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16189174-DS-9 | 29,323,977 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing left lower extremity
- Posterior hip precautions left lower extremity
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- Evaluate and treat
- Touchdown weight bearing left lower extremity
- Posterior hip precautions left lower extremity
Treatments Frequency:
Monitor incision for signs of infection/breakdwon. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left both column acetabulum fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for Open reduction internal fixation
both column acetabular fracture with posterior exposure, plating
of the posterior column and posterior wall fragments with
posterior to anterior columnar screws to secure anterior column
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to a
rehabilitation facility was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and was voiding/moving bowels spontaneously.
The patient is touchdown weight bearing in the left lower
extremity with posterior hip precautions, and will be discharged
on lovenox for DVT prophylaxis. The patient will follow up in 2
wees per routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 186 | 271 |
17169964-DS-22 | 26,877,141 | Dear Mr. ___,
It was a pleasure being involved in your care.
Why you were here:
-You came in because you were having pain associated with you
Gtube
-You also came in because you were having some low oxygen levels
at home
What we did while you were here:
-GI evaluated you and replaced your g-tube. They felt that it
would be best if you had continuous tube feeds rather than bolus
tube feeds.
-you worked with ___ and respiratory therapy to help clear some
of the mucous in your lungs
-We found that you had an aspiration pneumonia and started you
on an antibiotic called augmentin
You next steps:
-continue taking augmentin until ___
-continue to do continuous tube feeds rather than bolus feeding
if you can tolerate it
-consider a GJ tube in the future to minimize aspirations
We wish you well,
You ___ Care Team | ___ yo M w/ history of oropharyngeal cancer s/p surgical
resection and radiation ___ years ago), hx of dysphagia, vocal
cord immobility and multiple aspiration PNAs with G-tube since
___, recently admitted for hypoxic resp failure for PE who was
admitted for for hypoxic respiratory failure and pain associated
w/ his g-tube. On presentation the patient noted increasing 02
requirement (on 2L at home) as he had new 02 desaturations to
___ at home (patient measures 02 sats ___. CXR w/ c/f
superimposed pneumonia or aspiration. However, given patient
afebrile w/ no cough, and CXR difficult to interpret iso chronic
pulmonary diseases from chronic aspirations/aspiration pna,
patient was evaluated with Chest CT. Chest CT c/f extensive
mucous plugging, e/o aspiration and potentially infection. Given
new 02 requirement and high risk of aspiration, patient started
on 14 day course of augmentin (day 1: ___, anticipated end date
___ with improvement of 02 requirement. On day of discharge
patient was satting ___ on 2L, requiring 4L to maintain 02
sats>89 on ambulation. With regard to g-tube associated pain the
patient was evaluated by GI and thought to have superficial skin
irritation due to tape patient was using on his skin. In
addition the patient was thought to have reflux symptoms. His
g-tube was replaced and GI recommended that the patient consider
GJ tube to minimize reflux symptoms and potentially aspiration.
However, the patient declined GJ and thus recommended to use
continuous rather than bolus tube feeds; the patient said he
would reconsider in the future. Hospital course c/b supratx INR
on admission, warfarin held and re-started at lower dose of 3mg
qday; INR on day of discharge: 1.8.
#Aspiration Pneumonia
#Hypoxic Respiratory Failure: Patient recently admitted for
hypoxic respiratory failure found to have a PE (___).
On this presentation the patient noted increasing 02 requirement
(on 2L at home) as he had new 02 desaturations to ___ at home
(patient measures 02 sats ___. CXR w/ c/f superimposed
pneumonia or aspiration. However, given patient afebrile w/ no
cough, and CXR difficult to interpret iso chronic pulmonary
diseases from chronic aspirations/aspiration pna, patient was
evaluated with Chest CT. Chest CT c/f extensive mucous plugging,
e/o aspiration and potentially infection. Given new 02
requirement and high risk of aspiration, patient started on 14
day course of augmentin (day 1: ___, anticipated end date ___
with improvement of ___nd respiratory
therapy worked with patient for mucous clearing. On day of
discharge patient was satting ___ on 2L, requiring 4L to
maintain 02 sats>89 on ambulation.
#G-tube pain: Patient was admitted ___ for upper GI
bleed ___ erosions and ulcerations in the stomach body around
PEG tube confirmed by EGD ___, s/p 3 clips. On this admission
the patient presented with skin-pain around the site of his
g-tube as well as internal burning sensation w/ no e/o GI bleed.
Skin pain was felt to be secondary to irritation from tape
patient was using on his skin. In addition the patient was
thought to have reflux symptoms. His g-tube was replaced and GI
recommended that the patient consider GJ tube to minimize reflux
symptoms and potentially aspiration. However, the patient
declined GJ and thus recommended to use continuous rather than
bolus tube feeds; the patient said he would reconsider in the
future. The patient initially had difficulty tolerating tube
feeds at a continuous rate, but on day of discharge was
tolerating tube feeds with no issue and had complete resolution
of pain. Patient was continued on IV pantoprazole BID while in
house, transitioned to lansoprazole liquid suspension 30mg BID
on discharge.
#Severe malnutrition: Patient w/ severe malnutrition (as
evaluated by nutrition) likely related to hx of
cancer/complicated medical hx as evidenced by weight loss 8% x 4
months, inability to maintain weight, low BMI, tube feeding
dependence to meet nutrition needs. TF were continued, as above.
#hx PE: Patient hospitalized ___ for sub-segmental
PE for which he was started on warfarin for planned duration of
3 months. On presentation patient was found to have a
supra-therapeutic INR, home warfarin 3mg/4mg decreased to 3mg
qday. Patient to have close followup for INR monitoring and dose
adjustment. INR on day of discharge: 1.8.
#Anemia: Improved from baseline (___). Chronic anemia, likely
iso chronic disease vs nutritional given patient cachectic
appearing. Hb on day of discharge 9.2. | 134 | 717 |
11686707-DS-19 | 21,594,149 | Dear Ms. ___,
You were admitted with chest pain which we were concerned
could be a heart attack. You underwent catheterization during
which a blockage in one of your stents was angioplastied
(opened). Unfortunately, during the procedure one of your
arteries had a tear which we needed to cross with a stent.
After your procedure, you had chest pain possibly related to
low blood counts and disease which we were unable to pass. We
treated your pain with nitroglycerin and gave you blood which
improved your chest pain. Your warfarin was held during your
hospitalization. You should discuss restarting it with your PCP
during your followup appointment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You should stop warfarin until you see Dr. ___ have your
blood counts checked. | drug-eluting stent of proximal RCA and PTCA of mid
RCA. Distal 70% RCA lesion could not be crossed ; to continue
medical therapy
___ PMH of 3 vessel CAD s/p DES, atrial fibrillation, cerebral
aneurysmal rupture s/p coiling and VP shunt placement due to
hydrocephalus, presenting with chest pain.
# Chest Pain: Patient presented with 2 week history of chest
pain. Troponins were were negative. Patient underwent cardiac
catheterization, complicated by dissection with placement of a
drug-eluding stent to the proximal RCA and PTCA of mid RCA. The
distal 70% RCA lesion could not be crossed. Patient had
intermittent chest pain following catheterization, which
improved and then resolved with nitro, morphine and transfusion
of pRBCs. Echo showed an EF of 40-45%, symmetric LVH with mild
global systolic dysfunction, mild mitral regurgitation, moderate
tricuspid regurgitation and mild pulmonary hypertension. She was
continued on ASA, plavix, and statin.
# Anemia: Patient had a hematocrit drop from 28.4 admission to a
low of 22.7 following catheterization. She received 3 units of
pRBCs and her hct was 35.5 at discharge. There was no evidence
of bleeding, and a CT abd and pelvis was negative. Warfarin was
held.
# Afib s/p cardioversion ___: Patient was ventricularly paced
consistently. She was continued on amiodarone. Warfarin was held
given hematocrit drop (see above).
# UTI: Patient had a positive UA and was treated with macrobid
x5 days.
# HTN: Patient had elevated SBPs, so her home dose of valsartan
was increased.
# H/o cerebral aneurysm rupture: S/p coiling and VP shunt
placement for hydrocephalus. Patient was without neurological
symptoms. | 140 | 266 |
10598267-DS-8 | 28,584,593 | Dear Mr. ___,
It was a pleasure participating in your care. You were
admitted for worsening shortness of breath and oxygen
requirement and found to have a new pleural effusion. The fluid
was removed by interventional pulmonology and your symptoms
improved. The studies appear preliminarily to be due to your
heart disease, however there are still a number of studies
pending at the time of your discharge. We will follow up with
these studies and notify you once the results are available. In
the mean time, you should continue to take your lasix daily, and
follow-up with your PCP and cardiologist as below. | ___ year old male with Hodgkin's lymphoma (neck and groin) in
remission s/p chemoradiation in ___ complicated by thyroid
cancer s/p radioiodine in ___, chronic pain ___ peripheral
neuropathy and severe aortic stenosis (mean of 26 mm Hg and sCHF
(EF ___ in ___ who presented to his PCP's office with
worse than usual shortness of breath and was noted to have
loculated pleural effusion, found to be transudative.
# Pleural effusion: Pt presented to ___ with worsening DOE, and
CT chest showed new loculated pleural effusion (since ___,
worse on the R side. IP was consulted and did a thoracentesis
with 130cc of serous drainage. Studies were indicative of a
transudative process, and cytology was negative, with flow
showing insufficient cells. Given transudative fluid, a TTE was
done to evaluate for worsening cardiac status. LVEF was improved
to 40-45%, with persistent severe aortic valve stenosis (valve
area 0.8cm2). The pt was discharged on lasix 40mg daily (he had
previously only been taking it intermittently) with plans to
follow-up with cardiology as an outpatient. At the time of
discharge the pt felt improvement in his dyspnea and was stable
on RA at rest and with ambulation.
# Eosinophilia: pt with abs eos >1000 for two days, which was
concerning given his hx of hodgkins lymphoma. In reviewing
Atrius records over the past year, has been (%)
6.8-->8-->4.9-->6.5-->7. Transient eosinophilia was of unclear
significance but Dr. ___ (the pt's oncologist) was
notified. At the time of dc the pt's eosinophilia had resolved.
# CAD/sHF: Pt was continued on home aspirin, plavix, statin, BB,
ACE-I. He was given lasix 40mg PO daily. CE were neg on
admission. TTE as above.
# Radiation lung disease/reactive airway disease: Continued home
advair and albuterol.
# Hypothyroidism: Continued home levoxyl
# Chronic pain: Continued home hydrocodone
# BPH: Continued home tamsulosin | 106 | 314 |
10729692-DS-11 | 26,731,515 | Dear Ms. ___,
You were admitted to the hospital with recurrent vomiting and
abdominal pain, similar to your prior episodes. The cause of
these symptoms was unclear, but may be due to a viral illness or
related to your marijuana use. Your symptoms improved with
supportive care, and you are being discharged home.
We would recommend that you discontinue marijuana use, which can
contribute to a cyclic vomiting syndrome.
Please take the remainder of your medicines as prescribed and
follow-up with your primary care doctor and with a
gastroenterologist after discharge.
With best wishes,
___ Medicine | ___ is a ___ female with a history of GERD,
depression/anxiety, episodic cyclic vomiting who presents with 4
days of nausea/vomiting and abdominal pain.
#Nausea/vomiting:
#Abdominal pain:
Patient reports intermittent episodes of vomiting over the last
___
years, for which she has been hospitalized at ___ and ___,
last
in ___ per patient. Per patient, prior w/u, including EGDs,
without abnormalities and negative for H.pylori. She presented
this admission with 4-days of her typical symptoms, with
abdominal discomfort and cyclic vomiting. Upreg neg, LFTs/lipase
WNL, and CT A/P without acute pathology. Ddx includes viral
gastritis vs cannabinoid hyperemesis syndrome given significant
marijuana use (~2g/d, although patient reports that her symptoms
have not improved previously with cessation of cannabinoid use),
less likely gastritis given patient report of negative EGD
previously in setting of similar symptoms. She was treated
supportively with bowel rest, IVFs, and analgesics/anti-emetics,
with complete resolution of her symptoms, and she was tolerating
a regular diet without pain or N/V at the time of discharge. She
will be discharged on her home Zofran, omeprazole, and
ranitidine
(provided a 7d supply on discharge). Marijuana cessation was
encouraged. Patient to schedule short-interval outpatient f/u
with her PCP and with ___ gastroenterologist at ___ after
discharge.
#Leukocytosis:
WBC 25 on presentation, likely in setting of viral gastritis
with
contribution from hemoconcentration. Improved to ___ at the
time of discharge. Low suspicion for bacterial infection,
including C.diff in absence of diarrhea. CT A/P w/cont negative
for intra-abdominal source, and no other localizing
signs/symptoms of infection. Would repeat CBC at outpatient f/u
to document complete resolution of leukocytosis.
#Depression/anxiety:
Continued home amitriptyline.
#GERD:
Continued home omeprazole. She will establish outpatient care
with ___ gastroenterologist as above.
** TRANSITIONAL **
[ ] repeat CBC at outpatient f/u to document resolution of
leukocytosis
[ ] f/u with ___ gastroenterologist for further w/u of chronic
cyclic vomiting | 91 | 271 |
16475636-DS-2 | 27,320,939 | Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were having chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-We checked your markers for evidence of heart damage and they
were unremarkable.
-After discussion regarding the risks and benefits of staying in
the hospital, you decided with the team to leave the hospital
and follow up closely with your primary care doctor and
Cardiologist.
WHAT SHOULD I DO WHEN I GO HOME?
-Please call your primary care doctor's office TOMORROW to
schedule a follow up appointment.
Thank you for letting us be a part of your care!
Your ___ Team | Patient presented with chest pain that was atypical. Initially
put on heparin drip in ED but upon coming to floor, his story of
seconds of twinging chest pain was reassuring and heparin drip
was stopped. He was planned to be observed overnight with
consideration of a possible stress test. When patient found out
he was in observation status, he left AMA. He should follow up
with Dr. ___ as an outpatient. | 97 | 71 |
19461484-DS-19 | 27,809,009 | Dear ___,
You were admitted because you felt off balance and because you
complained of numbness on the right side of your body. On
neurological exam, we found that your findings were compatible
with your previous examinations. Mostly, your neurological
problems stem from your previous stroke. Also, we found that you
are depressed, and we believe that some of the stress in your
mind shows up as physical symptoms in your body.
We asked the psychiatry doctors to help with your assessment,
and their findings were similar to ours. They suggested
increasing your bupropion (Wellbutrin SR) from 150 mg daily to
twice daily. You should keep your sertraline and all your other
medications the same. They also scheduled follow up appointments
with your therapist and with your psychiatrist. It will be
important for you to go to these appointments.
You should also follow up with Dr. ___ in neurology stroke
clinic.
During this admission, you were evaluated by our physical
therapists, who thought that your level of functioning is very
close to your baseline. At this point, your walking is probably
more limited by your feeling of anxiety. We will give you a
prescription for outpatient therapy. | ___ yo RH woman with a hx of a coagulopathy, b/l
cerebellar/pontine ischemic stroke, and significant depression,
on enoxaparin, who presented with vague symptoms of feeling off
balance, nausea, and right face numbness. Noteably she stopped
using a cane to help with her balance about 2 weeks ago. She
also reports
increased stress at home and "not feeling like herself" for the
past few weeks. Her neurological exam shows the patient to have
a
depressed affect, monotonic prosody, maintaining eyes closed
throughout
the interview despite being able to open them easily when asked,
slowed processing, but accurate on tests of attention such as
MOYB. Mental status, cranial nerves (with exception of
sensation)
intact. Full strength. Dysmetria on left FNF and toe-to
finger/HKS. Intact on right. Sensation exam is difficult and has
significant functional overlay as she splits the midline at
sternum and forehead to vibration. She reports decreased cold,
pin, vibration, and proprioception on right hemibody including
face. Gait shows good initiation, able to ambulate independently
with a widened stance, slightly unsteady. Unable to tandem.
Sways
on Romberg. Labwork so far is normal, although UA/UCx pending.
___ show no blood, unchanged from prior. CXR pending.
Overall the patient's symptoms are vague and she has had
multiple
similar visits in the past. Her exam is not concerning. Etiology
of symptoms were consistent with etiology of
metabolic/infectious disturbances vs mood related.
During this admission, SW consult was obtained and pt was seen
by psychiatry. Based on their recommendations, increased
bupropion SR 150 mg daily -> BID. Continued sertraline. Pt was
already known to psychiatry, and they also scheduled follow up
appointments with your therapist and with your psychiatrist.
During this admission, pt was evaluated by physical therapy, who
thought that her level of functioning was close to her baseline,
and her walking probably more limited by anxiety. She was given
a prescription for outpatient ___. | 194 | 337 |
11962176-DS-20 | 22,214,972 | Dear Ms. ___,
You were admitted to the hospital for abdominal pain, and you
were found to have an infection in your urine. You were started
on IV antibiotics, and you improved. You are being discharged
with more antibiotics that you will take by mouth as prescribed.
Best wishes for a speedy recovery,
Your ___ Medicine team | ___ year old woman s/p renal transplant in ___ on prednisone and
tacrolimus, chronic pain, CAD s/p NSTEMI ___ (no stent), hx of
recurrent UTIs, admitted with AMS, ___, and UTI.
#Pyelonephritis: AMS, abdominal pain, UA and UCx with evidence
of infection. Given UTI in context of renal translplant, pt was
treated for pyelonephritis. Empiric treatment with IV
ciprofloxacin started on admission. Urine culture grew E. Coli
resistant to ciprofloxacin, sensitive to ceftriaxone.
Antibiotics changed to IV ceftriaxone on ___. Transitioned to
PO Cefpodoxime at discharge on ___ to complete a 14day course
(___). Blood cultures all negative at time of discharge.
#Hypotension: Patient developed hypotension while in the
hospital with blood pressures in ___. DDx included
hypovolemia, adrenal insufficiency, worsening infection.
Inappropriately low/normal AM cortisol (3.9) and lack of
improvement with fluids on HOD#3 suggested adrenal insufficiency
more likely. Pt started on stress dose hydrocortisone on HOD#4
(___) with good improvement in BP. Pt was given a 30mg PO dose
of prednisone prior to discharge to finish stress dose course.
Discharging to home on home-dose prednisone (5mg QD)
# ___ on CKD: Cre 2.1 on admission, from baseline 1.3-1.5. This
was likely pre-renal in the setting of infection and poor PO
intake. Improved with fluids/abx. Cre back to baseline at 1.5
(___) and 1.4 (___) at discharge.
# Hypoxia: Patient was started on 2L NC on admission. CXR
unremarkable. Lung exam overall unremarkable. Patient was weaned
off O2 and discharged to home on room air.
CHRONIC ISSUES:
# s/p renal transplant in ___: Patent renal vasculature on
ultrasound. Patient was continued on her home medications.
Tacrolimus was held for a dose, but restarted prior to
discharge. Home dose prednisone and acyclovir were continued.
Her home fluconazole was stopped and NOT restarted at discharge
per renal transplant team recs.
# CAD: s/p NSTEMI ___ (no stent): Patient was continued on
home aspirin and statin. Her home metoprolol was fractionated to
tartrate 25mg PO q6h and then dose reduced to 12.5mg PO Q6H due
to hypotension during admission. Prior to discharge she was
restarted an Toprol XL at half of her home dose (50mg PO QD).
# Hypothyroidism: Patient was continued on home levothyroxine.
# Diabetes: last A1c 6.2 ___. No issues during admission.
Diet-controlled.
# Chronic pain: on oxycodone 5 mg q6H PRN at home. This was
continued during admission and at discharge.
# Anxiety: on clonazepam PRN at home
# GERD: Continued home omeprazole
# bone health: Continued home calcitriol | 55 | 427 |
10250672-DS-23 | 21,069,238 | You were admitted with fever. We didn't find any signs of
bacterial infection so this was likely due to a virus or due to
significant immune stimulation by the trial drugs you are
getting for your cancer (these work by stimulating the immune
system, so that would make sense).
If you have any more fevers or new symptoms please let your
oncologist know right away. | ___ Pt w/ stage III gastric cancer, s/p total gastrectomy,
partial esophagectomy, and distal pancreatectomy ___,
progressed on ECX, currently in disease regression on
investigational immunotherapy who p/w fevers x 3 days as high as
103.7F w/o any localizing symptoms.
# High Grade Fevers - no documented fever in ED or during
hospital course, however presentation concerning given degree of
reported fever, though pt felt like his "normal self" other than
night sweats. Complete ROS was unrevealing for localizing
process and physical exam only notable for some mild thrush on
the tongue. he was not neutropenic, and remained hemodynamically
stable. CXR and urine culture unrevealing. presented w/ a mild
leukocytosis to 13 but this downtrended. While he was given
antibiotics in the ED (vanc/cefepime/azithro), these were not
continued at all on the floor. His port was without erythema or
pain or drainage. He had no nasal congestion or rhinorrhea or
sore throat or cough, nothing to suggest respiratory infection.
While his alk phos was found to be newly mildly elevated at 136,
all other liver function tests were WNL and reassuring and he
had no RUQ pain.
RUQ ultrasound for completeness showed.....
He had no diarrhea or dysuria.
He has no implanted hardware. While he was at the ___ for a
wedding a few weeks ago he never noted a tick bite or rash and
has no other symptoms that would be consistent with Lyme
disease. He had no leukopenia or signs of hemolysis or worsening
anemia or significant LFT abnormalities which might suggest
other tickborne illness. While his inflammatory markers were
quite elevated which would ordinarily be suggestive for
bacterial infection, in his case he is receiving two
immunostimulators as an outpatient and ultimately it was felt
that the fever as well as the elevated inflammatory markers were
consistent with significant immune response due to these
immunomodulators. Ultimately fevers attributed to self-resolving
viral process versus inflammatory response from
immunostimulating drugs (on clinical trial), as there was no
evidence of bacterial infection. While I did urge him to remain
in the hospital until we had at least 48 hours of negative
culture data, his strong preference was to be able to go home on
___ rather than wait until Am of ___ so he left the hospital
with very close to 48 hrs of culture data and understand that
there are risks that antibiotics in the ED masked an infection,
however his physical exam, labs, and clinical picture has been
so benign other than fever it was reasonable to discharge him.
He knows to call if he has any new symptoms or recurrence of
fever.
# OP thrush - nystatin suspension was very effective. Denies
odynophagia/dysphagia and had normal EGD on ___ (note the
indication was dysphagia, but pt denies having had dysphagia)
# Gastric Ca - Followed by Dr ___ Dr ___ currently
on trial drug (2 immunostimulants, last gioven ___.
Reassuringly disease per recent CT torso ___ notes decreasing
adenopathy and it was felt he is having good response to trial
drugs. He has f/u ___ for next infusion.
# Chronic malignancy related pain - continued home regimen with
good control on oxycontin and oxycodone prn
# Mildly elevated alk phos - mild elevation but new. GGT had
been sent on admission and was also mildly elevated. Recent abd
CT with very small liver lesion, could be ___ metastatic
disease, RUQ u/s was reassuring and nothing to suggest
obstruction or cholangitis at this point. other liver function
tests reassuring. Outpt oncologist to trend LFTs this week.
# Anemia - likely chemotherapy induced, no evidence of bleeding.
In ___ ferritin was only in 30 range, but was upt o 129 at
this point likely consistent with immune response from
immunostimulation therapy. Smear reassuring, low tbili argued
against any hemolysis, and Hct remained stable. Likely anemia of
inflammatory block.
Greater than 30 minutes were spent in planning and execution of
this discharge. | 64 | 642 |
14392547-DS-21 | 20,645,067 | Dear Mr. ___,
You were admitted because your INR was elevated and you had
bleeding from your pacer replacement site.
WHY WAS I ADMITTED?
You were admitted because your INR was elevated and you had
bleeding that would not stop from your pacer site.
WHAT WAS DONE WHILE I WAS HERE?
We monitored your INR and put bandages on your wound. We also
had the electrophysiologists see you to make sure that you did
not have to have your pacer replaced.
WHAT SHOULD I DO NOW?
-Please take your medications as instructed
-Please your doctor know if your pacer site starts to bleed or
if you develop fevers or increased pain at the pacer site
-Please have your INR checked on ___ and fax to your
outpatient ___ clinic.
-Please continue to have your INR checked regularly.
We wish you the best!
-Your ___ Care Team | ___ s/p MVR in ___ and pacemaker generator change ___ who
presented with bleeding at pacemaker pocket site.
#Pacer pocket bleeding
#Supratherapeutic INR: Patient presented with bleeding after ICD
generator changed on ___, found to have INR 6.3. INR likely
elevated ___ warfarin interaction with cephalexin and fact that
pt's dose of warfarin was increased
rather than decreased after starting post procedural abx (due to
dosing miscommunication/misunderstanding). INR ___ at 4.9 and
3.1 on ___. Was not reversed with vitamin K as INR continued to
downtrend and bleeding was controlled. The electrophysiologists
saw the patient and did not think any intervention needed to be
made. Once the patient's INR was at goal (2.5-3.5), his warfarin
was restarted on ___ at 10 mg, resuming his prior regimen of 10
mg 6x per week (Mo, ___, Th, Fr Sa, ___ and 12.5 mg 1x/week
(___) - with planned INR check on ___ and adjustment
PRN.
#s/p MVR:
Patient with prosthetic mitral valve replacement ___ years ago.
We targeted the goal INR to be 2.5 - 3.5 as above.
#AFib with complete heart block, s/p PPM: PPM functioning
appropriately. We continued his metoprolol.
#Pacing-induced CMP s/p ICD: The patient appeared euvolemic on
exam. We continued his digoxin, lisinopril, and metoprolol. | 136 | 198 |
12977644-DS-25 | 29,853,514 | You presented to the hospital after a fall. Because of your
fall, you had several CT scans in the emergency room. These
showed a new vertebral compression fracture (for which you were
seen by the spine doctors) as well as overall progression of
your cancer. You had a chest tube placed for increasing fluid in
your lung, which was later removed. You also met with the
oncologists and the palliative care team and ultimately decided
to go home with home hospice. | ___ y/o F with PHMx of macular degeneration, cataracts, as well
as metastatic colon cancer (treatment currently on hold in the
setting of recent hip fracture), who presented following a
mechanical fall at home. Course notable for large R pleural
effusion now s/p R chest tube, with an ultimate transition to
comfort-focused care and discharge to hospice.
#Metastatic colon cancer
#Pleural effusion.
Imaging on presentation showing progression of disease. The
patient currently remains off of treatment given recent hip
fracture and poor functional status. After discussion with IP,
chest tube was placed for drainage given concern for longterm
complications of untreated pleural effusion (i.e. trapped lung).
Chest tube has since been removed and patient expresses strongly
that she would not consider replacement given the pain she
experienced and lack of improvement in symptoms. During family
meeting on ___ it was discussed with the patient and her sons,
___ and ___, that she is not currently a candidate for any
further cancer therapy and the possibility of hospice was
discussed. The patient expressed interest in a plan that
focusedon comfort and reduced unpleasant treatments and
procedures. ___ patient decided to be DNR/DNI. On ___, she was
discharged home on hospice.
#E. coli UTI
Patient was treated for a urinary tract infection with
ciprofloxacin from___.
#Fall.
Neurosurgery evaluated her -- no interventions. | 81 | 211 |
11593763-DS-14 | 25,999,898 | Mr. ___,
It was a pleasure taking part in your care. You were admitted to
___ for weakness. During your stay, we limited medications
which could make you weak (oxycodone). You had a blood culture
that grew bacteria as well as a urine culture that grew the same
bacteria. You were started on an antibiotic which will need to
be continued for 2 weeks and administered intravenously, so you
had a PICC line placed. You had an echocardiogram as well to
rule out endocarditis, which was negative.
You worked with physical therapy and did well. They recommended
that you be discharged home with physical therapy at home.
Other than the antibiotic, we have not made any changes to your
medications. | ___ man with Hep C cirrhosis c/b encephalopathy, varices,
ascites undergoing transplant evaluation, presenting with
difficulty with balance and falls, found to have enterococcal
bacteremia and urinary tract infection.
ACTIVE ISSUES
# Falls/weakness: More consistent with difficulty with balance
rather than weakness based on exam. Patient worked with ___ and
did very well, was recommended for home with home ___. He felt
symptomatically better from his strength standpoint and looks
well per his family compared to how he was at home. Oxycodone is
likely contributing at home. Concern that enterococcal
bacteremia and UTI could be a contributor as well, though
unclear; see below.
# Bacteremia: Grew enterococcus in blood and urine; initially
thought to be contaminant when present in blood but more
confirmation for real pathogen given the bacteriuria. Started
on daptomycin given VRE for planned 2 week course. Other than
the falls, he had no clinical signs of infection, with no
fevers, or symptoms, but did have leukopenia. TTE was negative
for endocarditis. PICC was placed and antibiotics should be
continued through ___.
CHRONIC ISSUES
# GIB/VARICES: Bleeding from hyperplastic polyps last admission.
Known varices, no bleeding on last EGD. Hct stable with no
signs of frank bleeding during this admission.
# Hep C Cirrhosis: c/b frequent encephalopathy, varices,
ascites, known PVT and SVT, undergoing transplant eval. Waxing
and waning confusion and this is his home baseline. Paracentesis
shows no evidence for SBP. Continued furosemide,
spironolactone, nadolol.
# HEPATIC ENCEPHALOPATHY: Frequent encephalopathy in past,
including waxing/waning mental status at last hospitalization.
Mental status was clear and at his baseline, though with
cognitive slowing as previously. This could very well be
contributing to his falls. High likelihood of oxycodone
contributing. Continued lactulose 30mL po q6h titrated to 4BMs
per day, rifaximin 550 BID.
# ASCITES: Continued lasix, spironolactone.
# PVT & SMV Thrombi: Anticoagulated with warfarin prior to
previous admission but holding due to acute bleeding.
# Splenorenal shunt: Had been planned for embolization by ___
after endoscopy. However, put on hold at this time due to the
recent acute GIB.
# Restrictive lung disease: Discovered at last admission,
paradoxically reversible with bronchodilators. Continued
tiotropium. Pulm follow up scheduled as outpatient.
- Pulm outpatient f/u
# Coronary artery disease: reversible defect in LCx territory on
perfusion study from ___. Per outpatient cardiology at ___,
LHC is not indicated and this can be managed medically. Upon
talking with inpatient consult, concerns were raised regarding
whether LHC would be safe or indicated, given intervention
should there be findings would be complicated in setting of
thrombocytopenia and bleeding. Plan to discuss as outpt.
TRANSITIONAL ISSUES
-Blood cultures from ___ pending at time of discharge | 120 | 448 |
18978687-DS-21 | 21,640,782 | Ms. ___,
You were admitted to ___ for fluid collections and concern of
infection in your abdomen. While you were here you were given IV
antibiotics and were monitored closely. It appears your
infection has improved.
Personal Care:
1. Please make sure your dressings are changed twice a day, with
packing and gauze. Keep Dressings clean.
2. You may shower daily 48 hours. No baths until instructed to
do so by Dr. ___.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 20 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. Please take your prescribed antibiotic medications in its
entirety.
3. You may take Tylenol or ibuprofen for pain controll
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 wound.
2. A large amount of drainage or malodor
3. Fever greater than 101.5 degrees.
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. | The patient was admitted to the plastic surgery service on
___ for observation and treatment of abdominal wall
abscesses. On hospital day #2, patient was debrided at bedside
and abdominal fluid pockets were drained and cultured and packed
with packing tape.
.
Neuro: The patient received pain medication as needed with good
effect and adequate pain control.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient tolerated a regular diet. She was also
started on a bowel regimen to encourage bowel movement. Intake
and output were closely monitored.
.
ID: The patient was started on Vanc, cipro, flagyl. The wound
culture was growing pan sensitive Staph A. Coag positive. She
was discharged home on cefadroxil PO.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on hospital day #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. Abdominal incision open area was clean
with packing in place. | 278 | 212 |
14357970-DS-19 | 23,185,608 | - 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:
- NWB RUE in coaptation and cock-up wrist splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add *** as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per ___ regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take <<<<<>>>> 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.
Physical Therapy:
NWB RUE in coaptation splint
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right distal third humerus fracture that was initially
suspected to be open and with concomitant radial nerve injury
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for I&D of superficial
laceration and closed reduction of with coaptation and cock-up
wrist splint placement under anesthesia, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the right upper extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up in Ortho
Trauma clinc per 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.
She was followed by the ___ diabetes management service while
she was in the hospital. They uptitrated her diabetes regimen
and recommended continued close monitoring as an outpatient with
her PCP. Additionally, the patient was started on Norvasc during
her hospital stay for continued poor blood pressure control,
which should be monitored as an outpatient. A conversation was
had with the HCP regarding continuing to closely monitor BP and
blood glucoses upon discharge with the patient's PCP. The HCP
stated she would attempt to secure a PCP appointment within one
week. | 475 | 374 |
10999333-DS-11 | 27,249,872 | Dear ___,
___ was a pleasure taking care of you during your stay at ___.
You were admitted for shortness of breath and cough. You were
found to be in congestive heart failure with fluid overload,
prompting diuresis with IV medication. Further work-up of your
heart did not show any ischemia, or poor blood flow. After this
IV diuresis, your weight came down, you appeared less fluid
overloaded, and your breathing improved. You will be discharged
on a new diuretic, torsemide, at a dose of 40mg to take once a
day.
On admission your INR was found to be very high, prompting IV
vitamin K which reversed the anti-coagulation. This caused your
INR to drop too much, and to protect you from stroke, you were
started on IV heparin until your INR was back to the target
range. The target range was met and the heparin was stopped.
You were discharged home on new medications to help keep fluid
off and to help your heart pump as well as it can.
During your stay, you were found to have a small ulcer on your
left buttock that was evaluated by the wound specialists.
You also developed a rash in the skin fold of your right groin
thought to be fungal in nature that was treated with an
anti-fungal cream. You should continue applying this cream for 2
weeks.
Wishing you well,
Your ___ Cardiology Team
Weigh yourself every day, if weight goes up by 3 pounds or more,
notify your M.D. | This is a ___ with a history of CAD s/p bypass and afib on
coumadin, HTN, GERD who presents from ___ with concern
for pnuemonia and elevated troponin i to 0.41. Based on physical
exam, repeat imaging, and labwork, thought more likely to
becongestive heart failure. Posterior wall motion abnormalities
seen on ECHO on repeat read. T P-mibi ruled out ischemia,
troponin leak more likely demand. Diuresed while in house with
total net -4.5L.
# CHF exacerbation: Patient was making good UOP on lasix 20 IV
BID, switched to torsemide 20 qd, not as net negative as would
have hoped, and then transitioned to 40 qd, which she will
continue upon d/c.
# Troponinemia: Troponin I elevated 0.41 with troponin-t here
0.09 -> 0.10 -> .12. CK-MB flat. ___ be a component of renal
failure versus demand from heart failure. Afib rate controlled
and no recent episode of RVR. P-mibi negative, likely
demand-related.
# UTI: UA from ___ revealed 94 WBCs and few bacteria. Patient
was started on 3-day course of ciprofloxacin (last day = ___.
# Anemia, macrocytic: Slowly downtrending and fluctuating daily.
VSS throughout. Most recent H/H in ___ system from ___
was 9.1/27.3. Concern for UGIB based on heartburn hx. Guiaic
exam positive ___ (trace). H/H has fluctuated but has been
overall stable with otherwise stable VS. Hemolysis and iron def
labs negative, b12 above target range.
# INR: Admitted with INR 8. Became sub-therapeutic after vitamin
k on admission. Restarted warfarin at 3 mg, went up to 4 mg on
___, back down to 3 mg daily on ___ for rapid rise in INR. Was
bridged on heparin (CHADS score of 5) but now therapeutic;
discharged on 3 mg qd.
# Hypertension: Compliance in general is unclear. Patient with
CHF will benefit from afterload reduction. Started coreg 12.5 mg
BID, increased amlodipine to 10 mg daily, added captopril,
switched to lisinopril 20.
# ___: Most recent Cr of 1.1 in ___, admitted at 1.4,
trended down to 1.0 ___ ___, but as of ___ AM was 1.3.
Initially improved after diuresis at admission, but bump in Cr
at end of hospitalization possibly due to slight overdiuresis.
___ to draw Cr later in week.
# Buttock ulcer: ___ pt noted to have small ulcer left sacram
above buttock. 1-2 cm, no erythema, pus, or significant
tenderness. Seen and evaluated by wound care nurse.
# Intertrigo: ___ patient developed rash in right groin,
painful to touch. Red, with satellite markings in skin fold of
right groin. Provided clotrimazole cream.
CHRONIC ISSUES
# Atrial fibrillation: CHADS-2 of 5. On coreg and coumadin.
Currently rate controlled, anticoagulated appropriately.
# Depression: stable however patient endorses decreased
appetite. Continued sertraline, half home dose ativan prn
# Neuropathy: stable, given tylenol and oxycodone 2.5mg prn,
restarted home dose gabapentin but changed to BID per pharmacy
# GERD: home omeprazole, added simethicone for belching | 243 | 473 |
17562503-DS-11 | 24,235,468 | Dear Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You came into
the hospital because of right foot pain and high fevers and very
poor blood supply to your foot (peripheral artery disease) that
is likely related to your long history of smoking. One of the
arteries that supplies blood to your right leg was entirely
blocked. You were started on a medication (Lovenox) to thin your
blood and prevent new blockages from forming.
You also had a very high fever, which was determined to be
likely due to a virus infection. We also determined through
special bone scans that you did not have an infection in the
bones of your foot (called osteomyelitis).
*** You should have blood cultures drawn at ___ when you
have your cardiology visit at ___ on ___. You will be
provide with provided with lab requisition slip at discharge.,
please bring it with you to ___ on that day.
*** It is also important that you do NOT take any antibiotics.
If you have a fever (higher than 100.3) at home, please call Dr.
___ in the ___ Disease department at ___ to
have blood cultures drawn. ***
You were evaluated by vascular surgery who recommended that you
should have a surgical intervention in the future. Dr. ___
will plan to perform your surgery at an upcoming date. He will
discuss this with you at the appointment below. If you have any
issues/questions, you can call his office at ___. You
will have a home visiting nurse to assist you with your medical
needs prior to surgery and assess the need for other home
services.
You will be sent home on blood thinning medications called
lovenox (enoxaparin) which you will inject twice a day. Please
do not take this medication the night before your operation or
the morning of.
Please take your medications as directed below and follow up
with your primary care physician as below. If you experience any
of the warning signs listed below, have a recurrence of the
symptoms that brought you to the hospital, or have any other
concerns below, please seek medical attention.
Be well and take care.
Sincerely,
Your ___ Care Team | PATIENT
Mrs ___ is a ___ year old female with history of HFrEF (EF
25%, s/p ICD), pAF, PVD s/p L AKA, IDDM, HTN, HLD who presented
with right foot pain and redness
ACUTE ISSUES
# Fevers Without Source: Mrs ___ developed high fevers while
hospitalized. Patient was started empirically on cefepime,
vancomycin and metronidazole and the infectious disease service
was consulted. Infectious studies did not identify a source of
infection. Antibiotics were stopped and patient remained
afebrile for greater than 72 hours between cessation and
discharge. Osteomyelitis of the right foot was ruled out with
nuclear bone scans. Bone scan identified a region of uptake in
the lumbar spine but on correlation with previous CT imaging
appeared to be related to degenerative changes. On
recommendations of infectious disease consulting team, patient
was advised to have surveillance blood cultures taken at
follow-up visit one week post-discharge and to return to
hospital if any fever developed.
# PAD/Right SFA occlusion: Mrs ___ was admitted to the
vascular service with right leg redness and pain. Angiography of
the leg revealed an acute occlusion of the superficial femoral
artery. Patient started on a heparin drip and quickly reached a
therapeutic level. After patient was transferred to medicine
service, anticoagulation was changed to enoxaparin and aspirin.
Recannulation was deferred during this hospitalization for a
point later in time per vascular surgery recommendations.
Procedure was not scheduled at time of discharge, but as it was
anticipated to be around two weeks after discharge, patient was
continued on enoxaparin instead of warfarin. Teaching of
enoxaparin injection technique were provided to patient and
family prior to discharge. Aspirin continued through discharge.
CHRONIC ISSUES
# DM2: Patient placed on insulin sliding scale while inpatient.
Resumed home insulin schedule at discharge.
# LV thrombus: Was not an active issue while hospitalized
# CAD: Continued aspirin and statin
# HFrEF: EF 25%, AICD in place. Appears euvolemic on exam.
- Continue home beta blocker, losartan, lasix, and
spironolactone
# COPD: Continue home fluticasone-salmeterol, Daliresp
(roflumilast), albuterol inhaler PRN.
# HTN: Continued home carvedilol and losartan.
# History of breast cancer- Continued home anastrozole
# Depression- Continued home citalopram
# GERD- Continued home omeprazole
# Dementia - Continued home memantidine
TRANSITIONAL ISSUES
# Patient provided with sufficient oxycodone and lovenox to last
through her vascular surgery follow-up appointment. Please
reassess need for these medications at this time and prescribe
as needed based on date of upcoming vascular procedure.
# Patient should have blood cultures drawn at ___ labs when
she has her cardiology visit on ___. Patient provided with
lab requisition slip at discharge.
# If patient develops any fever: she should contact the
infectious disease clinic at ___. NO ANTIBIOTICS
should be prescribed to patient unless she has had blood
cultures already drawn.
# Patient will have a revascularization performed by vascular
surgery. Date of procedure is not yet scheduled, but vascular
surgery will contact patient with pertinent details.
# Anticoagulation: Patient will continue taking lovenox
injections twice a day until the night prior to surgery.
# Nuclear Bone Scan demonstrated a focus of increased uptake in
the right lumbar spine is present, but no suspicious lesions
were identified on the CTA in ___. On review of recent CT
films, thought most likely due to degenerative changes. Patient
did not have any signs or symptoms to suggest lumbar pathology.
Please consider in the future should patient develop back /
neurologic symptoms.
# Heart Failure with Reduced Ejection Fraction (EF 25%):
Consider transitioning from ___ to ACEi if not contraindicated
given lack of data for ___.
# Previous CTA imaging showed non specific wall thickening and
edema in the cecum with mild adjacent stranding. Patient did not
have abdominal pain to suggest colitis. Recommend colonoscopy
and regular age appropriate cancer screening as outpatient.
# DM2- A1c 7.3%. Patient followed closely by ___, recommended
lantus 16U qhs, glipizide 10mg BID. Patient will follow up with
___ as outpatient.
# Code Status: Full
# Emergency Contact: ___: ___, ___:
___ | 366 | 648 |
13140413-DS-11 | 21,917,966 | Dear Mr ___,
You came to ___ for chest pain, fatigue, and concerns for
heart problems following an overdose and resulting episode of
pneumonia. Please see more details listed below about what
happened while you were in the hospital and your instructions
for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- An EKG, a test for the electrical activity of the heart, was
conducted when you arrived in the emergency room that showed
changes consistent with significant strain on your heart.
- An xray of your chest revealed an infection (pneumonia) in the
upper aspect of your right lung.
- We also performed a CAT scan of your head to make sure there
was no bleeding and incidentally discovered a small area in your
brain that may have diminished blood flow. However, this may be
an artifact of the imaging. A better imaging technique (MRI) is
suggested at a future date. While here you exhibited no clinical
signs that were concerning for bleeding or stroke.
- You were started on IV antibiotics to treat the pneumonia and
transitioned to an oral antibiotic which you completed with no
signs of resistance and improvement of symptoms.
- During your stay at one of the outside hospitals and repeated
here, an ultrasound of your heart was done and some issues were
found:
1. Flow through one of the main valves of your heart (aortic
valve) is restricted due to, likely, an unusual structure to
this valve. Instead of three leaves, your aortic valve has two
leaves. This causes some restriction of flow from the heart and
the murmur you to which you are aware.
2. The right side of your heart was not pumping as well as it
should. The repeated ultrasound of your heart revealed that this
has resolved. Your heart is pumping as it should.
- While staying with us, we were able to get you back into the
___ clinic of your choice and we initiated your treatment.
We discharged you on 40mg methadone daily given some concerns
for a lower heart rate. Given concerns for your heart health
care should be exercised as you re-start your treatment.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please check in to the ___ clinic (Habit OP___
on ___ at 10:00am for your intake appointment.
- Please follow up your primary care provider who will be
provided with all of the information regarding this admission.
- Consider discussing cardiac rehab with your primary care
provider (information was provided to you by our social worker).
- Stop all alcohol use and illicit drug use.
- Continue smoking cessation. | ___ year old man with past medical history of polysubstance abuse
(inc. IVDU), hepatitis C, bipolar disorder, GAD, and ADHD was
brought to ___ on ___ for overdose (heroin/cocaine) was
intubated with hypotension, TTE revealed AS and right heart
hypokinesia, and aspiration pneumonia. He was extubated and left
AMA on ___. He then went to ___ on ___ they found
elevated trops with a peak of 0.32, new t wave inversions, ___
Cr 3, and elevated LFTs ALT>AST. While he was waiting for
transport to BID Cardiology he left AMA on ___. He self
presented here at BID for further workup of cardiac concerns.
In the ED, he was complaining of pleuritic chest pain and
concerns of his heart health following this recent overdose. EKG
showed t wave flattening and mild t wave inversion in the
precordial inferior leads. He was afebrile, vitals were stable,
and troponins were down-trending (0.13->0.11). Non-contrast head
CT revealed no bleed but was notable for an incidental finding
of a small, hypodense regnio with the left globus pallidus which
may represent chronic microvascular ischemic changes but is
indeteriminant in nature; an out patient head MRI without
contrast is recommended. He was started on vancomycin and
cefepime empirically, blood cultures x3 were drawn, and ASA &
statin were started.
During his stay on the medicine floor, antibiotic therapy was
transitioned to oral levaquin and he was monitored for worsening
respiratory status and fever. He improved on therapy despite
lack of culture data (no sputum). A repeat TTE showed improved
cardiac function and a bicuspid aortic valve.
Our social worker was able to get him accept back to the
___ clinic in ___ with an intake appointment setup on
___ at 10:00am and a doctor's appointment on
___ at 7:45am. In consultation with this clinic
and our Psychiatry consult service, we restarted his methadone
treatment starting at 20mg and increasing the dose by ___ per
day as need. By discharge, he was on 40mg of methadone (last
dose prior this admission per ___ clinic was 95mg on
___. Last EKG QTc 419.
Mr. ___ medication for GAD, alprazolam 1mg daily, was
restarted while inpatient. But his Adderall prescription was
reduced to 15mg bid given concerns for cardiac strain. | 453 | 369 |
16331021-DS-5 | 25,433,972 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- Your heart rate was found to be fast and irregular.
- There was concern for your ability to manage you medications
and care for yourself at home due to your memory decline.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your heart rate was controlled with a new medication called
Diltiazem and you were started on a blood thinner called Eliquis
to reduce your risk of stroke.
- We found you a place to live where you can live as
independently as possible while still having assistance with
your medications.
- You had an episode of knee and ankle pain that responded to
Tylenol and naproxen (Aleve), and an episode of arm swelling
when one of your IVs was removed.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You should apply hot packs to your right arm to reduce the
swelling and use Tylenol for the pain if you need it.
We wish you the best!
Sincerely,
Your ___ | PATIENT SUMMARY
===============
___ with pAF, HTN, HLD, cognitive decline admitted after concern
for inability to care for self in setting of severe short term
memory loss of unclear etiology, although workup so far has been
negative for a reversible cause. He was changed from his home
HTN medications to diltiazem for BP and rate control of his
Afib, and was started on Eliquis for anticoagulation. His sister
___ was affirmed as HCP along with financial POA, and they
both agreed that he would need more care in the future, patient
was discharged to ___.
ACUTE ISSUES
============
# Dementia
Patient recently hospitalized ___ for cognitive
decline/confusion where ___ revealed age-related global
involutional changes and mild sequellae of small vessel ischemic
disease, utox negative, BMP unremarkable, TSH 1.1 and B12
normal. HIV negative in ___. Denies significant drinking
history (~1 glass of wine a night) or drug use besides decades
ago. Psychiatry and Occupational Therapy both evaluated him with
concern for his ability to live alone due to memory deficits and
inability to manage medications / other ADLs. Sister ___ was
affirmed as HCP for placement. Patient was continued on home
donepezil ramelteon, and thiamine.
#Right arm swelling
Recently started on eliquis for anticoagulation, only with mild
pain and no systemic signs of infection or neurovascular
compromise. Likely superficial thrombophelibitis with no role
for antibiotics. Continue hot packs and Tylenol for
pain/swelling, which should be expected to resolve in several
days.
# Paroxysmal AF
CHADSVASC 2. Last hospitalization, in discussion with sister
___ and cardiologist Dr. ___ warfarin due to
patient's risk for inappropriate warfarin management in setting
of confusion. With current plan for memory care/assisted living,
patient was started on Eliquis. Rate is well controlled on
Diltiazem 120MG BID.
# Prolonged QTc
Avoid QTc prolonging agents like anti-psychotics
CHRONIC/RESOLVED ISSUES
=======================
#Left knee and right ankle pain
Warm and erythematous, possible gout falir, although patient and
sister don't know of a history of gout. Xrays of bilateral knees
were negative, pain/swelling resolved with NSAID use, continue
ibuprofen/Tylenol PRN.
# Hypertension
Patient normotensive on admission with SBPs 100s-120s in ED, up
to SBP 150s on the floor. Discontinued home antihypertensives in
the setting of starting diltiazem for Afib, with both HR and BPs
well controlled on current regimen.
# Hyperlipidemia
- Changed home simvastatin to 10 mg PO QPM iso starting
diltiazem
- Continued ASA 81 MG for primary prevention
TRANSITIONAL ISSUES
===================
[ ] Monitor heart rates and blood pressures, consider increasing
diltiazem if both are elevated.
[ ] Had one episode of ankle swelling and pain that resolved
with NSAIDs with normal Uric acid. If it reoccurs consider
further gout workup or starting on allopurinol.
[ ] Please provide access to painting / art materials, patient
is an ___ and this is very important to his emotional and
mental well being.
CODE: Full (presumed)
___ (daughter) Phone number: ___.
Alternate ___ ___ | 187 | 455 |
13385351-DS-26 | 25,968,778 | Dear ___,
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you fell at home.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have a large wound on your back side which
caused bacteria to get into your blood stream.
- Your wound was cleaned by the surgeons.
- You were treated with IV antibiotics, which you will
continue until ___.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Patient Summary:
=================
___ with PMH of uncontrolled IDDM2, PVD s/p bl BKA, afib on
DOAC, CKD (baseline Cr 2.5-2.9), HTN, hidradenitis suppurativa,
pressure ulcer of R buttock, recurrent UTIs, recent enterococcal
bacteremia, and multiple recent admissions s/p fall, who
re-presents again s/p fall. She was found to have klebsiella
bacteremia ___ right posterior thigh ulcer. She received
debridement and antibiotics to treat the ulcer and bacteremia.
She was discharged in stable condition to rehab. | 149 | 74 |
12964119-DS-20 | 23,358,623 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of abdominal pain and nausea. A CT of your
abdomen was obtained which showed no significant abnormalities.
You symptom most likely comes from a condition called narcotic
bowel syndrome. It is a result of escalated pain sensitivity
from chronic narcotics use. The treatment of this condition is
to gradually stop the pain medication. This is not going to be
a pleasant process, but it is the only way to cure from this
condition. Please discuss with your primary care physician
about cutting down the use of the narcotics (the fentanyl patch
and oxycodone).
Please make sure that you also follow up with your
endocrinologist since your steroids might have to be adjusted.
You should also follow up with your gynecologist for your
endometriosis. | ___ with PMHx of conversion disorder and chronic abdominal pain
presents for abdominal pain, nausea, vomiting, diarrhea.
# chronic abdominal pain/n/v/d: per records, patient with
multiple inpatient and outpatient diagnostic studies for this
including CAT scans, ultrasounds, gastric emptying studies, and
EGD/colonoscopies, which have found no clear etiology. CT scan
during this admission did not show any acute intraabdominal
process. She remained afebrile, without leukocytosis, and with
normal LFTs and lipase. Abdominal exam is soft with no evidence
of acute abdomen. Differential includes adrenal insufficiency
(although patient currently on hydrocortisone) vs.
gastroenteritis vs. depression/IBS vs. narcotic bowel syndrome
vs. endometriosis. Recent stressors include miscarriage last
month. Gastroenteritis was unlikely as patient without fevers
and her diarrhea/vomiting resolved the day prior to admission.
Most likely etiology is narcotic bowel syndrome given history of
several negative workups, chronic narcotic use, narcotic-seeking
behavior, and characteristic of the pain (moving in location).
Her narcotics was minimized - she was kept on the fentanyl
patch, but her oxycodone dose was decreased, then stopped. Her
nausea was controlled with low dose Ativan (she is allergic to
all other anti-nausea medications) and her diet was advanced to
regular as tolerated. She was kept on maintenance IVF when she
was not taking enough po. At discharge, patient was able to
tolerate a regular diet but her abdominal pain only mildly
improved. She was discharged with follow up with her primary
care physician the next day. Patient also advised to follow up
with ob/gyn for her endometriosis.
# conversion disorder: patient with recurring clinical
complaints including abdominal pain, nausea, vomiting, weakness
on lower extremities, chronic migraines. Recent stressor include
miscarriage one month ago. Also states that her ___ daughter has
a difficult time seeing her in and out of the hospital. Social
work was consulted and support was provided to the patient.
# lower extremity weakness: patient reported generalized
weakness and on physical exam, she had weakness in the lower
extremities and LUE. However, exam was inconsistent as patient
was seen walking to and from bathroom without any difficulties
or deficits.
# Adrenal insufficiency: narcotic induced. pt BP in the 100s
which is around baseline for her. Missed her recent endocrine
appointment on ___. She received a stress dose of dexamethasone
in the ED on ___. On arrival to the floor, she was kept on her
home hydrocortisone 20mg po QAM and 10mg PO QPM. AM cortisol was
checked and it was low at 1.3. She was discharged with
instruction to continue with her home dose of hydrocortisone and
with follow up with endocrinology.
# uncomplicated UTI: positive UA and suprapubic pain. She was
given Cipro for 3 days and her suprapubic pain resolved.
# Depression: denied feeling depressed or any suicidal/homicidal
ideation though seemed quite anxious about her abdominal pain
and has a flat affect. She was continued on her home alprazolam
0.5mg po TID, duloxetine 120mg daily, zolpidem 10mg po qHS.
# asthma: stable, continued with Fluticasone-Salmeterol Diskus
(250/50) 1 INH IH BID, Montelukast Sodium 10 mg PO DAILY, and
tiotropium 1cap IH daily
# Migraines: Stable. She takes oxycodone/fentanyl patch for
migraines. Given narcotic bowel syndrome, oxycodone was cut
down, but patient was continued on the fentanyl patch. She did
not complain of migraines during this hospitalization.
# narcotic abuse: patient with history of narcotic abuse with
visits to multiple ED for narcotics. Attempt was made to
minimize use of narcotics.
# anemia: Hct in the low ___ which is chronic. Folate and vit
b12 checked recently and was normal. Iron studies showing a high
ferritin and normal TIBC. Patient denied any BRBPR, hematuria,
or melena. Normal LDH and bilirubin, which makes hemolysis
unlikely. TSH was high, but free T4 was normal.
#TRANSITIONAL ISSUES
-please consider cutting down use of narcotics as this is likely
the cause of her abdominal pain
-please consider TCA for migraines, which can also treat
possible IBS
-needs follow up with ob/gyn to further investigate her history
of endometriosis
-patient cortisol level of 1.3. Please recheck cortisol level
and adjust hydrocortisone dose as appropriate. Has f/u appt with
endocrinologist.
-positive UA, patient received 3 days of Cipro | 150 | 692 |
15021356-DS-12 | 21,262,976 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital with fatigue and abdominal pain, and
it was found that your TIPS had clotted.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were transitioned to a heparin drip as a blood thinner
while you awaited a procedure.
- You underwent a procedure to remove the clot from the TIPS on
___. You were immediately started back on heparin and coumadin
after the procedure. However, you continued to have abdominal
pain, and an ultrasound showed that the TIPS had clotted again.
- You underwent a second procedure on ___. After the procedure,
you were started on Lovenox and Aspirin for anticoagulation.
Your abdominal pain was much improved, and you were ready to
leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-You will return for abdominal ultrasound about 1 week following
procedure, on ___. This will make sure that there is
good flow to/from your liver following the procedure.
-It is very important that you take your Lovenox and Aspirin as
directed each day, and that you follow-up with the hematologists
at ___, even while you see the hematology team at ___, so that
there is no lapse in your care.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY:
====================
This is a ___ year old man polycythemia ___ with JAK2
mutation complicated by portal hypertension, and dysmorphic
liver regeneration with portal hypertension resulted in
esophageal varices s/p banding ___ and TIPS placement ___ c/b
TIPS thrombosis requiring several TIPS revisions ___
and
___, presenting with 2 weeks of abdominal pain, found to
have an occluded DIPS. He was transferred to ___ for ___ guided
DIPS revision; he underwent embolectomy on ___. However, his
DIPS reoccluded (while therapeutic on Coumadin with a heparin
bridge), and he underwent second procedure ___ which was
ultimately successful on restoring hepatic flow. He was
evaluated by hematology, who recommended changing his
anticoagulation to therapeutic Lovenox with 81mg Aspirin. | 249 | 115 |
19472679-DS-19 | 26,526,989 | Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
after suffering a heart attack and also experienced an abnormal
heart rhythm called atrial fibrillation. We treated you by
opening the blockage in your stent. It is EXTREMELY important
that you take your aspirin, clopidogrel, and warfarin every day.
Do not stop these medications unless instructed by a
cardiologist. Please weigh yourself every morning, call Dr.
___ weight goes up more than 3 lbs in 1 day or 5 pounds in
3 days.
Take care, and we wish you all the best.
Sincerely,
Your CCU team at ___ | BRIEF SUMMARY STATEMENT: Mr. ___ is an ___ man with a
history of sCHF (EF 40%), CAD s/p BMS x 2 placement on ___,
hypertension, hyperlipidemia, COPD, spinal cerebellar
degeneration and osteoarthritis who presents to ___ with a
STEMI; received thrombectomy. His hospital course was
complicated by AFib with RVR, ___, transient hypotension
requiring pressors post cath, and acute delirium.
ACTIVE ISSUES
#STEMI ___ in-stent thrombosis: Patient stopped his ASA/Plavix
on ___ prior to knee surgery scheduled for ___ and
subsequently suffered a LAD in-stent thrombosis. Thrombectomy
successfully performed, procedure complicated by hypotension.
Norepinephrine was successfully weaned after extensive
discussions with the patient's son and daughter-in-law regarding
goals of care and his R femoral venous sheath was pulled.
Pressures subsequently remained soft in the 80___ but stable
and the patient was asymptomatic. Troponins trended down. He was
started on integrelin drip for 6 hours, ASA 81, clopidogrel 75
mg, and warfarin 5mg daily as triple therapy given apical
akinesis visualized on his echo and concern for risk of an LV
thrombus. His atorvastatin was increased to 80 mg.
#Atrial Fibrillation: After his cath, pt. converted to A-fib
with RVR and was started on amiodarone. He underwent successful
cardioversion with return to normal sinus rhythm. Given the
patient's soft blood pressures, metoprolol was held. At time of
discharge, pt. was sent home on amiodarone and warfarin (held at
time of discharge for supratherapeutic INR, should resume when
INR returns to therapeutic range).
#Hypotension: Patient was hypotensive during his cath on
___. He has had previous problems with orthostasis and at
his last hospitalization, his beta blocker and ACE inhibitor
were held. He was started on norepinephrine and briefly trialed
on dopamine but experienced recurrent chest pain and
tachycardia. Norepinephrine was ultimately weaned per above.
#sCHF: Patient's last EF recorded at 40%. TTE showed mild
symmetric left ventricular hypertrophy with regional
biventricular systolic dysfunction most c/w CAD (mid-LAD
distribution) with severe hypokinesis of the distal ___ of
the anterior septum/anterior wall, dyskinetic apex, with mild
hypokinesis of remaining walls. Mild-moderate mitral
regurgitation. Mild aortic regurgitation. LVEF: ___. Patient
was initially volume overloaded and was diuresed with lasix
boluses and a lasix drip. He was tapered to an oral regimen of
lasix 20mg PO Daily prior to discharge and placed on lisinopril
2.5mg PO Daily.
#Acute kidney injury: Patient experienced a Cr bump from 0.8 to
1.8; likely from cardiorenal syndrome and prior vasopressor use.
Cr was trended daily and gradually improved as patient's volume
status was optimized. Pt. should have follow-up labs as
outpatient to monitor for return of normal kidney function.
#Acute on Chronic Altered Mental status: Per pt's son, pt does
have some baseline cognitive deficit, however patient is
reportedly improved since his stent placement. Never received
the suggested outpatient cognitive workup recommended after his
last hospital stay. During this hospital stay, the patient
occasionally became delirious; he pulled out his PICC line twice
and sometimes refused medications, labs, and vitals. Efforts
were made to ensure a proper sleep/wake cycle and reorient.
Seroquel, olanzapine, and haldol were also trialed, none were
continued at time of discharge.
#Goals of care: several discussions were held with the patient's
family regarding goals of care. The decision was made to make
the patient DNR/DNI although he he was cardioverted during his
stay. Palliative care was also consulted. At time of discharge,
Palliative care team has been in touch with the children of Mr.
___. His family is going to discuss palliative care options
and possible transition to hospice once at the rehab facility
with the rehab facility team.
CHRONIC ISSUES
# COPD - continued advair, albuterol, tiotropium prn
# GERD - continued omeprazole
TRANSITIONAL ISSUES
# Heart Failure Management: Consider beta blocker if pressures
improve and digoxin if deemed appropriate. Also, consider
uptitration of lisinopril as tolerated. Pt. was discharged on a
regimen of lasix 20mg PO Daily (previous home dose 40mg Daily,
held for low BPs). Discharge standing weight 73.7 kg. If sign
of increasing weight, would resume lasix 40mg PO Daily.
# Anti-Plt Therapy: Pt. should remain on aspirin and plavix
indefinitely.
# Code Status: Palliative care consult team very involved.
Confirmed DNR/DNI. ___ transition to hospice/comfort care in
the near future.
# ___: Pt. with ___ on admission, baseline Cr 0.9-1.1. Needs
repeat lytes to ensure resolution of ___.
# Anticoagulation: Pt. needs repeat INR on ___, restart
warfarin if INR < 3.0, INR aon day of discharge is 3.6.
# Baseline Blood Pressures: FYI, at time of discharge, pt.
asymptomatic with systolic BPs consistently in the ___. | 101 | 769 |
13507926-DS-29 | 21,947,652 | Dear Ms. ___,
It was a pleasure to take care of you during your
hospitalization. You were admitted on ___ from ___
after concern for not receiving enough tube feeds. During your
stay, you have received continuous tube feeds and were
ultimately changed to a regular diet with a plan in place for
tube feeds overnight. You have remained medically stable during
this stay and are now being discharged to an inpatient
psychiatric unit for further care. | ___ F with history of eating d/o NOS, depression, and suicidality
who presents from ___ after concerns for inducing
vomiting and/or removing tube feeds using a syringe. | 76 | 27 |
10048244-DS-11 | 21,843,889 | Dear Mr. ___,
Why were you admitted?
You were admitted to ___ because your kidney function was
slightly worse. We were concerned that this might have been
because of your immunosuppressant medications so we stopped your
Everolimus and decreased your Tacrolimus to 2.5 mg twice daily.
We also started Prednisone 7.5 mg daily.
What changes did we make?
We changed your immunosuppressant medications to: Decreased
Tacrolimus to 2.5 mg twice daily and we also started Prednisone
7.5 mg daily. We stopped your Everolimus.
What do you need to do when you leave?
-Please follow up with your PCP, your kidney specialist Dr.
___ your liver doctor Dr. ___ below)
We wish you all the best.
Sincerely,
Your care team at ___ | Mr. ___ is a ___ year old man with history of HCV cirrhosis
complicated by ___ s/p liver transplant ___, course c/b
mild acute rejection ___ and recurrent HCV now s/p cure, CVA
in ___ with residual right sided weakness, and newly diagnosed
focal sclerosing glomerulonephritis, presenting with worsening
renal function and chills with concern for worsening FSGS, now
with slightly improving renal function after stopping everolimus
and decreasing the dose of tacrolimus.
___ on CKD, Focal segmental glumerosclerosis: Patient
presenting with proteinuria and creatinine 3.2 above baseline
low 2s, and discharge Cr of 2.5 (___). Given recent FSGS
diagnosis, concerned for worsening disease, as it may be rapidly
progressive in some people. Although his biopsy does not
comment, suspect FSGS is secondary type and may be secondary to
HCV. Patient denied decreased po intake and denies infectious
symptoms. Renal ultrasound showing no hydronephrosis and stable
left perinephric hematoma. Urine prot/cr worsening (6.5 from
3.8). Renal was consulted who felt that the acute worsening of
his renal function could likely be attributed to his
immunosuppressants so they recommended minimizing Everolimus and
Tacrolimus. He was discharged on a decreased dose of Tacrolimus
(2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was
initiated.
#HCV cirrhosis c/b ___ s/p liver Transplant ___, with
recurrent cirrhosis: Patient unfortunately developed recurrent
cirrhosis despite HCV cure with simeprevir and sofosbuvir. He
has had no identified liver lesions c/f HCC. He is currently on
a study drug to treat fibrosis. He has no varices on recent EGD,
no ascites, and no documentation of recent encephalopathy. He
was continued on home study drug (per Dr. ___, and the
following immunosuppressants: He was discharged on a decreased
dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and
Prednisone 7.5 mg daily was initiated. He will follow up at
transplant clinic on ___.
#Hypertension: As above, BPs may be more elevated than in his
past with the current FSGS and worsening renal function.
Currently elevated BP most likely due to missed doses of home
medications while in the ED, and BP stabilized but were still
elevated to 150's systolic during the hospitalizations. We
continue home labetolol 200 mg BID, amlodipine 10 mg PO daily on
discharge. Would recommend eventually initiating ___ once
kidney function stabilizes. Spironolactone 50 mg daily was held
in setting of ___, and remained off on discharge. He should
discuss this with his outside providers.
# Anemia: Hgb 8 on admission, stable from prior discharge
baseline. Last iron studies in ___ c/w AOCD with low retics
suggestive of hypoproliferation. Hgb remained stable throughout
discharge, Hgb 7.7 on discharge.
#Chest pain: The night prior to discharge he developed L sided
sharp chest pain which was completely new and happened at rest
and resolved spontaneously after less than an hour with no
intervention. His ECG and cardiac enzymes were negative and his
chest pain did not recur. He was able to walk comfortably
without recurrent pain so he was deemed safe for discharge. | 112 | 493 |
12637819-DS-10 | 29,024,413 | Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS IN THE HOSPITAL?
- You had shortness of breath and chest pain.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a condition called "Giant Cell
Myocarditis," an autoimmune disease that affects the heart.
- Because of this Myocarditis, you developed trouble with your
heart pumping and with the electricity (conduction) of the
heart.
- You were in the ICU for close monitoring, including temporary
wires to help your heart's electricity and to check on its
pumping. - You were started on several medicines including
immunosuppressant medications to treat the Myocarditis.
- Since you are on immunosuppressants, you were started on
prophylactic medications to prevent infection.
WHAT SHOULD I DO WHEN I GO HOME?
- It is important that you continue to take your medications as
prescribed.
- On ___, please take the second dose of your
tacrolimus 12 hours before you have your labs drawn on ___,
___ (see below).
- You will need to have repeat echocardiogram and labs drawn on
___. Please go prior to your cardiology appointment
(see below). We will provide you with a lab slip for the lab
draw. Your echocardiogram was scheduled for***
- Please follow-up with your cardiologist appointment on
___ at 1 pm.
- You should follow-up with infectious disease to finish your
vaccines. The infectious disease office will call you to
schedule an appointment. If you do not hear within 2 days,
please call the office at ___.
We wish you the best in your recovery!
Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
___ is a ___ old male who presented to the hospital
with intermittent SOB and atypical chest pain, found to have
conduction abnormalities, narrow pulse pressure, and low output
heart failure with restrictive physiology s/p cardiac biopsy
that confirmed giant cell myocarditis.
#Giant Cell Myocarditis
#Acute Heart Failure with Reduced Ejection Fraction
#Cardiogenic shock (resolved)
The patient was admitted with atypical chest pain and dyspnea.
Because of EKG changes concerning for NSTEMI or prior missed
STEMI, he underwent catheterization which showed clean
coronaries. On admission, he quickly progressed to cardiogenic
shock with new mildly reduced ejection fraction of 53%. He was
also noted to have progressive electrical changes, notably PR
prolongation with an evolving RBBB, and then left anterior
fascicular block. Due to concern for impending complete heart
block in the setting of progressively worsening conduction
abnormalities, he was taken for septal endomyocardial biopsy, PA
catheter and urgent temporary wire pacemaker placement. His
biopsy returned with Giant Cell Myocarditis. Patient was
initially on a temporary milrinone drip, which was weaned and
CVO2 remained stable. He was started on afterload reduction and
discharged with lisinopril 15 mg BID. Metoprolol was not started
due to hypotension and lightheadedness.
He was started on an aggressive immunosuppression regimen with
prednisone 40mg BID (after initial 3-day pulse-dose solumedrol),
Mycophenolate Mofetil 1000 mg PO BID and Tacrolimus 2.5 mg PO
Q12H. Would recommend a prednisone taper weekly with next change
on ___ to prednisone 35 mg BID after cardiology appointment.
Patient's tacrolimus level reached steady state of ~8 while
inpatient on tacrolimus 2.5 mg PO Q12H. He will need continued
monitoring of tacrolimus levels with goal trough level ___.
For prophylaxis he was started on valacyclovir 500 mg BID,
bactrim SS 1 tablet daily, nystatin oral suspension 5 ml TID,
calcium carbonate 500 mg TID, vitamin D 1000 mg daily and
pantoprazole 40 mg daily. Transplant ID was consulted and he had
an extensive workup. He was negative for CMV serologies but had
positive EBV antibodies (VCA-IgG, EBNA-IgG, negative VCA-IgM).
Per transplant ID, he did not require prophylaxis for EBV.
Pending results include histoplasma and coccidioides.
Quantiferon GOLD was unable to be collected inpatient. It will
be collected as part of patient's lab draws on ___.
Additionally, he received the flu, Prevnar, HAV and HBV vaccines
(see transitional issues). He is being scheduled for an
appointment with infectious disease.
#Trifasicular block (resolved): Likely due to myocardial edema.
After starting immunosuppression, his QRS narrowed on serial
EKGs and his temporary pacer was removed.
TRANSITIONAL ISSUES
===================
[ ] Please follow up repeat TTE
[ ] Recommend tapering prednisone weekly with decrease to 35 mg
BID on ___.
[ ] Please continue to monitor tacrolimus levels with goal ___.
He was discharged on tacrolimus 2.5 mg BID.
[ ] Please follow-up infectious work-up including histoplasma
and coccidioides serologies. Quantiferon GOLD to be ordered on
___.
[ ] Patient was started on lisinopril 15 mg BID. Please monitor
for orthostatic symptoms.
[ ] Start metoprolol as outpatient if hemodynamics will
tolerate.
[ ] Continue HAV and HBV vaccine courses (dose ___. Will
need repeat ___ and HepB titers in the future as vaccines given
while relatively immunosuppressed.
[ ] Flu and prevar vaccines given ___, tetanus was given last
___ years ago
Follow-up lab work: Chem 10, CBC, troponin, BNP, tacrolimus
level, Quantiferon-GOLD on ___
CODE STATUS - Full, confirmed
CONTACT/HCP - ___ (wife) ___ | 256 | 558 |
15372801-DS-29 | 20,828,486 | Dear Ms. ___,
You were admitted to the hospital because of fatigue, chest
pain, and dark stools. We ran some tests to check your heart,
and we found that there is no sign of anything wrong with your
heart. The pain in your chest may be coming from acid in the
stomach, so we started you on an acid-controller medication
called omeprazole. Your dark stools may have been due to very
small amount of bleeding in your stomach, but your blood
pressures and blood counts are stable. You should follow up
with Dr. ___ nurse next week, and there they can decide
if they want you to undergo further work up.
While on your way into the ED, you were hit on the head with the
parking gate. We did some scans and found that you haven't had
any bleeding complications from that hit. It is ok for you to
continue your pradaxa.
Because of your congestive heart failure, please weigh yourself
every morning and call MD if weight goes up more than 3 lbs.
Changes to your medications:
START omeprazole 20 mg daily (acid blocker)
Continue all your other medications as prescribed by your
doctor. | ___ female with history of atrial fibrillation on
dabigatran, nonischemic cardiomyopathy, hypertension, moderate
MR, TR, dyslipidemia, history of TIA x2, anemia, history of PMR,
dementia, and depression who presents with intermittent chest
pain over the past week, weakness, and dark stools. | 203 | 41 |
19109135-DS-7 | 22,239,201 | Dear Mr. ___,
You were admitted to ___ due to confusion and sleepiness. You
underwent a scan of your head which showed an increase in the
size of your brain cancer. You were given steroids to help
prevent swelling in your brain. We also gave you medications to
help keep your blood pressure from getting too high. You were
started on radiation treatment for your cancer. You responded
well to the treatment and were noticed to have less confusion
and you became more alert. Please continue to take the steroids
as prescribed and to receive your radiation treatment.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ year old man with a recent diagnosis of
primary CNS lymphoma who presented with altered mental status
and lethargy. On CT head and MRI brain, he was found to have
enlarging bilateral CNS masses with areas of hemorrhage and
increased mass effect, midline shift, and some evidence of
obstructive hydrocephalus. He was started on dexamethasone, SBP
was kept under 150, and he began to receive WBXRT with marked
improved in his mental status and attention. Patient also
developed SIADH during hospitalization and was started on 2L
water restriction.
#CNS Lymphoma:
Patient with recent diagnosis of primary CNS lymphoma
(___), with plan to begin treatment with rituxan and
temodar who presented with alerted mental status and lethargy
prior to beginning treatment. He was found to have enlarging
brain lesions with mass effect and midline shift on CT scan. An
MRI brain confirmed the findings and also showed evidence of
potential obstructive hydrocephalus. He was started on
dexamethasone and bactrim for PCP ___. He was
hypertensive to the 160s and was started on antihypertensives
for SBP goal <150 (see below). He started WBRXT on ___ for a
planned 36 Gy in 18 fractions. Neurosurgery was consulted for
the potential obstructive hydrocephalus seen on MRI but
currently no surgical interventions were warranted. Patient's
mental status and attention showed marked improvement by the
time of discharge.
#Hyponatremia: patient with acute decrease in Na. Urine
osmolality and lytes c/w SIADH although per RN patient with
decreased PO intake. Now improving with fluid restriction.
Restriction liberalized from 1.5L to 2L s/p patient with
decreased urine output.
#Hypertension:
Patient with history of hypertension per OMR, on lisinopril 5mg.
On admission he was hypertensive to the 160s and was started on
hydralazine for SBP goal <150. He transitioned to captopril,
then losartan 25mg PO BID with adequate blood pressure control.
#Eosinophilia:
Patient was found to have eosinophilia on admission with
absolute eosinophil count of ~1200. It was of unclear etiology
although patient with history of eosinophilia in ___. His
eosinophilia resolved without intervention.
___ staph bacteremia:
Patient with admission blood cultures that grew GPCs in
clusters. He was started on vancomycin on ___, which was
discontinued on ___ when the GPCs spectated as ___
staph in 1 out of 5 bottles. It was thought to be a contaminant
and no other intervention was performed. Patient remained
afebrile and hemodynamically stable. All remaining blood
cultures were negative.
MEDICATION CHANGES:
==================
- added dexamethasone 4mg PO daily
- add Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY for PCP
prophylaxis
- started omeprazole while on steroids
- changed lisinopril 5mg PO daily to losartan 25mg PO BID for
better blood pressure control | 105 | 443 |
15081383-DS-3 | 22,170,712 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted because your wife noted that you were more
fatigued and sleepy than usual and you had a worsening cough
over the past three weeks. In the hospital, a chest x-ray showed
that you had a pneumonia, for which we started antibiotics. You
responded well to these antibiotics over 48 hours, becoming more
alert and interactive and improvement, and you will take an
additional 5 days of antibiotics.
Sincerely,
Your ___ care team | ASSESSMENT AND PLAN: ___ male with history of CVA,
dementia, and recurrent aspiration pneumonia presents with
altered mental status and left lower lobe consolidation.
ACUTE ISSUES
============
# Altered Mental Status: The patient presented from ___
___ with increased lethargy in the setting of HCAP on
CXR, which makes a toxic-metabolic encephalopathy the most
likely etiology for the depressed mental status. Other
infectious etiologies (UA negative) and traumatic (normal ___)
were ruled out. While initially "unresponsive", his mental
status steadily improved once antibiotics were initiated.
# HCAP: The patient has a history of recurrent aspiration
pneumonia and his CXR showed a retrocardiac opacity c/w
pneumonia. Since he lives in a long-term care facility and has
been hospitalized frequently, he was treated for HCAP w/
vancomycin (PM___), Zosyn ___ ___, cefepime (___)
and flagyl (___). After being afebrile and no growth in
blood cultures after 48 hours, the patient was transitioned
briefly levaquin (___) and discharged with moxifloxacin (plan
for an 8d course to be completed (___). Having received 2
days of antibiotics, he was discharged to continue on
antibiotics for six additional days. His urine legionella
antigen was negative, and blood cultures are pending at
discharge. The patient was also evaluated by our speech and
swallow specialist. The patient did very well with the nectar
thick diet and recommended that the patient have a formal video
swallow study, as he may be able to take a more advanced diet.
# Acute kidney injury: The patient's creatinine was 1.5 on
admission with no history of renal disease. However, this rise
in creatinine was likely secondary to decrased oral intake, as
the creatinine decreased back to baseline after 1L IVF.
CHRONIC ISSUES
==============
# AFib: Given prior CVAs, the patient's warfarin 4mg was
continued in-house and at discharge.
# HTN: Given initial ___, the patient's losartan was held. His
amlodipine and hydralazine were continued, and all blood
pressure medications were continued at discharge.
# Dementia: Likely vascular in nature given his history of
significant CVA. His memantine and donepezil were continued
in-house and at discharge.
# Narcolepsy: Nuvigil is not on formulary, but was continued at
discharge.
# Recurrent UTIs: The patient's UA was normal and he had no
symptoms of urinary tract infection. His suppresive
nitrofurantoin 100mg daily was continued while in-house and at
discharge.
TRANSITIONAL ISSUES
===================
- Pt should continue with moxifloxacin for 6 days at his ___
___ facility.
- Please check INR in 2 days due to continuation of
fluoroquinolone antibiotic.
- The pt should see his PCP within one week of discharge.
- Please follow up on final blood cultures.
- Recommend that the patient have a formal video swallow study,
as he may be able to take a more advanced diet.
# Code: DNR/DNI (confirmed w/ HCP)
# Emergency Contact: ___ (wife and HCP) ___ | 88 | 458 |
14158698-DS-13 | 22,865,381 | You are being discharged with new medications. Please take as
directed. You may resume your home medications unless otherwise
instructed.
You are to be NONWEIGHTBERING to LEFT FOOT in a bivalve cast.
Your dressings will consist of: adaptic, sterile 4x4, Kerlix,
Bivalve cast at all times. Your dressing will be changed
every-other-day, and your bivalve cast should remain intact even
during dressing changes.
Please keep dressings clean, dry, and intact. Avoid getting your
dressings wet.
You may resume your home diet.
If you develop any of the symptoms listed below or anything else
concerning, please see your PCP or go to the nearest ER.
Please keep all follow up appointments. | Mr. ___ was seen in the ED on ___ after being
transferred from ___ due to concern for vascular
status. Pt was admitted to the podiatry service and scheduled
for L foot TA tendon repair and wound closure (please see
operative report). IV antiobiotics included vanc/cipro/flagyl.
Regional popliteal and saphenous nerve blocks were administered
pre-operatively. A fiberglass bivalve cast was applied
post-operatively to remain for the next ___ days until his
follow-up appointment with Dr. ___. At his post-op check, pt
was in ___ pain and the left foot had neurovascular status
intact. His wound site was well coapted with sutures intact and
no signs of infection. Pt was discharged on ___ with PO levo
and clinda. He was instructed to begin daily aspirin to prevent
blood clots in his leg. All postoperative instructions were
discussed in detail with the patient including dressing changes,
medications, strict NWB and elevation. Pt will follow up with
Dr. ___ at ___ in 10 days. | 110 | 165 |
17266901-DS-11 | 27,662,090 | Please shower daily including washing incisions gently with mild
soap, ___ baths or swimming, and look at your incisions
Please ___ lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
___ driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
___ lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | She was admitted on ___ and underwent routine preoperative
testing and evaluation. She was taken to the operating room on
___ and underwent coronary artery bypass grafting x 5.
Please see operative note for full details. She tolerated the
procedure well and was transferred to the CVICU in stable
condition for recovery and invasive monitoring. She weaned from
sedation, awoke neurologically intact and was extubated. She was
weaned from inotropic and vasopressor support.
On the night of the procedure she had an episode of VF that was
successfully defibrillated. Lidocaine drip was initiated. EP was
consulted. Lido was discontinued and Amiodarone was started.She
remained in sinus rhythm after the
event. Ep felt that it was possible that the VF was associated
with reperfusion injury, in which case it should be
self-limited. Bedside echo performed. On ___ TTE performed
revealed:per Cardiology: IMPRESSION: Suboptimal image quality.
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Mild mitral regurgitation. Mild
pulmonary artery systolic hypertension. She had ___ further VFib
events.
Beta blocker was initiated and she was diuresed toward her
preoperative weight. She remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. She was
evaluated by the physical therapy service for assistance with
strength and mobility. Her chest tubes and pacing wires were
discontinued per protocol without incident. Post pull CXR showed
a small left apical pneumothorax. She seemed a little sleepy
and narcotics were discontinued. On ___ ___ had a
nonsyncopal fall. ___ injuries incurred. Her electrolytes were
abnormal with hyponatremia and she was placed on free water/
fluid restriction.
On ___, she was set to go to rehab when she had a PEA arrest
requiring chest compressions for a period of less than a minute.
She was transferred back to the CVICU. She was resuscitated and
woke up neurologically, not requiring intubation. An
echocardiogram was performed at bedside demonstrated a large
pericardial effusion with compression of the right ventricle.
She was taken emergently to the operating room for 1. Urgent
mediastinal exploration and 2. Replacement of ascending aorta
with a 30 mm Gelweave tube graft with reimplantation of the vein
grafts to the posterior left ventricular branch artery and the
first diagonal artery. She remained hemodynamically stable over
night. The following morning she was woken up, neurologically
intact and weaned to extubate. Beta-blocker, Statin, ASA and
diuresis was resumed. On ___ the chest tubes and pacing wires
were discontinued without incident. She was transferred back to
the step down unit for further monitoring. Physical Therapy was
again consulted to evaluate her strength and mobility. EP
continued to follow. Per EP recommendations she was kept on oral
Amiodarone. During her hospital stay on ___ 6 she had 2
additional falls without loss of consciuosness. Xrays of her
pelvis and femur were negative for fracture.
On ___ she was complaining of nausea. Her Total Bili was rising
and maxed out at 5.5. An ultrasound was performed that
showed:per radiology:IMPRESSION:
1. Cholelithiasis without specific signs of acute
cholecystitis.
2. Small right pleural effusion.
Her LFTs were trended and her Tbili trended back downward. ___
intervention warranted.
Scant serous drainage was noted on the distal pole of her
sternal incision. Her sternum remained stable. ___ antibiotics
needed. The drainage diminished. Despite her complicated postop
course, ___ continued to slowly progress and ___
___ her for discharge on pod# 12 to ___ in
___. All follow up appointments were advised.
By the time of discharge on POD **** she was ambulating
freely, the wound was healing, and pain was controlled with oral
analgesics. She was discharged ***** in good condition with
appropriate follow up instructions. | 121 | 609 |
18026603-DS-18 | 26,994,111 | Dear Ms. ___,
You came to the hospital with weakness and weight gain.
In the hospital you were found to have a heart failure
exacerbation. You were given medications to remove extra fluid
from your body and your breathing improved.
Also in the hospital-
- Imaging of your heart was done which showed that it is pumping
well and the valve is in the right place.
- A leg ultrasound showed on ___ showed large hematoma (blood
clot) in your thigh from your recent TAVR surgery. This should
improve with time
- ___ (our diabetes experts) helped manage your blood sugars
in the hospital
When you leave the hospital-
- Weigh yourself every morning before breakfast, and using the
same scale. Call your doctor if your goes up more than 3 lbs.
Your discharge weight is 172 lbs.
- Continue to take lactulose daily as this helps prevent you
from becoming confused due to your liver disease. You should
have ___ bowel movements daily. If you do not have enough bowel
movements, you need to call Dr. ___ someone from the liver
team.
- Make sure to take your medications on time. Your medications
are listed below.
- Follow up with your doctors as advised. These appointments are
listed below.
It was a pleasure taking care of you,
--Your ___ Care Team | Ms. ___ is a ___ w/ aortic stenosis s/p TAVR (___), NASH
cirrhosis (c/b hx of grade I varices, HE), DM2, syncope s/p ILR
and recent admission c/b right thigh hematoma admitted, weakness
concerning for decompensated CHF.
#ACUTE ON CHRONIC DIASTOLIC HEART FAILURE (EF LVEF >55%):
Presented with 20lb weight gain in setting of recent diuretic
discontinuation. Diuresed well on Lasix boluses (120 mg) and
lasix drip. It was unclear if all of her lower extremity edema
represented heart failure, as may have been from known hematoma
on right side. Continued on Spironolactone 150 mg. Patient
received no Afterload reduction because she was not on ___
due to h/o orthostatic hypotension, for which midodrine was
continued. Discharged on her home torsemide 200 mg daily.
#HEPATIC ENCEPHALOPATHY:
Patient was triggered on ___ due to altered mental status,
likely iso decreased bowel movements ___ refusing doses of
lactulose. Labs showed increased lactate that down trended
(likely from low hepatic clearance given underlying cirrhosis),
elevated asymptomatic Tbili (1.7) and LDH of 360 (RUQ ultrasound
only showed cholelithiasis and cirrhosis without portal vein
clots), and UA was normal. Lactulose was increased and
patient's symptoms improved.
#RIGHT THIGH HEMATOMA:
S/P recent TAVR iso long-standing thrombocytopenia: Asympomatic,
Repeat ultrasound ___ showed large hematoma. Had no symptoms or
evidence of compartment syndrome.
#AORTIC STENOSIS, NOW S/P TAVR:
Hepatology and hematology were consulted on prior admission with
the plan for Plavix x 3 months and no ASA given history of
facial swelling. Plavix was continued. Off ASA since had allergy
resulting in severe facial swelling in the past. Post-TAVR TTE
showed a well seated valve with very minimal regurgitation.
#NASH CIRRHOSIS:
c/b hx grade 1 varices (none on recent EGD). BMs titrated to ___
daily via lactulose. Was continued on rifaxamin,
spiranoloactone, and ursodiol.
TRANSITIONAL ISSUES:
===================================
- CODE: Full (confirmed)
- CONTACT: ___ (son) ___
ADMISSION WEIGHT: 82.7kg (182 lb)
DISCHARGE WEIGHT/DRY WEIGHT: 78.1 kg (172 lb)
____________________________
FYI:
- The patient triggered here for hepatic encephalopathy, which
improved with increased frequency of lactulose to Q2H. 3 bowel
movements daily seem to be sufficient for her.
- Post-TAVR TTE showed a well-seated valve with minimal
regurgitation.
- Insulin uptitrated per ___ recommendations; please continue
to check fingerstick blood glucose and uptitrate insulin as
necessary
- Not on a BB, ___ due to history of orthostasis
____________________________ | 219 | 385 |
12219185-DS-20 | 21,782,142 | Discharge Instructions
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
Please keep your incision dry for 72 hours after surgery.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture removal.
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. ___ 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.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | Mr. ___ presented to ___ on ___ with fevers and
purulent wound drainage after a recent L3-L4 Laminectomy and
microdiscectomy ___ who presents with fevers and wound
drainage. He was taken to the OR for incision and drainage of
the wound. A drain was left in place draining serosanguinous
fluid.
The patient remained stable ___ and on ___ was afebrile with
a stable neuro exam. His drain output slow down and the drain
remained in place with a plan to remove ___. Infectious disease
made antibiotic recommendations and suggested the patient switch
from vancomycin and ceftaz to dicloxacillin 500 mg for 14 days.
On ___ the patient remained afebrile with a stable neurological
exam. His JP drain output remained low and there was no swelling
or discharge at the surgical site. Sutures were intact with
minimal erythema. The patient requested a visiting nurse to
accompany his discharge to evaluate his incision. Case
management is involved to coordinate. The patient's JP drain was
removed without complication. He is ambulating independently and
was discharged in stable condition with instructions to follow
up with Dr. ___ in 14 days for wound check. | 222 | 190 |
10284802-DS-13 | 25,193,580 | It was a pleasure to participate in your care at ___. You came
to the hospital for ongoing loose stools containing blood. We
treated your with IV steroids. We also gave you antibiotic
medications to treat the infections in your intestine. You will
need to take antibiotics for many days after leaving the
hospital. Please take all medications as prescribed. Please
keep all follow up appointments. | ___ year old female with newly diagnosed ulcerative colitis
complicated by superinfection of c. diff and salmonella
infections presenting with persistent diarrhea and bloody
stools.
# Ulcerative colitis, complicatd by Salmonella and C. difficile
infections:
She was diagnosed with concurrent C diff and Salmonella
infections prior to this admission. Despite taking flagyl,
asacol and prednisone 40mg daily, she noted having bloody
diarrhea without improvement in the days prior to admission.
Patient was compliant with low residue diet and home
medications. When she was admitted to the Medicine service she
was seen by the GI consult service who recommended starting her
on methylprednisone IV. GI also recommended treatment with PO
vancomycin for C diff infection and 7 days course of bactrim for
her Salmonella infection. In the following days her diarrhea
improved and she noted have only ___ non-grossly blood bowel
movements per day. She was transitioned to PO prednisone and
continued on PO vancomycin and bactrim. CMV viral load was sent
and pending at the time of discharge. PPD was placed in right
forearm on ___. Patient will follow up with Dr. ___
for reading of PPD on ___.
# Hypokalemia, likely due to diarrhea: The patient presented
with potassium of 2.9 and given 40 mEq in ED and further
repletion on the Medicine floor with appropiate response. | 68 | 219 |
16392764-DS-14 | 24,922,008 | Mr. ___,
You were admitted with confusion and left sided weakness and
were found to have a hemorrhage in your ___. This is likely
due to a combination of of high blood pressure and a change in
your blood vessels due to age. | Mr. ___ is a ___ year old male with HTN, hypothyroidism,
and dementia who presented with increased confusion, mild left
sided weakness and left neglect who was found on CT to have a
right parieto-occipital intraparenchymal hemorrhage with
intraventricular extension. This is likely a primary hemorrhage,
likely due to a combination of hypertension and amyloid
angiopathy. | 42 | 56 |
11493624-DS-16 | 25,754,440 | Ms. ___,
It was our pleasure taking care of you during your admission to
___. You were admitted with worsening right arm pain and
weakness. You were seen by neurosurgery and had a CT myelogram-
an imaging test which showed significant spinal cord narrowing.
You are scheduled to have surgery to repair this narrowing on
___ with Dr. ___ which you will be re-admitted
to the hospital. We have stopped your aspirin in preparation for
your surgery. Please call your cardiologist within the next
week so he can check your pacemaker.
We wish you the best,
Your ___ Care team | Ms. ___ is a ___ female with a past medical history of CVA,
spinal stenosis, and tachy-brady syndrome with sinus pauses s/p
PPM placement in ___ who presents with right arm pain,
weakness, and paresthesias. | 98 | 35 |
13388641-DS-13 | 25,922,898 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
-You were having numbness and tingling in your hands and feet.
You were admitted for monitoring of your heart rhythm and
electrolytes.
What was done for me while I was in the hospital?
-You were given potassium for low potassium levels.
What should I do when I leave the hospital?
-Take all of your medications as prescribed (listed below).
-Please establish care with a primary care provider ___ 1
week.
-___ medical attention if you have new or concerning symptoms
listed below.
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[] K low on admission, will need follow up of repeat CMP within
1 week. K 3.9 on discharge.
[] Repeat EKG at next outpatient visit for QTc monitoring.
[] LFTs elevated on admission, would consider further monitoring
and workup of transaminitis. Consider RUQUS and Hepatitis Panel
outpatient.
[] Reports parasthesias x1 month. Workup including B12, TSH
elevated but T4 wnl, HbA1c unrevealing. Would consider referral
to neurology for EMG testing
[] ___ and HIV ___ labs pending on discharge - Returned as
Negative- Letter was sent to the patient with these results | 113 | 91 |
18059276-DS-22 | 28,045,330 | Mr. ___,
You were admitted with nausea/vomiting unable to tolerate good
oral intake concerning for recurrent obstruction. You underwent
an endoscopy ___ with a small dilation around your anastomosis
site; given the appearance of the anastomosis and the small size
of the opening a feeding tube was placed to ensure you could
maintain your nutrition. Once you have put back on the weight
you lost you will follow up with Dr. ___ to determine if
you need further surgery.
You were dehydrated with some kidney damage that resolved with
IV fluids. Your electrolytes (chemicals in your blood such as
sodium, potassium, phosphorus, and magnesium) were abnormal,
which were corrected with IV fluids and starting tube feeds.
It was a pleasure taking care of you.
-Your ___ team. | ___ h/o PUD complicated by perforated ulcer (s/p ___ patch
___ at ___), subtotal gastrectomy for perforated duodenal ulcer
s/p Roux en Y reconstruction (___ ___ complicated by recurrent
GJ stricture, and gastric outlet obstruction requiring frequent
balloon dilatations presented with nausea/vomiting and inability
to tolerate PO concerning for recurrent obstruction found to
have ___.
1. Nausea/vomiting, poor PO intake, weight loss with severe
protein calorie malnutrition h/o gastric outlet obstruction
-Complicated GI history including perforated peptic ulcer s/p
___ patch ___ at ___ and subtotal gastrectomy s/p Roux en Y
reconstruction (___ ___, recurrent GJ stricture, and gastric
outlet obstruction. Patient presents with weight loss due to
poor PO intake and nausea/vomiting, which is likely in setting
of worsening gastric outlet obstruction although differential
includes gastroenteritis. s/p EGD ___ that demonstrated friable
anastomosis s/p small dilation and placement of NJ tube (unable
to place bridle). Dr. ___ without any acute
inpatient surgical interventions but potentially anastomosis
revision or PEG-J tube placement in the future. As per nutrition
Jevity 1.5 or Isosource 1.5 at 45mL/hour continuously or
90mL/hour for 12 hours overnight with free water flush 100mL Q6
hours regardless of rate. He can advance diet as tolerated and
continue with ensure clear supplements. Flush all tube feeds and
medications with 30mL water to prevent clogging.
2. ___, hypernatremia (hypovolemic, dehydration), anion gap
metabolic acidosis
-Due to poor PO intake and vomiting, which resolved with IV
fluids transitioned to free water flush via NG tube. Lactate
normal without other clear cause of anion gap metabolic
acidosis. Repeat BMP in 1 week to ensure sodium within normal
limits given current free water flush regimen.
3. Hypomagnesemia, hypophosphatemia, hypokalemia
-At high risk of refeeding syndrome. Electrolytes
monitored/repleted and stable at discharge. Repeat BMP (with
magnesium and phosphorus) in 1 week.
4. Leukocytosis
-No clear infectious etiology other than possible
gastroenteritis. Suspect reactive leukocytosis or in setting of
volume depletion.
5. ST depressions
-In setting of sinus tachycardia likey rate related. Troponin
negative.
6. Constipation
-Started bowel regimen with miralax and senna.
TRANSITIONAL ISSUES
[]BMP (with magnesium and phosphorus) in 1 week
>30 minutes spent on discharge planning | 127 | 359 |
13525396-DS-14 | 29,670,106 | You were admitted with abdominal pain. Your abdominal aortic
aneurysm is slightly enlarged,but not to a size that is
concerning. You were found to have a pneumonia on CT scan and
were started on Azithromycin for this. You should continue
taking this antibiotic through ___.
You should resume all of your home medications.
Please keep the following appointments below.
You should call your doctor or go to your nearest emergency room
if you develop worsening abdominal pain, chest pain, shortness
of breath, inabililty to eat or drink, or any other changes that
concern you. | Mr. ___ was admitted from the ED with abdominal pain and
slightly enlarged abdominal aortic aneurysm. He was made NPO
and examined by Dr. ___ felt that his AAA was not
the cause of his pain. He was noted to have a right inguinal
hernia, and Dr. ___ team was consulted as he has
been managing this as an outpatient. He did not feel there was
any need for intervention and that a diet could be started. His
abdominal pain had resolved by the end of ___ and the
patient was very anxious to return home. He was therefore sent
out on a 5 day course of Azithro for PNA and instructed to see
his PCP. He was advanced in a diet and was tolerating regular
food at the time of discharge without return of abdominal pain. | 91 | 138 |
12298833-DS-14 | 20,141,136 | You were admitted to ___ on
___ when you were found to have a new fluid collection near
your descending colon (left side). You were sent to the
radiology department where you underwent a CT-guided drain
placement to remove that fluid.
Due to poor wound healing, your abdominal wound was opened up at
the bedside and a "wound vac" was placed. This vac will be
managed by the rehabilitation facility. It should be on suction
at all times and changed every three days.
You are now being discharged to the rehabilitation facility with
the following instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
.
Avoid driving or operating heavy machinery while taking pain
medications.
Personal Care:
1. While wet-to-dry dressings are in place, please change ___
times a day or as needed for increased soiling.
2. While VAC is in place, please clean around the VAC site and
monitor for air leaks of the VAC
3. A written record of the daily output from the VAC drain
should be brought to every follow-up appointment. Your VAC drain
will be removed as soon as possible when the daily output tapers
off to an acceptable amount and the wound is no longer
concerning for ongoing infection
4. You may shower daily with assistance as needed.
5. Okay to shower, but no baths until after directed by your
surgeon
Activity:
1. You may resume your regular diet.
2. DO NOT drive while taking pain medications
.
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. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take your antibiotic as prescribed.
5. 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 softerner if you wish.
6. 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,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(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.
.
VAC DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with wet-to-dry dressings and plans for
___ services to place a VAC wound drain once the equipment
arrives. Wound care is a clean procedure. Wash your hands
thoroughly with soap and warm water before performing wound
care. Perform drainage care twice a day. Once the VAC is placed
it should be changed every 72h and the amounts of drainage
should be recorded. | Mr. ___ is a ___ year old male with a history of CAD, DM2,
failed fem-fem bypass c/b bilateral AKAs, bladder CA s/p ileal
conduit, with recent admission for LLQ phlegmon, now readmitted
with new pelvic abscess s/p drainage on ___. CT imaging of
the patient's abdomen and pelvis revealed a large 14.6 cm
loculated fluid collection adjacent to the collapsed descending
colon tracking into the left anterior pararenal space. He was
taken to Interventional Radiology on ___ where he underwent
CT-guided placement of a drain. Two hundred milliliters was
obtained on initial tap. Fluid was sent for culture and
sensitivity. Results showed pseudomonas aeruginosa and mixed
bacterial types. Infectious Disease continued to follow the
care of this patient. He was continued on oral Vancomycin for
prior C. difficile infection, as well as IV Daptomycin and
Meropenem for the abdominal infection coverage.
On ___, Mr. ___ surgical staples from his prior
abdominal surgery were removed. Upon moving from the bed to the
chair, the RN noted that his wound opened up approximately 2cm x
1.5cm. The wound was explored at the bedside and the decision
was made to place a wound vac in place due to it's poor healing.
The patient was also seen by the wound/ostomy RN for care of
his colostomy and ileostomy.
Since that time, the patient has been tolerating a regular diet
without issue. He had a normal WBC during his admission. At
the time of discharge, Mr. ___ was afebrile, hemodynamically
stable and in no acute distress. He is being discharged with a
mid-line wound vac in place. It was removed prior to discharge
and a wet-to-dry dressing was placed in preparation for the
patient's arrival at ___. The patient has a
right-sided urostomy that is functioning well. Lastly, he has a
left-sided JP drain that has drained scant serosanguinous
drainage. The patient has follow-up appointments with ACS and
the Infectious Disease services in the next two to three weeks. | 610 | 342 |
15439322-DS-23 | 26,018,413 | Dear ___:
You were admitted to ___ because you had belly pain and
bloating as well as feeling short of breath. We found that you
have too much fluid in your body. We gave you medications to get
rid of the extra fluid.
We have stopped your insulin because your blood sugars were low
while you were hospitalized. Please check your blood sugar in
the morning before breakfast and 2 hrs after lunch and write
down all of the results. Bring this list to your next primary
care and ___ appointment.
You should carry something with sugar in it at all times, in
case you get low blood sugars again.
****PLEASE GO TO ___ AND GET YOUR LABS CHECKED
___ AM****
It was a pleasure to care for you!
Your ___ team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is a ___ year old male with history of HFpEF (LVEF
55%), bicuspid aortic valve, Afib on pradaxa, and CKD who
presents with nausea and abdominal pain, DOE, PND, orthopnea. | 141 | 32 |
12879244-DS-11 | 21,612,476 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for syncope (loss of consciousness). When you fell,
you hit your head. Examination and imaging of your head did not
show any injuries your brain. You only had a small bruise on
your head and a headache.
You were assessed for possible causes of your syncope. Your
blood tests and heart tests were normal. The most likely cause
of your syncope was "orthostatic hypotension" (low pressure upon
standing up) which can occur with rapid standing. Physical
therapy evaluated you and felt you were strong enough to go
home.
Your home medications were not changed and please continue to
take them as prescribed. Remember to stand up slowly in the
future and drink ample amounts of fluids to prevent another
episode. If you have any symptoms as listed below, please
return to the ER or contact your primary doctor (___).
Please follow up with your previously scheduled appointments
(see below).
Have a wonderful time in ___! | ___ year old woman with a history of breast cancer in remission
who presents after syncope and fall.
ACTIVE ISSUES
-------------
#. Syncope: She was admitted for syncope and fall. She had hit
her head with a resulting superficial hematoma. Examination did
not reveal focal neurodeficits. CT of the head and C-spine did
not reveal any underlying injuries. Syncope evaluation did not
yield a clear precipitant. There was no indication of seizure
activity. She has no history of heart disease. She was monitored
on telemetry overnight and no events were recorded.
Electrolytes, CBC, lactate, D-dimer, and INR were all within
normal limits. Her syncopal episode was most likely due to
orthostatic hypotension upon rapid standing from the couch.
Orthostatic blood pressures in the hospital at discharge were
notable for stable blood pressure with a 17 point increase in
heart rate. She was able to ambulate normally and was cleared by
physcial therapy. At discharge, she had only left sided headache
over where she had hit her head. Her headache improved with her
home dose of vicodin. A follow up appointment was her PCP (Dr.
___ was scheduled. She was instructed to stand up slowly and
maitain good fluid intake. Home medications were not changed.
INACTIVE ISSUES
---------------
#. Diabetes Mellitus Type 2: She received home dosing of
humulin-N and sliding scale. Glucose was well controled.
#. Hypertension: Home amlodipine and HCTZ were continued.
#. Breast Ca: She has been in remission since ___ and currently
was not on active treatment.
#. Hypercholesterolemia: She continued her home dose of
prevastatin.
TRANSITIONAL ISSUES
-------------------
Follow-up: Appointment was scheduled with her PCP, ___.
Code status: Full Code
Contact: patient phone ___ | 178 | 276 |
13650860-DS-30 | 23,851,701 | Ms. ___,
You were admitted to the ___
for your anemia. On admission your blood counts were very low.
You were given blood products which you responded very well to.
In discussion with our gastroenterology team, it was decided
that the most likely source of your bleeding were your known
"AVMs" in your small bowel or large bowel.
We monitored you for 36 hours and your blood counts were
stable and rising. You were discharged in stable condition.
It is very important for you get labs drawn on ___ to check
for continued resolution of your blood counts. You were given a
prescription for this lab testing. The results will be forwarded
to your primary care physician, ___ MD, MPH.
If you experience further episodes of melena (dark black tarry
stools) or bright red blood in your bowel movements it is very
important to return to your doctor or emergency room to get your
cell counts checked.
It was a pleasure taking part in your care. Happy New Year and
have an amazing ___!
___,
Your ___ ___ and
___ Teams | In brief, this patient is a ___ year old with a complex medical
history most significant for HFpEF (LVEF>55% in ___, CAD s/p
CABG x 2 (last in ___, HTN, HL, afib s/p PPM, pulm HTN, AAA
s/p EVAR, COPD, CKD, GERD and a history of LGIBs ___ to AVMs who
presents with melena that began one day prior to presentation
found to be anemic on outpatient.
#Acute on chronic Anemia ___ GIB
Patient with chronic anemia from GIB found on admission to be
anemic in setting of melena. Throughout admission was
hemodynamically stable. Patient was given 1 unit of blood
products w/sustained appropriate response from ___ to ___.
GI was consulted for evaluation of need for endo/colonoscopy. It
was decided given known history of AVMs and stability on
admission that Ms. ___ would be ___ managed conservatively
with outpatient follow up.
Discharge Hemoglobin 9.1 from 6.8 on admission. Will have
outpatient labs drawn ___.
================== | 186 | 157 |
18534747-DS-24 | 23,054,601 | Thoracic decompression with fusion:
You have undergone the following operation: Thoracic
Decompression With 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 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 while lying in bed.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home
medications.
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. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was complicated by her pain control, anxiety, and bradycardia.
Pain Service was consulted to assist with mgmt of her pain.
Medicine and Cardiology Services were consulted for her
bradycardia and several episodes of chest tightness and sob.
Work up revealed a normal baseline bradycardia which is also
documented pre-op and at her outpatient pcp appointments in the
___. Cardiac Markers were negative. Echo was negative for
heart dysfunction. Cardiology felt her chest tighness and sob is
a result of her anxiety. Hospital course was otherwise
unremarkable. Social work was consulted for her anxiety related
to her social and financial stressors contributing to her
anxiety. Support was provided and is recommended to continued at
rehab. On the day of discharge the patient was afebrile with
stable vital signs, comfortable on oral pain control and
tolerating a regular diet. | 620 | 240 |
18715059-DS-11 | 26,058,772 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
You were on Aspirin prior to your injury, you may safely
resume taking this on ___.
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine. Please take this for 7 days
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Patient presented to the emergency department after a mechanical
fall striking his face. Imaging showed a right parietal
subarachnoid hemorrhage and he was admitted to the floor for
observation and management. Imaging of the cervical spine was
done and was negative for any abnormality and his aspirin was
held. He was given a tetanus shot and started on Dilantin for
anti-seziure prophylaxis. He remained stable overnight into ___
and a repeat head CT was done which was stable. He was seen by
physical therapy who felt that he would benefit from home
physical therapy.
He was deemed fit for discharge to home with home physical
therapy on the afternoon of ___. He was given prescriptions for
required medications, instructions for follow-up, and all
questions were answered prior to discharge. | 155 | 128 |
19146208-DS-15 | 25,198,583 | Ms. ___,
You were admitted to ___ for abdominal pain. When you arrived
in the ED, you underwent a CT image which revealed a significant
stool burden. Your blood tests also demonstrated mildly elevated
liver enzymes. You were then admitted for further evaluation and
observation. While in the hospital, you were treated with pain
and ___ medications. You also received an enema and
medications to reduce your constipation and promote the motility
of your bowels. An endoscopic procedure was performed to
evaluate your upper GI tract and was found to be normal.
Additionally, blood tests were collected to evaluate for
hepatitis and celiac disease, which are now pending.
It was a pleasure participating in your care. | # Abdominal pain: In the ED, the patient underwent CT imaging
which revealed a significant stool burden and no other acute
___ process. She was admitted to medicine for
further ___ and evaluation. While hospitalized, she received
an aggressive bowel regimen consisting of an enema, bisacodyl,
docusate sodium, senna, and polyethylene glycol, which
precipitated several loose watery bowel movements. For her pain,
she was treated with acetaminophen and tramadol. No additional
opioids were prescribed to avoid further constipation. Based on
elevated ___ levels from an OSH, ___
Transglutaminase Antibodies were sent and were WNL.
Gastroenterology was also consulted. An EGD was performed with
biopsies that were also pending at discharge. Nothing abnormal
was discovered on the EGD.
# Transaminitis: During hospital admission, blood tests revealed
a mild transaminitis. Blood tests were negative for HIV and HCV.
At the time of her discharge, HAV, HBV, IgA, and BCxs were
pending. Liver enzymes were also downtrending when patient
departed.
The patient was discharged with plans to continue the aggressive
bowel regiment with subsequent close ___ with the ___
___ (Dr. ___. | 118 | 181 |
12320511-DS-3 | 20,280,015 | Dear Mr. ___,
You were admitted to ___ due to acute pancreatitis. Your
symptoms improved with intravenous hydration, pain medications,
and anti-nausea medications. We are not sure what triggered this
episode, but it may have been related to victoza so we recommend
discontinuing that for now. Please continue to stay hydrated
for the next few days. Your digoxin level was still elevated.
Please continue to not take the digoxin. You should have your
level drawn on ___ and faxed to your primary care physician.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___ | ___ w/ DM2, CKD, HTN, PAF with 4 days of diffuse abdominal pain
secondary to acute pancreatitis.
# Acute pancreatitis: Elevated lipase and evidence of
inflammation of the pancreas on ultrasound. Unclear etiology -
no gallstones on U/S, no EtOH use, no elevation in triglycerides
or calcium. Most likely drug-induced given temporal nature with
increase in dose of liraglutide (Victoza). After dose of
morphine and ondansetron in the ED and IV fluids overnight, pt.
was feeling well and tolerating PO without pain and nausea. Pt.
was discharged home with close follow-up.
# Acute on chronic kidney disease: Elevated creatinine on
admission that resolved to baseline after hydration.
# DM (diabetes mellitus), type 2: Complicated by distal
neuropathy. Last HGBA1C 8.7 on ___. Pt's home medications
were held during this admission, and glucose levels were
controlled with humalog sliding scale during this admission.
Pt. was discharged off liraglutide but on his home glipizide and
metformin.
#Paroxysmal Afib: In sinus rhythm on admission. Pt. is usually
controlled with digoxin, metoprolol, and baby aspirin. Digoxin
serum level, however, had been recently elevated and so digoxin
was held. He was discharged off digoxin as level still elevated
on day of discharge. Pt. will have level drawn the following
day and sent to PCP for discussion of restarting digoxin.
# HLD: Pt. continued on home simvastatin.
# HTN: Pt. continued on home metoprolol, lisinopril, and
chlorthalidone.
# GERD: Pt. continued on home omeprazole.
# Depressive disorder: ___. continued on home duloxetine.
# Transitional issues:
- Please monitor FSG and consider starting additional agent to
manage his diabetes
- Digoxin level ___ was 1.3 and ___ was 1.1. Pt. was
discharged off digoxin with plans to have dig level drawn on
___. Please restart as needed. | 102 | 293 |
14137218-DS-4 | 22,766,220 | Dear ___,
___ were admitted to the hospital with confusion and severe
dehydration and kidney injury. ___ were given IV fluids and your
hydration level improved and ___ started feeling better. Your
kidneys improved. ___ also received antibiotics for a urinary
tract infection, however your culture returned negative.
Please have your labs checked again through your home visits to
make sure ___ are not getting too dehydrated in the heat, and
make sure to drink plenty of fluids this summer.
We wish ___ the best. | ___ w/dementia, hearing loss, HTN, DM, presenting with acute
encephalopathy for 3 days, found to be dehydrated with possible
UTI though culture negative, hypernatremia, acute renal failure.
# Acute encephalopathy on chronic dementia: Likely
multifactorial in setting of dehydration with hypernatremia,
hypercalcemia worsened in dehydration and possible infection.
TSH normal. Resolved with treatment of hypernatremia, IVF, and
at baseline upon discharge. Due to deconditioning, ___
recommended home with 24 hour care and home ___, daughter and
family in agreement.
# Hypernatremia and dehydration: Hypovolemic. Likely in setting
of severe heat with reported minimal PO intake. Improved and
stable prior to discharge, tolerating PO well on day of
discharge.
- recommend repeat labs in follow up, given heat, age, dementia,
she is at risk of recurrence
# Acute kidney injury: Cr last checked in ___, between 1.0-1.3,
1.4-1.5 upon discharge, significantly improved from admission Cr
of 3.6 due to prerenal hypovolemia.
- repeat labs in follow up as above
# Unconfirmed/Suspected UTI: Per daughter had episode of
incontinence prior to admission. Unclear if due to profound
weakness, confusion, or dysuria prior to admission. Given CTX
for complete course despite negative culture given reported
incontinence, encephalopathy and leukocytosis.
# Leukocytosis: Initially downtrending and attributed to UTI vs
inflammation/dehydration. Resolved prior to discharge. Repeat
CXR without pneumonia, repeat UA contaminated, completed
antibiotic course.
# Anion gap metabolic acidosis: most likely due to ___ resolved
with IVF though still slightly hyperchloremic upon discharge
(IVF= LR/D5LR through admission).
# Hypercalcemia: chronic, followed by endocrine in the past who
recommended parathyroidectomy but pt declined. Was previously on
Sensipar, confirmed no longer taking with daughter.
# HTN: Held home ___ due to renal failure on admission,
decreased diltiazem due to hypotension/normotension. Given new
prescription for lower dose diltiazem upon discharge. Could
consider transitioning back to ___ once confirming renal
function stable.
Transitional:
- repeat labs in ___ days to ensure stability
- home with ___
- decreased home dilt dose, discontinued home ___
Medically stable for discharge home with services and 24 hour
care.
> 30 minutes spent on discharge day services, counseling, and
coordination of care. | 85 | 345 |
11040157-DS-4 | 21,203,213 | Dear Ms. ___,
You were hospitalized at ___
after a car accident. Unfortunately, you had multiple injuries
from the accident, including two broken legs and broken ribs.
You were followed by the orthopedics team and the physical
therapists, and your right leg was put in a cast. You should
follow-up with the orthopedists after discharge.
While you were here, you also had a bleeding ulcer in your small
intestine. You were given blood transfusions, and the ulcer was
fixed.
You also developed inflammation in the liver due to alcohol use.
This is called "alcoholic hepatitis" and it is a serious
condition. You are being treated with prednisone for this. It is
very important that you do not drink alcohol any more. Even a
small amount of alcohol could cause your liver to fail and could
cause death.
We wish you all the best!
-Your ___ Team | ___ w/PMH of EtOH cirrhosis c/b varices, encephalopathy, mild
ascites and pancreatitis who was a pedestrian struck by a motor
vehicle found to have multiple traumatic fractures, but also
decompensated cirrhosis and upper GI bleed. She had the
following fractures:
1. Right posterior ___ and 6th rib fracture
2. An abdominal wall hematoma adjacent to a large recannalized
umbilical vein
3. Left fibula fracture
4. Multiple right tibia/fibula fracture - notably, right tibial
plateau fracture and right distal tibia fracture
She was not felt to be a surgical candidate and here fractures
were casted. She will follow in orthopedics clinic for
additional care.
She also had an upper GI bleed, and required transfusion of 6u
pRBCs. This was found to be due to a duodenal ulcer which was
clipped. Following this she did not have any additional episodes
of GI bleeding and remained hemodynamically stable. She did not
require transfusion after ___.
She also had elevated bilirubin and labs consistent with
alcoholic hepatitis. She was treated with prednisone and
responded well, with plan for a 4 week total course of
prednisone (___). A nasogastric tube was placed and she
was started on tube feeds. She did well and her bilirubin was
trending down at time of discharge. She will follow with the
___ additional management.
===============
ACUTE ISSUES
===============
#EtOH cirrhosis c/b grade 1 varices, encephalopathy, mild
ascites - Patient with most likely alcohol cirrhosis. She
currently was decompensated with encephalopathy and mild ascites
on exam. Child ___ class C, MELD-Na 22. Hepatitis serologies:
Immune to Hep A, negative Hep C, non immune Hep B. She was
treated with Lactulose PRN to ___ BM/day, Rifaxamin 550mg BID
and spironolactone 25mg daily. Nadolol was held until patient
can follow up at the ___.
# Alcoholic Hepatitis - Clinically met criteria for alcoholic
hepatitis. Patient with high discriminant function. Initially
had multiple contraindications to steroids with GI bleed and
___ but was able to start steroids ___. She responded well
with Lille score = 0.1 on day 7. She will continue Prednisone
40mg (___) for 28 days with Pcp ppx with ss Bactrim daily.
She also had a NG tube placed and started tube feeds for
nutrition supplementation. She should continue this until her
bilirubin normalizes. She will follow-up with liver.
#Upper GI bleed/Duodenal ulcer/Acute blood loss anemia - Patient
reported 1 week of melena, and presented with anemia. She
underwent EGD on ___ which revealed a bleeding duodenal ulcer.
This was injected with epinephrine. However, she had continued
bleeding, requiring further transfusion (6 units pRBC, 1u FFP,
1u platelets in total), so she had repeat EGD on ___, with
clipping of the ulcer. She was re-scanned (without contrast due
to rising creatinine) - there were no overt findings to suggest
bleeding source. She received Cefriaxone and Octreotide with
stable H/H and started pantoprazole BID. She did not have any
additional episodes of bleeding. She had been intubated for
these endoscopies, and was extubated uneventfully.
# MVC trauma with bilateral lower extremity fractures - Only
intervention was been reduction of R lower extremity. She was a
poor surgical candidate given high ___ class and
alcoholic heaptitis. Plan for cast to stay in place for 6 weeks
on RLE. No cast needed for LLE. Can use long air cast boot for
LLE if needed for working with ___. She should continue SQ
heparin for 4 weeks (___). She should continue nonweight
bearing R extremity, WBAT left extremity and follow up as
planned in orthopedics clinic.
#Abdominal wall hematoma: Noted on CT. She was transfused, as
above, and repeat CT did not show further bleeding.
#Acute blood loss anemia - From cirrhosis and GI bleeding and
abdominal wall hematoma. Stable but persistently low. On the
floor her counts were stable and she did not require any
additional transfusions.
# Rib fractures - Patient had moderate pain. RR normal. Pain
control with oxycodone, gabapentin and Tylenol.
# EtOH withdrawal - Arrived intoxicated with EtOH level >300.
Patient was found to be in withdrawal and started on phenobarb
protocol. No evidence of withdrawal currently. Completed
phenobarb ___ without additional complications. She started
folate, thiamine and MV and was counseled on abstaining from
etoh.
# Coagulopathy - Likely related to liver, perhaps some
nutritional aspect with heavy drinking. She received vit K x3
days (___).
# Depression: Continued fluoxetine 20mg daily and topiramate.
TRANSITIONAL ISSUES
=============
- Patient was started on prednisone 40mg daily for alcoholic
hepatitis to continue for 4 week course (___) with SS
Bactrim daily for pcp ___.
- She also started rifaximin and lactulose to prevent hepatic
encephalopathy.
- A tube feed was placed and she started tube feeds. She should
continue these until her bilirubin normalizes to baseline. She
started insulin glargine and Q6H HISS for blood sugar control.
- She was prescribed Tylenol, gabapentin and oxycodone for pain
control.
- She was counseled on abstaining from etoh and given thiamine,
folate and multivitamin supplements.
- Following GI bleed she was written for pantoprazole BID to
prevent additional bleeds.
- She will follow with ___ and ___ orthopedics
for outpatient management.
- consider starting nadolol in future for variceal prophylaxis
- Continue subcutaneous heparin for 4 week course (___)
for lower extremity fractures. | 140 | 863 |
12369417-DS-19 | 28,694,316 | Dear Mr. ___,
You were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. You received blood thinner medication
to break up blockage in major blood vessel as well as vascular
intervention to retrieve this clot.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
Diabetes
We are changing your medications as follows:
Please continue taking Eliquis 5mg twice daily
Please continue taking Atorvastatin 40mg every evening
Please continue taking Metoprolol XL 150mg daily
Please continue taking Digoxin 0.25 mcg daily
Please continue taking Lisinopril 2.5mg daily
Please take your other medications as prescribed. Upon
discharge, please arrange to have a cardiac event monitor to
monitor heart rate and atrial fibrillation.
Please followup with Neurology and your primary care physician.
Please follow up with Cardiology and consider seeing a
cardiologist near your home (below is a list). With their
assistance, you will be able to undergo a repeat ultrasound of
the heart with cardioversion after sufficient time has passed on
blood thinner medication. Please continue to work with physical
therapy, occupational therapy, and speech therapy as outpatient
(prescriptions provided).
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ with HTN, HLD, DM who felt right sided weakness and was
transferred to ___ where ___ showed hyperdense sign. NIHSS
was 15. He was given tpa at 11:25am. Repeat NIHSS was 10. He was
transferred to ___ for possible intervention. On arrival to
ED, NIHSS was 4. Imaging showed clot in the left M1 with large
area of mismatch on CT perfusion. There was significant
discussion regarding the risk benefit of thrombectomy. However,
as the patient was only 3 hours from his last known normal and
there was a significant portion of cortex at risk. The decision
was made to go for clot retrieval knowing that it was possible
that the patient would worsen significantly without
intervention.
.
Neurologic:
Pt was given tPA at ___ and underwent ___ clot retrieval
for L MCA thrombus. 24 hr post tpa showed a small degree of
hyperdensity in left frontal region consistent with evolving
infarct vs hemorrhagic conversion. ASA and SQH were started 24
hour after tPA. TSH 3.4. He was seen on MRI to have infarcts in
L MCA distribution. He was transferred out of Neuro ICU to ___
and monitored on q2 neurochecks. Heis exam was seen to improve
with only persisting nonfluent aphasia. He worked with ___
while inpatient. On ___, he underwent repeat NCHCT which was
negative for new hemorrhage and patient was started on Eliquis
for AC therapy. He was recommended for discharge home outpatient
___.
.
Cardiovascular:
He was found to be in atrial fibrillation with RVR that did not
respond to two doses of Lopressor. Diltiazem gtt was started and
titrated up for rate control. Patient was maintained with SBP
goal 100-180. Echocardiogram showed ___ dilation, no ASD,
severe global left ventricular hypokinesis (LVEF = ___ %),
right RV dilation with moderate mid to distal free wall
hypokinesis. He was later started on Eliquis for AC therapy as
noted above. He was switched to q6 Diltiazem titrated for
appropriate HR control while inpatient. Pt had continued
tachycardia with physical exertion with no relief from ___ rate
control agent (Metoprolol). He was evaluated by Cardiology and
underwent TEE with planned cardioversion on ___, although seen
to have mobile thrombus in left atrial appendage. He was started
on Digoxin with Diltiazem stopped. After discussion with
Cardiology and pt's family, decided to continue with Eliquis for
AC therapy >1 month prior to repeat TEE with cardioversion as
well as outpatient event monitor.
Endocrine:
Found to have undiagnosed DM with A1C 7.1. He was maintained on
Insulin sliding scale and diabetic diet.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed â () 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 = 90) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if | 358 | 512 |
11714071-DS-80 | 21,919,307 | Dear Ms. ___,
You were admitted to the hosptial for weakness from a urinary
tract infection and you recieved IV antibiotics which improved
your symptoms. Since you improved, we switched your antibiotics
to ones that you can take by mouth (called cefpodoxime). You
will need to continue taking these until your last two doses on
___.
While in the hospital we decided that your irregular heart rate
caused by atrial fibrilation is putting you at an increased risk
for having a stroke. To prevent you from having a stroke, we
started you on a blood thinner called apixaban. It does increase
your risk for bleeding, but we discussed the risks and benefits
with you and your primary care physician, ___ you
felt it would be better to take the blood thinner.
You need to make several follow up appointments which are listed
below. Your medication changes are also detailed in your
discharge medication list. You should review this carefully and
take it with you to your follow up appointments.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | ___ y/o with chronic foley p/w weakness and UA c/w UTI. In
addition pt had pacer placed ___ for symptomatic bradycardia
and has been complaining of chest discomfort since.
#Acute Complicated UTI with chronic foley
Foley replaced, new U/A showed leuks but (-) for nitrites.
Suprapubic pain improved. Likely cause of weakness. Started on
Ceftriaxone. Urine Cx grew klbesiela pan-sensitive.
-start cefpodoxime x7days 10 days total, last day ___
-Urology as outpt for chronic foley
#Non-cardiac chest pain
Improved ___ Pt. has been complaining of intermitant chest pain
since insertion of pacemaker. No improvment with nitro. Trop neg
x2. EKG showed no ST elevations/changes though paced.
#A. fib.
Seen on EKG, also noted in last hospital admission. Not
currently anticoagulated. Meets CHADS2-Vasc > 7. Spoke with PCP
___ and is agreeable to NOAC. Risks of stroke explained to pt.
Pt. agreeable to NOAC but not coumadin.
-d/w pharmacy re: initiating NOAC, recommended apixaban 2.5 mg
BID
#Itching
Pt. does have PNC allergy, but no rash is noted and rash has
improved throughout day. No trouble breathing. Hesitant to give
antihistamine given age.
-will monitor
# Chronic Kidney Disease: Baseline Cr appears to be 1.1-1.3.
Currently stable.
- Renally dosed meds
# DM: Home dose Lantus is 12 U QHS with wide swings in sugars
per pt.
Continued home glargine. HISS while in house.
# CAD: Stable, see above.
- Continued ASA 81mg (previously underwent desensitization)
- Continued home simvastatin
# History of stroke:
- Continued ASA 81mg (previously underwent desensitization) | 176 | 232 |
16773578-DS-17 | 23,752,693 | Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room! | ___ y/o M s/o R MCA clipping on ___ presents from rehab with
SAH. On exam, patient was following commands on the R side with
minimal movement in the L side. He was admitted to the
neurosurgery service, started on nimodipine and keppra and
SBP<140.
On ___, patient was taken to angiogram where he had 1 coil
placed in his R MCA aneurysm. The sheath remained in place and
he was started on a heparin gtt at 500 u/hr. Blood pressure was
liberalized.
On ___, the heparin gtt was stopped. The sheath was pulled,
pressure applied to the femoral artery site and he remained on
bedrest for an additional 6-hours. He underwent a head CT which
was stable.
On ___ the patient underwent CT scan of the head which showed
evolution of a right MCA territory infarct as well as a CT Brain
perfusion scan.
On ___ he developed left upper extremity tremors, TCDs were
obtained, his arterial line was discontinued, and neurology was
consulted to assist in his care given his extremity shaking. He
was ordered for continuous EEG and his Keppra was increased to
1500mg BID.
On ___ the epilepsy team recommended giving a 1 gram bolus and
increasing the standing Keppra dose to 2 grams BID. EEG
initially negative for seizure activity. He was started on
valium for dystonia likely secondary to basal ganglia stroke.
Head CT scan was stable.
On ___ left arm tremor improved with valium. EEG showed no
seizure activity therefore is was discontinued. Keppra taper was
started due to no seizure activity. Foley was discontinued. TCDs
were negative for vasospasm on the right; TCDs were unable to be
obtained on the left secondary to agitation and movement.
Physical therapy evaluated the patient with plans for dispo to
an acute rehab.
On ___, Mr. ___ underwent an angiogram which was negative for
vasospasm. He was seen by neurology who recommended tapering his
Diazepam which is used intermittently for tremors localized to
the left upper extremity.
On ___: the patient was transferred out of the icu after an
uneventful course. His Keppra wean to 500 BID was written and
he continued taking Nimodipine. On ___, the patient remained
stable and he was screened for rehab. There was no bed at
___. On ___, he remained stable and continued to wait for
a rehab bed. The patient had a + UA and was started on Bactrim.
On ___ he was discharged in stable condition to rehab. | 265 | 412 |
11152718-DS-24 | 23,561,267 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for fever in the setting of a past kidney
transplant. You also had headaches and blood in your urine.
What was done for me while I was in the hospital?
- In the hospital, you were found to have a urinary tract
infection. Your urinary tract infection was treated with
intravenous antibiotics. On discharge, you were given oral
antibiotics to be finished at home.
- You received tylenol to treat your fever and headache.
- You did not have any evidence of rejection or decline in
kidney function while in the hospital.
What should I do when I leave the hospital?
- Be sure to take all of your medications, listed below, exactly
as prescribed.
- Be sure to attend all of your follow-up appointments listed
below.
- You have been discharged on a 10 day course of antibiotics. Be
sure to take these medications exactly as prescribed and finish
the full course.
Sincerely,
Your ___ Care Team
MEDICATION CHANGES:
===================
New medications:
[ ] Ciprofloxacin 500 mg po bid for 11 days
Discontinued medications:
[ ] None
Held medications:
[ ] None | SUMMARY
Ms. ___ is a ___ year old female with PMH significant for
FSGS
s/p DDRT in ___ on belacept infusions monthly, tacrolimus, and
prednisone hospitalized for fever found to have pan sensitive E.
cli UTI in the setting of renal transplant. Improving on
antibiotic therapy with ceftriaxone. She received 3 days of IV
ceftriaxone in the hospital and was discharged with an
additional 11 day supply of ciprofloxacin for outpatient
treatment of UTI. Discharged afebrile with WBC of 4.8.
#Fever
#Pyuria/bacturia
#Hematuria
Patient febrile on admission with WBC as high as 17. Had one
episode of hematuria in the hospital. Also complained of
headache with accompanying fevers, both of which resolved with
tylenol. Urinalysis showed pyuria and urine culture grew
pan-sensitive E.coli. Patient received 3 d of IV ceftriaxone and
was transitioned to oral ciprofloxacin for an additional 11 days
on discharge. Hematuria and headache resolved.
#Rash
Patient developed a rash on ___. Initially there was concern
for drug reaction but the patient had received multiple
cephalosporins in the past without any adverse reactions.
Reaction was attributed to allergy to flowers which were in the
room, a reaction she has had before. The rash improved with
benadryl and shower and movement to different room.
#Tension headache
Patient had new gradual onset headache worse than she usually
experiences, across front of head, accompanying her fever.
Improved with tylenol and resolved at discharge.
#ESRD ___ FSGS s/p DDRT in ___
Cr of 0.9 at baseline on admission. S/p belatacept infusion on
___. Compliant with home immunosuppression. Continued home
immunosuppression with prednisone and tacrolimus. Tacro level
stayed within therapeutic range. BK viral load was <500.
Continuted home calcitriol and lamivudine for prophylaxis. | 202 | 267 |
17989869-DS-21 | 24,934,882 | -Continue VAC therapy to LLE knee wound. Change VAC dressing
every 3 days.
-Keep knee immobilizer ___ place at all times
-Adaptic + gauze to distal left lower extremity wounds (x2)
daily.
Rewrap with separate ACE bandage.
-Adaptic dressing changes to left forearm skin tear daily.
-Non-weight bear to LLE at all times.
.
Personal Care:
1. You will have a wound VAC dressing with a wound vac machine
___ place. This dressing will be changed every three days or so
when you return home.
2. While VAC is ___ place, please clean around the VAC site and
monitor for air leaks of the VAC
3. You may shower daily with assistance as needed. You should
do this with wound vac apparatus disconnected from you. Once
you have showered you will need to reconnect your dressing to
the wound vac apparatus and make sure it is functioning
properly.
4. No baths until after directed by your surgeon.
.
Activity:
1. Avoid strenuous activity with wound vac ___ place.
.
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. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take your antibiotic as prescribed if you are discharged on
one.
5. 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.
6. 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 ___ 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) or drain(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 ___ 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 ___ your symptoms, or any new symptoms that
concern you.
Physical Therapy:
NWB to LLE
Treatments Frequency:
-VAC change every 3 days
-Site: LLE
Type: Surgical
VAC- Suction: Continuous
VAC- Dressing: Black Foam
VAC- Target Pressure: 125 mm Hg
-Daily adaptic, gauze, ACE wrap to 2 LLE excoriations and 1 left
forearm skin tear.
-Knee immobilizer ___ place at all times
-Non weight bear LLE (uses walker)
.
PICC care per protocol
IV access: PICC, non-heparin dependent Location: Right Basilic,
Date inserted: ___
.
Ancef 2gm IV Q8H
Start Date: ___
Projected End Date: ___
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
.
WEEKLY LABS:
CBC with differential, BUN, Cr, crp
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
.
Blood sugar monitoring/control | # LEFT KNEE INFECTION (SOFT TISSUE, NOT JOINT)
Patient was taken to the OR on ___ with Ortho and Plastics for
wound exploration and debridement. The patient presented with
purulent drainage from the proximal
donor site of previous gastroc flap. Upon I&D by Dr. ___
(___), there was question whether the superficial abscess
communicated with the knee joint. Dr. ___ injected
dilute methylene blue into the left knee joint. No
extravasation of the methylene blue solution was visible at the
abscess site and the superficial abscess was deemed not
communicative with the knee joint. Plastics then proceeded with
incision and drainage left medial calf, application of negative
pressure wound therapy with instillation (Veraflo VAC). Cultures
were obtained and sent to microbiology. Patient tolerated the
procedure well. He was started on IV Vancomycin and Infectious
Disease consult was ordered. Patient was noted to have two skin
tears on his LLE and one on his left forearm which were treated
with daily adaptic dressing changes. VAC changes were every
three days to his left knee wound. He was maintained non weight
bearing to his LLE. All OR cultures grew MSSA and ID
recommended stopping vancomycin and starting ancef IV Q8H. A
PICC line was placed for plan for long term IV Ancef per ID.
Patient discharged with wet to dry dressing over his wound and
will undergo VAC placement at the rehab facility.
.
# CONSTIPATION
Patient was maintained on daily Colace and sennokot. On POD#2,
patient complained of constipation and dulcolax and miralax were
also added to bowel regimen. Despite multiple oral bowel meds,
patient became very uncomfortable and a Fleets enema was given.
Patient was able to have a large bowel movement and felt
immediate relief.
The patient otherwise had an uneventful hospital stay. He was
maintained on his home medications, including his home apixaban.
He remained hemodynamically stable and his vital signs were
routinely checked per protocol. | 577 | 329 |
19461484-DS-29 | 24,116,236 | You presented to the hospital with sudden onset of pain in your
left leg. You had an ultrasound and an MRI performed. Ultimately
you were found to have a strained muscle in your leg. You were
seen by our physical therapists. You should use heat pack and
compression wraps to help with the pain in your leg
You also complained of shortness of breath. There was no
evidence of pneumonia or blood clot on your scans. The shortness
of breath is likely related to your emphysema. You were treated
with inhalers.
It was a pleasure taking part in your medical care. | Pt is a ___ y/o F with PMHx of b/l cerebellar/pontine ischemic
stroke, DVT/PE on Lovenox, centrilobular emphysema,
hypertension, hyperlipidemia, CKD, hypothyroidism, who presented
with L leg pain suspicious for presumed ruptured popliteal cyst.
# Gastrocnemius Strain: Initially attributed to presumed
ruptured popliteal cyst; however, MRI performed and showed
gastrocnemius strain. She was seen by ___. Treated with heat and
compressions wraps.
# COPD with mild exacerbation: Pt also reported shortness of
breath, although she was not a great historian. There was no
acute process on CXR or CTA. She was treated with albuterol and
ipratropium and discharged on these inhalers. Recommend formal
PFTs if not performed recently as patient denies known diagnosis
of emphysema.
# DM2: Metformin held during admission. On ISS, metformin
restarted on discharge.
# DVT/PE: Imaging negative for acute thromboembolic event.
Continued Lovenox.
# HLD: Continued statin.
# HTN: Continued Atenolol.
# Hypothyroidism: Continued Levothyroxine.
# Prior CVA / Cognitive Issues: No acute issues at this time.
However, medication non-compliance raises concerns over her
cognitive issues. ___ arranged post-discharge to assist with
medication administration. | 99 | 178 |
11138821-DS-7 | 22,336,657 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
===========================
- You had worsening swelling of your parotid gland
WHAT HAPPENED TO ME IN THE HOSPITAL?
======================================
- You had imaging that showed an abscess of your parotid gland
as well as surrounding inflammation
- You were placed on antibiotics (IV Vancomycin, IV Ceftriaxone,
and oral Flagyl)
- The infectious disease specialists saw you, and ultimately
recommended transitioning to oral antibiotics (Linezolid and
Augmentin) for an additional 7 days (from ___
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
==============================================
- Continue to take all your medicines and keep your
appointments.
STUDY RESULTS FROM THIS HOSPITALIZATION:
=========================================
___ MRI IMPRESSION:
1. There is a loculated branching left intraparotid collection
with draining
sinus to the infra-auricular skin region through the
subcutaneous tissue with
underlying parotid gland swelling and ___ fat
stranding indicating
parotitis. Ultrasound-guided drainage/biopsy would be helpful
for further
evaluation.
2. The collection is in close proximity and inseparable from
the anterior
aspect left sternocleidomastoid muscle with underlying acute
edematous changes
and swelling raising suspicion of sternocleidomastoid
inflammatory
involvement.
3. There is no definite intraparotid mass lesion; however
further follow-up
till complete resolution of the abscess is advised.
___ L PAROTID FNA FINDINGS:
Fine needle aspiration, left parotid: NON-NEOPLASTIC.
- Numerous neutrophils and lymphocytes. See note.
- A few groups of spindled/epithelioid cells with reactive
changes, suggestive of granulation tissue.
Note: The granulation tissue and acute inflammation is
consistent with the patient's recent history of parotid abscess;
the numerous lymphocytes may represent sampling of an intra- or
___ lymph node. Overt evidence of a neoplastic or
mass-forming lesion is not seen in this sample; correlation with
clinical and imaging findings is recommended.
___ PAROTID ABSCESS MICROBIOLOGY:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ with left parotid abscess s/p recent
incision and drainage, s/p primrose drain removal and discharged
on augmentin (surgery ___ at ___, who presented with
fevers/chills, continual pain, and drainage from the incision
site - found to have continued parotid abscess, now s/p repeat
I&D and IV antibiotics, transitioned to PO antibiotics and
stable for discharge. | 370 | 60 |
17896834-DS-16 | 20,723,522 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were admitted to the hospital:
- You had severe pain in your right leg and it was cold to the
touch
- You were having chest pain and shortness of breath
What was done for you in the hospital:
- You had a CAT scan of you leg that showed a blood clot in the
arteries of your right leg.
- The vascular surgeons were consulted and recommended treating
your blood clot with a blood thinner medication, which made your
right leg feel better
- You had a PICC line placed in your right arm
- You received antibiotics to treat your urinary infection,
pneumonia, and bloodstream infection. Your infection worsened so
the infectious disease doctors were ___ and recommended
increasing your antibiotics, which was effecting at treating
your infection.
- You had some bleeding from your GI tract, related to the blood
thinner your were taking for the blood clot in your leg.
- To discover the source of the bleeding, you underwent an upper
endoscopy and a colonoscopy, neither of which showed any major
source of bleeding.
- You then swallowed a pill camera and had another procedure
called a single balloon enteroscopy that visualized your small
bowel more clearly and showed several areas in your small bowel
(called "AVMs") that likely were the source of your bleeding.
Some, but not all, of these lesions were treated in an effort to
stop your bleeding.
- You were given multiple blood transfusions to treat your
anemia ("low blood counts")
- You received a diuretic ("water pill") to help take off fluid
from your lungs given your history of heart failure. You also
received steroids and nebulizer treatments to treat your COPD.
Both of these were done to help improve your breathing and
oxygenation level.
-You received BiPAP each night for as long as you were able to
tolerate to optimize your COPD management.
What you should do after you leave the hospital:
- Please take your aspirin 81mg once daily.
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms, particularly of pain in
your right leg. If you do not feel like you are getting better
or have any other concerns, please call your doctor to discuss
or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ is a ___ year-old woman with h/o RA, COPD (on
chronic steroids and 3L home O2), remote DVT/PE and severe PVD
s/p LLE stent (___), admitted for RLE critical ischemia managed
non-invasively with anticoagulation, also found to have Proteus
UTI and pneumococcal PNA c/b bacteremia and presumed
endocarditis (TEE negative), with transfusion-dependent anemia
___ GIB i/s/o A/C for leg ischemia.
ACTIVE ISSUES
==============
# ISCHEMIC RIGHT LOWER EXTREMITY
# PERIPHERAL VASCULAR DISEASE
Pt with known peripheral vascular disease and presented with
acute ischemia of the right lower extremity. History of L groin
stent ___ years ago at ___ (___). Heparin gtt was initiated
with rapid improvement and patient was followed by vascular
surgery. Vascular surgery felt that no surgical intervention was
indicated, as shortly after initiation of anticoagulation,
pulses in the RLE quickly returned and the foot remained warm
throughout the remainder of her stay. TTE w/ bubble study showed
no signs of embolic source or intracardiac shunt. Patient was
started on atorvastatin 40mg QD. Was eventually transitioned to
combination ASA + apixaban. However, she continued to have
ongoing GI bleeding from AVMs in her GI tract (see below) in the
setting of the anticoagulation (both heparin and apixaban). She
was transitioned back to heparin gtt, then apixaban dose reduced
to 2.5 mg BID (given least risk of GI bleeding among the DOACs),
and then rivaroxaban 2.5mg BID, but she continued to have occult
GI blood loss and transfusion-dependent anemia on all these
anticoagulation regimens. After extensive discussion with the
vascular surgery and vascular medicine team weighing the benefit
of anticoagulation versus the risk of ongoing GI bleeding
requiring consistent transfusions, it was decided that she will
be discharged on aspirin 81mg monotherapy with close follow up
for returning symptoms of right leg ischemia.
# TRANSFUSION-DEPENDENT ANEMIA ___ SMALL BOWEL AVMs
Patient has chronic iron-deficiency anemia with Hb ___ in the
outpatient setting. Experienced Hct drop and melenic stools
after initiation of apixaban for her RLE ischemia, with
appropriate response to transfusion. She was switched to heparin
gtt with gradual stabilization of her Hb. To search for the
source of the bleeding, she underwent upper endoscopy with push
enteroscopy, which showed only a small angioectasia in her
proximal small bowel that was coagulated. Colonoscopy showed
diverticulosis and internal hemorrhoids but no angioectasias or
e/o active or recent bleeding. She then underwent capsule
endoscopy which showed a small non-bleeding erosion of the
antrum not visualized on prior endoscopy, as well as numerous
non-bleeding small bowel angioectasias. She finally underwent a
small bowel enteroscopy that identified 4 AVMs in the jejunum
that were coagulated, but the GI team noted that there are
likely other non-intervenable AVMs that are responsible for her
ongoing blood loss. During this admission, she had a total of 10
blood transfusions for Hb<7. The optimal anticoagulation to
prevent acute limb ischemia while minimizing risk of GI bleeding
was discussed extensively with the vascular surgery and vascular
medicine teams as stated above, and it was determined that any
more than one transfusion per week would not be a reasonable
goal. In this light, she was discharged on ASA 81 mg
monotherapy, with plans to monitor both her blood counts and her
right lower extremity closely.
# Pneumococcal pneumonia
# Bacteremia
# Native valve endocarditis
Initially presented with fever and marked leukocytosis to 38
with respiratory symptoms and radiographic evidence of
pneumonia. CTX/azithromycin were started for empiric treatment
of community-acquired PNA. CT chest showed consolidation of the
RML and LUL. Initial blood cultures subsequently grew out
streptococcus pneumoniae which was being adequately treated with
ceftriaxone 1g IV Q24H. Respiratory symptoms improved with
ongoing antibiotics and treatment of her COPD exacerbation
(detailed below). Was initially planned for a 14-day total
course of antibiotics, but after a nadir of 18.2 on HD#4, her
leukocytosis again worsened to a peak of 32 despite presumably
adequate treatment of her PNA. ID was consulted and felt her
clinical picture was concerning for endocarditis, and
recommended increasing her CTX to 2g IV Q24H for a 4-week total
course. Patient then underwent TTE as well as TEE (after already
having received 2 weeks of treatment) that showed no vegetations
or evidence of endocarditis, and only a small abnormality near
the aortic root that was better-characterized on follow-up CT as
just mediastinal fat. Repeat BCx have been negative x6.
# COPD exacerbation
GOLD stage D. With 100 pack-year smoking history. Patient has
chronic hypoxemic respiratory failure with 3L baseline
requirement. Was on prednisone 40 mg for one year prior to
admission; as per outpatient pulmonologist, she has not been
able to wean down from ___ mg given worsening of symptoms. No
PFTs in ___ system; most recent PFTs as per outpatient
pulmonologist are from ___ FEV1 of 45% pre albuterol
treatment and 47% post albuterol treatment. Briefly tried
weaning steroids down to 35 mg, but returned to home dose of 40
mg given worsening cough. Treated with albuterol, duonebs PRN.
Held home tiotropium, home formoterol, home budesonide
(nonformulary). Advair was given while inpatient 250/50 BID.
Home Flonase, nasal drops, loratadine, Mucinex PRN were
continued. Started Bactrim, vitamin D and PPI for prophylaxis
given chronic steroid use. Encouraged BiPAP use each night with
Ativan 0.5 mg prn to help alleviate anxiety/claustrophobia, but
she had difficulty wearing BiPAP for more than ___ hours most
nights.
# Acute on chronic HFpEF
TTE this admission reassuring, but TEE showing 1+MR, 1+TR and
new 1+AR. Was maintaining oxygenation above goal of 88-92% with
___ (home O2 is 3L). Diuresed with IV Lasix until euvolemic,
based on volume exam, daily weights, and laboratory data. Prior
to discharge, was transitioned to home furosemide 40mg daily +
IV Lasix PRN with transfusions.
- Discharge standing weight: 170.19 lbs
# PROTEUS UTI
On arrival to the hospital, Mrs. ___ reported dysuria. UCx
grew pan-sensitive Proteus that was adequately covered by the
CTX she was already receiving for her PNA. After a few days of
antibiotics her symptoms had completely resolved, but she
continued CTX for an additional 3.5 weeks for treatment of
presumed endocarditis.
# ACUTE KIDNEY INJURY
Elevated on arrival most likely from hypovolemic state while
septic. Resolved with fluid resuscitation.
# ATYPICAL CHEST PAIN
Pt initially presented with reports of sharp, stabbing,
post-prandial pain radiating to left shoulder, likely c/w GERD.
No ischemic changes on EKG, troponin negative x2. Had a similar
repeat episode while inpatient, which also showed no concerning
signs on EKG, troponin negative, and resolved with GI cocktail.
She would benefit from outpatient stress testing.
# HEMOPTYSIS
Few episodes of blood-tinged sputum likely ___ to
bronchitis/bronchiectasis. ___ have been precipitated by A/C on
top of poor lung substrate from emphysema and significant
smoking history.
CHRONIC ISSUES
===============
# RHEUMATOID ARTHRITIS: Continued on Hydroxychloroquine Sulfate
200 mg BID
# DEPRESSION/ANXIETY: Continued on Mirtazapine 15 mg QHS and
Lorazepam 0.5 mg QHS
# GERD: Continued Prilosec 40 mg every 12 hours.
TRANSITIONAL ISSUES
============================
[ ] Please monitor hemoglobin every ___ days (given history of
blood loss anemia in the setting of anticoagulation). Transfuse
for Hgb <7.
- If she continues to need transfusions (particularly if >
1x/week), may need to consider stopping her aspirin and monitor
the leg off anticoagulation and antiplatelet agents altogether.
[ ] Please monitor patient's extremity exam; if concerning for
new pain, pallor, pulselessness, or cold temperature in lower
extremities, please restart heparin gtt and bring the patient in
to the emergency room. Would need to consider invasive vascular
intervention at that time.
[ ] PICC was left in place due to her anticipated ongoing need
for lab draws in the coming weeks and difficult access. The PICC
was placed on ___, and should be removed by ___.
[ ] Please obtain daily standing weights. If weight increases by
>3lbs from discharge weight, please increase dose of furosemide
accordingly. Her home dose is 40mg PO daily.
- Discharge standing weight: 170.19 lbs
[ ] Please obtain repeat CBC in ___ weeks to follow up
leukocytosis and thrombocytosis. In the meantime, please monitor
for any localizing infectious symptoms. She completed her course
of ceftriaxone for S. pneumo bacteremia and possible
endocarditis on ___.
[ ] Please encourage patient to take BiPAP each night. She can
receive 0.5mg Ativan each night to help with her claustrophobia
prior to BiPAP.
[ ] Pt with iron deficiency anemia this admission. Would repeat
iron studies in ___ weeks to reassess iron stores after multiple
transfusions and ongoing PO iron supplementation.
[ ] Will need pneumococcal vaccination series.
[ ] CT chest showed multinodular thyroid, some nodules calcified
on the left. A dedicated thyroid ultrasound can be considered
for further evaluation on a nonurgent basis.
[ ] Pulmonary follow up: outpatient pulmonologist for outpatient
PFTs, outpatient sleep for BiPAP optimization
[ ] Continue to reassess ability to wean steroids for her COPD.
She has been on prednisone 40mg daily over the past year.
[ ] Please monitor electrolytes on furosemide, and consider
adding a potassium supplement if needed. | 461 | 1,468 |
16771388-DS-5 | 22,448,315 | Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Continue home IDDM regimen, including continuous glucose
monitoring, Lantus, SSI. Titrate as needed for glycemic control.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
- You were given information about headaches after TBI and the
impact that TBI can have on your family.
- If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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 | Dr. ___ was admitted to ___ on ___ for close
neurological monitoring after fall with traumatic SAH and IPH.
Upon arrival, a repeat head CT was performed showing stability
of the hemorrhage, and he was admitted to the TSICU. There was
also a question of UTI, therefore he was started on 3-day course
of Cetriaxone. Urine culture was negative. The patient's
neurological exam remained stable, with confusion but no focal
deficits. His hard cervical collar was cleared. A second repeat
head CT revealed interval evolution of the left parietal SAH and
right intraventricular hemorrhage of the lateral ventricle. He
was subsequently transferred to the inpatient floor. A foley was
replaced due to failure to void; this will need to be removed at
rehab for an additional void trial. He was seen by ___ with
recommendation to discharge to rehab. He has a history of IDDM,
on continuous glucose monitoring, with hyperglycemia during
hospitalization; ___ was consulted for assistance in
titrating insulin regimen. He was restarted on his home Lantus
with sliding scale coverage. HgbA1c = 8.1. He will need
outpatient follow-up with his PCP upon discharge. He was
discharged on ___ in stable condition. | 500 | 195 |
10404360-DS-29 | 25,791,092 | Dear Ms. ___,
It was a pleasure taking part in your care during your recent
hospitalization at ___. You
were admitted for cough and increasing weakness. You were found
to have a pneumonia, and treated with antibiotics for this. You
were evaluated by the physical therapy team, and it was
determined that it would be most safe to temporarily go to
rehabilitation to gain back strength.
Please continue to take your medications as prescribed. Should
you note any new or concerning symptoms, please seek medication.
We wish you the best,
Your ___ care team | ___ female with CAD s/p CABG, asthma, seizure disorder, afib, and
hypothyroidism presented with 1 week of productive cough and
progressively increasing weakness, found to have community
acquired pneumonia with course complicated by atrial
fibrillation with rapid ventricular response. Started on
azithromycin and ceftriaxone with rapid clinical improvement and
transitioned to PO azithromycin and amoxicillin for a total of 7
days of antibiotics. Her atrial fibrillation was treated with
increased metoprolol succinate. Patient was at her goal heart
rate of less than ___nd ambulation and was stable
on room air prior to discharge.
# Community acquired pneumonia: presented with productive cough,
weakness and with intermittent oxygen requirement with LLL
pneumonia on CXR. Treated with azithromycin and ceftriaxone
initially but transitioned to azithromycin and amoxicillin for a
7 day total antibiotic course ending ___. Patient improved
and was stable on room air without fevers or leukocytosis.
# Atrial fibrillation: course complicated by rapid ventricular
response to the 140s. Likely trigger was respiratory infection.
Home metoprolol was increased with guidance of cardiology
consult. Discharge dose is metoprolol succinate 150mg QD.
Recommend titration of this dose as needed with goal heart rate
less than 110 bpm. Workup notable for depressed TSH in the
setting of illness. Recommend rechecking TSH after resolution of
illness and dose adjustment of levothyroxine as appropriate.
# Weakness: evaluated by Physical therapy and recommended
rehabilitation. Patient ambulated with rolling walker.
CHRONIC ISSUES
# Seizure d/o: no evidence of seizure while hospitalized.
Continued home gabapentin and lamotrigine.
# Asthma: treated with home Advair, albuterol and ipratropium
nebulizers.
# CAD s/p CABG: continued home aspirin, atorvastatin and
lisinopril
# Hypothyroidism: TSH was low in the setting of illness,
continued home levothyroxine dose and recommend repeating TSH
after resolution of illness.
# Anemia: near baseline according to previous labs for last
several years. | 90 | 296 |
19481153-DS-17 | 24,003,367 | You were admitted to the hospital with left sided abdominal
pain. Your cat scan findings were concerning for sigmoid
diverticulitis. You were placed no bowel rest and started on
antibiotics. You abdominal pain has now resolved and you have
resumed eating. You are being discharged home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* Recurrence of abdominal pain
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered | ___ year old female admitted to the hospital with nausea,
vomitting, and abdominal pain. Upon admission, the patient was
made NPO, given intravenous fluids, and underwent cat scan
imaging of the abdomen which showed acute sigmoid diverticulitis
with scattered foci of free air concerning for contained macro
perforation. The patient was started on a course of
ciprofloxacin and flagyl and placed on bowel rest. The patient's
pain was controlled with intraveous analgesia. On HD #2, the
patient's abdominal pain began to resolve and she was started on
a clear liquid diet and advanced to a regular diet. Her vital
signs remained stable and she was afebrile. The patient was
discharged home on HD #2 in stable condition. An appointment
for follow-up was made with the acute care service to address
the need for surgery for her recurrent diverticulitis.
*********Patient informed of cat scan imaging. Cat scan report
given to patient. Finding of enlarged uterus, endometrial
thickening vs adnexal cyst. Rec. for pelvic US if patient is
post-menopausal. | 203 | 175 |
11404988-DS-6 | 27,094,964 | Dear Ms. ___,
You were admitted to ___
because you seemed very tired and were not eating. While you
were here, we found that you have a urinary tract infection, and
we treated you with antibiotics. We also found that you were not
urinating, and we put in a foley catheter so that you could let
go of urine. Finally, we found that you have some blood clots in
your legs and we started you on a blood thinner for this. Over
your hospitalization, you got less tired and seemed more like
yourself. Your urinary tract infection also improved with
antibiotics.
When you go home, remember to take all your medications as
directed. Remember that it will be very important to continue
eating and drinking enough. Please follow up with you primary
care doctor as well as a urologist for your urinary problems.
Thank you for letting us care for you here,
Your ___ care team | The patient is a ___ year-old female with a past medical history
of Peripheral vascular disease complicated by necrotizing
fasciitis status-post above-the-knee amputation in ___,
Hypertension and diabetes who presents for evaluation of altered
mental status. She was found to have a new anemia as well as a
urinary tract infection with bilateral pyelonephritis. She was
started on Ceftriaxone with resolution of encephalopathy and
improvement in dysuria, with switch to oral ciprofloxacin prior
to d/c. She was also found to have urinary retention of
approximately 1L multiple times during hospitalization, and she
was catheterized and sent to rehabilitation facility for a trial
of voiding. Finally she was discovered on ultrasound to have
bilateral DVTs and started on apixaban. | 152 | 118 |
18810205-DS-12 | 23,046,263 | Dear Mr ___,
You were transferred to ___ to have a pacemaker placed
after evaluation of your symptom for near fainting showed and
EKG with heart block.
A dual chamber pacemaker(MRI compatible)was placed
Activity restrictions and care of the pacemaker site are in the
nursing discharge instructions
Please continue all your usual medicines except the Xarelto has
been stopped due to the new finding for cancer.
an antibiotic will be take for 3 days. This has been faxed to
your Stop and Shop for pickup on the way home. Please take all
of this medication, it was ordered for prophylaxis to prevent
infection following placement of your pacemaker. | # Cardiac: Afib/sick sinus syndrome
___: placement of ___ dual chamber pacemaker
via left axillary vein
Post procedure recovery uneventful. Low dose metoprolol and
flecainide were restarted the evening post procedure. He
remained in NSR. Xarelto stopped as contraindicated in his
diagnosis for metastatic brain cancer.
# Oncology
f/b Dr ___ at ___. Recent diagnosis
for metastatic NSCLC with a primary LUL lung mass found
incidentally on CXR as well as mediastinal lymphadenopathy, an
adrenal met and 4 asymptomatic brain metastases found on MRI.
Radiolog oncology has arranged follow up and recommend
continuing dexamethasone 4mg QD. Consult also placed with
neurology oncology. He has an appointment at ___ ___ for a
second opinion for treatment strategies. | 109 | 115 |
19034608-DS-8 | 27,695,534 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted with fever, headache and
left arm swelling. Your fever and headache were likley due to a
viral illness and improved. You were also found to have a blood
clot in your left arm. You were started on an injection blood
thinner and a medication called Coumadin. You will need to
continue the injections until your INR (a lab test we use to
monitor coumadin) has been between ___ for 48hours. Your primary
care physician ___ follow your coumadin levels.
You also were found to have very low blood pressure on standing.
This improved with intravenous fluids. It may have also been due
to your sleeping pill, Doxepin. You should hold this medication
until you speak with your doctor. No other changes were made to
your medicaitons. | This is a ___ y/o female with history of recent MI, CAD,
hypertension who presents with fever, back pain and LUE
swelling, found to have occulsive thrombus of left basillic
vein.
#Acute DVT
___ with LUE edema and evidence of DVT on ultrasound.
___ also reports she was told she had a lower extremity clot
while in the ___, although was not discharged on
anticoagulation. CTPE in the ED was without pulmonary embolus.
___ did not show clot in lower extremities. Given family
history of clot, may benefit from hypercoaguable work up,
although given personal history of PE, will likely require
lifelong anticoagulation. The ___ was started on Coumadin
with Lovenox bridge. INR on discharge is 1.2. The ___ will
follow up with her PCP for INR monitoring.
#Fever, headache
___ with fever and headache. WBC count normal and no other
localizing symptoms of infection. ___ have fever from DVT. U/A
unremarkable and CT without signs of pneumonia. Fever and
headache resolved prior to discharge. Fever was likely due to
viral infection.
#Orthostatic hypotension
On the day of discharge the ___ was noted to be orthstatic.
She was given a dose of Doxepin, her home sleep aid, the night
prior which may have contributed. She received 1L of IVF and was
no longer orthostatic. She was advised to discontinue Doxepin
and discuss different sleep aid with PCP.
#CAD, native vessel
#Chronic diastolic CHF
Unclear if ___ was hospitalized in the ___ or
for unstable angina. ECHO was repeated during this
hospitalization and was relatively unchanged. No changes were
made to cardiac medications. THe ___ was continued on
BBlocker, Plavix, ASA, Statin and ACEI. Furosemide was held
during admission but resumed on discharge. The patent has follow
up scheduled with her cardiologist.
#Hypertension, benign
Continued medications as above
#Hyperlipidemia
Continue Statin (substitute for Vytorin which is nonformulary)
#Memory problems?
___ daughter reports recent memory problems sicne return
from ___. Question if related to depression vs.
delirium after recent hospitalization there. ___ was AAOx3
and appropriate throughout her hospitalization. Would benefit
from additional evaluation as an outpatient. | 142 | 334 |
15636979-DS-10 | 29,216,467 | Dear Ms. ___
,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for high blood pressure and nausea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with medications to lower your blood
pressure.
- You were monitored closely to endure blood pressure stayed
within an acceptable range
- You underwent ultrasound to rule out renal artery
stenosis(narrowing of your kidney vessels).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY
=============================================
Ms. ___ is an ___ y/o female with a history of HTN, HLD, CKD
stage IV, afib on apixaban, ___ s/p right nephrectomy, and
collagenous colitis who presents with hypertension to 200s and
nausea, treated with IV and po medications
ACUTE CONDITIONS
=========================================
#Hypertension
Chronic history of HTN with BP in the 150-160s as an outpatient,
presented with SBP in the 220s. EKG/troponin, BMP, and
neurologic exam without any signs of end-organ damage to suggest
hypertensive emergency. Etiology of hypertension progression
unclear, likely essential hypertension with poor blood pressure
control vs ___ pain and nausea. No hx of known substance
use/exposure. Started on nitro gtt in the ED, titrated down and
weaned off while uptitrating and/or making changes to home
medications. S/p renal ultrasound which showed no renal artery
stenosis. BP has been under control with 7.5-10mg of amlodipine,
12.5mg BID of carvedilol, 25mg of chlorthalidone and home dose
aliskiren 150mg daily.
- Pt discharged on 5mg amlodipine daily, 12.5mg carvedilol BID,
25mg chlorthalidone daily and home dose aliskiren.
#Nausea
#Acid reflux
Describes ___ days of acid reflux and nausea following opioids,
which have caused vomiting in the past. Possibly med-induced,
though the persistent symptoms is concerning for another
etiology. No signs of cardiac ischemia, intracranial process or
other GI symptoms to suggest an acute intrabdominal process.
Treated with zofran and continued home famotidine. Nausea
improved with treatment.
#Leukocytosis
___ 13 on admission. Suspect a stress response from pain and
hypertension. No infectious symptoms. WBC trended down to 11 on
discharge. | 125 | 229 |
12017101-DS-4 | 24,911,607 | You were admitted to the hospital with abdominal pain. An
abdominal CT scan was revealing for acute appendicitis,
therefore, you underwent a laparascopic appendectomy.
Post-operatively, you recovered in the hospital. You were given
antibiotics which you will need to take for a total of 7 days.
Additionally, 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. | Ms ___ presented to the ___ Emergency Department on
___ with one-day history of abdominal pain, worse
in the right lower quadrant, with associated chills, anorexia
and nausea; leukocytosis with a left-shift was also present. An
abdominal CT was obtained and preliminary reports were
suggestive of a 'dilated fluid-filled appendix with an
appendicolith and surrounding stranding' consistent with acute
appendicitis. The patient was subsequently given intravenous
cefazolin and metronidazole and taken to the operating room
where she underwent a laparascopic appendectomy; please see
operative reports for details. Post-operatively, the patient
was taken to the PACU for recovery where she was extubated.
Once deemed stable, she was transferred to the general surgical
ward for further observation.
On POD1, the patient remained afebrile with stable vital signs.
Intravenous antibiotics including ciprofloxacin and
metronidazole, which were initiated post-operatively, were
transitioned to an oral regimen . Pain was initially managed
with Vicodin, but transitioned to oxycodone with good effect.
The patient's diet was advanced to regular, which was well
tolerated. Additionally, she was voiding adequately and
ambulating independently. The patient was subsequently
discharged to home. She will continue oral antibiotics for a
total of 7 days and will follow-up with Dr. ___ in clinic 2
weeks from discharge. | 261 | 215 |
11180696-DS-5 | 23,025,237 | Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted for vomiting and abdominal swelling, and were
found to have pancreatic cancer. After seeing multiple
specialists, and it was determined that the best treatment is
urgent radiation therapy. After speaking with you and your
family, you had a strong preference to return to ___ for
treatment and an expedited transfer was arranged.
During your stay, you developed a pneumonia and started on
antibiotics. You will continue treatment at ___.
Wishing you well,
Your ___ Medicine Team | ___ with new pancreatic head mass and peritoneal carcinomatosis
p/w GI bleed in setting of erosion of tumor into stomach.
# Pancreatic mass
# GI bleed
Patient with recently diagnosed pancreatic mass complicated by
GI bleed secondary to mass erosion into the stomach. Patient
treated with IV PPI and H/H stabilized with resolution of
hemetemis, albeit patient had intermittent episodes of biliary
emesis. On ___, the patient underwent EGD and noted to have a
circumferential ulcerated fungating mass of about 2 cm in length
in duodenal bulb. Biopsies were obtained and are pending at the
time of discharge. An NJT was also placed for feeding. He was
evaluated by the hematology/oncology service who recommended
palliative radiation to control bleeding duodenal mass. Patient
would like to pursue palliative radiation therapy and the family
would like to have this done at ___ and transfer was
arranged. Additionally, patient was evaluated by palliative care
who recommended starting Reglan 10mg TID and dilaudid 0.5 IV q4h
for pain. He will need ongoing involvement from palliative care
for symptom management moving forward. Radiation oncology team
at ___ aware of the patient and can begin with radiation
treatment ASAP.
# Aspiration pneumonia:
Patient with new 02 requirement over the weekend ___ after an
episode of nausea/vomiting and likely aspiration event. CXR with
evidence of possible aspiration pneumonia. Initial concern for
aspiration pneumonitis. However, given persistent and rising 02
requirement, patient was started on Vanc/cefepime on ___. He
endorsed improvement in dyspnea on ___ and ___ requirement has
decreased from 4L to 2L nasal cannula. He is transferred on
Vanc/Cefepime. MRSA swab pending. Consideration of transition to
levofloxacin to complete course for aspiration/HCAP pneumonia.
# CKD:
Renal function at baseline with Cr of 1.4. He received
intermittent IVF to replete GI losses from persistent emesis.
# Leukocytosis:
Likely secondary to underlying malignancy, though cannot rule
out that may be in part secondary to aspiration event as above.
# Hyponatremia:
Patient presented with Na 125 on admission. Likely secondary to
underlying malignancy/SIADH. Sodium remained stable throughout
admission and is 128 on transfer. | 92 | 342 |
14827799-DS-14 | 29,063,811 | You were admitted to the hospital with a infection of your hand
as the result of a cat bite. You had a small bedside surgery to
open up your wound by the Plastic Surgeons. You will need to
take antibiotics for 1 more week following discharge. You will
need to see the surgeons in follow-up in clinic. You were also
seen by your Cardiologist in routine follow-up while you were
hospitalized (you were scheduled to see him in Clinic during
your hospitalization). You should continue your current
cardiovascular medications and you should follow-up with Dr.
___ in ___ year.
.
Please take your medications as listed below.
.
Please follow-up with your doctors as listed below.
. | ___ with CAD, admitted with cellulitis of hand following Cat
bite:
.
# Right Hand Cellulitis ___ Cat Bite: Clinically stable. s/p I&D
at bedside by Plastics. No fever, LAD or drainage. Labs WNL and
blood cultures with no growth to date. Following I&D, his hand
was soaked in betadine soaks, wrapped in dressing, supported in
brace and elevated. He initially was placed on IV Unasyn, and
given stability, was transitioned to PO Augmentin. He was
deemed stable by Plastics for discharge to home on ___ on PO
antibiotics with outpt f/u on ___.
.
# Thrombocytopenia / Anemia: He has a mild thrombocytopenia and
anemia. No evidence of active bleeding. He will need CBC
re-check at f/u with PCP and further ___ as indicated.
.
# CAD, native vessel: No active chest pain. Followed by Dr.
___.
- Continued ASA, Statin, B-Blocker, ___, Imdur, PRN Nitro
- He was scheduled to see Dr. ___ in Cardiology ___ on
___, but was still hospitalized. Dr. ___ see him at
the bedside as an inpatient, recommended continuing his current
medications and to see Dr. ___ in clinic in ___ year.
- Of note, he has stable bradycardia with HR in the 40-50's.
This is chronic for him. Dr. ___ continuing
his Atenolol at the current dose.
.
# HTN: Stable. Essential HTN.
- Cont B-Blocker, ___, Amlodipine, Imdur
.
# Gout: Asymptomatic, continued allopurinol.
.
# Hyperlipidemia: Stable.
- Contined Statin.
.
# GERD: Stable.
- Cont H2 blocker
. | 118 | 275 |
11378589-DS-7 | 21,448,326 | Dear Ms. ___,
You came to the hospital because you were having seizures and
issues with your memory at home.
We imaged your ___ to make sure that you did not have any
bleeding. We found that you had a urinary tract infection and we
started you on antibiotics. Your memory issues improved after
the treatment was started. The neurology team also saw you for
the seizures and you had an MRI of your ___ to look for
evidence of new strokes. It did not show that you had a recent
stroke. We also made sure that you were continued on your
seizure medicine (Keppra) that you were taking at home.
Please take the medicines prescribed to you in the hospital.
Please also follow up with your primary care doctor (___) at
___ within 5 days of discharge.
We wish you all the best in your continued recovery!
-Your ___ Care Team | Ms. ___ is a ___ with hx of ETOH use d/o, alcoholic
cardiomyopathy, provoked seizures in the setting of alcohol
withdrawal, chronic hyponatremia, hx of TIA in ___ and PVD s/p
left BKA presenting as OSH transfer iso confusion/AMS and
witnessed seizure with concern for underlying infection versus
subacute stroke process versus alcohol withdrawal.
#Witnessed Seizure
#Toxic-Metabolic Encephalopathy
#Sepsis ___ UTI
#Abnormal EEG
Patient presented to ___ with increased confusion and
somnolence with possible witnessed seizure by her husband at
home. At OSH, she had two additional possible focal seizure
episodes (R-sided eye deviation and R-sided facial twitching)
for which she was given Ativan and loaded with keppra and
transferred to ___. Work-up there also notable for fevers as
high as 102 and a leukocytosis of 14. Upon arrival to ___,
febrile to 101. Initial concern for provoked seizure associated
with underlying infection (UTI vs. meningitis). Lumbar puncture
attempted x3 in ED but unsuccessful. Initially on empiric
treatment for meningitis, but based on repeat exam, no
meningismus. Greater concern for UTI given +UA. OSH Ucx ___ +
for 50-100k Enteroccocus, so started on ampicillin monotherapy
___ for complicated UTI tx. Transitioned to vancomycin pm ___
in the setting of ampicillin-resistance on final cx
sensitivities. Ultimately transitioned to tetracycline to
complete a 7 day course (through ___ first full day of
antibiotics). Bcx with no growth throughout admission. Per
neuro, also concern for possible underlying new subacute stroke
(or recrudescence of old stroke) as contributory to AMS and
seizures, especially given 24h EEG at time of admission
___ showing L temporal slowing. MRI Brain ___ w and w/o
contrast not concerning for acute or subacute stroke process or
obvious seizure focus. Stroke labs pursued and wnl. Continued on
home atorvastatin and aspirin for stroke risk factors, and also
maintained on Keppra 500mg BID given abnormal EEG and prior
abnormal EEG ___. Throughout admission, alcohol withdrawal also
maintained as possible cause of acute changes in mental status.
Patient was kept on CIWA during admission, and scored >10
consistently through ___ requiring frequent Ativan 2mg PO,
occasionally IV when not taking PO well. Had no documented
seizures while inpatient. There was also some concern for
Wernicke's encephalopathy on admission, so she completed 3 days
of high dose thiamine, but notably lacked some of the classic
neurologic findings. She was mentating well and was AxOx3 and
with good attention on neurologic testing, back to baseline per
her husband. ___ by speech and swallow given AMS and
recommended soft diet, which patient accepted. Screening by
___ and cleared for home.
#Alcohol Use Disorder
#History of Alcohol Withdrawal Seizures
Patient has known history of ETOH use d/o with reported alcohol
withdrawal seizures. Last known drink was ___. Stox negative
for ethanol on admission. No seizure activity observed during
admission, although with two observed seizures at OSH (R-sided
facial twitching and R-sided eye deviation). Scored on CIWA
through ___, requiring frequent Ativan (initially q2hr).
Patient maintained on three days of high dose thiamine given
risk of Wernicke's Encephalopathy as above, and then
transitioned to home thiamine regimen. Also maintained on folate
and MVI. ETOH cessation assistance was offered several times
and she declined it.
#Malnutrition
Patient appeared cachectic with low BMI, concerning for
malnutrition. Albumin 3 at time of admission. Malnutrition
likely ___ to heavy alcohol use. On numerous home vitamin
supplements. Nutrition consulted and recommended additional
Ensure supplements at mealtimes during inpatient stay. Other
home vitamins/supplements held during admission given changes in
mental status, but restarted at time of discharge.
#Skin changes
Patient noted to have diffuse scaling on RLE with erythema which
appeared chronic, and developed overlying ecchymosis likely due
to trauma while rolling around the unit in wheelchair. She
remained asymptomatic from this. Consider dermatology referral.
#History of CVA:
Patient has history of CVA with reported residual right sided
weakness in ___. Continued on home ASA, atorvastatin.
MRI showing chronic stroke-related changes, but was not
concerning for acute or subacute stroke process.
#Hypertension:
Patient continued on home metoprolol and Lisinopril.
Hypertensive during admission likely exacerbated by alcohol
withdrawal. Normotensive at discharge.
Transitional Issues:
============
[ ] Ensure back to baseline mental status, AxOx3 with good
attention on neurological testing at time of discharge
[ ] Should continue on tetracycline through ___
[ ] Keppra downtitrated to 500mg BID in hospital, recommend PCP
refer to neurology to titrate Keppra dosing
[ ] Seen by speech and swallow and was recommended for soft
(dysphagia) diet; please continue to reassess and consider
outpatient speech and swallow evaluation
[ ] Continue to address alcohol cessation
[ ] Patient reports she has had UTIs in the past and had urinary
incontinence during hospitalization, unlikely to be retaining
given presumed PVRs but please consider Urology referral for
further workup
[ ] Consider dermatology referral for skin changes on RLE | 149 | 785 |
11401045-DS-21 | 29,315,809 | Discharge Instructions
Brain Tumor
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches Feeling more tired or
restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
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
Right Humerus Fracture:
- Recommend sling for immobilization and comfort
- Activity: non weight bearing to Right upper extremity | #Meningioma
The patient was admitted for incidental findings of a
meningioma. She underwent a MRI of the brain on ___ to further
evaluate the lesion. A formal neuro oncology consult was ordered
and the patient was seen and evaluated by Dr. ___. The
patient will follow up as an outpatient with Dr. ___ Dr.
___ in 4 weeks to determine if a surgical plan is appropriate
for her case.
#Right Humerus Fracture
The patient was found to have a right humerus fracture and
placed in a sling prior to transfer. A formal orthopedic consult
was ordered on ___ and recommendations were appreciated. She
remained in a sling for comfort and immobilization and was
instructed to follow up with orthopedics as an outpatient.
#Dispo:
The patient was cleared for safe discharge to home with home
___. | 272 | 133 |
14458979-DS-5 | 24,910,158 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain and lab
values concerning for infection. You had a CT scan of your
abdomen that showed possible infection in your colon
(diverticulitis). We had the surgery team see you given concern
for appendicitis (infection of your appendix and need for
possible removal of your appendix). Ultimately they did not feel
you had this. You improved on antibiotics. We also increased
your stool softners (laxatives) to help with constipation. When
you leave the hospital you should continue antibiotics for an
additional 8 days. You should see your primary care doctor and ___
have referred you to a GI doctor as well
(Gastroenterologist/Abdomen doctor). | Assessment and Plan:
___ year old male w/PMH of gastritis and COPD presenting with
RLQ/RUQ pain with CT findings concerning for colitis or
diverticulitis that improved with initiation of antibiotics.
#Abdominal pain: Likely related to diverticulitis seen on CT.
Evaluated by surgery for possible appendicitis but surgical team
did not feel he had appendicitis and felt diverticulitis and
constipation more likely. He was discharged with on oral
antibiotics to follow-up with his PCP and with GI referral to
consider colonoscopy.
-continue IV Ciprofloxacin/Flagyl 10 day course through ___
-GI referral made for possible colonoscopy
-Discharged with bowel regimen for possible contribution from
constipation per surgery team.
#Miscroscopic Hematuria- UA with trace blood and 14 RBCs, no
leuk/nitrite/bacteria; urine culture sterile. Will need repeat
UA and possible urologic evaluation
-repeat UA/Urologic eval
#H.pylori positive on endoscopy ___ with esophagitis and
gastritis noted.given patient did not obtain proper therapy
(took once daily). Patient may need to repeat therapy for H.
Pylori eradication but will defer to PCP/GI team.
-Consider retreating for H. Pylori
-GI f/u | 113 | 167 |
12395220-DS-11 | 24,784,582 | Dear Ms. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to chest pain. You had cardiac
enzymes checked which showed no evidence of a heart attack. You
had 2 stress tests which were reassuring. You were found to be
in a rapid heart rhythm (atrial fibrillation) and your
medications were adjusted.
After discharge, please follow up with your physicians as
described below. | ___ y/o female with PMHx of atrial fibrillation, CVA, HTN, HL,
CKD who presents with right-sided chest discomfort for the past
10 days.
# Chest pain: She presented with 10-days of intermittent
right-sided chest pain, without clear trigger. The patient does
have discomfort when swallowing, raising the possibility of a
component of esophageal spasm (though she thinks this is a
distinct sensation). Of note she saw ENT in ___ and was
diagnosed with esophageal dysmotility. ETT performed on ___ in
the ___ ED with anginal symptoms and nonspecific EKG changes.
She was continued on metoprolol and aspirin was initiated. Home
nabumetone was discontinued. Stress MIBI on ___ showed no
evidence of inducible cardiac ischemia.
# Paroxysmal atrial fibrillation: CHAADS-VASC score of 6. She
presented in atrial fibrillation, then spontaneous returned to
sinus rhythm. She subsequently returned to ___ fibrillation
with RVR in 140s. She had metoprolol titrated for rate control
with inconsistent effect. She was started on amiodarone and
subsequently returned to sinus rhythm. Dabigatran was
discontinued during hospitalization ___ to GFR~30. She was
transitioned to apixaban on discharge. She was discharged with a
___ of hearts monitor.
# HLD: Home cholesterol regimen had been fenofibrate 145 due to
?intolerance to statins. She was initiated on a statin while in
house and tolerated it well. | 71 | 213 |
11201605-DS-9 | 28,837,818 | Ms. ___,
You were admitted to ___ for evaluation of
abnormal left sided facial sensation. You described that your
right cheek felt "heavy" and possibly weak. Of note this was in
the setting of a low INR of 1.8 since per your report you had
missed Warfarin dose and ate spinach.
Your INR while admitted was 1.9 and therefore you were restarted
on your home dose of Warfarin. No changes were made to your
medication and we recommend you continue to take your
medications as prescribed.
We recommend you follow up with your PCP and primary neurologist
(Dr. ___ within 2months of discharge.
We believe your symptoms are related to your underlying
diabetes. Sometimes individuals with diabetes can have
neuropathy (nerve abnormality) which can lead to sensation
changes in the body. We recommend that you have a facial
neuropathy nerve test as outpatient. | Pt is a ___ yr F w/ PMH of Afib on Coumadin, hx of ?TIAs,
uncontrolled DMII, HTN, and HLD who presented for acute onset of
R sided sensory changes in lower face. Code Stroke called w/
NIHSS of 1 for right sided facial droop. Repeat neurological
exam showed resolving R lower facial droop, otherwise stable.
Neuroimaging was negative for stroke. Last INR noted to be 1.9,
therefore heparin bridge was not initiated. No changes were made
to home medications. ___ only had symptoms in V2-V3 area of
left lower face, no upper face involvement. She has had 5
lifetimes episodes that were similar. Distribution and absence
of other symptoms does not fit with typical TIA. Suspect
symptoms may be due to uncontrolled diabetes leading to
neuropathy of a branch of the right CN VII.
Hospital course by system:
# Neuro
While admitted, ___ had similar report of right sided facial
"heaviness" which self resolved in approx. 20min. There was no
visible facial droop, no facial weakness on testing and some
mild temperature deficit in v2-v3 area of right face. BP at time
of event was 147/72 and finger stick showed BG of 229.
- Stroke risk factors: A1c 8.9, TSH 1.5, ldl 42
- MRI brain w/o contrast --> No evidence of infarction, edema,
or mass. Punctate right frontal lobe microhemorrhage, perhaps
related to
hypertension.
- Home Coumadin continued
- Maintained euglycemia and normothermia
- SBP allowed to autoregulate with Goal SBP <200 an DBP <120
- No need for ___ consult
- ___ passed RN Bedside swallow and transitioned to po
intake
- Distributed stroke education packet
- Continued home statin
# Cardiopulmonary:
- Monitored by telemetry
- Goal SBP <200 an DBP <120. Held home BP meds and halved B
blocker at Metoprolol Tartrate 12.5mg BID
# Endocrine
- QID FSG with HISS
- Held home Metformin
# Hospital Issues:
- PPX: pneumoboots, Colace, Coumadin
- Code status: Full
- Dispo: d/c home | 143 | 311 |
12522208-DS-8 | 23,355,965 | Dear Mr. ___,
You were admitted to the hospital because of a diabetic crisis
that resulted from not taking your insulin properly. You had
issues with insurance and pharmacy that caused you not to be
able to take the insulin you needed. We also found that you had
a UTI. We made sure that your long acting insulin was available
from the pharmacy. We had to change your mealtime insulin from
Novolog to Humalog because of a restriction by your insurance
company. Take them exactly the same. Use the scale your diabetes
doctor has given you. We provided you 2 free sample Humalog pens
to use until your PCP gets you prior authorization straightened
out. We also gave you a prescription for 3 more days of
antibiotics to treat your UTI. If you have trouble, ask for
help. Call Dr. ___ Dr. ___ come to the emergency
room. If you have trouble with the pharmacy, call your ___
Free Care Insurance at ___.
Best Wishes,
Your ___ Care Team | ___ with ESRD on HD (MWF), DM, and ___ 3+4 prostate cancer,
who presents after rigors, nausea, and abdominal pain at
dialysis, then found to be hyperkalemic and with hyperglycemia
and elevated anion gap concerning for DKA.
#DKA: Hyperglycemia and metabolic acidosis with positive anion
gap. No lactate elevation to suggest lactic acidosis. Per
recommendations of renal dialysis team, will he was treated for
DKA. Cause of DKA likely to be non-compliance with insulin;
patient told ED providers he ran out of one of his insulin pens.
He also was found to have urinary incontinence and a UA
consistent with UTI, which may also have contributed to his
development of DKA. Medical records notes from both PCP and
___ provider indicate insurance and pharmacy issues with
insulin prescriptions. He is unable to recount his insulin
regimen. He was continued on an Insulin drip until anion gap
closed. Fluids were given gently as he does not make significant
urine. Despite several amps of bicarb and insulin drip, his
bicarbonate persistently was ___, suggesting ongoing acidosis.
Dialysis was performed ___ for acidosis. He was started back on
his home lantus and Humalog was substituted for his home
novolog. His pharmacy confirmed that his lantus prescription was
available and that his Humalog prescription was on hold awaiting
prior authorization. The patient was not able to communicate
what issues he was having getting his prescriptions filled, nor
was he able to indicate what he had at home and what he needed.
Social work met with the patient and urged him to seek help from
his sister, whom he lives with, to manage his insulin and ensure
that he takes what he needs and is able to get his prescriptions
filled, but he was not willing to do this. We confirmed that his
lantus was available to be picked up at the pharmacy. ___
provided 2 free sample Humalog pens to cover him until his prior
authorization is completed.
#UTI: Patient had urinary incontinence, UA with pyuria and
bacteruria and recent foley catheter. Urine culture was
contaminated. He was treated with ciprofloxacin and given a
prescription to finish a ___SRD on HD: Received HD on usual schedule in house. Continued
home medications.
#Insulin dependent DM. Management of hyperglycemia and DKA as
above. ___ endocrinologist and diabetes educator followed the
patient in house.
#Elevated troponin. Pt presented with elevated troponin to 0.20,
which then downtrended. No chest pain, ischemic EKG changes.
Likely poor clearance given renal disease.
#Mixed central and obstructive sleep apnea. Pt states he no
longer uses CPAP at night. It was ordered while he was in the
hospital and he was inconsistently compliant.
#HTN (with h/o hypotension during HD). Had intermittent BP to
190s in MICU, started on Hydralazine 25mg PO q6h. Medication
list includes lisinopril, but patient has not filled any
prescriptions recently. This was resumed on discharge.
#HLD. Continued home statin
#Hypothyroidism. Continued home Levothyroxine
#Anemia of chronic kidney disease. Baseline Hgb ___.
TRANSITIONAL ISSUES
===================
#Humalog pen will requires prior authorization by PCP
___ exhibited signs concerning for early cognitive decline.
This likely contributed to his inability to resolve his insulin
issues and will potentially cause problems in the future. His
___ doctor was concerned and we explored possible ways to get
him more help. Unfortunately, he is not willing to have a family
member help him and there are no outside resources available to
provide the level of help he would need. We elected to return
him to his old insulin regimen since he is comfortable with it,
with the planned change of novolog to Humalog and no adjustment
to his sliding scale. | 167 | 595 |
18678857-DS-12 | 29,971,979 | Dear ___,
___ were admitted to the hospital because ___ were found to have
a blood clot in your lungs (pulmonary embolism) as well as
bloody diarrhea. ___ were treated with blood thinners and
discharged on a blood thinner called apixaban.
For the bloody diarrhea, ___ had an endoscopic GI procedure
called a flexibile sigmoidoscopy to look at your colon which
showed inflammation with biopsies being consistent with
inflammatory bowel disease. ___ were started on steroids with
improvement in your symptoms. ___ also received a blood
transfusion given low blood counts from your anemia. ___
received a remicade (infliximab) infusion. ___ were discharged
on prednisone 40mg to be taken daily with further dosing to be
adjusted at your follow up with GI.
___ were also diagnosed with a C. diff infection and were
started on an oral antibiotic called vancomycin which ___ will
take until ___.
It was a pleasure taking care of ___ and we wish ___ the best!
Sincerely,
Your ___ team | ___ female with h/o obesity and hypothyroidism who was
transferred from ___ with a PE/lower extremity thrombosis
and bloody diarrhea.
#Pulmonary Embolism/DVT - CTPA at ___ showed a large
acute thrombus in the right lower lobe pulmonary artery
extending into segmental and subsegmental branches with
possibility of more widespread emboli. She was started on a
heparin drip and transitioned to warfarin but given she had no
evidence of ongoing bleeding was transitioned to apixaban.
Patient's inflammatory bowel disease most likely pre-disposed to
PEs. (see below)
#Ulcerative Colitis/Bloody Diarrhea: Had a CT Abd/pelvis showing
pan-colitis. Underwent initial infectious studies including
negative C. diff. Underwent a flexibile sigmoidoscopy by GI and
started on IV steroids for IBD most likely ulcerative colitis.
Biopsies showed chronic inflammation without granulomas
consistent with IBD. Subsequently re-tested for C. diff as
symptoms were not improving and tested positive. Started on oral
vancomycin to complete a 14 day course on ___. By discharge,
transitioned to PO prednisone 40mg which will need to be tapered
at GI follow-up. Received an infliximab 10mg/kg infusion on ___
given severity of flare and duration of symptoms prior to
hospitalization. Patient will follow up with GI as an outpatient
for further work-up including full colonoscopy. During
hospitalization also started on omeprazole given concurrent
administration of steroids. Patient preferred to continue it as
an outpatient.
# Anemia: On admission hemoglobin 8.3 with microcytosis down
from ___ level of 13.2. Iron studies from ___ are notable
for iron 13, TIBC elevated 410, low transferrin, ferritin 4.5
consistent with iron deficiency which is most probably secondary
to chronic blood loss in context of chronic bloody diarrhea.
During hospitalization levels downtrended to 6.8 and patient
received 1 pRBC on ___ with improvement in levels. At discharge
hemoglobin was improving to 8.3. Patient discharged on oral iron
supplementation.
TRANSITIONAL ISSUES
===================
- started on apixaban for pulmonary embolism and should be
continued for at least 3 months until ___
- started prednisone 40mg for inflammatory bowel disease. Dose
will be tapered at GI follow-up
- consider starting PCP prophylaxis with ___ and
VitaminD/Calcium if patient will continue steroids long term as
outpatient.
- started on oral vancomycin for a 2 week course (completion
date ___
- started omeprazole initially with IV steroids. Patient
preferred to continue it. Consider stopping once tapered off
prednisone.
- started on oral iron supplementation. Monitor iron
levels/degree of anemia as outpatient and consider increasing
dose.
- discharged with instructions to follow low fiber diet,
consider liberalizing to regular if patient no longer
symptomatic from colitis
- Code status: Full code
- Contact: ___ (husband) ___ | 160 | 424 |
18460230-DS-27 | 27,144,827 | Dear Mr. ___,
It was a pleasure taking care of you while you were here at
___.
You were brought to the hospital from rehab because you weren't
feeling well and blood tests from rehab showed that your liver
wasn't working properly. From testing performed here, it was
determined that this was due to your heart not pumping properly
and had bakced up the blood in the liver. Because your heart
wasn't pumping very well you were in the ICU and on IV
medications to keep your blood pressure up for a short time.
After they put your heart back a slower speed (by using your
AICD to shock the heart), you were transfered out of the ICU to
the cardiology floor.
Your heart continued to not pump very well despite giving you
medications to try to help it pump better. We discussed with you
and your health care proxy that the long term prognosis for the
heart not pumping well were not good, and that you have end
stage heart failure. During these discussions you decided to
focus your care on comfort, and we will be transferring you back
to a rehab facility with this goal of making you comfortable.
Transitional Issues:
You are being transfered to rehab for palliative care. | MICU Course: ___ year old male transferred from ___ to the MICU
for congestive hepatopathy and encephalopathy due to Afib with
RVR whose heart condition continued to decompensate and it was
determined that given his poor perfusion and recent studies that
he has end stage heart dieseae and changed his goals of care to
comfort measures only.
# Goals of Care: Goals of care discussion occured on this
admission with both Mr. ___ and with the 2 healthcare proxys.
Decision was made to be CMO, focus on comfort. Pt was given
morphine elixir as needed for SOB. He may also get lasix 40-80mg
IV prn for SOB. He is on lactulose for bowel movements, but has
not had a bm in a few days. This should continue to be address
at his rehab. HCP and pt request that patient is not
re-hospitalized. Pt is eating meals and ice cream by mouth and
is aware of aspiration risks. His ICD was turned off prior to
discharge.
# Acute hepatitis- patient was originally admitted with
transaminitits and this was felt to be int he setting of poor
forward flow of the heart given his Afib with RVR. His workup
for other causes was negative. His LFTs continued to downtrend
after his heart rate improved.
# A. fib with RVR: Pt with a known history of atrial
fibrillation with BiV ICD. It was unclear if this was actually
pacing him at the time that he came in. The ICD was used to
cardiovert him into regular rate. He then went into afib to the
130s on additional occasion however responded well to
metoprolol. His pacer was interogated and felt to be working
properly. His warfarin was d/c'd due to his changes in goals of
care to CMO.
# End stage heart failure- Patient has history of both systolic
and diastolic heart failure with an EF of ___. A repeat TTE
did not demonstrate any significant changes. The patient
originally required dobutamine in the ICU. His medical
management was optimized however due to his low blood presures
and EF. It was then felt that his heart failure with worsening
renal function was end stage, and his goals of care were changed
to CMO.
.
# Acute renal failure- Patient had intermittently elevated Cr in
the setting of oliguria likely due to decreased perfusion of his
kidneys from his poor cardiac output.
.
#Cystitis: Patient had a positive urine culture for E. coli.
patient was given 3 days of ceftriaxone. No associated
complications.
Transitional Issues: Patient was discharged to Rehab for
palliative care/hospice care, with the goal to NOT be
rehospitalized. his ICD was turned off prior to being
discharged. | 211 | 449 |
18325012-DS-18 | 28,637,843 | Cranioplasty
Surgery
You underwent surgery to have your skull bone (or an
artificial bone) placed back on.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
***You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Headache or pain along your incision.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
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 | #Subgaleal fluid collection:
Mr. ___ presented the night of ___ with altered mental
status from ___. He was found to have a large
fluid collection on the left crani site. In the ED he was tapped
for 30 cc, and CSF was sent for cultures. The patient was
afebrile and WBC was 10. A shunt series was obtained to verify
integrity of the valve and catheter which appeared to be stable.
He was transferred to the ___ due to the lack of floor bed
availability. His eliquis was stopped in the anticipation of
possible VPS revision. His fluid collection was tapped for 40cc
on ___, and again for 35cc on ___. Consent for surgery
was obtain from the patients Medical Legal Guardian ___
on ___ and pre-op planning was initiated. CSF from ___
showed no growth. Blood cultures and urine cultures were
negative. The patient went to the OR on ___ for cranioplasty
revision. The shunt was evaluated intra-operatively and was
working properly. See operative report for full details of
procedure. On ___ the patient was lethargic with no verbal
output. ___ showed post-op air and possible worsened
hydrocephalus. He was put on 100% non-rebreather and transferred
from the floor to the ___ for closer monitoring. Overnight he
became tachycardic with respiratory compromise and he was
transferred to the ICU. EEG was placed. A repeat ___ showed a
small intraventricular hemorrhage and continued hydrocephalus.
While in ICU, the patient's head wrap was removed and subgaleal
fluid collection had recurred. CSF was noted to be draining
through sutures; staples were placed and the collection was
drained multiple times. NCHCT showed improved pneumocephalus
and no worsening hydrocephalus. He was taken back to the OR on
___ for revision of cranoplasty with methyl methacrylate seal.
He was called out to the ___ on ___. NCHCT showed increased
pneumocephalus; the patient was positioned HOB flat and remained
in ICU out of concern for declining mental status. HOB was
increased to 30 degrees on ___ and the patient was placed on
non-rebreather for pneumocephalus. Subgaleal collection again
required drainage. He was transferred to ___ again on ___. He
remained stable. Patient more lethargic on neurologic
examination ___, shunt tapped for 30cc. Exam improved after
shunt tap. Repeat NCHCT on ___ was stable. On repeat imaging
on ___ and ___ his ventricle size has decreased and the
subgaleal collection has improved.
#Seizures: The patient has a history of seizures. His phenytoin
level was 1.7 on ___. Neurology was consulted and assisted with
optimizing his antiepileptic medications. He was given a loading
dose of Dilantin. Repeat corrected Dilantin level was 13.6. The
patient was maintained on continuous EEG monitoring and AED's
were titrated by the epilepsy team. Corrected dilantin level on
___ was 16.8.
#Pulmonary embolism: On ___, early morning the patient
developed tachycardia and tachypnea, A CTA of the chest was
obtained to r/o PE which showed a small right lower lobe
subsegmental pulmonary embolism, intervention was not
immediately implemented as the patient was planned for surgery
on ___. He remained on telemetry, hemodynamically stable and
tachycardia resolved. He remained asymptomatic, sats were WNL on
RA. Post-operatively on ___, he was ordered a heparin gtt to
bridge to Coumadin per medicine recs given contraindication of
Eliquis with Dilantin. He was re-started on the Heparin gtt
post-operatively on ___ which was discontinued on ___ for PEG
placement. He remained on Heparin ___ PEG planning. On ___ he
was started on ___ bridge to Coumadin.
#Right lower extremity DVT: On admission the patients Eliquis
was held for the OR. A bilateral lower extremity ultrasound
confirmed a occlusive and nonocclusive thrombus involving the
right common femoral, superficial femoral, and posterior tibial
veins. The LENIs showed resolution of the left sided clot noted
on prior ultrasound. Post-operatively we were planning on
resuming the Eliquis however the concentration is lowered when
given with Dilantin. Medicine was consulted and agreed to begin
a heparin to Coumadin bridge on ___.
#Nutrition: Due to poor arousal a NG tube was placed on ___ so
the patient could receive his medications. Chest x-ray confirmed
placement and it was advanced a few cm per recommendations. The
patient vomited x1 after medication administration. Nutrition
was consulted and tube feeds were ordered per recommendation.
The patient had multiple evaluations by SLP and failed. He has
been kept NPO and was started on TF which he has tolerated well.
He will be re-evaluated one last time on ___ and if he fails
will need PEG placement. On ___, the patient's swallowing was
unable to be evaluated by the speech pathologist secondary to
his lethargy. On ___, he failed his speech and swallow
evaluation and a PEG was recommended. ACS was consulted and a
PEG was planned for ___, which was successfully placed. Tube
feeds were restarted 24 hours after placement.
#Ankle pain: He complained of ankle pain, xrays were obtained on
___ and were negative for fractures.
#LUE pain: The patient endorsed LUE pain on AM exam on ___,
therefore he underwent LUE venous duplex and LUE plain films of
his wrist and forearm to assess for DVT versus fracture. Both
studies were within normal limits.
#ID
During his ICU stay, the patient was intermittently febrile;
multiple cultures were sent. PICC line placement was delayed due
to fever. CSF was sent on ___ for possible meningitis. He
received decadron on ___ for possible aseptic meningitis and
started on ceftriaxone for UTI on ___ for urine culture growing
Providencia. CTX was changed to Bactrim on ___, course ended on
___.
#Hyponatremia
The patient was hyponatremic during his ICU course. He was
bolused with normal saline and started on PO salt tabs. His
sodium level remained stable, on ___ his salt tabs were
decreased to 2mg TID.
#Disposition
The patient came from a longterm care facility, Sachem Skilled
Nursing and Rehab in ___. On ___, he was tolerating
tube feeds. His vital signs were stable and he was afebrile. He
was discharged back to that same facility. | 453 | 999 |
12928622-DS-14 | 25,025,126 | Dear ___,
___ were admitted to ___ on ___ after ___ presented to the
ER for your rectal prolapse. ___ were admitted for concerns ___
were not taking adequate care of yourself at home. The medical
and psychiatry teams feel ___ need to be admitted to an
inpatient geriatric psychiatry facility to meet your daily
needs.
___ will be evaluated in the colorectal surgery clinic on
___ (see instructions below) to talk further about
repairing your rectal prolapse.
Upon discharge, future appointments and adjustments in your
medications will be managed by your doctors in your facility.
Please take all medications as prescribed.
It has been a pleasure participating in your care, we wish ___
the best of luck. | Mrs. ___ was admitted to ___ on ___ after presenting
to the ED as above. Her hospital course is reviewed here.
1) Rectal prolapse - Patient presents with reducible rectal
prolapse associated with occasionally bleeding and bowel
incontinence. Undoubtedly the etiology of presentation to ED
covered with stool. Administered high fiber diet. Colorectal
surgery consult demonstrated patient may benefit from surgical
repair, but would require colonscopy beforehand given her prior
repair. Colonscopy results as above, normal to cecum with
exception of erythema consistent with her known prolapse.
Intervention/operative repair was then deferred due to patient's
unwillingness to consent to procedure. Determined to have
capacity to refuse this operation. She later relented and
decided she definitely wanted to proceed with the operation.
Unfortunately, OR time was unavailable by the time her decision
was made. She will be seen in ___ clinic on ___ with
Dr. ___ further discussion.
2) Paranoid delusions regarding neighbors - Patient has been
evaluated by psych service in ___, who concluded persecutory
delusions likely the result of chronic frontotemporal dementia.
Patient adamantly refused services at home. Previously (___)
discharged to ___ inpatient geripsych
facility; discharged after short stay after determining she had
capacitance for medical decisions. Pysch consult demonstrated
patient appropriate for discharge to ___ ___
facility. She was discharged to ___ facility.
3) ___ - Patient with acute kidney injury, as evident by
creatinine rise from 0.7 to 1.2. Encouraged PO intake and
trended creatinine, with return to age-appropriate levels prior
to discharge.
4) PVD/skin grafting - Patient followed by Dr. ___,
___ in ___. Receives q2 weekly dressing changes
after refusing compression stockings at home. Per discussion
with Dr. ___ presents to his office every few ___
requesting dressing changes, visit is largely social in nature. | 114 | 287 |
13918079-DS-8 | 24,024,639 | Please call the ___ access clinic at ___ for dialysis
access issues to include loss of bruit and thrill, increased arm
swelling, cold blue or numb fingers, loss of sensation or
numbness/tingling in the left hand or arm.
Patient is to continue abdominal VAC changes every 72 hours.
Specific instructions for VAC dressing are included in nursing
referral notes. Specifically the abdominal wound area has been
dressed first with adaptic, white sponge, then black sponge,
with an opening around the area of the fistula to assist with
fistula tract formation and control of the stool contents
contaminating the rest of the wound bed.
If the dressing is not holding, please call Dr ___ office at
___. | ___ with ESRD likely from HTN and DM on dialysis ___
presented with clotted R arm AV fistula and hyperkalemia.
Hyperkalemia was treated with calcium, bicarb, Lasix, Kayexalate
and emergent dialysis via temporary line. Potassium normalized.
Interventional radiology performed a fistulogram which showed
non-working AV fistula due to total thrombus. ___ thrombectomy
was unsuccessful. Dr.. ___ from Transplant surgery
service was consulted for dialysis access placement. Coumadin
(for R AVG maintenance) was stopped and vitamin K was
administered for INR of 2.7.
On ___, a venogram was performed noting chronic bilateral upper
arm venous occlusions with collateralization noted. A 15.5F 24cm
(19cm tip to cuff) tunneled access catheter through the right
internal jugular vein approach with the tip
situated in the right atrium was performed. The catheter was
ready for use. Hemodialysis was done via the line.
On hospital day 2, a bowel enterocutaneous fistula was noted
upon changing the abdominal wound VAC what was present since
prior bowel surgery in ___ at ___. She had a h/o bowel
perforation and required an ileostomy with a chronic healing
abdominal wound treated with wound VAC at home. Fistula was
found to be within abdominal wound at approximately 7 o'clock,
draining stool. Transplant surgery was notified of this and
collaborated with wound care team to manage fistula using
Adaptic, white sponge then black sponge for dressing changes.
VAC dressing did not last greater than ___ days without leaking.
This improved by making a small hole in white sponge and
thinning the black sponge. Prior mesh remnant was noted sutured
to the large abdominal wound. This was further trimmed back to
the edge near visible sutures. Ileostomy continued to average at
least 250 cc of stool per day. Ileostomy output averaged
900-1000 cc of green stool per day. Please refer to enterostomal
RN note.
Plans for fistula were conservative with goal of containing
stool to facilitate healing of wound then pouch fistula tract
eventually. No surgical intervention was attempted at this time.
She was kept NPO for a day then slowly advanced to a regular
diet to assess fistula output. Diet was resumed without
significant stool increase.
DM was managed with NPH and sliding scale Humalog insulin.
She did undergo a left upper arm AVG placement on ___.
Surgeon was Dr. ___. AVG was successful with bruit and
positive thrill. Left radial pulse was present. The 2 incisions
were intact without redness or drainage after the initial
dressing change.
Coumadin was stopped and no further Coumadin was planned at this
time.
Overall, the remainder of her hospital stay was uneventful. She
continued to receive dialysis via the tunnelled line while AVG
healed. Midodrine 5mg was given 1 hour prior to dialysis for low
SBP. Prior to hospital stay, she had been on
Carvedilol,Hydralazine and Lasix. These were stopped for
hypotension. She managed well without these meds. O2 2 liters
was used to keep sats greater than 92.
Urine output was oliguric via a foley averaging 100ml per day.
Urine was cloudy. UA was positive on ___. Urine culture isolated
Klebsiella resistant to many antibiotics. It was sensitive to
Meropenem and Cefepime. Meropenem was started on ___ and this
was continued for one week stopping after dose on ___.
Other skin issues consisted on 2 skin abrasions on LLE that were
covered with Adaptic then Kerlex. Sacrum appeared pink without
breaks in skin. Mepilex applied.
Physical therapy was consulted and recommended rehab. However,
the patient and daughter adamantly refuse rehab, preferring that
patient go home with ___. Assistive devices were already in the
home. VAC supplies were ordered via KCI. ___ was
contacted and arranged to follow.
CAD. Was on statin, ASA and Lasix. Lasix was stopped during this
hospitalization as Simvastatin and Aspirin were continued. | 116 | 623 |
19246656-DS-3 | 27,954,572 | It was a pleasure to participate in your care. You were
admitted with abdominal pain, nausea, and vomiting. You were
found to have a dilated bile duct, which may be due to a past
gallstone. You underwent ERCP. You tolerated the procedure well.
Your diet was advanced to a regular diet, which you tolerated
well. Your sympoms improvedd. Please follow up with your primary
care physician and GI doctor.
You reported a cough. A chest X-ray did not show pneumonia.
You reported urine frequency. This was likely due to the IV
fluids you were getting. A urinalysis was normal. | The patient is a ___ year old female with hep B, s/p CCY who
presents with worsening epigastric pain radiating to the back
now found to have worsening biliary dilatation s/p ERCP with a
dilated CBD s/p sphincertromy with sludge removed.
.
#BILIARY DILATION: She underwent ERCP that noted dilated CBD up
to 13mm without apparent filling defect. No etiology was
identified for dilated CBD, possible that she may have been a
past stone. A sphincterotomy was performed with extraction of
sludge. She was given IV fluids and diet slowly advanced the day
following her procedure. Abdominal and back pain improved
following ERCP. Tolerating regular diet the day of discharge.
.
#CHEST PAIN: She reported an episode of chest pain in the
emergency department. It resolved on the floor following removal
of the telemetry box from her chest. No events on telemetry.
Cardiac enzymes negative. CXR unremarkable.
#CHRONIC HEPATITIS B: Viral load ___ was 687 with normal LFT.
Elevated transaminases on admission that were improving at time
of discharge. Recommend outpatient hepatology follow up.
.
#URINE FREQUENCY: She endorsed urinary frequency in the setting
of getting IVF post-ERCP. She was concerned for urinary tract
infection. Her UA was normal.
.
#GASTROESOPHAGEAL REFLUX DISEASE (GERD): She was continued on
protonix.
. | 100 | 207 |
19483323-DS-2 | 25,428,214 | You were admitted with a cough and abnormal chest xray.
This is most likely pneumonia, but we needed to rule you out for
TB.
With the sputum tests - we found that you are not coughing up
large amounts of tuberculosis bacteria, but to absolutely rule
out TB, the tests get monitored for 60 days.
IF you develop weight loss, night sweats, chills, cough up
blood, come back to the hospital. | Assessment and Plan: Mr. ___ is a ___ yo male here with fever,
cough, with CXR concerning for atypical pneumonia, or less
likely tuberculosis. The acuity of his infection, and his
likely immunocompetent state, makes tuberculosis less likely,
but he does have recent possible exposure to people from endemic
areas.
## Possible tuberculosis
## Likely pneumonia
He was admitted, treated for community acquired pneumonia with
ceftriaxone and azithromycin. He was ruled out for smear
positive TB with 3 negative concentrated smears. His general
sputum culture had upper airway secretions and therefore was not
resulted. He defervesced. HIV was negative.
He was switched to cefpodoxime and continued on azithromycin and
discharged home. He does have a pencillin allergy, with hives,
but tolerated the ceftriaxone well, and treatment options were
limited due to desire to avoid agents that are active against
TB.
He was discharged home, with pcp follow up next week, and all
questions answered.
No other medical problems were active. | 68 | 166 |
18030855-DS-18 | 28,290,912 | Ms. ___,
You were admitted to ___ with a bowel obstruction which has
now resolved and you are ready to recover at home.
Please see below for your follow up appointment.
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. | ___ w/ h/o LBO requiring urgent ex-lap, appendectomy ___ years
ago presents to ___ ED with 1 day of increasing epigastric
abdominal pain. CT demonstrating complete small bowel
obstruction with transition in the upper pelvis as detailed
above. The patient was tender focally over mid-epigastrum on
exam but was otherwise hemodynamically stable. Of note, the
patient reports that she was still passing flatus and having
bowel movements. She was admitted to the ___ service for serial
abdominal exams, made NPO, given IV fluids and IV analgesia, and
had a nasogastric tube placed for stomach decompression.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV analgesia
and then discontinued once SBO resolved.
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. On HD3, the NGT
was clamped and later removed, therefore, the diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored. She
continued to pass flatus and have bowel movements throughout the
hospitalization.
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. Abdominal exam was much improved, though still
mildly tender over epigastric area. She had TSH, CRP, and a SED
RATE labs drawn that were pending at time of discharge, results
of which would be followed-up by her PCP. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. She had an
appointment made with her PCP and in the ___ clinic. | 208 | 373 |
10684430-DS-11 | 23,911,770 | It was a pleasure taking care of you in the hospital. You were
admitted with cellulitis and a foot ulcer. You were treated
wtih oral antibiotics and did well. You will be going home to
complete a ten day course of antibiotics. A visiting nurse ___
help care for your wounds. Please follow up with your PCP and
podiatry (see appointments below).
The following medications were added:
1) Bactrim Double Strength Tab; take 2 tabs twice daily until
___
2) Augmentin Extended Release 1000mg; take 2 tabs twice daily
until ___
3) Mupirocin cream; apply twice daily to open skin areas | ___ with a PMH significant for DM complicated by neuropathy who
was admitted for persistent superficial toe ulcer, improving on
oral antibiotics.
.
# Diabetic Foot Ulcer, plantar surface right hallux: Likely
caused by repeated trauma secondary to diabetic neuropathy, as
patient has minimal feeling of his feet bilaterally. Wagners
diabetic wound classification of grade 1 (superficial). Podiatry
was consulted in the ED and requested admission to medicine for
monitoring and treatment of cellulitis. Xray of foot report
showed no osteomyelitis or soft tissue swelling. Afebrile, WBC
within normal limits (9.3 on admission to 7.5 the following day
on discharge), lactate remained within normal limits. WBC at
clinic the day prior to admission on ___ was 13.3, when patient
started treatment with bactrim and augmentin, and ceftriaxone
1gm IM. Per clinic notes, cellulitis was improving on this
antibiotic regimen. This time around, patient received IV vanc
and cipro 500mg in ED. Borders of the cellulitis were marked.
Given rapid improving cellulitis, patient was continued on his
outpatient oral antibiotic regimen of bactrim and augmentin for
a total of a 10day course (___). Podiatry recommended
saline or diluted betadine wet to dry dressings daily for which
patient was assigned a ___.
.
# Diabetes: ___ HgbA1c was 7.5% (improved from 9.5% on
___. Held metformin/glimepiride and patient was maintained
on lantus and HISS. Aspirin and lisinopril were continued.
Family expressed concern about the patient's self-management of
his diabetes, given his progressing dementia. The patient was
willing to allow his wife to assume the responsibility of his
diabetic regimen. His wife was trained with the nurse on insulin
administration and felt comfortable with this.
.
# Anemia: On admission patient had a hct of 34.1 (baseline
around 38-40). MCV 83. Patient had no evidence of bleeding. It
is possible that his decreased hct was due to myelosuppression
from infection or antibiotics. Hct was trended and remained
stable over admission.
.
# Excoriations on shins, elbows, hands: Family is concerned that
patient continues to scratch and pick at his skin. There was no
indication for a dermatology consult, despite families request
for it. Patient has bee set up with an outpatient dermatology
consult in the upcoming months. Mr. ___ appears to be
subconsciously picking at his skin for unclear reasons. Despite
being told by his family to stop, he has Alzheimers and a very
short term memory. Mupirocin was applied to lesions to prevent
infection and it was recommended that Mr. ___ where long
sleeve shirts and pants to prevent self-injury.
.
# Hypertension: Continued lisinopril, BP remained well
controlled during admission.
.
# Hypercholesterolemia: Continued atorvastatin.
.
# BPH: Continued finasteride, tamsulosin.
.
# Dementia: Continued donepezil Qhs. | 104 | 438 |
13475033-DS-64 | 27,176,329 | Dear Mr. ___,
It was a pleasure to care for you during your admission to ___
___. You were admitted with
abdominal pain that was similar to your previous episode of
diverticulitis. A CT scan revealed evidence of active
diverticulitis on this admission, so you were managed medically
with IV antibiotics. Your required very little pain management
as you improved rapidly on antibiotics. While hospitalized, you
also recieved hemodialysis per your usual
___ schedule. It is important that you get
a colonoscopy after your diverticulitis clears (in about 6
weeks), which will be set up by your primary care provider.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please attend all of your follow-up appointments as detailed
below. Please continue to take your medications as prescribed
below. | BRIEF HOSPITAL COURSE:
======================
___ with Hx ESRD s/p cadaveric renal transplant in ___ c/b
rejection in ___ now on HD ___, CAD s/p DES
x2 to right coronary artery, ___ esophagus, gastritis, and
duodenal ulcers who presents with abdominal pain x1 day with
radiographic evidence of diverticulitis on abdominal CT scan. | 131 | 53 |
11209282-DS-16 | 22,878,876 | Dear Ms. ___,
It was a pleasure caring for during your hospitalization at ___
___.
WHY WAS I ADMITTED?
- You felt fatigued, and your pacemaker was found to be at the
end of its battery life.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
- You were seen by the heart doctors, and they gave you a new
pacemaker.
- You were seen by the kidney doctors, who said you do not need
emergent dialysis.
- You had an ultrasound of your liver, that did not show any
liver masses or blood clots.
- You had an ultrasound of your heart that showed some problems
with the heart relaxing, sometimes call diastolic heart failure.
There is nothing to change for your medications now, but please
make sure you continue to see your heart doctor.
- You were seen by the diabetes team, who changed your insulin
dosing. We wrote the new insulin dosing below.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take your medications as prescribed. Please note the
changes we made below (included in this letter and in the
discharge packet).
- Please go to all of your appointments as below.
- We were unable to make the liver appointment. Please talk to
your primary care doctor about referring you to the liver
doctors.
- Please take your warfarin daily. Have your next INR checked on
___ with the ___ clinic at your primary care doctor's
office.
WHAT ARE REASONS TO SEEK MEDICAL ATTENTION?
- If you feel more weak, if you have chest pain, shortness of
breath, black or bloody bowel movements.
- If you have any symptoms that concern you.
We made some changes to your medications:
Please stop:
- Clonidine
- Pregabalin
- Metoprolol succinate
Please decrease:
- Insulin U-500 to 56 units with breakfast and 32 units with
dinner
- Pantoprazole decrease to daily, NOT twice a day
We wish you the best!
Warmly,
Your ___ Care Team | Ms. ___ is a ___ year old woman with T2DM on insulin, CKD stage
V (fistula placed ___, Childs A ___ cirrhosis, atrial
fibrillation on warfarin, and history of ?sick sinus syndrome
s/p PPM who presented with one year of fatigue and failure to
thrive, along with objective bradycardia while at her primary
care doctor's office.
#Failure to thrive
#Fatigue
Patient presented with one year of feeling tired and low energy.
She had no shortness of breath, orthopnea, leg swelling, fevers
or chills. She did note weight loss of about 50-100 pounds over
the past ___ years. Initial concern was that this may be uremia,
but from lab work up and renal evaluation, this was deemed an
unlikely etiology. After reviewing her medication and vitals,
suspect her anti-hypertensive regimen and insulin regimen may
have been too strong for her. She also generally has worsening
of her multiple chronic diseases, and this contributes to her
symptoms. Her medication regimen was adjusted (see problems
below) and she was feeling mildly improved at discharge. She was
ambulating independently and will be discharged with ___ for
further medication and compliance support.
#Bradycardia
#History of sick sinus syndrome
Patient with potential history of SSS as trigger for PPM
placement. While in her PCPs office, she was noted to be
bradycardic to the ___ and her battery life was noted to be at
its end. It's unclear if she was truly symptomatic from this.
She was evaluated by EP and pacemaker was replaced ___.
#CKD stage V
Patient s/p fistula placement ___ but has not yet been seen
in follow up due to moving and not re-establishing care. She was
seen by nephrology, and had no indication for urgent renal
replacement. She was continued on home calcitriol. Renal follow
up with Dr. ___ was scheduled at discharge.
#Chronic diastolic heart failure
TTE ___ with signs suggestive of diastolic heart failure.
Patient was euvolemic on exam and diuresis was not initiated.
Medications for hypertension were managed as below.
#___ A ___ Cirrhosis
Patient with Childs A cirrhosis, unclear what complications she
has had in the past from this but overall seems well
compensated. Her RUQ Doppler showed no PVT, no ascites. She will
need hepatology referral as we were unable to schedule this
appointment for her.
#T2DM on insulin
A1c 7.2%. Patient takes D500 as an outpatient. ___ was
consulted inpatient and D500 was decreased to 56U with breakfast
and 32U with dinner. She has endocrinology follow up scheduled
at discharge.
#Atrial fibrillation on warfarin
Warfarin was held pre-pacemaker replacement and started at
discharge. We spoke with ___ clinic at her PCPs office and
they confirmed they will manage her INR.
#Anemia of chronic disease
Anemia workup consistent with that of chronic disease: CKD,
liver disease. Active type and screen was maintained while
inpatient given unknown variceal status.
#Access to care
Patient recently moved to her brother's to take care of him as
he has cancer. Since moving, she has not established renal,
endocrine or liver care. Renal, endocrine, cardiology and PCP
appointments were arranged at discharge. She will also have ___
at discharge. She will use the ride to get to appointments.
#Positive UA with no urinary symptoms
Positive UA on admission, culture with mixed flora. She had no
symptoms. Antibiotics were started in the ED but not continued.
#Hypothyroidism
TSH wnl. Continued home levothyroxine.
#Hypertension
Well controlled inpatient on imdur and nifedipine. Held
clonidine and metoprolol.
#?GERD
Decreased home PPI to daily. Consider stopping as outpatient as
no clear indication for this and patient not actively
complaining of GERD.
#Bipolar disorder
Continued home divalproex and Seroquel.
#HLD
Continued home rosuvastatin. | 310 | 577 |
12406461-DS-18 | 27,719,548 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with abdominal pain and nausea related to your G-J tube being
displaced. Your tube was replaced by interventional radiology,
however, it again became dislodged. A longer tube was replaced
and you were able to tolerate your tube feeds but at a lower
rate.
Please resume your medications and tube feeds as you were taking
them at home and slowly titrate up your tube feeds as tolerated. | Brief Course:
___ F w/ eosinophilic esophagitis/gastritis, antral ulcer, and
dysautonomia causing gastroparesis requiring tube feeds via G-J
tube who presents with abdominal pain at site of G-J tube and
nausea after tube became displaced. Patient underwent ___ guided
replacement of G-J tube after it became dislodged twice and was
restarted on her tube feeds. | 81 | 55 |
11759287-DS-7 | 26,644,170 | Dear Mr. ___,
You were admitted to the cardiac intensive care unit at ___
___ because you passed out and were
found to have a very slow heart rate. This was caused by
malfunctioning of your heart's natural pacemaker. We do not know
the reason your natural pacemaker started to malfunction.
To treat your slow heart rate, you had a permanent pacemaker
placed to make sure your heart always beats at an appropriate
rate. The procedure went well. You can take the bandage off in
48-72 hours. Please do not get the bandage wet before that time.
You should follow up with the electrophysiologists (EP) doctors
___ 1 week to check on the functioning of your pacemaker. You
should also follow up with plastic surgery for removal of the
staples in your scalp.
We did not give you your home blood pressure medication,
hydrochlorothiazide, because your blood pressures were normal in
the hospital. Do not re-start your HCTZ until discussing with
your primary care doctor.
Please seek immediate medical attention if you pass out, develop
chest pain, trouble breathing, or fever >101.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ Team | ___ with PMHx HTN and HLD who presented with syncope and
resultant nasal septal fracture subsequently found to have
intermittent bradycardia and sinus arrest. He syncopized with
only minimal prodrome and was found on initial presentation to
have a HR in the ___. He subsequently syncopized again in the
emergency ward while being monitored on telemetry and was found
to one which occurred following p-p prolongation consistent with
a vasovagal syncope but another which did not have p-p
prolongation and instead showed sinus arrest lasting 14 seconds.
A temporary pacing wire was initially placed and then on ___,
Electrophysiology placed a ___ dual chamber PPM via left
axillary vein. He tolerated the procedure well with no
complications. TTE obtained showed no evidence of intracardiac
source for syncope and LVEF >55%. | 198 | 131 |
16958962-DS-21 | 26,467,554 | Mr. ___ you were brought to ___ ED ___ ___ after falling
down 13 steps. Full physical exam, several imaging studies and
blood tests were done. Multiple injuries have been found on the
imaging studies
C1-C2 fractures ___)
Subarachnoid hemorrhage
Right frontal intraparenchimal hemorrhage
Right orbital wall fracture
Intraluminal clot at level of C2 fracture
You have been admitted to Acute Care Surgery Service and been
treated properly.
Please, follow these instruction after you are discharged from
the hospital
-please, wear the hard collar till your appointment with Dr.
___ ___ one month, see the appointment's details below
-please, take LeVETiracetam(Keppra) 750 mg PO twice a day till
your appointment with Dr. ___ the appointment's
details below
-follow up with ___ clinic as instructed below
-please, continue taking other medications as instructed
-follow up with your PCP ___ ___ weeks after you are
discharged | On ___ Mr. ___ was brought ___ ___ ED ___ ___ by
ambulance after falling 13 stairs. Hard collar was placed by
EMT. Multiple imaging studies were obtained showing several
injuries
Right frontal intraparenchimal hemorrhage
C1, C2 fracture
Subarachnoid hemorrhage
Intraventicular hemorrhage without hydrocephalus
Right orbital wall fracture
Fracture through the right the transverse foramen of the C2
vertebral body impinges on the vertebral artery which appears
thinned ___ this region and contains focal clot
___ the ED the patient was severely agitated, therefore he was
intubated and sedated to prevent his airway. Neurosurgery was
consulted, who recommended non surgical management. Orthopedic
surgery was also consulted, they recommended non surgical
management as well. Pt was admitted to trauma ICU under acute
care surgery service. CIWA protocol was also started given the
patient's history of alcohol abuse. On ___ Neeurology was
consulted for management of L. vertebral artery dissection. They
recommended to continue C-Collar, start Keppra and hold aspirin
due to the risk of intracranial bleeding. Decadron was also
administered due to concern of airway edema. On ___ pt
remained intubated due to agitation and tachipnea. On ___
pt was taken to the operating room and tracheostomy tube was
placed before extubation. The procedure went well without
complications. Orogasrtic tube was removed and nasogastric was
placed. Repeat CT head showed no significant interval changes.
Pt was off sedation, lethargic but he opened eyes to his name
being called. He followed simple commands like "open your eyes.
On ___ tube feeds were started, clonidine was started per
neurology. On ___ patient failed speech and swallow
evaluation. NG tube was removed, 3 attempts of dobhoff
placements were failed. On ___ pt was transferred to the
floor. He was then triggered for seizure activity due to missing
the dose of Keppra, he was transferred back to the ICU. He was
stabilized ___ the ICU and transferred to the floor again on ___
___. Repeat CT showed decreased SAH, bur slightly enlarged
ventricles. He was initially placed on dysphagia diet. He
underwent swallow evaluation on the ___ and the diet was
advanced to regular. Pt had multiple episodes of fever, chest
xray was negative for pneumonia, blood cultures, urine cultures
negative, C.Diff was also negative, which was sent due to 6
loose bowel movements, which then resolved without intervention.
Nutritional supplements were also started three time a day. Head
CT was repeated again per neurosurgery request, which showed
decreased size of SAH, SDH and IVH. Pt's mental status
improvements was also reported. Multiple high blood pressure
recording were noticed, labetolol dose was increased from 400 to
600, since then blood pressure was better controlled, no high
recordings were reported. On ___ trachestomy tube was
downsized to 6 fenestrated non cuffed tube at beside. Pt
tolerated the procedure well. He was able to speak with the new
tube without issues, no breathing issues was reported as well.
On ___ pt was triggered was nursing concern ___ mental
status change and possible seizure activity, the patient was
seen and evaluate by MD immediately. No seizure activity or
change ___ mental status was noticed and a follow up CT on ___
showed 1. No residual subdural, subarachnoid or
intraventricular blood products. No new focus of
hemorrhage. Stable ventricular size.
Patient was evaluate and treated by physical and occupational
therapy throughout the hospitalization.
Appointments with Neurosurgery, Orthopedic/Spine Surgery, Acute
Care Surgery were scheduled for the patients.
He was given verbal and written instructions and discharged to
___. | 137 | 585 |
14068504-DS-4 | 20,603,095 | Mr. ___,
It was a pleasure taking part in your care. You were admitted
for shortness of breath to the ICU. You also needed a medication
called Narcan to reverse the effects of some of the pain
medication you take. During your hospitalization you were
treated for a COPD exacerbation. You were treated with steroids,
azithromycin, and nebulizers. Your oxygenation and symptoms
improved by time of discharge. We are currently working on a
follow-up appointment for you to see your pulmonologist.
Please quit smoking as we have discussed. | ___ with COPD, tobacco abuse, depression with SI qho was
transferred from inpatient psych facility with dyspnea and
somnolence, now admitted to MICU for monitoring while on
naloxone drip.
#) Dyspnea/Hypoxia/Hypercarbia: Believed to be multifactorial
related to COPD flare and opioid overdose. Respiratory viral
swab returned negative. No leukocytosis or fevers or infiltrate
on CXR to suggest PNA, sputum production at baseline. The
patient was started on ipratropium/albuterol nebs Q6H standing,
prednisone 60mg daily, and azithromycin 250mg x 5 days for
concern of COPD flare. He was continued on narcan gtt for less
than 12 hours until it was ultimately weaned off. After this,
however, the patient remained with somewhat low O2 sats. It was
felt that this was likely his baseline, related to his smoking
history. He has been hypoxic with ambulation on RA
intermittently. At rest his O2 sats are 88-90% and he is
asymptomatic. On the day of discharge he was 87-90% on
ambulation and asymptomatic. For treatment of his COPD, he
received 6 days of 60mg of prednisone, and should continue with
40mg daily x2 days, then 20mg daily x2 days, then he can stop.
He has been started on tiotropium and continues on Advair and
albuterol. At time of discharge his respiratory exam was clear
with poor to moderate air movement.
- Steroid taper as described, no further antibiotics and
inhalers as described
- If he becomes transiently hypoxic, anxiety often is causing
him to hypoventilate. Encourage deep breathing. His oxygenation
responds to slow deep breath.
#) Depression/suicidal ideation/attempt: The patient was
transferred from ___ on ___ out of concern for suicidal
ideation. The patient was seen by psychiatry after weaning from
narcan drip, who recommended CIWA protocol, return back to
___ when medically clear, 1:1 sitter, continue
zyprexa, depakote, and buspar. They also recommended minimizing
opiates, anticholinergics, and benzodiazepines. The patient's
home dose of methadone 140 mg was continued.
#) HTN: Normotensive. Continued propranolol. | 88 | 319 |
14344430-DS-2 | 29,625,752 | Dear Ms. ___,
You were transferred to ___ after a motor vehicle collision.
On imaging, you were found to have right a sternal fracture,
sided rib fractures ___, and a left wrist fracture. You were
seen by the Orthopedic Surgery team, who determined the wrist
fracture could be managed nonoperatively. They have splinted the
arm and would like you to follow-up in clinic in 1 week. Please
avoid weight bearing with this extremity. You have worked with
Physical Therapy, and you are cleared for discharge home to
continue your recovery. Please note the following discharge
instructions:
* Your injury caused 8 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 female s/p MVC, transfer from ___
___. The patient was pan scanned at the outside hospital
and her evaluation was remarkable for a sternal fracture and
right sided rib fractures #2 through #8, a left wrist fracture
and question of small subarachnoid hemorrhage. She also had an
incidental kidney mass of which the patient was notified. The
patient was admitted to the Acute Care Surgery service for
further medical management.
On HD1, the patient had was evaluated by Neurosurgery for
question of tiny focus of parenchymal and/or subarachnoid
hemorrhage in the anterolateral right frontal lobe. A repeat
head CT was performed on HD2 which demonstrated no acute
intracranial abnormality, with no evidence of acute intracranial
hemorrhage. No keppra or antiseizure prophylaxis was necessary.
The Orthopaedic Surgery Service was consulted for the patient's
left distal radius fracture and recommended non-operative
management with cast placement.
The patient was alert and oriented throughout hospitalization;
pain was initially managed oxycodone and tramadol and
acetaminophen. At the time of discharge, the patient reported
effective pain relief from acetaminophen alone. On HD2, the
patient had a carotid duplex which demonstrated no significant
stenosis of b/l internal carotid arteries. The patient had an
ECHO which demonstrated no structural cause of syncopal event.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. The patient remained
stable from a pulmonary standpoint. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient tolerated a Regular diet.
Patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient worked with Physical and Occupational
Therapy and was medically cleared to be discharged home with
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 337 | 387 |
15265941-DS-18 | 27,524,191 | Dear Ms. ___,
It was a pleasure to participate in your care at ___
___. As you know, you came here with a hip
fracture, and our orthopedic surgeons operated on you to fix
your broken hip. You lost some blood during the operation and
needed a blood transfusion.
After the operation, you had some worsening shortness of breath,
which we thought was due to worsening of your COPD. We treated
this with prednisone, azithromycin, an antibiotic, and
nebulizers, and your breathing improved. You completed the
course of prednisone and azithromycin while you were in the
hospital. When you were on the floor, your potassium was also a
little high, which we treated and brought back down.
While you were in the hospital, you were also found to have a
urinary tract infection. We are treating you with ciprofloxacin,
an antibiotic, which you should continue taking until ___.
You also had some panic attacks, which we think the steroids
were contributing. We encourage you to continue taking deep
breaths and relax your muscles during these attacks. We will
also give you some Ativan (aka lorazepam) for you to take as
needed.
Now that your breathing is better, you are ready to go to rehab.
We will send you with some oxygen since you are still requiring
it with exertion.
We wish you a speedy recovery!
Your ___ team | ___ y/o CAD s/p MI and stent placement in ___, COPD, OSA on
CPAP, HTN, HLD who presented with hip fracture s/p ORIF by ortho
with postop course complicated by respiratory distress and
hypotension, then transferred to the floor for management of
suspected COPD exacerbation, hyponatremia, and anxiety/panic
attacks. | 226 | 49 |
15006152-DS-20 | 20,177,317 | * Your injury caused multiple 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). | On ___ the patient was admitted to ___ for pulmonary
contusion and close monitoring and had an uneventful ICU course. | 243 | 20 |
14600308-DS-15 | 29,278,560 | Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ after having fevers and
low blood pressure at your rehabilitation center. You were
continued on antibiotics for a urinary tract infection. No other
source of infection was found. After your course of antibiotics
was finished, you remained without a fever.
You had an echocardiogram (ultrasound of your heart) performed
which upon careful review was thought to show no signs of
recurrence of your previous endocarditis. You had an MRI of your
spine, which showed changes consistent with your previous
surgery. The Infectious Disease and Neurosurgery Teams were
consulted, and it was felt that there was likely no active
infection in your spine.
Again, it was great to meet and care for you. We wish you all
the best.
-Your ___ team | PRIMARY REASON FOR HOSPITALIZATION:
==========================================
___ y/o male with history of IVDA; recently discharged (___)
after prolonged hospital stay for MSSA bacteremia c/b TV
endocarditis and epidural abscess. Presents from rehab facility
after two episodes of fever and a BP of 80/50. | 137 | 40 |
16393563-DS-10 | 23,243,667 | Dear Mr. ___,
You were admitted to the hospital on ___ with low sodium and
confusion. You were given fluids and your sodium level has now
improved. Your confusion has also improved, but we believe that
some of your confusion ___ be permanent and due to dementia.
After discussion with you and your wife, we are discharging you
to a rehabilitation unit.
The following changes have been made to your medications:
1. DO NOT TAKE ANY FURTHER HERBAL MEDICATIONS. THIS ___ HAVE LED
TO YOUR SODIUM BEING LOW BECAUSE SOMETIMES THESE MEDICATIONS
CONTAIN WATER PILLS.
2. Stop taking ambien, which ___ worsen your confusion.
3. Take seroquel at night (___) as needed for agitation.
4. Take miralax, metamucil senna and docusate as needed for
constipation. | Mr. ___ is a ___ gentleman with ___ disease who was
referred to the ED by his outpatient Neurologist because of
hyponatremia, and also has a recent h/o falls at home. | 120 | 31 |
15275579-DS-11 | 23,814,287 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for broken bones in your leg.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing to left lower extremity in a long-leg cast
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast 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
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Nonweightbearing to left lower extremity in a long-leg cast
Treatments Frequency:
Cast will remain until your follow-up appointment. Please keep
cast clean and dry. If you have any concerns regarding your
cast, please call the clinic at the number provided. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia and fibula fracture and was admitted to the
orthopedic surgery service. Closed management of this injury
with long-leg casting was pursued. The patient's home
medications were continued throughout this hospitalization. The
geriatric medicine service was consulted for comprehensive care.
Her home dose of HCTZ was held per their recommendations is the
setting of mild hyponatremia. To prevent hospital delirium it
was recommended to use a ___ Creole translator, and it was
made sure she has her hearing aids and eyeglasses available to
her and on during the day.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications without narcotics, and the patient was
voiding/moving bowels spontaneously. The patient was discharged
on tylenol alone for pain control as her pain was well managed
without narcotics. The patient is non-weightbearing in the left
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 352 | 250 |
19615440-DS-23 | 20,514,577 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with heart failure. You were given diuretics to remove extra
fluid and pressor medication to support your blood pressure. You
were intubated for respiratory support intially but at discharge
you were breathing well on your own. You completed the course of
vancomycin as planned. Your PICC was removed. Your foley was
left in at your request. Your tube feeds were continued.
You expressed desire to be DNR/DNI and transition to hospice
care. You were discharged home for this care.
Numerous medications were stopped during this admission
consonant to your goals of care.
Please take the remaining medications as prescribed. | Mr. ___ is a ___ M hx dCHF (EF >55%) s/p pericardial stripping
in ___ for constrictive pericarditis, Cirrhosis likely due
to EtOH, new AFib(in the setting of pericardial stripping) on
coumadin, CKD stage 3, COPD, lung ca s/p chemoRT in ___, and
cirhosis ___ ETOH who initially presented with AMS from rehab
found to be hypotensive likely ___ decompensated heart failure
with preserved EF in the setting of rising creatinine,
discharged home with hospice care.
# Hospice: During this admission the patient and his family
decided to make him DNR/DNI and transition him to hospice care.
As below, all aggressive interventions were withdrawn. His PICC
was taken out. He was transitioned to less frequent vitals and
blood draws, and off telemetry. His Remeron, Sertraline, and
tube feeds via PEG were continued. He was discharged home with
hospice care. His foley was left in because he has had urinary
retention in the past. He was given a bowel regimen. The
following medications were discontinued: simvastatin, coumadin,
digoxin, aspirin, omeprazole, spirinolactone, finasteride,
furosemide, metoprolol succinate, levothyroxine, Ultram, MVI,
trazodone.
# Decompensated heart failure with preserved EF/respiratory
failure: Mr. ___ was admitted on ___ from rehab with
hypotension and AMS. Baseline BPs in high ___ to ___ usually,
but when admitted SBPs were in the ___ systolic. Pt started on
levophed. Pt developed respiratory distress in the ED and was
intubated. Bedside ECHO showed poor squeeze, so dobutamine was
added. Pt also started on Zosyn and Vanc for possible PNA.
Bronch was negative and presentation was felt to be more
consistent with cardiogenic shock/decompensated heart failure.
His care was transferred to the CCU team given his primary
cardiac presentation. Dobutamine and levophed were weaned off
and he was started on neosynephrine for BP support, which was
able to be stopped before discharge with BPs at his baseline
(80s). Zosyn was discontinued and he completed his IV vancomycin
course. He was felt to be volume overloaded and was given a
lasix drip with adequate diuresis. This was transitioned to PO
torsemide. He was given a 2g sodium restriction and 2L fluid
restriction to help keep him euvolemic.
# Sternal wound infection: During previous admission he had
revision of sternotomy with wound vac placement on ___,
removal of sternal hardware and bilateral pectoral advancement
flaps on ___. He was discharged on an IV vancomycin course,
completed ___ his levels were 46.1 and it was held
given supratherapeutic. His wound did not appear infected to
complete his course.
# Anemia: Hematocrit of 22 and hemoglobin of 6.7 on presentation
with guiaic positive stool in ED. Unclear etiology w/ obvious
evidence of bleeding. He received 2 units of pRBCs prior to
transfer to the CCU. Hct was stable since transfer. At
discharge, his hematocrit was stable. Since he is now hospice
care, further workup was deferred.
# L arm pain/swelling: Unclear etiology but improved during
admission. Could have been secondary to a DVT but since he is
going to hospice care and did not desire systemic
anticoagulation (requested to stop coumadin as below) no
diagnostic studies were pursed.
# ___: Cr rose from 1.4 on admission to 2.8 at discharge. He
continued to have good urine output. Renal was consulted, who
felt that this was consistent with ATN (diffuse muddy brown
casts) in the setting of hypotension, supratherapeutic
vancomycin, possible infxn, diuresis, and baseline CKD III with
likely poor renal reserve. Was transitioned from lasix drip to
gentler PO torsemide. Serum creatinine was no longer followed as
patient was transitioned to hospice care.
# Hx of Atrial Fibrillation on Warfarin: Initially was
maintained on coumadin but family request that this be
discontinued. Warfarin was discontinued before discharge.
# Altered Mental Status: Patient presented with AMS. Several
potential etiologies are present, including hypotension,
infection, and respiratory distress. No asterixis to suggest
hepatic encephalopathy. This improved with optimization of his
respiratory/hemodynamic status.
# Cough: Has been aspirating per speech and swallow evaluation.
At discharge he was coughing, bringing up secretions, but has
not had evidence of pneumonia. He was given pureed (dysphagia)
diet with Nectar prethickened liquids. He was given Guiafenisin
for cough, albuterol, and famotidine.
# Cirrhosis (EtOH): Stable, MELD was 6 at last liver followup.
No esophageal varices. This was not an active issue during this
admission.
# Tube feeds: Were continued via PEG. At discharge: Two Cal HN
Full strength at 65 ml/hr for 14 hrs/day overnight. | 112 | 737 |
10390732-DS-20 | 22,177,535 | Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, increased abdominal
pain, pain at the new port site, incisional redness, drainage or
bleeding, dizziness or weakness, decreased urine output or dark,
cloudy urine, swelling of abdomen or ankles, weight gain or loss
of more than 3 pounds in a day, monitor for signs of elevated
INR to include nosebleed, rectal bleeding, dark tarry stools or
easy bruising or any other concerning symptoms.
You will have labwork drawn twice weekly every ___ and
___ as arranged by the transplant clinic, with results to
the transplant clinic (Fax ___ . CBC, ___ Chem 10,
AST, T Bili, Trough Tacro level, urinalysis.
Transition to Belatacept is under discussion and will be
implemented in conjunction with the transplant clinic.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower.Drink enough fluids to keep your urine light in
color.
Have your blood sugars and blood pressure checked.
Report consistently elevated values to the transplant clinic
Check your weight daily. If weight decreases 3 pounds in a day,
hold the torsemide
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise | ___ y/o male well known to transplant service who was admitted
with pain over the transplant kidney three weeks post transplant
kidney biopsy.
Ultrasound showed a large subcapsular hematoma. He underwent
evacuation of the hematoma on ___. Surgeon was Dr. ___
___ who noted a large amount of relatively fresh appearing
hematoma upon opening the renal capsule. Also of note when the
capsule was opened there was no evidence of high pressure within
the kidney itself. Renal parenchyma was boggy, but pink and did
exhibit bleeding. Approximately 100 cc of clot was removed. He
was transferred to the ICU for further management. Heparin drip
was started following surgery. INR was subtherapeutic on
admission at 1.9
Baseline creatinine of 2.0 was increased to 2.9 that further
increased to 3.4. He also had hyperkalemia with K of 5.8 which
was initially treated with insulin, dextrose and calcium
gluconate. A temprorary dialysis line with VIP port was placed
in anticipation of need for dialysis as well as very poor access
history.
Potassium was 7.2 post op, and he underwent a single
hemodialysis session. Urine output on admisison was less than
400 cc. Urine output improved after hematoma evacuation(~1000 -
1500cc/day). Creatinine decreased from a peak of 4.3 post
operatively to 2.5 by POD 12.
On POD 2, he was having complaint of chest pain. Cardiology was
called and troponins were cycled and negative. A cardiac echo
was done showing mildly dilated and hypokinetic right ventricle
with moderate to severe tricuspid regurgitation and at least
moderate pulmonary hypertension. Well seated AVR and MVR with
elevated
gradient across the mitral valve. Mildly dilated thoracic aorta.
He then underwent a cardiac perfusion study which showed normal
cardiac perfusion with moderate left ventricular enlargement and
normal ___ motion with an ejection fraction of 54%.
He was stable and was able to transfer to the regular transplant
floor. Heparin drip and warfarin were resumed on POD 2. He
required 7 days on the heparin drip before the INR was at a
therapeutic level.
On ___, he went to the OR for a PORT placement in a small
vessel noted on chest CT. Surgeon was Dr. ___.
Interventional radiology was contacted and after premed with
steroid and benadryl prep (3 doses of 50mg of prednisone)he
underwent removal of the OR placed port and revision of the left
chest ___ Port-A-Cath, with 28 cm length of tubing terminating
in the right atrium. Also noted was distally occluded or tightly
stenosed Left internal jugular vein at junction with
rachiocephalic vein. Small contrast injection beyond this
demonstrated entral patency of the brachiocephalic vein into the
superior vena cava and right atrium. At end of case he
developed hives and shortness of breath and required emergent
treatment for anaphylaxis. He was transferred to the ICU for
management and did well eventually transferring back to the
med-surg unit.
Facial swelling and generalized edema was treated with IV doses
of Lasix then he was transitioned back to torsemide with
improved edema. He did complain of shortness of breath/cough and
was evaluated by a pulmonary consult. Repeat CXR was concerning
for worsened loculated right pleural effusion. TTE revealed
65-70%EF with moderate TR and severe systolic pulmonary
hypertension. Pulmonary Consult recommendations were to continue
diuresis as volume overload may have exacerbated severity of
pulmonary hypertension. Inhalers were continued. He was also
given 1 unit of PRBC for hct of 23 and epogen was increased to
3000units 3x per week in attempt to improve anemia. No
intervention was planned to intervene on the loculated effusion
given that he remained afebrile and wbc was wnl.
Overal edema decreased with weight dropping to 74kg by ___ on
torsemide 40mg daily. Baseline weight pre-hospitalization was
74kg.
Overall, he was feeling well and ready for discharge back to ___
___. RLQ incision staples were removed. Incision was inctact | 253 | 635 |
13891765-DS-4 | 23,601,491 | Dear Ms. ___,
You were admitted to the hospital because of low sodium. This
can often happen with large volume shifts with paracentesis.
Your sodium improved with fluids. You continued on chemotherapy
while you were with us. You were started on two new medications:
Lasix and Spironolactone to try to keep the fluid out of your
abdomen. However the fluid continued to accumulate in your
abdomen causing discomfort. You underwent another large volume
paracentesis (5L) on the day of your discharge.
You will follow up with Dr. ___ at ___ in ___ on
___ at 9 am. Please take your neulasta when you
get home today. | ___ w/ HIV, cervical dysplasia s/p LEEP, breast cancer (s/p
lumpectomy, RT, adjuvant tamoxifen), and recent dx of metastatic
pancreatic cancer dx ___ c/b widespread carcinomatosis of
the abdomen, malignant ascites, recently discharged from the
hospital on ___ for submassive PE and initiation of
FOLFIRINOX ___ who followed up with primary oncologist for
C1D15 who was found to have lethargy and hyponatremia to 124
(most recently 128) and now possible SBP.
ACTIVE ISSUES
=============
# Hyponatremia: Occurring in the context of poor PO intake and
malignant ascites. Improving with administration of IVF and
albumin. HCTZ dc'd at outpatient oncologist office on day of
admission. UOSM 300, Na <10, c/w adequate Na retention but
activation of ADH ___ intravascular volume depletion.
Stabilizing around baseline of 130. Following paracentesis
___, acute decrease in Na suggesting role of fluid shifts with
paracentesis in underlying hyponatremia.
# Metastatic pancreatic cancer: C1D15 FOLFIRINOX due ___ but
deferred due to hyponatremia. Restarted FOLFIRINOX C1D15
(delayed) ___. Will receive Neulasta at home following
discharge on ___.
# Malignant Ascites: Peritoneal fluid revealed 560 PMN (slightly
less after corrected for RBC). Started empiric treatment with
CTX 2 GM D1 ___. Most likely malignancy: while PMNs are
more commonly associated with infection, blood/ascites cultures
remained negative. Started on spironolactone + furosemide;
however, patient became hyperkalemic so dc'd spironolactone in
discharge.
# ___: Present on admission, most likely pre-renal from poor po
intake and frequent large volume paracentesis resulting in
decreased renal perfusion. Abd US revealed stable L
moderate/severe hydronephrosis/hydroureter. Creatinine improved
quickly with IVF administration, confirming prerenal etiology.
CHRONIC ISSUES
==============
# Pulmonary embolism: continued Lovenox BID, weight based at 70
BID. Returned to home dosing on discharge.
# HIV: Followed recs Per Dr. ___: continued on her current
antiretroviral therapy.
TRANSITIONAL ISSUES
===================
Patient had Na of 128 on discharge, after large volume
paracentesis (near her baseline). She also had K of 5.6 likely
___ spironolactone. Spironolactone discontinued prior to
discharge.
Please recheck labs at ___ follow-up visit. | 104 | 327 |
19538777-DS-17 | 29,405,687 | Dear Mr. ___:
It was a pleasure caring for you at ___. You were evaluated
here due to nausea and vomiting, and you were found to have a
small bowel obstruction. We relieved your obstruction with with
a nasogastric tube which helped resolve your abdominal
distention. You were also able to eat without difficulties at
the time of discharge.
We wish you all the best.
Sincerely,
___, MD | ASSESSMENT AND PLAN: ___ with pmhx of CAD, HTN hx of sigmoid
volvulus s/p sigmoid colectomy now with colostomy presenting
with nausea, coffee ground emesis, large volume osteomy output
concerning for partial small bowel obstruction vs ileus.
Acute Issues
# Nausea, Vomiting
The patient was found to have a partial small bowel obstruction
on CT, and he was made NPO with nasogastric tube decompression.
ACS was consulted, and they felt there was no need for surgical
intervention. Mr. ___ abdominal distention improved,
his NG tube was clamped, and then pulled as there was no longer
residual output. He is now tolerating a liquid diet with no
nausea or vomiting. He has mild distension on discharge (KUB
___ negative for SBO).
# Increased ostomy output
The patient was also experiencing increased ostomy output with
concern for infectious etiologies such as C. Diff vs viral
gastroenteritis. His stool was guaiac negative, and his stool
cultures and C. Diff assay were also negative. With resolution
of his SBO, his ostomy output has also down trended.
# Developing pneumnonia.
Patient had one fever on ___. No clear source of infection. CXR
___ reassuring, but mild rhonchi on upper airway exam and
non-productive cough suggested atelectasis vs. developing
pneumonia. No leukocytosis but mild AG metabolic acidosis.
Ceftriaxone 1gm IV Q24 hr was started on ___ given concern
for developing pneumonia. He will complete the course on
___. Since starting his abx, he has remained afebrile and
HD stable, saturating well on room air.
Chronic Issues
# HTN
The patient was hypertensive upon arrival to the floor. He
received hydralazine IV once for BP control. His home Metoprolol
was held while NPO, and has been re-started as patient is
tolerating PO.
# BPH
The patient has had a foley in place during his admission. His
home medications of tamsulosin and finasteride were held while
NPO and have now been re-started.
# Orofacial Dyskinesia:
The patient's home xenazine was held while NPO. He received
trazodone PRN for facial spasm.
# Depression:
The patient's home medications of citalopram, mirtazapine,
trazodone, and xanax were held while NPO. Have since been
re-started as patient is tolerating clears.
# Hypothyroidism
The patient's home PO levothyroxine was held while he was NPO,
and he was transitioned to IV levothyroxine.
# Insomnia
The patient was unable to take his home dose of Ambien 10mg
while NPO. This dose is also against FDA recommendations. He
received Benadryl IV once for insomnia.
# Hx of DVT.
The patient's admission INR currently was 1.9 which is slightly
subtherapeutic. He received sc heparin while NPO with a
subtherapeutic INR. We spoke with his rehab facilitiy who
advised that he would no longer need to be treated with warfarin
upon discharge.
Transitional Issues
- patient is being discharge on ceftrixone 2gm q24hrs for
presumed developing pneumonia. His 7 day course will be
complete on ___.
-please evaluate patient's abdomen for increasing distention
-please evaluate for nausea and vomiting
-please check weekly electrolyte levels
-please continue liquid diet (no more than 300c every ___ hours)
and advance as tolerated in 1 week
-coumadin was discontinued given remote history of DVT in ___
-please monitor blood pressure given re-initiation of
anti-hypertensives
-foley in place, d/c as tolerated, hx of urinary retention | 64 | 537 |
12724735-DS-32 | 20,128,872 | Dear ___,
You were admitted to the hospital because you had fluid in your
lungs. You were treated with hemodialysis and your blood
pressure medications were adjusted. Please continue to take all
your medications as prescribed. It is important that your
tacroilmus level be checked by your nephrologist within the next
week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | ___ with Alport's syndrome, ESRD s/p renal transplant x2 now
back on HD, ___ with EF 45%, atrial fibrillation on Coumadin,
T2DM, HTN, presents to ED with shortness of breath. She said she
vomited blood once this morning. HD TTS with last HD on
___. She said she is compliant to HD and her BP meds. She
was admitted in mid-___ for similar presentation.
# Hypoxic Respiratory Failure. On admission to the MICU she was
fluid overloaded on exam with e/o bibasilar crackles. CXR with
bilateral opacities most consistent with pulmonary edema. She
underwent HD, with 4L fluid removed. Resp failure subsequently
resolved. Etiology was thought to be ___ CHF with flash
pulmonary edema. Echo in house showed EF of 45-50% which was
stable from prior, no new wall motion abnormalities. Etiology of
decompensated CHF thought to be secondary HTN urgency, as BPs as
high as 180s/120s upon admission. She had a TEE to rule out MR
as the etiology of her brittle volume status (as TTE had
acoustic shadowing); this showed only mild MR. ___ the end her
episodes of flash pulmonary edema were attributed to her brittle
blood pressure. She subsequently continued on her home
torsemide on non-HD days. She also underwent additional HD
sessions while in-house for consideration of uptitration from 3
days to 4 days of HD with the ___ day being ultrafiltration.
# Atrial Fibrillation. She was reportedly in Afib with RVR while
getting HD In the MICU, a diagnosis first reported in ___
of this year at an earlier admission. On review of available
EKGs and telemetry, none confirmed atrial fibrillation but
rather there was significant atrial ectopy. She was continued on
home warfarin and carvedilol. She was sent out with a monitor
to assess for paroxysmal atrial fibrillation. If confirmed, this
is likely contributing to her episodes of flash pulmonary edema.
# Back pain. She has a history of chronic back pain and was
continued on home regimen of Acetaminophen, lidocaine patch,
tramadol, and gabapentin.
# Hematuria: Patient presenting with microscopic hematuria.
#Hypertension: She was started on a nitro drip while in the ICU
for initial BPs 180s/120s. Her BPs were very labile while
in-house, running between 80-180 systolic. This was most likely
related to her ESRD from Alport's syndrome. In order to control
her blood pressures, hydralazine was started and increased as
tolerated.
==============
Chronic Issues
==============
#Chronic pain: She has known chronic back pain as well as
intense cramping associated with HD. She was continued on her
home gabapentin. Nephrocaps were added to help treat cramps
during HD. She was started on nortriptyline qHS.
#Chronic systolic HF (EF 40-45%): Appears volume overloaded on
exam. CXR with pulmonary edema. She received HD as above. She
was continued on carvedilol and torsemide (torsemide on non HD
days).
# Diabetes mellitus, type II with peripheral neuropathy. HbA1c
7.6 (improved from 9.2 in ___. She had some low AM blood
sugars so her insulin was decreased to 70/30 16 units @
Breakfast and 70/30 12 units @ Bedtime, as well as ISS. She
continued on gabapentin for her neuropathy.
# Hyperlipidemia: Continued home pravastatin.
===================
Transitional Issues
===================
#Chronic back pain: She was discharged with a plan to follow up
with pain clinic on ___.
#Total body pain: The etiology of this was unclear. She was
started on nephrocaps to help prevent cramps during dialysis.
She was started on nortriptyline qHS given the possibility that
this represented neuropathic pain. She was also treated with
flexeril PRN.
#Hypertension: Hydralazine was intiated and uptitrated as
tolerated. Her home imdur was also uptitrated.
#INR should be chedked on ___ by ___ fax results to ___
___ clinic.
#Atrial fibrillation: she was reported to be in afib with RVR
while in the ICU; however, review of EKGs showed only atrial
ectopy. She was discharged with ___ of hearts monitor. If her
evaluation is negative for atrial fibrillation, then her
Coumadin should be discontinued.
#DISCHARGE WEIGHT 45.8kg | 73 | 646 |
11213050-DS-5 | 20,047,797 | Dear Ms ___,
You were admitted initially to the Neurosurgery Service and then
transferred to the Neurology Service at ___
___ after presenting with headache, nausea and
vomiting. You were found to have bleeding in the left frontal
area of your brain. You were taken to the operating room by
Neurosurgery on ___ for removal of the blood and biopsy so as to
determine the cause of your bleed. At the time of discharge,
the results of your biopsy were still pending. You will have a
repeat MRI in one month. | Neurosurgery Course:
Mrs. ___ was admitted initially to the Neurosurgery Service
for further management of her left frontal intraparenchymal
hemorrhage. A CTA showed no significant stenosis, aneurysm or
other vascular abnormality. The patient was admitted to the ICU
for close neurologic monitoring. She was transferred to the
floor on ___ awaiting a MRI of the brain to assess for
underlying lesion.
On ___, a MRI of the brain with and without contrast was ordered
to assess for underlying lesion.
On ___, the patient remained neurologically stable. She
underwent a brain MRI. Stroke neurology was consulted for
additional work-up of etiology of hemorrhage. It was determined
she would undergo resection of the hemorrhage and possible
lesion on ___. She was made NPO after midnight and consented to
the procedure. | 95 | 128 |
10363340-DS-13 | 24,078,377 | Dear ___,
___ were admitted to ___
because ___ had difficulty breathing. ___ were found to have
fluid in your lungs, and ___ had a procedure where a drain was
placed in your chest to remove this fluid. When ___ leave, ___
will need to keep this drain in to remove any new fluid that
builds up. The visiting nurses ___ help drain the fluid EVERY
OTHER DAY. ___ can take Tylenol to help control your pain.
___ were also seen by our oncologists to create a plan to treat
your cancer. ___ were started on a medication called
anostrazole. When ___ leave, ___ should follow up with your
oncologist, Dr. ___. Her office is working on getting ___
an appointment. If ___ don't hear from her by ___, ___ should call her office at ___.
___ will go home on oxygen. Please make sure ___ are careful
with the cords and do not place the oxygen near fire or open
flame, as it is highly combustible. The oxygen will help ___
breathe more comfortably.
Sincerely,
Your ___ Team | Mrs. ___ is an ___ w/___ significant for
___ lung metastases unclear etiology, known
bilateral pleural effusions, a history of breast cancer who
presented to ___ for evaluation of dyspnea.
#Dyspnea: Admission CXR showed worsening left pleural effusion
and stable Right effusion following recent drainage by IP.
Cytology from recent thoracentesis was consistent with
metastatic malignant effusion, likely of breast origin. Pleurex
catheter was placed in Left hemithorax by interventional
pulmonology on ___ with improvement in her symptoms. Pt
was discharged with plan for QOD drainage and f/u with IP on
___. She was also discharged with oxygen for comfort.
-Follow up with PCP
___ Cancer: Cytology from ___ thoracentesis
was mammoglobin (+), CK7(+) ER(+), Her2 equivocal and CK20
negative. Pt was seen by ___ heme/onc. She underwent CT
abdomen/pelvis and bone scan for staging. She was started on
anostrazole and discharged with a plan to follow up with her
primary oncologist, Dr. ___.
-Continue anostrazole
-Follow up with Dr. ___
#Leukocytosis: Pt w/leukocytosis to 14.1 on presentation but
otherwise without infectious symptoms. She received a single
dose of CTX/azithromycin in the ED, and this was discontinued on
admission. Leukocytosis felt to be reactive to malignancy, as pt
had no other signs of infection.
#Left chest wall rash: Pt with erythematous rash on chest wall
and axilla, felt to be related to malignancy. Triamcinolone was
discontinued and pt given Sarna lotion for symptomatic relief.
-Discontinue triamcinolone
___ edema: Pt presented with L>R leg edema, felt to be ___
venous insufficiency. Improved with TEDs. Pt also continued on
home lasix.
#HTN: Pt continued on home atenolol.
#DM2: Pt maintained on home Lantus with SSI
#HLD: Pt continued on home atorvastatin and aspirin
**Transitional Issues**
- Follow up with PCP
- ___ up with interventional pulmonology on ___.
- Follow up with Dr. ___
- ___
- Code: DNR/DNI
Emergency Contact:
-___ (daughter) ___ (daughter) ___ | 174 | 295 |
Subsets and Splits