with antibiotics as pt is afebrile and
symptomatically better.
# Cough
Patient presenting with 2 days of cough and reported fever at
home. He states that the cough is worse with a deep breath and
again points to his RUQ when he describes where the cough is
coming from. Suspect diaphragmatic irritation in the setting of
biliary colic. However, pt had recent admission and chest CT
with GGO, and was ultimately treated with cefpedoxime and
azithroymicin. Cannot rule out PJP in this pt with untreated HIV
and CD4 count 314. CXR is reassuring against bacterial PNA.
Fever is resolved, and cough is not bothersome or productive.
#Hepatitis C
#Cirrhosis
RUQUS done in ED is reassuring. LFTs stable from previous
admission, and lipase only mildly elevated. No signs of
decompensated cirrhosis. Will trend for now, consider additional
workup for persistent pain or fever. Should have outpatient
follow up with liver clinic.
# HIV
Not on HAART. During previous admission, VL 2.5 log10 copies/mL
and CD4 314 (though difficult to interpret in setting of acute
illness.) RPR was negative. As noted above, patient has had
multiple conversations about starting HAART, and remains not
ready at this time. Pt is worried that his HIV will worsen with
initiation of HAART therapy. He declined initiation of HAART as
an inpatient.
We asked him if there was anything we could do to help him get
started on treatment for HIV. He expressed to us: 1) that
nothing I could do/say at this time that would change his
current "beliefs" about medication to treat HIV, 2) he says he
won't consider taking medication for HIV under any circumstance
until he has a stable housing situation, 3) he says he feels
great and he does not believe he will get worse without
treatment for HIV, and 4) he believes that he would have side
effects from the HIV medication, so he will ultimately feel
worse and says "How am I
supposed to manage that on my own and without a place to live?"
He went on to say that he is in fact interested in starting the
medication, and that if he had stable housing, he would start it
right away.
# Thrombocytopenia
Stable from prior. Likely related to HIV, cirrhosis.
Splenomegaly noted on RUQUS. Monitored. SHQ held.
TRANSITIONAL ISSUES
===================
- No medication changes
[] Please continue to educate pt about long term effects of HIV
[] Please refer pt to liver clinic for evaluation of cirrhosis
and hepatitis C
[] Consider outpatient referral to surgery for evaluation of
possible biliary colic
# Code Status/ACP: presumed FULL CODE | 125 | 584 |
13030735-DS-4 | 20,203,871 | You presented to the hospital with obstruction and infection of
your biliary ducts because of a gallstone. You also had some
inflammation of your pancreas from this. You underwent a
procedure called an ERCP, but they were unable to remove the
stone. Therefore, you had a drain placed in your bile ducts by
the interventional radiologists.
You will need to follow-up with the interventional radiologists
as directed below to further assess your biliary drain.
It was a pleasure taking part in your medical care. | ___ y/o F with PMHx hypothyroidism, HTN, CKD, prior CCY,
transferred from OSH for gallstone pancreatitis.
# Bile Duct Obstruction / Gallstone Pancreatitis / Cholangitis:
Pt was placed on cipro/flagyl on admission. She underwent ERCP,
which was unsuccessful (see report above). Of note, during ERCP,
pus was seen draining from the biliary tree. Given failed ERCP,
she then underwent PTC, which confirmed biliary obstruction.
Following PTC, her labs improved. Diet was advanced, and she
passed capping trial. She was discharged home to follow-up with
___ as an outpatient for repeat cholangiogram. She was continued
on cipro/flagyl to complete a 10 day course.
# Hypoxia: Of note, pt did have some hypoxia while in house. It
was felt to be ___s body habitus, given
that she was not mobilizing out of bed. She was weaned off of O2
once she started mobilizing more.
# Hypothyroidism: On synthroid.
# HTN: On atenolol.
# CKD, Stage III: Unknown baseline Cr. Ct stable. | 83 | 156 |
11737430-DS-36 | 21,192,078 | You were evaluated at ___ for
our concern of stroke given your complaints of increased right
sided weakness and difficulty with speech / word finding. We
performed a series of imaging tests to evaluate if any new
stroke or areas of blood clot are present, which were all
unremarkable for any new findings.
We have scheduled follow up for you with Dr. ___ in stroke
clinic as an outpatient. We have also scheduled an appointment
with Dr. ___ in Hematology for our finding of persistently
elevated white blood cell counts. While there has been no
symptoms we have seen associated with this finding, certain
associated diseases could increase the risk for stroke, and as
such we wish to evaluate for these. | # Neurology:
The patient was observed to have stable neurologic findings with
negative imaging (CT, CTA Head/Neck, and MRI Brain). The
patient was noted to have some lingual sound difficulties, but
no dysarthria. She also was seen to have right hemiparesis
consistent with previous evaluations. Urine Tox was only
remarkable for opiates, which is consistent with the patients
use of Percocet as an outpatient for pain control.
HgbA1c and Lipid panel were recently obtained during an
admission in ___, which were not rechecked given her recent
results (of note previous values showed good control on current
medical regimen).
Plavix was started pending the further evaluation and final
reads on imaging, but was discontinued in favor of the patients
ASA regimen as previously prescribed
# ID:
UA/UCx were unremarkable for infectious etiology. CXR was also
unremarkable. CBC showed a lymphocytic-predominant leukocytosis
which was consistent with previous admission findings. As the
patient was unremarkable for any infectious process and has had
persistent issues with elevated WBC count, Hematology was
contacted for further workup as an outpatient.
# TRANSITIONS OF CARE:
- Heme/Onc follow up has been scheduled as an outpatient to
further investigate the leukocytosis and concern for any
malignancy related hypercoagulability (given hx of stroke).
- Stroke Neurology follow up has been scheduled, with patient to
continue ASA 325mg. | 125 | 218 |
17924864-DS-7 | 25,258,318 | Dear Ms. ___,
You were admitted to ___ because of abdominal pain and because
you weren't eating and losing a lot of weight. You had a
colonoscopy which showed that you had a mass in your colon that
is likely to be cancer. You were seen by a colorectal surgeon
and will follow up in clinic with them.
Please make sure of the following:
- Please speak with your primary care doctor to discuss referral
to an oncologist when the biopsy results have returned
- Please follow up with the colorectal surgeon Dr. ___ on
___ to discuss surgery.
- Please take all medications as prescribed. Please pay
attention as you have some medication changes.
We wish you all the best!
- Your ___ care team | SUMMARY: ___ with history DM, ILD, no prior colonoscopy who
presents with many weeks of abdominal pain, PO intolerance, and
~20 pound weight loss. She had a EGD and colonoscopy done which
demonstrated a fungating mass in the colon highly suspicious for
malignancy. A CT chest was done; there is no evidence of
metastatic disease on either the CT abdomen/pelvis or the CT
chest. | 121 | 65 |
10692563-DS-9 | 22,433,025 | Dear Mr. ___,
You were admitted to the hospital because of fluid in your
lungs. You underwent a procedure called thoracentesis to remove
this fluid. You also received high doses of medications to help
your body get rid of this fluid. You continued to do well and
your shortness of breath improved. It is now safe for you to go
home. It was a pleasure caring for you!
Wishing you the best,
Your ___ Team | ___ year old Man with PMH NASH cirrhosis ___ B, MELD 21),
on transplant list, h/o hepatic hydrothorax, ascites now s/p
TIPS
___, HFpEF, atrial fibrillation and non-occlusive PVT not on
anticoagulation due to hemoptysis who presents with lower
extremity edema, dyspnea after discontinuation of diuretics.
# Ascites/Hepatic hydrothorax: Driven by pulmonary edema and
hepatic
hydrothorax. Evidence of volume overload on exam with CXR
showing persistent hepatic hydrothorax. S/p TIPS, patent without
increased velocities on Doppler. Active diuresis with IV lasix
on discharge, home diuretic regimen will be furosemide 80mg PO
BID and spironolactone 200mg PO Daily. Interventional
pulmonology did two thoracenteses ___ with 1.4L removed and ___
with 600ml removed. IP followed with concern for possible
trapped lung and recommended follow-up with IP in 2 weeks.
Breathing improved to baseline on discharge. Discharge weight:
101.4 kg.
# Chronic Dyspnea
# OSA
#reactive airway disease: Followed by Dr ___ likely
reactive airways disease/asthma. Continued home advair and
Flonase.
# HFpEF: Last TTE ___ with EF >75%, mild TR, mild pHTN. NO
clear dietary trigger will trend trop x2 for r/o. Active
diuretic management as above. Strict I/O and low Na diet. LENIs
negative.
# Hx of HRS: creat 0.7, prior crt to 2.0 was though to reflect
hepatorenal (failed albumin challenge, no e/o ATN) and CIN iso
TIPS. Recevied octreotide/midodrine last admission. Continued
midodrine.
# NASH cirrhosis (Child B, MELD-Na ___) c/b ascites, recurrent
pleural effusion, portal HTN, esophageal varices s/p banding,
SBP, non-occlusive PVT. Active diuresis s/p TIPS. Continued
ciprofloxacin for ppx. Prior variceal bleed s/p banding. Last
EGD ___ without varices. Not on home lactulose. On
transplant list. Continued home ursodiol.
# HCC: Found to have 2.6cm exophytic liver mass c/f HCC. Plan
was
for him to undergo outpatient liver ablation by ___. CT liver
completed ___, plan for repeat RFA on ___. | 74 | 293 |
14099518-DS-6 | 24,082,323 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
You came into the hospital because you were having bleeding in
your stool.
What did you receive in the hospital?
While you were here, we managed your bleeding by giving you
blood transfusions. You underwent a procedure to stop the blood
vessel that was bleeding into your intestines. Because you were
bleeding, your home blood thinners were stopped when you
arrived, and unfortunately you developed a clot in the stent in
your R leg. You underwent a procedure to have the blood vessels
in your legs reopened.
What should you do once you leave the hospital?
- You should continue to take all your medications as
prescribed.
- You should take 8u of lantus in the evening and increase the
dose based on your sugars. You should take ___ units of Humalog
with meals and continue carb counting. Talk to your
endocrinologist about getting another continuous glucose monitor
since your sugars are sometimes low overnight and you do not
feel it.
- You should follow up with your primary care doctor, your
endocrinologist, and your vascular surgeon. Your appointments
are listed below.
We wish you the best!
Your ___ Care Team | PATIENT SUMMARY FOR ADMISSION
===============================
___ y/o male with history of T1DM, CKD, HTN/HLD, hypothyroidism
and PVD on Coumadin and Plavix, s/p right above-knee popliteal
bypass graft and right second toe amputation who presented with
melena found to have duodenal bleed on CT now s/p ___
embolization of PDA ___ and multiple transfusions (8U total),
last unit ___, H/H stable and HDS, course c/b RLE graft
thrombosis now s/p hepatin gtt and revascularization with
vascular surgery (___), symptomatically much improved and on
Plavix.
ACTIVE ISSUES ADDRESSED
========================
#Acute blood loss anemia
#Upper GI bleed
Patient presented with melena and was found to have a Hgb 6.2.
Etiology of upper GI bleed unclear at this time, but most likely
duodenal ulcer given active extravasation on angiogram. Possible
contributing factors include anticoagulation, NSAID use. H.
pylori antigen negative. No significant alcohol use history. S/p
___ embolization of IPDA and total 7u PRBCs (last ___. Patient
was continued on Pantop 40 BID at discharge.
#THROMBOSED RLE GRAFT
#PVD
On admission, patient's home Coumadin and Plavix were held in
the setting of significant GI bleed. ___ patient began having
___ R foot burning pain, found to have complete occlusion of
the vascular graft on Duplex imaging. Pain was managed with oxy
___ q6PRN, Tylenol ___ q8 PRN. Given stability of bleeding
post PDA embolization, heparin gtt was restarted per vasc
surgery and ___ with return of DP pulse to R foot. Patient did
not have any further bleeding, and underwent a R SFA and stent
placement on ___ without complications. On discharge, patient's
legs and feet were warm bilaterally with palpable pulses.
Patient was loaded on 300mg Plavix, with plan for 75mg for 30
days, and was started on ASA 81mg. Patient was not d/c'd on
Coumadin. Patient is non-weight bearing on R leg for the time
being, will re-evaluate at 2 week vascular follow up.
# HYPERGLYCEMIA
# DM1
History of type I DM, presented w/anion gap acidosis,
hyperkalemia, and hyperglycemia. Did not meet DKA per ___
assessment. Patient's sugars were well controlled at the time of
admission. Was d/c'd on 8u lantus qPM, ___ Humalog with meals
+ sliding scale. Endocrinology here recommend patient get
outpatient continuous glucose monitoring given episodes of
asymptomatic hypoglycemia to ___ during admission.
RESOLVED ISSUES
===============
# ?GPC Bacteremia
Blood culture on ___ growing gram positive cocci, CONS on final
culture. Patient without any evidence of infection, afebrile, no
clear source, no leukocytosis. CXR did not show evidence of PNA.
Patient received Vancomycin 1000 mg IV Q12H (___).
# ___, resolved
# CKD
Baseline Cr = 1.3, peaked at Cr 1.8 now back at baseline. Likely
secondary to acute DKA and dehydration. Patient was prehydrated
prior to vascular procedure ___. Discharge creatinine 1.2.
CHRONIC ISSUES
==============
# HTN: patient's home medicines were held initially given GI
bleeding and then were held throughout the majority of stay
given normotension. ___ patient was hypertensive to SBPs
150s-170s and home medications were restarted, with home
metoprolol reduced to 12.5mg BID from 25mg BID.
# HYPOTHYROIDISM: continued home levothyroxine
TRANSITIONAL ISSUES
===================
[] Outpatient CGM per ___ need f/u with pt outpatient
endocrinologist (office was closed on the day of discharge)
[] Uptitrate metoprolol (reduced to 12.5mg BID due to HRs in the
___
[] Continuing high dose PPI (40 pantoprazole BID) for suspected
duodenal ulcer, consider stopping in ___ weeks.
[] Follow up BP as outpatient and titrate medications.
[] Patient to continue Plavix for 30 days per inpatient vascular
team. Will follow with them after discharge for consideration of
BKA pending patient symptoms.
[] Discharged with 14 pills of oxycodone due to some ongoing
right foot pain at the time of discharge. Also sent with bowel
regimen given constipation in-house with opioids.
[] Discharge insulin regimen: 8u lantus at night (uptitrate
based on sugars) with ___ of Humalog with meals.
[] Consider Tarceva for diabetes management.
# Communication: Wife ___ ___
# Code: Full code - confirmed with patient | 217 | 624 |
14031588-DS-14 | 26,115,739 | Dear Mr. ___,
.
It has been a pleasure caring for you at the ___. You
presented to the emergency room after feeling unwell for a few
days and experiencing a transient right facial droop. You were
admitted to the neurology service overnight for further
evaluation and care.
.
As there was concern for a vascular cause of symptoms (such as a
transient ischemic attack - a small stroke without persistent
deficits), imaging of the brain and its vessels was performed.
The CT of the head showed no evidence of bleeding or obvious
stroke. The vessel pictures continue to demonstrate a blocked
left internal carotid artery, which serves the left part of the
brain. The facial weakness could be related to a small piece of
clot or plaque from the top of the blockage in the internal
carotid artery that travelled to the left side of the brain
(which controls the right aspect of the face).
.
It is quite possible that discontinuing aspirin one month ago
contributed to the symptoms. It will be very important to take
the aspirin every day. Please also take the
cholesterol-lowering medicine; your doctors ___ help monitor
your liver function tests and cholesterol. It will also be
important to eat healthfully and exercise. Please work with
your primary care doctor to gradually decrease your alcohol
intake. It will be important for your primary care to follow the
results of the pending ___ study.
.
Please continue to take all medications as presecribed. Please
attend all follow-up visits suggested.
.
During the hospitalization, the following medication changes
were made:
- the aspirin was restarted
- thiamine, folate, and a multivitamin were started
- simvastatin has been started | Mr. ___ is a ___ year-old right-handed man with a history
including a small left MCA infarct ___ causing a mild aphasia
and residual word finding problems with occasional paraphasias,
atrial fibrillation (not on anticoagulation secondary to
non-compliance), and known complete left ICA occlusion who
presented to the emergency room after feeling unwell for a few
days and experiencing a transient right facial droop. He was
admitted to the stroke service from ___ to ___ for
further evaluation and care.
.
As there was concern for a vascular cause of symptoms (such as a
transient ischemic attack), imaging of the brain and its vessels
was performed. A non-contrast CT of the head showed no evidence
of hemorrhage or obvious signs of ischemia. A CTA continued to
demonstrate an occluded left internal carotid artery. The
facial weakness was thought to be related to left internal
carotid artery 'stump' artery-artery embolis or small vessel
disease. It is quite possible that discontinuing aspirin one
month prior contributed to the symptoms. During the
hospitalization, aspirin was restarted.
.
To evaluate modifiable risk factors for stroke, lipids and
glycosylated hemoglobin were measured. The LDL was found to be
105, and simvastatin 20 mg po daily was started with a goal LDL
<70. Although the HBA1C was 5.4 %, blood glucose was monitored
regularly and an insulin sliding was instituted to maintain
normoglycemia.
.
Mr. ___ was ecnouraged to work with his primary care doctor
to gradually decrease alcohol intake. In the setting of ongoing
alcohol use, thiamine, folate, and a multivitamin were started.
He was also counseled to please continue to take all medications
as presecribed and attend all follow-up visits suggested.
.
The patient was discharged home. | 282 | 290 |
11944396-DS-21 | 23,719,774 | Wound Care:
- Keep Incision clean and dry.
- Keep pin sites clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be non weight bearing on your right arm, pendulums
only for range of motion
- You should continue to see Occupational Therapy after
discharge
- You should not lift anything greater than 5 pounds.
- Elevate right arm to reduce swelling and pain.
- Do not remove splint/brace. Keep splint/brace dry.
- You should use your sling for comfort to support your Right
arm
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Aspirin 325mg for 3 weeks to prevent blood
clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity: Right upper extremity: Non weight bearing
pendulums only
Treatments Frequency:
Occupational Therapy - NWB RUE, Pendulums only for 2 weeks
Wound monitoring, dressings PRN | Ms. ___ was admitted to the Orthopedic service on ___
for pain control with right humerus ORIF hardware failure after
being evaluated in the emergency room. She was noted to have a
RUL opacity on pre-op CXR and a mild cough so underwent rule-out
TB by 3 sputum AFB's. She was seen by pulmonology for question
of interstitial pulmonary process and TB and was cleared by them
for OR and outpatient management/monitoring. She did have
non-specific findings in her sputum culture and will follow up
with PCP and pulmonology, was not started on antibiotics per
Pulmonology. She underwent revision open reduction internal
fixation of the fracture without complication on ___. Please
see operative report for full details. She was extubated without
difficulty and transferred to the recovery room in stable
condition. Ms. ___ continued to complain of pain but was
able to be transitioned to PO medication. She required some
dilaudid for initial control but was stabilized on oxycodone
alone and NOT discharged with any Dilaudid.
She had adequate pain management, tolerated PO intake, ambulated
without assistance and worked with occupational therapy while in
the hospital. The remainder of her hospital course was
uneventful and she is being discharged to home with OT in stable
condition. | 341 | 213 |
14715644-DS-38 | 20,047,125 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for treatment of your
confusion. While you were here we gave you lactulose to help
remove the toxins which were likely causing your confusion
(hepatic encephalopathy). Additionally, you had an echo of your
heart, which was largely unchanged from your prior echo. You
also had an MRI of your abdomen, which was unremarkable.
You were seen by the nutritionist, who recommended that you have
nutritional supplementation via a ___ tube. This was
placed, and tube feedings were started. The goal of this is to
assist you in gaining weight and strength as part of your
pre-transplant work-up.
For other pre-transplant work-up, you will need to have your
pulmonary function tests checked. This can be done as an
outpatient. Please discuss the scheduling of this with your
primary hepatologist.
You were also found to have elevated AFP. We will repeat this
in the clinic with an AFP-L3.
Please see the medication sheet for any changes that may have
been made. | ___ with hx of liver transplant for HCV cirrhosis and
pancreas/kidney transplant for diabetes who presents with
confusion and vomiting.
# Hepatic encephalopathy: This patient presented with confusion
and behavior which is different from his baseline. At home he
had been taking rifaximin, but has not been on lactulose
recently. On admission he was noted to be jaundiced and to have
some asterixis, as well as impaired concentration. He was
treated with lactulose and rifaximin, and his encephalopathy
improved. The precipitating event for this episode is not clear,
but he did not have any evidence of bleeding, clot in the portal
or hepatic vasculature, or infection. CMV viral load was
negative as well. Infectious work up was negative and likely
his encephalopathy was related to poor nutrition. He improved
significantly and was discharged home with tube feeds for
nutrition and rifaximin and lactulose to prevent future
recurrences. His ascitic fluid cultures are no growth to date,
but need to be followed up on in the outpatient setting.
# DOE: On admission he complained of this, accompanied by
lightheadedness. His wife reports decreased PO intake, 30lb
weight loss, and now recent vomiting. Although his symptoms
could likely be related to dehydration, we felt that it was
reasonable to repeat an echo to evalaute for worsening valvular
dysfunction. This echo did show some worsening of aortic and
mitral regurgitation, but otherwise was basically unchanged from
prior in ___. We encouraged PO intake and he worked with
___. The patient was mildly symptomatic at the time of
discharge. He needs PFT as an outpatient for transplant work up
and they will evaluate these symptoms further at that time.
# Recurrent Cirrhosis: He has know HCV and has had prior liver
biopsies with stage II fibrosis of the transplant. On admission
he was decompensated with ascites and HE. Also, he has been
noted to have significantly elevated AFP on two consecutive
checks recently. RUQ U/S was negative for gross masses. Given
the chance of potential future transplantation, and elevated
AFP, MRI of the abdomen was performed. This showed no evidence
of HCC or focal liver lesions. He was maintained on tacro and
MMF for immunosuppression. his tacro level on the day of
discharge was 3.2. He will have a repeat level and discuss
adjusting his tacro dose in clinic on ___. He
will also need his AFP monitored and possibly send off an AFP
L3. He was also set up for repeated paracentesis on a weekly
basis at ___.
# Nutrition: Pt with very poor oral intake, and 30lb weight loss
over last few months. We encouraged PO intake and supplemented
his oral feedings with protein shakes. He was seen by nutrition,
who initially recommended a feeding tube. Given temporal
wasting and persistent poor PO intake a dobhoff was placed at
the bedside and then advanced post pyloric. He tolerated tube
feeds well and discharged home on isosource 1.5 at goal of
65ml/hr. He will need nutrition follow up in the outpatient
setting. | 176 | 509 |
19946593-DS-9 | 28,829,753 | Dear Ms. ___,
You were admitted to ___ for fever, nausea, and vomiting after
your lung biopsy. While you were here, you received fluids and
your nausea and vomiting improved. Your fever may have been due
to inflammation caused by the procedure or due to a pneumonia.
We treated you with antibiotics for pneumonia and you were no
longer having fevers at the time of discharge.
Your lung biopsy showed evidence of an infection with an
organism called mycobacterium. One type of mycobacterium can be
seen in a tuberculosis (TB) infection. We therefore performed a
series of tests to check for TB and found that you did not have
tuberculosis.
You will still need to undergo treatment for this mycobacterium
infection as an outpatient. You will follow up with the
infectious disease doctors after ___ leave the hospital and they
will pick which medications you will need to take at that time.
While you were in the hospital, you also had many elevated blood
sugars. We had the ___ diabetes team help us with your
insulin schedule. They recommended changing your insulin regimen
to glargine 20 units before dinner and using a Humalog sliding
scale. Please make sure to follow-up with Dr. ___ at the
___ (appointment information is below).
We wish you the best!
- Your ___ Care Team | Ms. ___ is a ___ year old woman with history of CAD, T1DM,
chronic sinusitis (s/p doxycycline, on Bactrim), and hemoptysis
(currently undergoing outpatient workup) who presented with
fever, nausea, and vomiting 1 day s/p transbronchial biopsy/BAL.
ACUTE ISSUES:
=============
# Fever:
Ms. ___ had a low fever of 1 day duration s/p
transbronchial biopsy/BA with a WBC of 15 with neutrophilic
predominance. She was started on ceftriaxone and doxycycline in
the ED for HCAP. Tm 100.3 subsequently, generally afebrile with
Tm ~99. Was felt to be secondary to post-operative inflammation
however given rare strep viridans on tissue pathology, ID
recommended CTX for 6day course. Afebrile at time of discharge.
# Nausea/Vomiting:
Patient presented with nausea and vomiting, without diarrhea or
abdominal pain, after her biopsy/BAL. Was felt to be secondary
to anesthesia and her procedure and resolved during her hospital
stay.
# Hemoptysis:
Patient with multiple episodes of hemoptysis since ___ and
was undergoing workup in the outpatient setting. Non-infectious
etiologies such as GPA considered but ANCA negative. Recent
biopsy demonstrated focally necrotizing granulomatous
inflammation, positive acid fast rod-shaped mycobacterial forms,
concerning for MAC versus TB. Patient ruled out for TB with
three negative sputum AFB smears. MAC growing on preliminary
acid fast culture from BAL. Patient with ID follow up for
initiation of MAC treatment after sensitivities return.
# T1DM:
Patient on a regimen of NPH and regular insulin as outpatient.
___ was consulted after patient with poorly controlled blood
sugars in house. ___ recommended changing outpatient regimen
to glargine 20 units prior to dinner and Humalog sliding scale.
# CAD:
Undergoing outpatient consideration for CABG. Patient with no
chest pain during hospital stay but with one episode of dyspnea
and dizziness ultimately felt to be vasovagal in etiology after
EKG negative and troponins negative. Was continued on
Atorvastatin 20 mg PO QPM, Lisinopril 10 mg PO DAILY, Metoprolol
Succinate XL 25 mg PO QHS, Aspirin 81 mg PO DAILY
# ___:
Creatinine slightly increased to 1.3 on admission that was felt
to be prerenal in etiology. Resolved with improved po intake.
# Pseudohyponatremia:
Hyponatremic but normo-natremia when calculated for glucose
levels. Glucose was controlled per above.
CHRONIC ISSUES
==============
# Glaucoma:
Patient was continued on home, Latanoprost 0.005% Ophth. Soln. 1
DROP BOTH EYES QHS, Pilocarpine 2% 1 DROP BOTH EYES Q8H but with
Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID broken
into individual components as combigan is NF
TRANSITIONAL ISSUES
===================
1. Will need follow-up in ___ clinic in 6 weeks time once
cultures and sensitivities have returned, as we suspect
hemoptysis is secondary to atypical mycobacteria (MAC) and she
would qualify for treatment
2. Will need follow-up with ___ for T1DM control. Insulin
regimen changed to glargine 20 units prior to dinner and Humalog
sliding scale.
3. Patient has not had mammogram or colonoscopy. Given reported
60lb weight loss in last year and presence of MAC infection in
otherwise non-immunosuppressed individual, she should undergo
age-appropriate cancer screening as an outpatient.
4. Patient reports that she was to have started Bactrim for
chronic sinusitis. Was not taking at time of admission and was
asymptomatic with regards to sinusitus so bactrim was not
started. Please follow up appropriate treatment course.
# CONTACT: husband ___ ___
# CODE: full (confirmed) | 217 | 539 |
13588636-DS-6 | 26,266,616 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital due to concerns about an
infection causing some confusion, fevers, and diarrhea.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- While ___ the hospital we developed a regimen to manage the
high output from your ostomy.
- You were found to have an infection ___ your belly that
required a drain placement and antibiotics. The drain was
removed, and on most recent imaging, the infection had gotten
smaller. However, you also unfortunately developed a pneumonia,
and thus required continued antibiotics.
- You developed electrolyte abnormalities, ___ particular high
calcium, that required medication and changes to your tube
feeds. These normalized after those treatments.
- There was some concern you may have developed a small bleeding
lesion ___ your stomach as your red blood cells continued to drop
during admission. Our gastroenterologists evaluated you for
sources of bleeding, and could not find any.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take the antibiotic linezolid and levofloxacin,
and the antifungal fluconazole until instructed otherwise. We
will schedule you an appointment with the infectious disease
doctor as below.
- Please continue to take the blood thinner apixaban until at
least ___, you should discuss the timing of
discontinuing this with your doctor.
- Please continue to take the pantoprazole medication twice
daily to protect your stomach lining
- You should also continue to take Vitamin D supplements as
instructed by the Endocrinologist.
- You will need a repeat camera study of your stomach ___
___
- You should discuss with the Surgeons whether you can start
transitioning to closing your tracheostomy.
- If you develop fevers, worsening breathing, abdominal pain,
confusion, you should return to the hospital
- Please keep your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year-old woman with a history of hydrocephalus
s/p VP shunt placement, and recent admission at ___ (___)
for small bowel perforation and meningitis, s/p ileostomy, VP
shunt replacement, c/b VRE meningitis/UTI/intra-abdominal
abscesses, encephalopathy s/p trach/PEG, and concern for
seizures (on AEDs), who presented from rehab on ___ with fever,
tachycardia, hypotension, significantly increased ostomy output,
and altered mental status, who then re-developed intra-abdominal
fungal/enterococcal abscesses and has subsequently developed
electrolyte derangements. Intra-abdominal abscess appears
improved on repeat imaging, and her electrolyte derangements
have been stable. Hospital course was complicated by two HAP
infections, both treated with intravenous antibiotics with
clinical improvement, as well as hypercalcemia, intermittent
hyponatremia, and toxic metabolic encephalopathy.
ACUTE ISSUES
=============
#HIGH VOLUME OSTOMY OUTPUT
#SMALL BOWEL PERFORATION S/P SBR And ILEOSTOMY:
On admission, febrile, WBC 29, tachycardia, hypotension
requiring IVF/pressors with ___. The patient was initially
started on vanc/pip-tazo and continued on daptomycin for
presumed septic shock, but initial diagnostic workup, including
CT A/P, CXR, NCHCT, UA/UCx, TTE, stool studies and C. Diff were
negative for infectious source, and Neurosurgery thought that
her presentation was inconsistent with CNS infection. Her
presentation was attributed to high ostomy output, and the
patient was started on loperamide, lomotil and psyllium for a
goal output ___. She was initially stable on this regimen and
transferred to the floor on ___, but on ___, stool output
increased to 8L and she was tachycardic and febrile with an
elevated white count to 24.6. She was readmitted to the MICU at
that time. There was concern for possible worsening of her
intrabdominal infection, as discussed below, but also patient
seemed to improve with modification of her anti-motility
regiment. She was trialed on TPN for a small period as well, due
to concerns for poor absorption, but after transfer back to the
floor on ___, was slowly restarted on tube feeds. Her output
remained stable until her tube feeds were switched to Nepro due
to concerns for hypercalcemia, as discussed below. Her stool
output increased to ___ a day, but this also resolved once
patient was switched back to Vital 1.5. At time of discharge
patient's ostomy output was <2L a day.
[] Ostomy output controlled to <2L daily with sliding scale
regimen of anti-motility agents including Psyllium 2 packets
TID, loperamide 4mg QID, cholestyramine 4gm BID, tincture of
opium 6mg q6h PRN, and diphenoxylate-atropine 2 tab q6h PRN.
#Recurrent HAP
Patient initially treated for HAP with linezolid ad cefepime x 7
days from ___ to ___. On morning of ___, patient had
developed a new fever. ___ the setting of a rising leukocytosis,
there was concern for a new infection. However, patient had no
clear signs or sources of an infection. Bcx and Ucx were
negative, but CXR was mildly concerning for PNA. After extensive
discussion with infectious disease, it was felt appropriate to
broaden her antibiotic coverage to linezolid and cefepime for
better pulmonary coverage to treat a recurrent HAP. On this
regiment (as well as fluconazole as below), patient's mental
status and labs markedly improved. Prior to discharge she was
switched to PO linezolid and oral levofloxacin to complete her
course of antibiotics.
[] Continue Linezolid and fluconazole through ___
[] Continue Levofloxacin through ___ (7 day course)
[] Patient should follow-up with ID for further evaluation
outpatient
#Enterocutaneous fistula
#VRE, Candidal Abscess
#Leukocytosis
Fistula was first noted on ___ with small volume serous
discharge from the left abdomen. ___ CT A/P showed fistula
tracking to upper descending colon, and previous abscess
increased ___ size, w/o evidence for active Crohns. Patient's
leukocytosis continued to trend up. She was continued on
daptomycin, cefepime, Flagyl. ___ was consulted for treatment of
both. She underwent CT-guided drainage with placement of a JP
drain by ___. Fluid from collection grew VRE and ___
parapsilosis. She had persistent fevers, pleural effusion and
worsening respiratory distress so was treated for HAP. Patient
had stabilized after HAP treatment and antibiotics were stopped.
However, beta-glucan returned positive on ___, suggestive of
possible underlying fungal infection, with fungal cultures also
positive for yeast. Fevers resumed on ___ with increased HR
concerning for sepsis, prior intra-abdominal fluid cultures
speciated with ___ parapsilosis, started fluconazole and
linezolid. Imaging showed a continued abdominal collection
(4x2) that was unable to be aspirated, possibly the cause of her
fever. She was transitioned to daptomycin (from linezolid given
low concern for pneumonia) and fluconazole ___ the setting of
sputum cultures repeatedly growing yeast. Her fevers seemed to
improve following this. She had repeat CT abdomen on ___ that
showed incremental decrease ___ the size of the abscess. However
___ the setting of fevers, as above, her anitbiotics were
broadened to linezolid and cefepime, as well as continuation
with fluconazole to treat HAP as described above. She was
discharged on linezolid and fluconazole through ___.
[] Continue linezolid and fluconazole through ___
[] Patient should follow-up with ID for further evaluation
outpatient
#RUE Non-occlusive DVT
PICC associated, noted on ___. Placed on heparin with duration
of AC likely 6 months (___). Heparin held starting ___
given upper GI bleed, see below. Heparin resumed ___.
Transitioned to rivaroxaban 20mg daily on ___. Transitioned
to apixiban on ___.
[] Apixiban BID until ___
#Upper GI Bleed
#Acute on Chronic Anemia
Hgb 8.7 at time of last discharge. Downtrended through
admission, but stabilized. Initially likely presented
hemoconcentrated from volume depletion. However, patient with
dropping hemoglobin starting around ___. Required 1 unit of
blood on ___ and ___. GI scoped the patient on ___ and found
stigmata of bleeding with clots ___ the distal esophagus, and
areas concerning for necrosis as well. They had trouble passing
the scope through the lower esophageal sphincter, and given
concern for on going bleeding the patient was transferred back
to the MICU for closer monitoring. Unclear etiology, but per GI,
concern for fistula, ulceration, or anatomic abnormality.
Patient made NPO, treated with IV PPI, subsequently with
stabilization of bleeding. MAPs and Hgb stable off pressors
following resolution of bleeding. CTA chest without any active
bleeding. Following transfer back to the floor, her Hgb remained
mostly stable.
[] PPI BID X 8 WEEKS, until ___
[] Repeat EGD ___
#Loculated R parapneumonic effusion
# Respiratory distress
Seen on CT ___. Secondary to VP shunt. Patient underwent
drainage and chest tube placement on ___ which demonstrated
transudative effusion. Tachypnea, shortness of breath, and
increased secretions noted while ___ MICU. Thought to be
secondary to volume overload and pulmonary edema. Respiratory
status improved with diuresis and frequent suctioning.
#Hypercalcemia
Pt noted to have Ca trending up and peaked at 12.6 (12.8
corrected for albumin). Initially treated with transition from
sevalemer to aluminum hydroxide binder and with Lasix IV 20mg x2
and IV fluids with subsequent mild kidney injury. Endocrine was
consulted. PTH noted to be low and Vitamin D low at 10, PTHrP
was nml at 16, and 1,25 Vit D <8. A cosyntropin stim test was
normal, though difficult to interpret iso hypoalbuminemia. Felt
to likely be secondary to immobility as she had been
hospitalized for greater than a month with prolonged immobility
and only up to chair with ___. There was initial concern her
tube feeds may have contributed to her elevated Ca, however
given the significant increase ___ ostomy output with switching
to a different formula, and the minimal response ___ her Ca
levels, she was switched back to Vital. Patient was started on
calcitonin 300mg twice daily, without much improvement.
Aledronate was given, with patient's calcium downtrending
appropriately. Endocrinology felt her elevated Calcium could be
worked up further outpatient, and was not at a concerning level.
Ca down to 8.9 (corrected) by time of discharge.
[] Will need to follow-up with Endocrinology for further
monitoring outpatient
[] Continue Vitamin D supplements ___ units once a week
#Encephalopathy
Patient noted to have frequently fluctuating mental status,
possibly related to acute illness, possibly related to recent
insults and hospitalization. Unclear baseline given complex
neurological history. Mental status has been acutely waxing and
waning with clinical status, especially infection and
electrolyte disturbances. However, appears to be improving after
management of these issues.
#EKG with transient diffuse t wave inversions
Patient has no chest pain. Her vital signs stable. Prior EKG
with similar finding ___ ___ that then resolved. Echo results
did not demonstrate wall motion abnormalities, suggesting that
this is not an ischemic phenomenon.
#Hyponatremia
Euvolemic on exam. Urine studies ___ significant for Urine Na
33, urine osmolality 427, most suspicious for SIADH. Of note,
significant water contribution ___ the motility slowing agent
regimen. Repeat examination and urine studies more consistent
with hypovolemia. Her sodium improved with intermittent
intravenous boluses. She was discharged on salt tabs and free
water flushes to maintain adequate volume to match her osteomy
output.
#Deep Tissue Wound
Hospital course c/b development of deep tissue wound over the
right buttocks. Wound care was consulted and provided regular
wound care. She should continue receiving daily dressing changes
and off-loading the area to allow for healing. | 331 | 1,483 |
13854372-DS-21 | 21,785,501 | Dear Ms ___,
It was our pleasure to care for you at ___.
You were seen in the hospital for weakness and shortness of
breath, most likely related to your lung disease and being
dehydrated. You were monitored in the ICU and your symptoms
improved with IV fluids.
Changes to your medications:
Please STOP taking warfarin
Please START taking cefpodoxime 200 mg twice a day until ___
Please START taking loperamide every morning as needed for
diarrhea. Do not take if you are having fevers. | ___ yo F with severe pulmonary fibrosis on 5 L O2 at home who
presents with presyncope and increased hypoxia, likely related
to dehydration in setting of diarrhea
# mechanical fall/dehydration: patient was brought into the
hospital with presyncope and a mechanical fall after diarrhea,
fall was likely related to dehydration and presyncope. She was
treated with IV fluids and given high flow oxygen per her usual
requirements due to IPF. She was found to have E. Coli UTI with
frequency and urgency that was treated with PO antibiotics which
may have also contributed to weakness that led to her mechanical
fall. She was evaluated by physical therapy and found to be in
need of wheelchair for mobility and of 24 hour care. The
patient was discharged to rehab.
# Interstitial pulmonary disease/Hypoxia: She was kept in the
ICU because of her desaturations into the ___ and high ___ while
speaking due to her underlying and progressive pulmonary
fibrosis. She was kept on her home O2 and occasionally required
increasing amounts of O2 by nasal cannula and high flow oxygen
for symptom control. She stayed in the ICU throughout her
admission due to desaturations with eating, talking and other
activity however the patient remained awake and conversant
throughout and other vital signs were stable. Prednisone
continued at 15 mg daily during admission and weaned to 10 mg
daily on discharge, bactrim continued for PCP ___.
# UTI: Ucx grew E. coli sensitive to ceftriaxone. Patient
transitioned to PO cefpodoxime for 7 day course, to finish on
___.
# ___: Most like prerenal in setting of dehydration from poor PO
intake and diarrhea. Improved with IV fluids. Cr returned to
baseline on discharge.
# anemia: Currently at baseline. no s/s of bleeding. Fe
supplementation continued and pt was started on B12
supplementation as well.
# Hx PE/DVT on coumadin: Now 6 months out from diagnosis of PE,
discussed with Dr. ___ and agreed with
discontinuing coumadin.
# DM2: Metformin held while in house with sliding scale insulin
for blood sugar controlled. Restarted metformin on discharge.
# CAD: continued ASA, metoprolol, simvastatin
# depression: continued lexapro, mirtazepine | 81 | 361 |
10065997-DS-4 | 25,252,424 | It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your right
foot infection. You were given IV antibiotics while here. You
were taken to the OR on ___ for resection of infected bone. You
are being discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to the heel only on your R foot until your follow up
appointment. You should keep this site elevated when ever
possible (above the level of the heart!)
No driving until cleared by your Surgeon
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
WOUND CARE:
Please leave the dressing to the Right Foot intact until your
follow up appointment. Keep the Right Foot dry. If the dressing
gets wet it must be changed.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient was admitted to the podiatric surgery service from
the ED on ___ for a R ___ toe infection. On admission, she
was started on broad spectrum antibiotics. She was taken to the
OR for Right ___ toe ulcer debridement and PIPJ arthroplasty on
___. Pt was evaluated by anesthesia and taken to the
operating room. There were no adverse events in the operating
room; please see the operative note for details. Afterwards, pt
was taken to the PACU in stable condition, then transferred to
the ward for observation.
.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. She was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with doxycycline. Her intake and output were closely
monitored and noted to be adequtae. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged. She worked with ___ during
admission who recommended discharge home with partial weight
bearing heel status.
The patient was subsequently discharged to home on ___. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 453 | 207 |
16392858-DS-22 | 20,694,488 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for a heart failure exacerbation. This was most likely
caused by eating too much salt in your diet. We gave you IV
Lasix and removed ___ pounds of fluid. Your breathing
improved and we switched your home diuretic to torsemide 20mg.
You also had a cough but no evidence of pneumonia on chest
X-ray.
You were feeling a bit dizzy while here after we diuresed you
(your weight went from 113kg down to 106kg) and it is possible
so much diuresis made you feel dizzy when walking. We let you
drink to thirst and you started feeling better, did not feel
dizzy walking at night. If you are still feeling a bit dizzy
when you go home please drink a lot of fluid. When you no longer
feel dizzy you should go back on a fluid restricted diet.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Remember to avoid salty foods, have a fluid restricted diet
(after your dizziness resolves).
While here your INR was initially elevated and your coumadin
dose was decreased and then your coumadin dose was decreased and
then your INR went down (1.6) so we increased your coumadin to
5mg daily which you should take for 3 days only and then go
back to taking 4mg daily. You should check your INR on ___ and
notify the ___ clinic about the results. | Mr. ___ is a ___ male with a PMH notable for CHF with
preserved EF with atrial fibrillation and sick sinus syndrome
s/p pacemaker placement who presents with diastolic CHF
exacerbation in the setting of poor diet adherence. | 245 | 38 |
12189596-DS-9 | 20,409,718 | Mr. ___, it was a pleasure taking care of you here at ___.
You were admitted to the hospital because you herniated a disc
in your spine. This put pressure on one of the nerve roots which
is what caused pain to shoot down your leg. You were given
multiple different medications to try to control the pain and
also the spasm in the muscles in your back. You also had a
steroid injection in your back to help control the inflammation
and reduce your pain. You were given prescriptions for several
different pain medications to use in the short term as the
inflammation goes down. These medications are for short term use
only because they have many serious side effects.
You should not take oxycodone or oxycontin for longer than ___
days. You should slowly taper these medications. You will not be
given any further prescriptions for these medications so you
should plan accordingly. You should also take acetaminophen
(tylenol) and gabapentin to help control the pain. Tizanidine
helps with muscle spasm. The pain medication causes severe
constipation so you were given prescription for laxatives to
take (senna, docusate, and bisacodyl). It is very important that
you do not drive, operate heavy machinery, or drink alcohol
while taking oxycodone, oxycontin, or tizanidine.
A few other abnormalities were noticed on your blood work while
you were here.
1) You have early type 2 diabetes. You can start treating this
by losing weight. You may require medications in the future
however and should talk to your new primary care doctor about
this.
2) You have high blood pressure (hypertension). This can be
extra high when people are in pain. We started you on 2 new
medications for this (lisinopril and amlodipine). You will need
close ___ with your new primary care doctor.
3) You have decreased kidney function. This may be due to having
high blood pressure over many years but it could also be from
other causes. Your primary care doctor ___ need to do more
testing.
4) You have anemia (low blood count). You will need a
colonoscopy to look for blood loss. Your primary care doctor may
need to do other tests such as tests for lead in your blood.
The most important thing you can do for your health is to get a
primary care doctor. You should try to get an appointment within
1 week. Bring all of your discharge paperwork with you when you
go to the appointment.
Please see the attached medication list for a summary of all of
your medications. | Primary Reason for Hospitalization:
===================================
___ with no significant PMH (though has not been evaluated by
PCP ___ ___ who presented with acute onset back pain from
lumbar disc herniation with radiculopathy and was found to have
multiple chronic medical illnesses.
.
# Acute disc herniation with radiculopathy: The patient had an
MRI at presentation showing disc herniation with nerve root
compression that correlated with patient's symptoms. The
patient's pain was very difficult to control. He required
surprisingly high doses of opioids to bring his pain down to
___. The patient was opiate naive per his history therefore the
high opiate requirement likely correlated to his body size and
severe pain. He was initially unable to ambulate secondary to
pain. After working with physical therapy he was subsequently
able to ambulate with a walker. Because his pain was poorly
controlled despite high opiate doses, the pain service was
consulted who performed an epidural steroid injection. The
patient was then discharged with prescriptions for short term
opioid therapy with gabapentin and acetaminophen as adjuncts. He
was also given a prescription for tizanidine for muscle spasms
in his back. Over 30 minutes were spent counseling the patient
on the risks of these medications in particular opioids
including respiratory depression, sedation, addiction,
tolerance, and withdrawal. He was advised to not drive, operate
machinery, or drink alcohol while taking these medications.
NSAIDS were not used because of allergy to ibuprofen as well as
elevated creatinine.
-- Case management and social work involved to help patient get
health insurance for quick ___ care. He was advised to
___ within 7 days with a new PCP
.
# CKD II: On routine lab work patient was noted to have a
creatinine of 1.6. This is a new diagnosis, but as above,
patient has not seen doctors ___ ___ years. Unclear etiology.
Patient was hypertensive during admission although hard to
interpret in the setting of pain. HbA1C 6.8% which is likely not
high enough to account for renal insufficiency and no
microalbuminuria.
-- Further workup should be performed by patient's new PCP
-- the patient was counseled on the importance of these findings
and that they need close ___.
.
# Type 2 diabetes, controlled: This was a new diagnosis based
upon HbA1C of 6.8%. No evidence of complications at this point.
No microalbuminuria.
-- 20 minutes were spent counseling the patient on this new
diagnosis.
-- Patient will start by trying to lose weight
-- He will need PCP to ___ and consider medication
initiation.
.
# Hypertension: It was difficult to discern what component was
from essential hypertension and what was secondary to pain.
However given that as high as 180/100 on high dose opioids, it
appeared that patient likely has some degree of underlying
essential HTN.
- He was started on amlodipine 5mg daily and lisinopril 5mg
daily
- As above he will need PCP ___ for ___ check and
likely further uptitration of antihypertensive regimen.
.
# Microcytic Anemnia. HCT as low as 28.2 with consistent values
in that range. Unclear etiology. Patient not deficient in iron,
folate, or B12. In setting of anemia and renal insuffiency,
multiple myeloma is in differential however it would be unusual
in this age demographic. Reticulocyte Production index was 0.87
suggestive hypoproliferative process.
-- The patient should have a colonoscopy and SPEP/UPEP for
additional work-up as outpatient. Could also consider serum lead
level but patient has no apparent history of exposure. Further
workup per PCP.
-- The patient was counseled extensively on the importance of
these findings
. | 424 | 582 |
13914124-DS-13 | 27,937,959 | Dear Mr. ___,
You were seen in our hospital because you had labs drawn that
showed that your kidneys were not working well.
We think this is because of your cirrhosis (liver disease). The
cirrhosis causes fluid to collect in your legs and abdomen, and
as a result your kidneys do not get enough blood.
We gave you two medicines (octreotide and midodrine) to help
your kidneys. Your kidney function was stable or possibly
slightly better on these medicines. You should continue
midodrine at home.
We also gave you medicine (lactulose) to give you loose bowel
movements. This prevents toxins from building up and causing
confusion or sleepiness. You should continue lactulose at home.
You also had an elevated white blood cell count, the cells that
help fight infection. We looked for signs of infection but could
not find a source. You did get 2 days of antibiotics because we
were concerned about a urinary tract infection, but this was a
false alarm.
Unfortunately, your lab values indicate your liver and kidney
function will not get better. You are not a candidate for a
liver transplant. We spoke with you and your family to make
arrangements for you to receive your care at outpatient
appointments and at home, where you are most comfortable.
It has been a pleasure to care for you.
We wish you the best!
-Your ___ Care Team | Mr. ___ is a ___ M with history of class III obesity
(BMI 64) and atrial fibrillation (not anticoagulated),
originally admitted following acute kidney injury (___) on
outpatient labs now with evidence of decompensated end-stage
renal disease (ESLD) secondary to alcoholic cirrhosis (MELD
___ concerning for hepatorenal syndrome II, additionally
found to have eosinophilia requiring outpatient ___.
=============
ACTIVE ISSUES
#ACUTE KIDNEY INJURY, POSSIBLY HEPATORENAL SYNDROME II: Patient
referred to ___ for creatinine increase to 2.1 from 1.5 one
week prior. Baseline Cr unknown; had been 1.2-2.6 in ___,
though this was during acute illness and diagnosis of end-stage
liver disease (see below). Negative ___ work-up (no casts on
microscopy; renal u/s normal). Cr remained 1.7-1.9 after 200g
albumin challenge (stable to possibly worsened from 1.5 in the
ED), consistent with HRS. However, as mentioned above, ___
be his baseline; importantly, the initial ___ that led to his
admission had improved by the time of the challenge, making it
difficult to interpret. Octreotide and midodrine started and
uptitrated with Mean Arterial Pressure change +13 on ___. He
was successfully trialed off the octreotide on ___ and was
continued on midodrine to 15 mg TID; creatinine was at nadir of
1.3 on discharge. Started calcium carbonate for
hyperphosphatemia.
#END STAGE LIVER DISEASE SECONDARY TO ALCOHOLIC CIRRHOSIS: MELD
___ on admission. ___ paracentesis in ED negative for
Spontaneous Bacterial Peritonitis. Some asterixis on exam
___, though improved ___ following lactulose 30mL PO TID.
Cr 1.4 on ___ (1.5 on admission) and INR of 2.8 (up from 2.4
after IV Vitamin K and 5 mg PO x3, initial 3.4). MELD 27
improved to on ___. Patient ineligible for transplant given
current weight and <6 months sobriety. Patient and family
informed and requested home hospice care upon discharge.
Continued cholestyramine and sarna lotion for pruritus, replaced
diphenhydramine with cetirizine, given concern for sedative
effect. Maintained low salt diet with Ensure Plus
supplementation TID while inpatient.
#LEUKOCYTOSIS with EOSINOPHILA: White Blood Count was 19.8 ___
(21 on admission). No clear source or symptoms. Received 2 days
of ciprofloxacin for presumed Urinary Tract Infection. Cultures
returned negative so antibiotic was discontinued. White blood
count rose again after this; C.difficle stool assay was
negative. Negative workup included blood culture with no growth;
chest x-ray ___ with no evidence of pneumonia; paracentesis
insertion site was leaking for several days, but resolved by
___ and was never tender, erythematous, warm or purulent. WBC
was 19.9 on discharge.
Of note, eosinophil count was high on admission (~10%) and
rose to 39% on discharge. Concern for possible malignancy as
infectious cause negative. Not likely in response to new
medications (he received two doses of ciprofloxacin and was
started on octreotide and midodrine during inpatient
hospitalization. Octreotide discontinued prior to discharge). On
further interrogation of ___ records,
patient had CBC with diff on ___ that showed nearly 10%
eosinophils; smear showed immature granulocytes concerning for
myeloproliferative, myelodysplastic or neoplastic processes.
Patient should follow up with hematology/oncology promptly for
further evaluation. CBC with differential should be done when
patient sees hepatology on ___ to follow up on diff.
====================
CHRONIC ISSUES:
#THROMBOCYTOPENIA: Thrombocytopenia and macrocytic anemia
consistent with h/o alcoholic cirrhosis. Folate within normal
limits. However, B12 was elevated at 1482 (potentially
concerning for malignancy in setting of eosinophilia described
above).
#ATRIAL FIBRILLATION: CHA2DS2-VASC 0. Patient has history of
atrial fibrillation with rapid ventricular response and DC
cardioversion x2. Not currently anticoagulated due to low CHADS
score. Continued diltiazem 30 mg QID for rate control and
aspirin 81 mg QD. INR was 2.7 ___ in setting of ESLD.
#ALCOHOL ABUSE DISORDER: Patient reports previously drinking at
least ___ drinks a day. He has been sober for ~ 2 months.
====================
TRANSITIONAL ISSUES:
#HEPATORENAL SYNDROME II: Started on TID octreotide (200mg) and
TID midodrine (15mg) for suspected hepatorenal syndrome (type
II). Discharged with TID midodrine (15 mg) as his kidney
function improved when trialed off the octreotide x 24h.
#LEUKOCYTOSIS with EOSINOPHILIA: Negative infectious workup as
above leads to concern for possible malignancy, especially given
abnormal smear. Patient should follow up with
hematology/oncology for further evaluation. CBC w/diff should
be done when patient sees hepatology on ___ to follow up on
diff.
#LACTULOSE: Continue lactulose TID titrated to ___ bowel
movements.
#VARICEAL STATUS: Unknown. Patient should have screening EGD as
outpatient.
#PRURITIS: Switched diphenhydramine to cetirizine PRN to avoid
sedation; continued cholestyramine and sarna lotion.
#ATRIAL FIBRILLATION: Continued patient on diltiazem 30mg QID
and aspirin 81 mg daily. Could consider switch to amiodarone for
rate control while receiving vasoconstrictive therapy for
hepatorenal syndrome, given diltiazem lowers BP.
#SBP PROPHYLAXIS: In setting of ESLD and likely HRS type II,
would consider diagnostic paracentesis for total ascitic
protein.
#ASPIRIN: Discontinued in setting of hypercoagulable state
(Elevated INR) and risk of variceal or other bleeds.
#CODE STATUS: Patient is full code despite his overall poor
prognosis. Consider code status talk with patient. | 230 | 811 |
16788421-DS-2 | 26,099,786 | Dear Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing repair of your jejunal intussusception. You
have recovered from surgery and are now ready to be discharged
to home. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- 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. | The patient presented to Emergency Department on ___ . Pt
was evaluated and found to have jejunal intussusception. She was
evaluated by anaesthesia and was taken to the operating room for
operative exploration and likely resection. 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 initially managed with dilaudid PCA
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 with a
___ tube in place for decompression. She had an NGT in
early post operative period which was then removed and her diet
was advanced to clears and then regular sequentially. She was
continously complaining of nausea and hypersalivation although
she wasn't clinically obstructed and was passing flatus and
having BMs. GI was consulted and recommendations were EGD, which
showed non obstructin Schatzki ring, duodentitis and gastritis.
As she was having bilious emesisx2 she was back to NPO and then
when nausea got improved she started on clears and advanced to
regular afterwards. She started her home medication
erythromycing to stimulate her gut motility. 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.
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. | 804 | 359 |
18713335-DS-6 | 22,468,745 | Dear Ms. ___,
You were admitted to the hospital for your chest pain. Lab tests
showed that you were not having an acute heart attack. We also
performed an imaging test of your heart to see how it functions
under stress. This test showed no acute process that could be
contributing to your pain.
You have had a cough for about one week and the chest pain gets
worse when coughing. We believe that your pain is most likely
musculoskeletal in origin. It may have been caused by a
combination of vomiting and coughing for extended period of
time. We gave you medication to decrease your cough here at the
hosptial. You chest pain gradually improved over the time of
your stay here. We expect the chest pain to slowly go away over
time. Please follow up with your PCP after discharge.
It was a pleasure taking care of you.
Your ___ medicine team. | Ms. ___ is ___ y/o F with extensive PMH including psych history
who was admitted for 1 week of chest pain.
==============
ACUTE ISSUES
==============
# Atypical Chest Pain: Most likely ___ musculoskeletal pain in
the setting of recent URI. Patient reports extensive coughing
which is starting to improve. Chest pain is reproducible and is
not worse at any particular time, including exertion. Patient
has some risk factors for CAD and although this dose not sound
like typical chest pain, she underwent nuclear perfusion stress
test which revealed no evidence of ischemia. Patient unable to
exercise for stress test due to knee pain.
# Cough: Most likely viral in origin. Unlikely pneumonia given
normal vital signs and normal lung exam. Tessalon pearls PRN for
cough.
# UTI: Patient reports symptoms of suprapubic tenderness and
dysuria. Afebrile and other vital signs stable. Pt diagnosed
with UTI ___ at OSH and took 5 days of cipro. Patient with
pyuria however urine culture comtaminated. Given patient's
symptoms, she was started on cefpodoxime (several antibiotic
allergies) and completed a 3 day course.
==================
CHRONIC ISSUES
==================
# T2DM: On insulin. Currently poorly controlled. home insulin
regimen
# Chronic kidney injury: Cr has been improving since ___
(2.8). Currently 1.2.
#Asthma: albuterol inhaler
#HTN: amlodipine, isosorbide dinitrate
#Depression and anxiety: diazepam
# Iron deficiency anemia: Longstanding anemia. Currently
asymptomatic. Continue to monitor.
# Knee/shoulder/neck pain: chronic from fall. tylenol PRN
==================== | 150 | 224 |
14895898-DS-13 | 21,632,397 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your heart rate was very fast and
you had chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We changed your medications to prevent further episodes of
atrial fibrillation (fast heart rate).
- We tried to complete a nuclear stress test while you were in
the hospital, but since scheduling this was difficult, we
decided to send you home with the goal of completing this test
as an outpatient.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- We scheduled you for a stress test on ___
at 1:30PM. Please report to ___
Building, ___ floor 15 minutes before your appointment. Follow
signs for nuclear medicine. Ask the front desk if you need
directions.
Thank you for allowing us to be involved in your care, we wish
you all the best!
- Your ___ Healthcare Team | PATIENT SUMMARY:
================
___ with PMH pAF on rivaroxaban, DM, bicuspid AS, COPD, GERD,
BPH, OSA on BiPAP who p/w chest pain, EMS ride c/b AF RVR now
spontaneously converted, found to have type II NSTEMI. Was not
able to have nuclear stress test while inpatient, so he was
discharged with plans for testing as outpatient and cardiology
follow up.
# CORONARIES: Unknown
# PUMP: EF54%
# RHYTHM: pAF, currently NSR w/ 1st degree AV delay | 193 | 69 |
18635022-DS-35 | 28,472,494 | Dear Mr ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital due to a non-healing foot
ulcer and had an amputation of part of your right foot. During
your hospitalization your kidney function worsened and you
briefly tried dialysis but your body did not tolerate dialysis
well. We talked about your goals for your medical care and you
decided that you do not want more invasive care, so we stopped
dialysis and did not do any more amputations. You also decided
that you prefer not to come back to the hospital, and instead to
spend the rest of your life comfortably at your ___ center.
We are discharging you with antibiotics for the infection in
your foot. The antibiotics will not cure the infection. The only
way to cure the infection is with more surgeries. We hope the
antibiotics will slow the infection down and we all support your
decision to avoid more invasive procedures.
We made the following changes to your medications:
- STOP Sinemet
- START Parcopa (dissolvable version of sinemet)
- START doxycycline (antibiotic)
- START cefpodoxime (antibiotic)
- START flagyl (antibiotic)
- START oxycodone as needed for severe pain in your foot
- START warfarin (blood thinner) | Mr. ___ is a ___ gentleman with a history of
significant vascular disease and ESRD who was admitted to the
vascular surgery service at the ___ on ___ for a nonhealing
right great toe ulcer. He received a right trans-metatarsal
amputation. His hospital course was complicated by progression
of his ESRD but he did not tolerate HD. After extensive
discussions regarding goals of care, patient decided he did not
want further HD, surgeries, or rehospitalization.
ACTIVE ISSUES:
1. R Foot Osteomyelitis: Patient presented with an ulcer on his
R great toe that appeared to be infected. He was started on
empiric antibiotics, received wound care, and was ordered for
non-invasive arterial studies, but these were not tolerated due
to pain. The podiatry service was consulted regarding
management/debridement of his infected foot ulcer, and they
performed a right hallux amputation on ___. The patient
underwent venous mapping on ___, which revealed patent
bilateral great saphenous veins, patent left cephalic and
basilic vein. His wound was monitored routinely and dressed with
dry, sterile dressing. On ___, the patient underwent a
diagnostic angiogram. Tissue samples from his debridement grew
back MRSA , Corynebacterium, and Proteus. His antibiotics were
tailored to treat for these microbes with the assistance of the
ID consult service. On ___, that patient was taken to the OR
with podiatry and a right transmetatarsal amputation was
performed. This went well without complication (refer to
operative note for details). On ___, the patient's TMA
suture line was opened secondary to concern for infection (there
was some pus that was able to be expressed from the wound). This
was drained at the bedside. Patient continued to show signs of
infection at the site of his TMA, and podiatry recommended
additional surgical debridement. Vascular agreed with additional
surgical debridement, and felt patient would ultimately require
a BKA. Patient's goals of care were discussed extensively.
___ without part of his leg was an unacceptable quality of
life for him, and he decided not to have any more invasive
procedures, including further surgeries or debridement. ID was
consulted regarding recommendations for a suppressive antibiotic
regimen and he elected for an oral course.
2. ___ on CKD: Prior to admission patient had ESRD with a
baseline Cr of ___, but her presented with a Cr of 7.5. The
renal service was consulted and recommended starting HD via R
forearm AVF which was placed a year prior. Patient initially
declined HD. He ultimately agreed to try HD but did not tolerate
it, with each session of his 3 sessions complicated by
hypotension, afib with RVR, hypotension, somnolence, or
discomfort. Creatinine and mental status did improve. He decided
not to have further HD. He demonstrated the capacity to make
this decision, and expressed clear understanding that he will
die without HD. HD was stopped and patient received maximal
medical management for his ESRD. He continued to make urine and
will be continued on PO diuretics for fluid management.
3. A. fib: Patient had an episode of a. fib on ___ and had
recurrent a. fib with RVR during his HD sessions. His RVR
responded to one-time dosing of diltiazem. He has a CHADS2 score
of 6 and multiple prior CVA's. He was started on warfarin with a
heparin bridge. Last INR 3.0 on ___. This will continue to
be managed by his PCP Dr ___ at ___. Next INR to
be drawn ___
4. Acute on chronic diastolic CHF: last EF 55% in ___, was
volume overloaded during his admission due to worsening renal
failure and fluids. Improved with diuresis with IV lasix.
Discharged on furosemide 40mg daily with metolazone 2.5mg MWF
for diuresis. Continued metoprolol, carvedilol, imdur for CHF
regimen. Discharge weight was 72.8 kg.
5. Altered Mental Status: Prior to initiating HD, patient's
mental status became progressively more altered, which was
likely multifactorial with contributions of uremia, missed doses
of Sinemet, and delerium. His Sinemet was changed to Parcopa (an
oral, dissolvible form that was easier for him to take) and he
received three sessions of HD as above. His mental status
rapidly improved to baseline and he was A+O x3 and consistently
demonstrated the capacity to make his own medical decisions.
CHRONIC ISSUES:
1. ___ Disease: Patient showed evidence of worsening
Parkinsonism in the setting of missing Sinemet. Switched from
Sinemet to Parcopa (oral dissolvible form) with significant
improvement.
2. Hypothyroidism: Continued synthroid ___ mcg daily.
3. GERD: Continued lansoprazole oral disintigrating tablet 30 mg
daily.
4. Depression: Continued Citalopram 10 mg daily.
5. HTN: Continued Carvedilol 37.5 mg BID and Isosorbide
Mononitrate (Extended Release) 30 mg PO daily.
6. Bowel Regimen: On docusate and senna. Required one enema
while inpatient with good results.
7. Cholesterol: Continued Simvastatin 40 mg daily.
8. BPH: Continued Terazosin 2 mg PO HS.
TRANSITIONAL ISSUES:
- Osteomyelitis: has declined further surgery. Will need to
continue doxycycline, flagyl, and cefpodoxime indefinitely.
- Anticoagulation: will need next INR on ___ - this should
be monitored closely given concomitant antibiotic use
- ESRD: patient will not undergo further dialysis and ESRD will
be medically managed
- Goals of Care: ___ has decided he does not want any
further invasive procedures, and he would like to focus on
prolonging his life only with medications and non-invasive
means. This includes:
--- DO NOT RE-HOSPITALIZE
--- DNR/DNI | 205 | 884 |
16882192-DS-27 | 27,849,137 | It was a pleasure caring for you at ___
___. You came to the hospital after a fall and an
episode of weakness. Testing showed no sign of a heart problem
or stroke, although we did see periods of a rapid irregular
heart beat. You are known to have this problem, and use the
diltiazem to control your heart rate. You had several episodes
of diarrhea during your admission. We did not find any sign of
infection, although you did seem dehydrated when you first came
to the hospital.
We recommend that you restart your regular medications,
including the diltiazem. We have provided refills of your
prescriptions. You should contact your primary care doctor at
___ (___) to work out your pain medication
prescriptions. | ___ with Hx EtOH abuse, chronic back and neck pain, paroxysmal
AFib not on coumadin, and HTN presents following possible
syncopal episode.
# Syncope: The patient's description of his episode could be
c/w orthostatic hypotension, a prior problem, and the patient
states it was somewhat similar to his prior falls. He was not
orthostatic the day after admission, however he had received
IVF. He has pAF and could have had a period of low forward flow
associated with arrhythmia that did not cause palpitations.
There was a captured episode of AF the afternoon after admission
that the patient noticed with symptomatic palpitations, but no
associated lightheadedness. There was no indication of
infection on imaging (CXR, CT abdomen/pelvis, CT spine) or blood
testing (no leukocytosis). There was no indication of stroke on
___ or neuro exam. He does not have seizure Hx and there is
no evidence of abnormal movements. Finally, he could have gait
imbalance ___ EtOH ingestion given his EtOH level remained
elevated (141) more than 12 hours after his fall. Telemetry
unremarkable, troponins negative x3.
# EtOH: The patient's reported EtOH consumption does not seem
entirely compatible with his elevated serum level. He may have
had more intake than reported, over a longer duration. Last
drink ___ at 1am. He has no history of withdrawal, no evidence
during this admission.
# Back pain: Chronic problem, recent difficulty accessing pain
medication may have contributed to his presentation. Provided
oxycodone Q4H as per prior practice. The patient had been
having difficulty with OxyContin PA, which will need resolution
with his PCP ___. We provided short Rx oxycodone on d/c to
tide the patient over until the ___ office is open and can
resolve access questions.
# Diarrhea: The patient states he often has looser stools when
he decreases his pain medication. He started to reduce
frequency of use ___, corresponding with the onset of looser
stools. He denies blood in the stools, just mild cramping.
However, he has a recent history of C diff that is
understandably concerning given his presentation with lactate
elevation, weakness, and a fall. Given several episodes of
loose stool, we attempted to rule out recurrent C diff
infection, however stool output slowed which precluded sample
but provided reassurance with regard to infection.
# Leg edema: Unclear etiology, most concerning for liver
pathology. Workup with RUQ u/s and LFTs underway as outpatient.
Edema appears improved today, possibly correlating with
possible dehydration/pre-renal state. Held Lasix due to
possible orthostatic hypotension, restarted on discharge to
address edema.
# pAF: Patient had not been using diltiazem for about 3 months
due to problems with refilling his Rx. BP and HR mildly
elevated on admission, which could also be related to pain
control. CHADS-2 score = 1 (HTN), on ASA. Restarted diltiazem.
# HTN: Elevated to SBP 140s on admission. The patient had
stopped both diltiazem (3 months) and lisinopril (6 weeks) ___
problems with refills. Restarted both medications.
# Precautions: MRSA
# Communication: brother ___ (___)
# Code: FULL | 130 | 523 |
12504054-DS-21 | 29,687,295 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted from another hospital because you heart
rate was very slow. You also had a low blood pressure. You have
had this problem for many years, but you consented to get a
pacemaker this time. The procedure went very well and your heart
rates are much improved. We reccommended that you be
anticoagulated for your atrial fibrillation, but you did not
want this. You can defer this decision to the future,
understanding the risks of delaying including stroke or death.
Please continue to take all of your medications and keep your
follow-up appointments.
Best,
The ___ Cardiology Team
TRANSITIONAL ISSUES:
#Weigh yourself every day and call Dr. ___ your weight
goes up by more than 3 pounds.
#Take ___ every other day for 5 days (total of 3 doses)
#Take your albuterol inhaler if you feel short of breath or
wheezy | ___ with chronic Afib, not anticoagulated, chronic angina and
intermittant AV block resulting in long symptomatic pauses now
s/p pacemaker placed by ___ EP.
#Symptomatic bradycardia s/p pacemaker: Patient intially
presented to OSH after several days of worsening chest
tightness, fatigue and shortness of breath and found to have HR
in the ___. A pacemaker had been reccommended several times for
similar episodes, but patient had always refused. He agreed this
episode given the severity and chronicity of his symptoms. A ___.
___ single chamber pacemaker
was placed without complication. He was given Vancomycin while
in-house and was discharged with 5 days of ___ to also
cover for a potential respiratory infection.
#Chronic Afib, not anticoagulated, CHADS4: On admission, patient
conducting in Afib with his native QRS which suggested
significant underlying conduction disease (RBBB and LAFB), and
he also had a slow ventricular response in Afib despite not
being on any nodal blocking agents. There were no identifiable
reversable causes for the patient's heart block, thus EP
reccommended a pacemaker. Anticoagulation has been discussed
multiple times with the patient as an outpatient given his high
risk (CHADS 4) and he has refused each time. He was counseled
here as well and was able to state the risks including but not
limited to stroke and death. He understood this and still wished
to defer anticoagulation. He was started on metoprolol XL 25mg
daily given no risk for bradycardia s/p pacemaker. Would
continue the anticoagulation discussion given high risk.
# Chronic angina/CAD: Patient experiences chronic chest pain and
tightness. Per clinic notes, this had been a long standing issue
with moderate relief with medical management. Significant risk
factors include current tobacco use and diabetes. No evidence of
ischemic changes on admission EKG. Last stress mibi positive for
perfusion deficit but not intervened upon given preference for
avoiding cardiac cath. He was continued on Imdur and losartan.
He was transitioned to metop 25 XL. He should discuss cath as an
outpatient.
# Acute on chronic sCHF: Last echo in ___ showing EF of
40-45%. Some acute exacerbation likely ___ persistent
bradycardia and decreased forward flow with back up into the
pulmonary circulation. Patient appears mildly fluid overloaded
on exam with lower extremity edema and CXR with evidence of mild
interstitial edema. BNP elevated. Shortness of breath improved
with one dose of Lasix. He was continued on home lasix 20mg PO
daily at discharge. He was also continued on CHF meds: imdur and
losartan.
# Recent URI: Patient with a few weeks of minimally productive
cough. Finished 5 day course of azithromycin without relief. PCP
called in ___ which patient had not started as an
outpatient prior to his presentation to the ED at ___. CXR
without evidence of infiltrate suggestive of infectious process,
did comment for mild interstitial edema and appeared mildly
fluid overloaded on exam. He was not started on antibiotics in
house given low suspicion for CAP. He was given albuterol nebs
as he was recently prescribed albuterol. He was briefly IV
diuresed x1 and continued on his home lasix dose.
# Acute on CKD, stage III: Baseline creatinine 1.4. Currently
elevated to 1.9 likely in the setting of persistent bradycardia
and episode of hypotension with decreased end-organ perfusion
exacerbated by mild acute exacerbtion of heart failure.
Medications were renally dosed.
# HLD: Chronic. Stable. Not currently on a statin per PCP ___
___.
# HTN: Chronic. Currently normotensive. Continued home
medications: Imdur, losartan
# DM: A1c 8.1%, which was an increase from previous level of
7.3. Followed by ___. Complicated by peripheral neuropathy.
Home medication tradjenta held while in hospital and insulin
sliding scale was used. | 153 | 603 |
16684569-DS-4 | 26,212,256 | Dear Ms. ___,
You were admitted to ___ after
a car crash and were found to have left and right sided rib
fractures. Your pain and breathing were monitored and you
worked with physical therapy. You were also found to have a
urinary tract infection and are being treated with an antibiotic
called Bactrim (Sulfamethoxazole / Trimethoprim). On your
admission imaging, you were incidentally found to have left and
right 1.6 cm thyroid nodules and it is recommended that you
follow-up with your primary care provider to have ___ thyroid
ultrasound done as an outpatient.
You are now ready to be discharged home with home physical
therapy. Please note the following discharge instructions:
* Your injury caused left and right sided rib fractures which
can cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Ms. ___ is a ___ y/o F w/ pmh afib on Coumadin, CHF, seizures
who presented to ___ s/p MVC with right ___ and left ___ rib
fractures. She was hospitalized for pain control, pulmonary
toilet, and ___. On HD1, a foley catheter was placed for
symptomatic urinary retention. The foley catheter was removed
on HD2 and the patient voided without issue. A urinalysis and
urine culture was sent which was positive for e.coli and Bactrim
was started. HCT was trended and remained stable. A tertiary
exam was performed which was negative for any additional
traumatic findings. Physical Therapy was consulted and
ultimately recommended discharge home with home ___.
The patient was alert and oriented throughout hospitalization;
pain was managed with acetaminophen and tramadol. She remained
stable from a cardiopulmonary standpoint. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. The patient tolerated a regular
diet, intake and output were monitored. 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 assist, voiding without assistance, and pain was
well controlled. The patient was notified of her incidental
thyroid nodules and she will follow-up with her PCP. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 363 | 253 |
17399799-DS-5 | 20,925,410 | Ms. ___,
It was a pleasure taking care of you while you were admitted at
___. You had confusion prior to coming in, but this resolved
very quickly. You were found to have a urinary tract infection,
and you were started on antibiotics. You got one dose IV, and
you got one dose by mouth. You will need to take your last
dose tomorrow, ___. You were also found to have dehydration,
and got fluids for this.
Because of the dehydration, please do not take your furosemide
(Lasix) for the next 2 days. We are giving you an order for you
to get labs checked and sent to your primary doctor on ___.
We will ask your doctor to look at the labs and let you know if
you should restart your Lasix on ___. Please check your
weight every day, and if it goes up by more than 2 pounds,
please call your doctor.
Your blood sugar was slightly high but you did not want to take
the form of insulin that we have. Please check your blood sugar
as soon as you get home and take your insulin per your home
sliding scale. | Ms. ___ is a ___ with history of hypertension, DMII, CKD who
presents with intermittent stabbing frontal headache x1 month,
found to have asymptomatic UTI. | 203 | 27 |
12316428-DS-8 | 25,396,725 | Dear ___,
It was a pleasure taking care of you. You were recently admitted
to ___ for abdominal pain. You
were found to have inflammation of your appendix (appendicitis)
and underwent surgery to remove your appendix. The procedure was
uncomplicated and you were observed overnight. At the time of
discharge, you were able to tolerate a regular diet, walk on
your own, and your pain was controlled. Please follow the below
instructions to ensure a smooth 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.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission history and physical consistent with acute
appendicitis, including tenderness at McBurney's point. The
patient underwent open appendectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor with pain well controlled, on IV
fluids, and hemodynamically stable.
On POD 1, patient was started on a regular diet and was placed
on oral pain medication with continued good effect. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 370 | 193 |
11583220-DS-3 | 23,582,110 | It was a pleasure looking after you, Ms. ___. As you know,
you were admitted with cellulitis (infection of the skin) after
sustaining a cat bite. You were given antibiotics called
doxycycline and clindamycin. The clindamycin was given
temporarily as an intravenous medication. On this regimen, your
white blood count was reduced, the redness slowly improved, and
you had not fever. The pain/tenderness also thankfully was
reduced. An ultrasound revealed no skin abscess. A tetanus
booster was given and an infectious disease consult was obtained
- who agreed with the overall management.
Please continue to take the clindamycin and doxycycline for a
total of 14 days. This will take time to heal.
You were admitted with transient loss of consciousness - and
this was attributed to being dehydrated (having not been able to
eat over the past week). Your vitals were stable and were able
to stand without difficulty. | ASSESSMENT & PLAN: ___ woman h/o hypothyroidism, HTN.
presenting with continued redness on her lower extremity, nausea
and vomiting s/p cat bite.
.
# Cellultis s/p cat bite: Ms. ___ was admitted with 1 week of
progressive redness, pain in the RLE despite being on 4 days of
levofloxacin. The working diagnosis on admission was partially
treated pasturella cellulitis. She was admitted with a WBC of
21. Given her reported allergy to PCN (recalls getting swollen
R arm and angioedema like symptoms), her antibiotic regimen was
kept at clindamycin and doxycycline. RLE U/S showed no evidence
of subcutaneous fluid collection or RLE DVT. ID was consulted
and agreed that the clinda/doxy was the best course for her. On
this regimen, Ms. ___ observed steady, but slow improvements
in her ___ cellulitis. Her WBC improved to 12 and she was
afebrile and noted significant reduction in pain. Per ID
recommendations, she will require at least ___ day course of
antibiotic. She was observed for an additional 24 hrs while
being on PO abx.
She received a Td booster since her last Td vaccination was
___. Blood cxs here have been negative to date.
.
# Headache, Nausea and Vomiting: Ms. ___ was admitted with
symptoms c/w with prior migraine. NCHCT here was negative. The
headache had largely resolved on Day#2. She had intermittent
headaches requiring fioricet vs. tylenol with good effect.
.
# Syncope/Presyncope: Symptoms were attributed to dehydration
and significantly reduced POs, plus nausea and vomiting (had not
eaten for 6 days). The syncope was witnessed. No hx of
palpitations. Considered unlikely primary neuro (sz) or cardiac.
No clinical evidence or story for VTE. Orthostatics here was
unremarkable. She was able to ambulate with crutches without
problem.
.
# Hypothyroidsm: Clinically stable. Cont levothyroxine.
.
# Hypertension: SBP controlled. Resume losartan once BP
improved.
.
# FEN: IVF/Replete PRN/Regualr
# PPX: Ambulate
# ACCESS: PIV
# CODE: Full
# CONTACT: Patient, Husband | 164 | 349 |
11013655-DS-16 | 24,231,467 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with abdominal pain and nausea/vomiting and were found
to have a small bowel obstruction likely due to Crohn's disease.
After an NG tube was placed, your obstruction resolved, and you
were treated with steroids as your diet was slowly advanced.
Please continue to take prednisone 40mg daily from ___,
35mg daily from ___, 30mg daily from ___, 25mg daily
from ___, then 20mg daily indefinitely from ___.
Until approximately ___, please do the following: no nose
blowing, sneeze with mouth open, no vigorous activity,
straining, or heavy lifting | ___ h/o HTN and Asthma who presents with abdominal
pain/distention, vomiting, and brief syncope found to have CT
findings of skip strictures and dilatations in the small bowl
concerning for Crohn's.
# Abdominal pain/distention: Admitted with small bowel
obstruction with CT evidence of late-onset Crohn's disease. NG
tube was placed and drained 750cc dark fluid with rapid
resolution of abdominal pain/distension and nausea/vomiting.
The NG tube was removed, and diet was slowly advanced. Patient
was originally placed on IV solumedrol 20mg q8h then after 2
days was started on PO prednisone 40mg daily, which will be
followed by a weekly taper decreasing by 5mg to a minimum of
20mg daily. He will need outpatient GI follow-up with Dr.
___ MR enterography
# Epistaxis: Had one episode of bilateral epistaxis after NG
tube removed, treated with afrin, ice, and holding direct
pressure. However, his right nostril continued to ooze for
several hours, and large clots were noted in the oropharynx
raising concern for possible airway compromise. ENT consulted
and suctioned large clots from right nostril, oropharanx and
nasopharynx, but found no source of active bleeding. There was
evidence of right septal deviation as well. He will follow-up
with Dr. ___ as an outpatient.
# Brief syncopal episode: likely vasovagal in setting of pain
and vomiting, possibly with component of hypovolemia. Did not
appear hypotensive, and cardiac and neurologic causes appear
unlikely given clinical presentation. EKG wnl, trops negative
x2.
# HTN: hypertensive on admission, did not appear to be
hypotensive despite brief syncopal episode. His SBP was
typically in the 140s-160s during his hospitalization. We
continued his home amlodipine and lisinopril. | 106 | 278 |
19919930-DS-14 | 22,621,778 | You were admitted to the hospital because you were having left
flank pain. A CAT scan was completed which showed stable and
migrating kidney stone. You will need to remain well hydrated
while this passes. You are being given a medication to help with
your pain. Please be sure to take this with food as to prevent
stomach irritation.
You will need to follow up with your PCP. (see below) | 1. Abdominal Pain LUQ due to Nephrolithiasis
- Stone is a very small obstructing stone. It would be unusual
for a stone this small to require lithotripsy.
- The patient cannot take flomax due to the sulfa allergy
- She has an upcoming urology appointment at ___ on ___
- Encourage large volume PO hydration
- Pain control with NSAIDs and Tylenol
2. Chron's Disease
- Mesalamine
3. Anxiety, Depression
- Citalopram
- PRN Ativan
Full Code
Social work consult as patient feels very alone, and clearly is
having trouble coping at home. | 69 | 81 |
15403581-DS-11 | 26,811,647 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital with
increased shortness of breath with activity. You were found to
have an irregular rhythm of your heart (atrial fibrillation)
that caused you to have poor pumping of your heart, leading to
fluid building up in your lungs causing your shortness of breath
(congestive heart failure). You were given electricity to your
heart to convert your rhythm to a normal rhythm (cardioversion).
You will need to continue taking warfarin as you have been as
directed by your cardiologist. You were also given medication to
take the fluid out of your lungs. You were then started on
medications to help preserve the pumping function of your heart
and another medication to keep your heart in a regular rhythm.
Please follow-up with the appointments listed below and take
your medications as instructed below. Please weigh yourself
every morning and call MD if weight goes up more than 3 lbs.
Wishing you the best,
Your ___ team | ___ year-old with CAD, afib s/p CVA, AS s/p aortic valve repair
who presents with decompensated heart failure in setting of
new-onset Afib. | 171 | 23 |
13112619-DS-19 | 24,825,504 | Dear ___,
It was a pleasure looking after you. As you know, you were
admitted with fever, chills, nausea, and elevated liver function
tests. Ultimately, it was discovered that your symptoms are
attributed to an acute EBV ___ Virus) infection -
acute mononucleosis. As discussed, there is no clear medical
treatments for this and the best course of action is rest and
adequate oral/fluid intake.
There are no changes to your medications. You may take Tylenol
or Motrin as needed (Tylenol should be less than 2 gm total per
day to avoid insult to liver).
We wish you good health!
Your ___ Team | ASSESSMENT & PLAN: ___ h/o IBS presented with 9days of fever,
headache, transaminitis.
# ID: Ms. ___ was admitted with constellation of symptoms
fever, headache, chills, N/V, cervical ___, transaminitis,
atypical lymphocytosis, mild hepatomegaly most c/w acute EBV
infection. Outpt tests included strep, Lyme, anaplasma
serologies which all returned negative.
Given the high suspicion, Monospot was sent and returned
positive - consistent with acute EBV infection. Recent
serologies obtained from the outpt showed no prior infection to
EBV, CMV - indicating her susceptibility to acute infection (as
noted for this presentation). She was treated with supportive
care: motrin/Tylenol PRN and she was able to tolerate regular
diet without difficulty. Steroids and antivirals (acyclovir)
were considered unnecessary (and unlikely to help).
Her LFTs were elevated but were stable. RUQ U/S here showed
mild hepatomegaly, borderline increased spleen size - but no
significant splenic enlargement to suspect she was at risk of
rupture. She was discharged in good condition.
# Depression/anxiety: cont Prozac
# GERD/dysphagia: cont Prilosec
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: ambulatory
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: None
#COMMUNICATION: Pt
#CONSULTS: None
#CODE STATUS: [X]full code []DNR/DNI | 109 | 232 |
17838301-DS-36 | 20,530,461 | Mr. ___,
It was a pleasure taking care of you ___
___. You were admitted for fainting. The fainting
was likely due to a condition called vasovagal syncope. You can
get this from straining while trying to use the bathroom. We
have started medications to soften your stools and stopped the
iron supplements, which can make you constipated.
We also found that you had too much fluid in your body, which
was caused by your heart failure. We have adjusted your
medications to improve your heart function. You should have
your weight obtained every day and if your weight is greater
than 245 lbs, you need to take an one dose torsemide 20mg by
mouth in addition to your daily dose of torsemide.
Medication Changes:
STOP taking Isosorbide mononitrate
STOP taking ferrous sulfate\
STOP taking omeprazole
Change to Metoprolol 50mg Daily
Change to torsemide 40mg Daily
If your weight increases to over 245lb, take an extra dose of
torsemide 20mg Daily
Start taking Cipro 500mg twice daily for 13 days.
Start taking ranitidine 150mg daily | Assessment and Plan: ___ year old male with a history of OSA,
COPD and RV failure presents with syncopal episode in setting of
having a bowel movement.
.
# Syncope - Occurred in the setting of a bowel movement, so this
most likely represents a vasovagal episode. He has had a
prolonged PR in the past, as well as a high degree AV block,
however none of these findings are apparent on EKG. cardiology
EP was consulted and felt EKG was consistent with Aflutter w/
variable block, unrelated to syncopal episodes. He was ruled
out for MI. He was monitored on telemtry, which demonstrated
Aflutter with variable block. Started on ranitidine,
and discontinued omeprazole given it's drug-drug interaction
with celexa (QTc prolongation)
.
# Altered mental status - The patient's altered mental status
was likely due to a UTI. His hypercarbia was not very profound
on blood gas; HCO3- is also not too elevated suggesting that he
may not be a chronic CO2 retainer; this mild elevation in CO2
may thus be contributing to his mental status but seems too low
to be the sole explanation. The +UA (had >180 WBCs in urine)
and has grown out pan-senstive pseudomonas (now on Cipro).
Improved with initally ceftriaxone and vanco, which have no been
narrowed to cipro 500 BID.
.
# Respiratory distress - The respiratory status was due to
volume overload. The patient was diuresis 5L length of stay and
is now marketly improved. He was restarted on torsemide 40mg
daily. His weight should be obtained daily. His dry weight on
discharge was 242 lbs. He was instructed to take an extra 20mg
of torsemide daily if his weight is greater than 245. Given his
right sided heart failure, imdur is a poor choice in medication
and was stopped. His ace inhibitor was held given his ___. He
was discharge on his baseline of 2L of supplemental O2 via nasal
canual. He will need to continue his CPAP at night.
.
# Hypertension - At home is on ACE inhibitor, metoprolol, and
imdur. As noted above, Imdur not the best choice given his RV
failure. His HTN may have led to flash pulmonary edema. He was
also volume overloaded and he was aggressively diuresis and his
blood pressure improved. He was normotensive on metoprolol and
lisinopril 10mg (lower dose) was restarted at discharge since
his kidney function was near baseline (1.8, baseline 1.6-1.7)
# Urinary tract infection - Significant pyuria on admission.
Grew >100,000 colonies of pan-senstive pseudomonas. The pateint
was initially started on ceftriaxone and vanco, but was narrowed
to Cipro 500mg BID for a 14 day course. He will need 13
additional days after discharge.
.
# Renal failure - Decreased renal function was likely secondary
to poor forward flow in the setting of RV failure and volume
overload. He was aggressively diuresis and was -5L length of
stay and his lisinopril was held. His returned to near baseline
at 1.8 (baseline 1.6-1.7) at the time of discharge.
.
# Dementia - Continue aricept, ropinarole, and celexa throughout
hospital course | 170 | 527 |
19700990-DS-6 | 21,204,649 | Dear Ms. ___,
You originally came to the hospital because of heavy vaginal
bleeding. The bleeding did not respond to medications, so you
underwent a procedure to block the blood supply to the uterus.
Unfortunately, you developed a serious infection that spread to
your blood-stream. In order to treat the infection, you had a
hysterectomy to remove your uterus. Afterwards, you stayed in
the intensive care unit (ICU) because you were very sick and you
needed medicine to keep your blood pressures normal. You
received antibiotics to treat the infection as well, and will go
home on antibiotics. Thankfully, this procedure is the
definitive treatment for vaginal bleeding, and your blood counts
have remained stable since.
Once you left the ICU, your heart was in an abnormally fast
rhythm. We evaluated you for some causes of this, including an
echocardiogram (ultrasound of the heart), which were all normal.
However, you went into this rhythm again, so were started on a
medication to prevent your heart from going too fast again
(metoprolol).
You have recovered well on oral pain medications and
antibiotics. The team feels that you are ready to leave the
hospital.
Please follow these instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Take a stool softener to prevent constipation. You were
prescribed Colace. If you continue to feel constipated and have
not had a bowel movement within 48hrs of leaving the hospital
you can take a gentle laxative such as milk of magnesium.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* You should remove your port site dressings ___ days after your
surgery, if they have not already been removed in the hospital.
Leave your steri-strips on. If they are still on after ___
days from surgery, you may remove them.
* If you have staples, they will be removed at your follow-up
visit.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Best wishes on your continued recovery,
Your ___ GYN Oncology team | ___ with hx Fe-deficiency anemia, ITP ___, pancytopenia
(followed by hematology/oncology outpatient), presenting with
vaginal bleeding, abdominal distention, and Hgb drop to 7.6
(baseline hgb mid-10s) admitted for concerns for vaginal
bleeding. Her course involved uterine artery emobolization
complicated by GNR septic shock and emergent hysterectomy
requiring ICU stay.
#Vaginal bleeding: patient with hemoglobin drop from 8 (in
___ to 7.6 likely from metromenorrhagia ___ uterine
fibroids. Patient was evaluated by ob-gyn in ED with
recommendation for transfusion of 2 units pRBCs and depo plus
oral provera. However, her bleeding continued, and
interventional radiology evaluated her, and decided to take her
for a bilateral uterine artery embolization on ___, after
which point her bleeding stopped, and her hemoglobin remained
stable. On day 1 post procedure, she developed increasing pain
and a small hematoma at the groin site used for the procedure.
An ultrasound of the area showed no active bleeding, and a CAT
scan showed no retroperitoneal bleed. She was initially
transferred to the floor on ___.
#Septic Shock: On day one after her procedure, the patient
became febrile and hypotensive and was started on Vancomycin and
Zosyn. She returned to the ICU the evening of ___. A right
internal jugular vein central line was placed, and she was
started on Neosinepherine and Vasopressin for blood pressure
support starting ___. She grew gram negative rods on her blood
culture. The source was likely due to the translocation of
bacteria from the necrotic uterine tissue following her uterine
artery embolization. She was initially started on vancomycin and
zosyn for broad spectrum emprirc coverage. Gynecology was
contacted regarding source control and the decision was made to
pursue emergent hysterectomy. She was on 3 pressors during the
case. Following the procedure, she again returned to the ICU
where she was intubated and on pressors stabilization. Her
antibiotics were switched to tobramycin from ___.
Cervical cultures grew gram negative rods. In response to blood
cultures growing E. coli sensitive to ceftriaxone, she was
transitioned to ceftriaxone ad metronidaxole starting ___. She
was eventually weaned off pressors and was extubated on ___.
She returned to the floor on ___ and was transitioned to oral
levaquin and flagyl on ___ to complete a 14 day course
(___). .
#) Narrow Complex Tachycardia: Upon arrival to the floor, her
cardiac rhythm was noted to be narrow complex tachycardia,
thought to be AVNRT, which resolved with carotid massage alone.
She was asymptomatic, but developed a new oxygen requirement of
3 L nasal cannua. A CTA was negative for pulmonary embolus, but
showed bilateral pleural effusions. She was given Lasix 10 mg IV
with adequate diuresis and resolution of her O2 requirement. TSH
and free T4 were normal. Cardiology consult was obtained.
Surface echocardiography showed normal structure and systolic
function. Again, two days later on hospital day 9 she went into
a regular tachyarrythmia (HR 180s) while on tele. She was
symptomatic with lightheadedness and shortness of breath and
desaturated to 80% on room air. Her symptoms and O2 requirement
resolved with metoprolol 5 mg IV, and she was subsequently
started on metoprolol tartrate per cardiology recommendations.
#) Post-op: Her pain was initially controlled with a morphine
PCA. Her diet was advanced slowly with return of the patient's
appetite, and she was transitioned to oral oxycodone, ibuprofen,
and acetaminophen. She ambulated. Her foley was removed and she
voided spontaneously. The JP drain was removed. She underwent
assessment and treatment by physical therapy.
===============
Chronic Issues
#Pancytopenia: patient has been diagnosed with pancytopenia with
unclear etiology and autoimmune thrombocytopenia in the past.
Followed by outpt heme/onc. WBC and Plt levels are at baseline
upon admission, and stabilized after the hysterectomy.
===============
By hospital day 13, she had met all post-op milestones, her
anemia was stable, and her heart rate was well controlled on
metoprolol. She was then discharged in good condition to rehab. | 475 | 644 |
15768973-DS-4 | 25,562,405 | You were readmitted to the hospital after a laparoscopic right
colectomy with small fluid collections near the anastomosis
(connection) from your surgery. You will need to take
antibiotics (Augmentin) twice daily for the next ___ days. You
should continue to take a regular diet, and drink nutritional
supplements like ensure if you feel as though you cannot take
enough. You should continue to take the metamucil wafer,
however, as your diet is more normal you may not need the wafer
and can stop taking it.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. | Ms. ___ is a ___ year old female who is recently status post
laparoscopic right colectomy for low grade appendiceal mucinous
neoplasm who was admitted to ___
___ on ___ for left lower quadrant abdominal pain.
Work up found a 2.0 x 3.6 cm fluid collection in the right lower
quadrant surgical bed, which was not ammenable for drainage. She
was started on IV antibiotics, provided pain medications, and
started on her home meds. Hospital day 1, she had a fever to
101.4, but had no increase in white count on recheck. During her
hospitalization, she complained primarily of nausea and loose
bowel movements. Stool c. difficile was negative. Her nausea
improved with medications. On hospital day 3, she began feeling
better after Reglan was started. She was transitioned to oral
antibiotics. On the day of discharge, she felt much better. Her
nausea and diarrhea were improving. She was able to tolerate
more orally and will be discharged on a 14-day total course of
antibiotics and follow-up as scheduled in clinic. She was given
appropriate discharge and follow-up instructions. | 303 | 179 |
11914866-DS-27 | 25,506,482 | Dear ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized with diarrhea.
We sent off many tests of your stool to look for infections that
may be causing your diarrhea. Sometimes these tests can miss an
infection so we started you on antibiotics just in case. Your
diarrhea improved! We think you likely had an infection called
Giardia or Cryptosporidum, but we can't be sure. Continue taking
your antibiotic and if you diarrhea returns, contact your
doctor.
Please have your labs drawn on ___ using the
prescription provided at discharge. These labs will be faxed to
the ___ Transplant Team.
We wish you the best,
Your ___ Treatment Team | Mr. ___ is a ___ year old male, with history of DDRT (___),
CAD and prior history of thalamic and right ischemic frontal
stroke, who presented with increased diarrhea in the setting of
recent international travel, with negative infectious work up
and diarrhea resolved with empiric PO Flagyl.
ACTIVE ISSUES
=============
# Chronic Diarrhea: He presented with watery diarrhea in the
setting of international travel. The differential was broad in
the setting of immunosuppression but highest suspicion was for
an infectious diarrhea (parasitic; helminth vs. giardia vs.
crypto) or for CMV given his ongoing immunosuppression. Multiple
stools studies, including O/P x3 with giardia/crypto DFA were
negative. Several tests including strongolydies were pending at
the time of discharge. Transplant ID was consulted. CMV VL was
negative. He was started on empiric Flagyl, with total
resolution of his diarrhea. GI was consulted. Given rapid
improvement in symptoms, colonscopy and EGD to biopsy/evaluate
for possible CMV were deferred. He tolerated PO intake and was
able to maintain his Cr without IV fluids for 48 hours prior to
discharge.
___ on ESRD s/p DDRT in ___, ___ BK viremia, baseline Cr 1.4.
Cr initially 2.1 on admission, decreased to 1.5 after IVF. Renal
transplant ultrasound was with elevated indices, w/o hydro,
likely in the setting of pre-renal. With regards to his
immunosuppression, home tacrolimus was decreased to 1mg BID. MMF
was continued at 250mg BID. BK in his urine was 17,000 on ___
but negative on ___. BK serology was pending at the time of
discharge. Outpatient transplant nephrologist was made aware and
he will need repeat BK testing done as an outpatient in 2 weeks.
He will have tacrolimus rechecked in 3 days as an outpatient and
follow up with Dr. ___.
# Hypertension: Continued home carvedilol. Lisinopril was
initially held in the setting ___ but restarted prior to
discharge with Cr returning to baseline.
CHRONIC ISSUES
===============
# Anemia: Normocytic anemia. Chronic. Likely ___ to
myelosuppression from transplant medications.
# CAD s/p DES ___: Continued atorvastatin and Plavix. His
aspirin was changed to Plavix for stroke prophylaxis during
prior admission.
# Prior h/o of thalamic and frontal stroke ___ and ___:
Patient was hospitalized in ___ for thalamic stroke, no further
neurologic deficits apart from baseline. He has been working
with ___ and OT as an outpatient. Per multiple family members
during admission, the patient was at his baseline mental status.
He was continued on his home diet of soft mechanical with thin
liquids.
# BPH. Continued tamsulosin.
TRANSITIONAL ISSUES
====================
# Diarrhea
- Empiric Metronidazole 500mg q8hrs for 10 days (___)
- F/u Strongyloides Antibody pending at the time of discharge
# Nutrition
- Inpatient speech and swallow evaluation did not reveal any
oropharyngeal dysfunction. Continued on outpatient diet thin
liquids and soft solids. Consider outpatient video swallow
evaluation if symptoms ongoing/concerning.
# Renal Transplant
- Immunosuppression: Tacrolimus 1 mg BID, MMF 250mg BID
- Will need repeat Cr and Tacrolimus level drawn on ___
___ with results sent to ___ Renal Transplant Team:
___
- BK, serology pending at the time of discharge
- BK, urine: 17,274 on ___, repeat <500 on ___
- Will need repeat BK in urine tested in 2 weeks (around ___
- Please follow-up blood cultures from ___
# CODE STATUS: Full
# CONTACT: Son, ___ ___ | 116 | 554 |
19804034-DS-17 | 20,803,534 | You came in with abdominal pain and jaundice. We found that you
have a new pancreatic mass on CT scan. This was biopsied and
you had a procedure called an ERCP to stent the duct open. You
tolerated this procedure well.
The multidisciplinary team of liver specialists, surgeons, and
oncologist will meet later today to discuss your imaging and
pathology. You will get called with a follow-up appointment. | ___ F with history of DM2, prior cholecystectomy p/w epigastric
pain, jaundice, found to have new pancreatic mass.
# Obstructive Jaundice
# Pancreatic Mass
Pt had CT a/p done prior to admission showing new pancreatic
head mass. Underwent EUS with FNA today, appearance c/f likely
adenocarcinoma. Biopsy result pending. Pt also underwent ERCP
with sphincterotomy which she tolerated well. Diet was advanced
to regular which pt was tolerating on day of discharge and LFT's
downtrended post-procedure. She was treated with Cirpo x5 days
post-procedure. She also underwent CTA pancreatic protocol
which showed known pancreatic mass with likely vascular invasion
and liver mets. Her case will be discussed in multidisciplinary
meeting and pt will be called with f/u appointment.
# Type 2 Diabetes
Held metformin and glipizide while inpatient and placed on ISS.
Pt will continue to hold metformin post-discharge until 48 hours
after CTA.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care | 71 | 160 |
13063188-DS-44 | 26,839,219 | Mr ___-
You were admitted to ___ for worsening difficulty in your
breathing. You were suffering from an exacerbation of your heart
failure, likely due to eating salty foods. This lead to your
body holding on to a lot of fluid. You were given medications to
help remove this fluid, and you will be sent out on a medication
called torsemide. This dose is higher than your previous doses.
Please take all your medications as described below.
Weigh yourself every morning. If your weight goes up more than 3
lbs from your DISCHARGE / DRY WEIGHT OF 245.5 lbs. | ___ w/ HFrEF (mixed systolic and diastolic, last EF 30% in
___, DM2, Afib/aflutter who presents with dyspnea on exertion,
lower extremity edema, elevated proBNP found to be in acute
heart failure exacerbation likely from medication noncompliance.
#CORONARIES: Clean coronaries ___
#RHYTHM: Afib
#PUMP: LVEF 30%. Mild MR (___)
#Acute on chronic heart failure exacerbation: On admission was
warm and wet. LVEF 30%, mixed etiology, including tachycardia vs
EtOH vs viral. Presented w/ DOE, orthopnea, minimal ___ edema,
BNP 2820, pulmonary edema on CXR. Clinically did not appear
grossly overloaded however his symptoms were consistent with
CHF. Likely due to non-compliance with medications and recent
indulgence of ___ food. Wt 117kg on admission. Pt was
aggressively diuresed, with good response to Lasix, however, pt
noncompliant with fluid restriction and diet, thus making
diuresis difficult. Eventually, after counseling, pt began to be
compliant with diet and fluid restriction. He was able to be
diuresed to euvolemic with IV Lasix and was eventually
transitioned to 120mg PO torsemide daily. His weight upon
discharge was 111.6.
# Supratheraputic INR- patient had been told to take 2.5 mg
after last admission, discussed with ___ clinic that
increased his dose to 5mg (prior dose). Held Coumadin for 1
evening and restarted when pt's INR was 3.5 given previous
stroke history with subtherapeutic INR for one day. The
patient's INR at discharge was 2.5. He was discharged on 2.5mg
of Coumadin daily.
# Elevated LFTs: Pt had elevated bilirubin with RUQUS c/w
congestive hepatopathy. His bilirubin remained elevated even
with diuresis. This should be worked up further as an
outpatient.
# Paroxysmal Atrial Fibrillation: Pt's anticoagulation was
managed as above, and his metoprolol was continued. He had no
episodes of rapid ventricular response. Of note, the patient
did have occasional runs of NSVT and lots of ectopy on
telemetry, and should be considered for ICD/PPM given his low EF
and overall risk profile.
# Diabetes: HgbA1C elevated to 8.8%. Held home metformin and
continued home NPH qAM with SSI and QACHS FSBS
#HLD: Continued on ASA and pravastatin 40mg daily
#Dry eyes- cont artificial tears PRN
# Gout: Frequent flares, likely tophus to left elbow. He
reports non-compliance with prescribed allopurinol. No signs of
acute flare. Pt had no symptoms of this during this admission,
allopurinol was not restarted. | 98 | 401 |
14737333-DS-14 | 28,606,297 | Dear Ms. ___,
You were admitted to the hospital because of an overdose. This
was in the context of a fight and some abusive behavior from
your boyfriend. We supported you with Social Work, who gave you
phone numbers to call in case you need to seek more support for
this issue. Medically, at first you had some changes in your
heart from the overdose, but these resolved. You were medically
stable without any irreversible damage at the time of discharge.
Please follow up with psychiatry tomorrow at 11am. We feel this
is very important for your wellbeing.
It was a pleasure to take care of you during your hospital stay.
We wish you the best,
Your ___ team | ___ year old female presents with altered mental status after a
toxic ingestion (anticholinergics and benzodiazepines).
# ALTERED MENTAL STATUS / TOXIC INGESTION / ANTICHOLINERGIC
TOXICITY: Patient presented with acute ingestion of
antihistamine and benzodiazepine. This occured in the setting of
domestic violence from boyfriend. Per mom, no other medications
or pill bottles are at home and urine tox and serum tox are
negative. Toxicology was consulted. Per their recs, on
admission, she received 1 amp sodium bicarb for QRS > 100msec.
Her mental status and EKGs improved. Her QRS and QT intervals
were not prolonged on discharge. She was evaluated by psych and
social work as well as domestic violence social work. She was
medically cleared for discharge.
# OVERDOSE and HOME SAFETY: Patient states she feels safe at
home. She was given resources for home safety. She states that
her intent with the overdose was to harm herself; however since
then she no longer has suicidal intent. She was evaluated by
psych and social work as above. She was felt to be safe for ___
home with close followup with psychiatry as an outpatient. She
has an appointment tomorrow 11am to establish Psych care at a
clinic in ___.
# Metabolic acidosis: Likely from polyuria, losing bicarb in
the urine. VBG checked and shows respiratory compensation. This
resolved by the time of discharge.
# HYPOKALEMIA: Likely due to significant urine losses. This was
repleted and remained stable. | 116 | 244 |
Subsets and Splits