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16747700-DS-4 | 25,858,852 | Discharge Instructions
Brain Hemorrhage without Surgery
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 may resume Aspirin 81mg daily. DO NOT restart any other
anticoagulation until cleared by Neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood swings
are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
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 | On ___ the patient was transferred to ___ s/p fall on aspirin
while getting out of his car when he fell backwards with head
strike. He did not have loss of consciousness. The patient had a
___ that was consistent with scattered bilateral SAH.
On ___ the patient remained neurologically stable. Radiology
read of chest xray after the fall was consistent with Possible
fractures of right posterior ___ ribs. A 9 mm ovoid opacity
projecting over the right anterior second rib may
represent a pulmonary nodule. As the patient was non surgical a
___ protocol transfer was initiated.
On ___, the patient remained neurologically stable. He
continued to work with both ___ and OT who recommend rehab
placement which is currently pending. Given that he has no
acute neurosurgical needs he will be transferred to medicine
today.
On ___ the patient remained hemodynamically and neurologically
stable. He was pending a rehab bed and insurance authorization.
His IVF were discontinued as he was taking in sufficient oral
intake. His telemetry was also discontinued as he was no longer
on standing hydralazine. He was started on subcutaneous heparin
for DVT prophylaxis.
On ___, patient remains hemodynamically and neurologically
stable. Aspirin 81mg was resumed. Patient being discharged to
rehab.
Follow up information given in discharge instructions. | 411 | 214 |
16235517-DS-10 | 26,078,063 | Mr. ___,
You were admitted to ___ with abdominal pain and found to have
acute cholecystitis. A drain was placed at this time and you
will return to clinic in 2 weeks to discuss the timing of
removing your gallbladder.
Please see below for appt. details.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so. BRING RECORD WITH YOU TO YOUR CLINIC APPOINTMENT.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
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. | Mr. ___ is a ___ y.o. who was admitted to the ___ on ___
with complaints right upper quadrant abdominal pain that had
progressed over a few days prior to admission. CT ABD/Pelvis
revealed a distended gallbladder with wall edema and extensive
surrounding fat stranding consistent with acute cholecystitis.
He was hemodynamically stable and afebrile with a WBC of 12.5 on
admission. The patient was made NPO with intravenous fluid and
started on Unasyn for antibioitc coverage. On ___, he
underwent placement of an ultrasound guided cholecystostomy
tube. The patient tolerated the procedure well and remained
hemodynamically stable. On ___, the patient reported no bowel
movement since admission and had a distended abdomen without
peritoneal signs on physical exam. He was started on a bowel
regimen and was able to pass flatus and stool later that
evening. At this time he was transistioned to an Augmentin in
preparation for antibiotic coverage at discharge. He tolerated
this well. On ___, the day of discharge, the patient's pain
was well controlled on oxycodone. He was tolerating a regular
diet without nausea, vomitting or abdominal pain. His ___ drain
remained patent in his RUQ and continued to have bilous output.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. He was educated on ___ drain care at the time of discharge
and will have a ___ evlauate him at home. He will follow-up in
the ___ clinic as listed below for drain evaluation and planning
for interval cholecystectomy. | 579 | 292 |
11093944-DS-18 | 22,422,871 | Dear Ms ___ ,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- Because your heart was beating fast and you felt dizzy
What did you receive in the hospital?
- We did a scan of your belly, your heart, and your chest to
make sure you were ok. All of the scans were normal.
- We monitored your heart and it was normal.
- We monitored your sugars and they were normal.
What should you do once you leave the hospital?
- Please keep your PCP appointment
___ think you felt this way because you did not eat before going
to dialysis and you got low blood sugars. Please make sure you
eat before you get dialysis.
We wish you the best!
Your ___ Care Team | Ms. ___ is a ___ with history of ESRD s/p failed kidney
transplant ___ years ago who is currently on ___ HD who presents
after having had an episode of unresponsiveness in HD,
hypoglycemia, hypertension, and mixed alkalemia.
=============
#Tachycardia
#Concern for PE:
Patient initially presented from HD with tachycardia and
subjective chest pain. In ED, EKG reveals sinus tachycardia in
the low 100s. VBG revealed pH 7.66 with a CO2 28, consistent
with a respiratory alkalosis. Patient has no prior history of
DVT. D-Dimer elevated in ED. Patient was placed on hepatin drip
empirically during PE workup. ___ performed and showed no DVT.
Echo performed and showed no evidence of right hear strain or
other pathology. CTA without evidence of PE. Heparin drip was
discontinued.
Patient EKG showed no dynamic changes. Troponin, CKMB negative
X3. Patient euvolemic without evidence of volume overload on
exam. Orthopedic vitals signs were within the normal range
In absence of PE, ACS, volume overload, hypovolemia, sinus
tachycardia likely due to hemodynamic shifts during HD. The
patient was observed on telemetry for 24 hours and remained in
normal sinus rhythm without ectopy. On admission to the hospital
floor, alkalosis resolved without intervention.
#Respiratory alkalosis:
#Metabolic alkalosis:
In the ED, initial VBG consistent with mixed alkalemia.
Metabolic alkalosis likely due underlining ESRD due to a high
bicarbonate bath during HD. Renal was consulted. The patients
alkalemia resolved without intervention. Respiratory component
felt to be most transient tachypnea in ED due to anxiety vs
hemodynamic changes secondary to HD. Respiration rate was normal
while on the hospital floor.
#Episode of Hypoglycemia
#Episode of Hypotention
Patient found to be hypotensive and hypoglycemic in HD. Per
patient not unusual for her to become hypotensive. Has never
become hypoglyceic. Patient recently discontinued steroid taper
as directed by nephrologist. Patient was fasting prior to HD due
to increased abdominal pain. Abdominal pain has been a chronic
issue for the patient and is secondary to chronic rejection of
transplant kidney. On abdominal pain consistent with patient's
baseline.
The patient has Q4 finger sticks, all of which were normal. She
did not have a repeat episode of hypoglycemia. AM cortisol was
WNL. Hypoglycemia likely due to fasting prior to HD rather than
other endocrine pathology.
#Pulmonary nodule: Incidental finding on imaging:
5mm pulmonary nodule at the right costophrenic angle.
Recommendation is for incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommended in a high-risk patient. | 153 | 411 |
12725192-DS-16 | 23,058,351 | ___ 3 DISCHARGE INSTRUCTIONS:
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing small bowel resection with anastomosis for
jejunal gastrointestinal stromal tumor. You have recovered from
surgery and are now ready to be discharged home. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
- Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | The patient presented to the emergency department on ___
with 4 days of melena, found to be in hemorrhagic shock with a
HCT of 16.3. He was transfused 4U pRBCs, resuscitated with 2L of
crystalloid fluids and prepared to be taken to the OR for
exploratory laparotomy, small bowel resection with resection of
known jejunal gastrointestinal stromal tumor. Of note, the
patient had presented one week prior to his presentation with
melena and anemia. The patient was stabilized during his
hospital stay and further plans were made to finish his work-up
on an outpatient basis. There were no adverse events in the
operating room; please see the operative note for details.
Post-operatively the patient was taken to the PACU until stable
and then transferred to the wards until stable to go home.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with dilaudid PCA
and IV Tylenol. Eventually he was transitions to oral pain
medications with adequate control of his pain. Pain was very
well controlled.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed intra-operatively,
which was discontinued on POD1 with autonomous return of
voiding. The patient continued to have melenic stools throughout
his hospital stay. This was as expected, as he was noted
intraoperatively to have a colon full of melenic stools. However
the source of his bleeding was confirmed to be controlled with
resection of his mass. The patient was initially managed with an
NGT post-operatively. This was removed on POD1 and the patient
was sequentially advanced to a regular diet over the course of
the next few days without complication. The patient was
tolerating a regular diet prior to discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices. Post-operatively, the patient's hematocrits were
followed s/p resection of his bleeding mass. On POD3, the
patient experienced a fall in HCT from 26.1 to 21.4, however he
remained asymptomatic. The fall in hematocrit was thought to be
due to equilibration. On POD5 he experienced another drop from
22.9 to 20.7 for which he was transfused one unit pRBCs. Over
the course of the next two days, his hematocrit increased to
27.6 and remained stable.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his home
tube feeds, as well as diet as above per oral, ambulating,
voiding without assistance, and pain was well controlled. The
patient was discharged home without services. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 811 | 492 |
13809067-DS-9 | 22,574,905 | Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___
office with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | The patient was admitted late ___ with concern for a bowel
process given her recent abdominal surgery. She was given
Tylenol/oxycodone, famotidine and ondansetron and observed over
night. Her epigastric pain, nausea and vomiting improved and she
was discharged in stable condition. | 171 | 42 |
16785490-DS-21 | 21,816,801 | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples. You must wait until after
they are removed to wash your hair. You may shower before this
time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home. | Mr. ___ was admitted to the Neurosurgery service after an
outpatient MRI revealed a new left-sided intracranial mass. He
was started on anti-seizure medication and steroids for seizure
prophylaxis and edema, respectively. The patient was admitted
to the ICU for close neurologic monitoring. He was prepared for
an operative resection the following morning. IV fluids were
initiated and he was kept NPO status overnight.
On ___, Mr. ___ was taken to the operating suite for his
operative procedure. Because he was taking aspirin prior to his
admission, the patient was given a pack of platelets, as well
and packed red blood cells, intra-operatively. Please see the
operative report for further details. A specimen was sent to
pathology for frozen analysis and was found to be likely
high-grade glioma.
Post-operatively, Mr. ___ was transferred to the ICU for
further management and observation. A non-contrast head CT was
obtained during this period and revealed normal post-operative
changes with little to no hemorrhage of the surgical cavity.
The patient remained neurologically stable during this time.
Due to poor venous access, a left IJ triple-lumen catheter was
inserted by the ICU team. He was extubated on the evening of
___. As he became more awake, his diet was advanced and IV
fluids were discontinued.
On ___, Mr. ___ surgical drain was discontinued. As he
continued to recover well, he was transferred to the inpatient
ward. He was tolerating a regular diet without issue. His
Foley catheter was discontinued and he voided thereafter.
On ___, Mr. ___ was seen by the Neuro-radiation Attending
for post-hospitalization treatment planning. Later that
afternoon, he was discharged home. He was given prescriptions
for Keppra, a taper for decadron (to 2mg BID daily) and narcotic
pain medication was provided. The patient was instructed to
follow up in the ___ clinic in one week (an appointment was
provided).
At the time of discharge, Mr. ___ was ambulating
independently, was afebrile, hemodynamically and neurologically
stable. | 197 | 338 |
19991085-DS-19 | 28,178,930 | Dear Ms. ___,
You were admitted to ___ after a PET scan revealed
lymphadenopathy concerning for malignancy and concerning for
spinal cord involvement. You underwent brain and spine MRI to
evaluate your spinal cord, and multiple brain and spine lesions
were detected. To better assess the nature of the lesions, you
subsequently underwent mediastinoscopy to obtain a lymph node
for histological analysis. The results of the biopsy showed that
you had sarcoidosis, not lymphoma. You were seen by rheumatology
and treated with high-dose steroids. You will need to continue
to take the prednisone steroid as well as your prophylactic
antibiotic.
Please report to an ED or your PCP with any worsening weakness,
numbness, cough, fevers, or chills. It was our pleasure taking
care of you,
Your ___ Team | Ms. ___ is a ___ y.o. woman with a history of spinal
stenosis, cervical radiculopathy, and obesity who presents for
workup after multiple CTs revealed cervical and mediastinal
lymphadenopathy and a PET scan on ___ was concerning for
lymphoma with possible cord involvment/compression. MRI ___
revealed significant brain and cord involvement with concern for
cord compression at C3 and T8 despite absence of clinical
findings. Lymph node biopsy consistent with sarcoidosis.
#Sarcoidosis: Patient found to have significant lymphadenopathy
on CT C spine done for progressive neuropathy and weakness now
with PET scan showing widspread lymphadenopathy concerning for
neoplasm with possible intrathecal involvement. MRI ___ showed
brain and cord involvement with possible compression of cord at
C3 and T8, for which patient was given steroids. In the mean
time, she underwent mediastinoscopy for biopsy and tissue
diagnosis on ___, with final pathology still pending but so far
consistent with sarcoidosis. HIV was negative. There was a low
suspicion for CNS lymphoma but it could not be ruled out because
LP was contraindicated given risk of cervical spine cord
compression. Rheumatology was consulted. She was treated with
methylprednisolone 1g qday x 3 days and will be discharged on
1mg/kg (IBW) prednisone (currently 50mg PO daily). She was
placed on PCP prophylaxis and ___ PPI that she will continue as an
outpatient. She will need a TB test as an outpatient. Lymph node
final pathology, ACE level, and hand xray reads are still
pending. She may need a cardiac-protocol PET to evaluate for
cardiac sarcoidosis.
#Gait abnormalities: The patient has had gait abnormalities
progressive over years, possibly related to stenosis but
concerning for worsening impingement on spinal cord. She was
managed with steroids and her gait problems have improved. She
should use a cane to ambulate per ___.
#Spinal stenosis: Patient has history of spinal stenosis for
which she takes gabapentin. She has no focal deficits on exam.
She should continue home gabapentin 300mg QD
#Cervical/vaginal lesion: PET showed uptake in cervix, which
would be atypical for sarcoid.Pelvic US revealed no lesions of
the cervix but MRI would better evaluate the vaginal canal.
#History of wide complex tachycardia: She has a pacer which
doesn't seem to be ICD. She was continued on metoprolol XL
100mg.
#Hypothryroidism: She was continued on levothyroxine 150mcg
daily | 129 | 379 |
12056668-DS-5 | 28,390,989 | Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting
-Increased shortness of breath
Pain
-Take stool softners with narcotics
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk ___ times a day for ___ minutes increase to a Goal of 30
minutes daily | Mr. ___ was admitted to the hospital, kept NPO and hydrated
with IV fluids. Based on his symptoms and anatomy, repair of his
large paraesophageal hernia was recommended. Unfortunately he
became delirious after having low dose Ativan which was given
preoperatively to reduce his anxiety. He was taken to the
Operating Room for surgery on ___ but immediately refused
the surgery when he arrived in the Operating Room. He appeared
confused and delirious, the surgery was cancelled and he
returned to the floor.
The Psychiatry service evaluated him and felt that the confusion
and delirium was prompted by Ativan in combination with poor
nutritional status and his age. At that point the patient wanted
surgery again. A decision was made to place a PICC line and
give TPN for ___ days prior to operating with the attempt to
help improve his nutritional status. A PICC line was placed on
___ and TPN began.
In the mean time he worked with Physical Therapy and had no more
episodes of confusion or delirium.
On ___ he was taken to the Operating Room and underwent a
laparoscopic paraesophageal hernia repair with PEG tube
placement. He tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics and
his pain was well controlled. Following transfer to the
Surgical floor he continued to make good progress. His pain was
controlled with Tylenol alone and his mental status was intact.
His TPN continued and eventually tube feedings were started and
well tolerated. He was maintained on 2 cal HN 1 can TID. His
TPN was weaned off ___ and his PICC line was removed.
His chest xray on admission to the hospital was notable for
bilateral pleural effusions but his respiratory status was not
compromised. His effusions did increase in size and on ___
he has a left thoracentesis for 1 liter of serosanguinous fluid.
He tolerated it well and his subsequent chest xray demonstrated
no pneumothorax and a clear diaphram. He was breathing
comfortably off of oxygen and had room air saturations of 95%.
He continued to work with Physical Therapy who recommended that
he go to a short term rehab prior to returning home to increase
his mobility and endurance. From a surgical standpoint he
continued to do well. His post sites were healing well and his
PEG site was dry. After a long hospital stay he was discharged
to rehab on ___. | 67 | 415 |
11227287-DS-8 | 22,094,133 | Dear Mr. ___,
You were diagnosed with ischemic stroke (ischemic means low
blood flow). Your imaging showed a clot in one of your blood
vessels, which may have predisposed you to stroke. It is also
possible that there was a tear in one of your neck vessels that
predisposed you to stroke. You are being discharged with Lovenox
shots and coumadin. The Lovenox shots will be stopped once your
coumadin is at a therapeutic level. You will need to get regular
INR levels (checking thinness of blood) to make sure you are on
the right coumdin dose. Your first INR level should be checked
___ (tomorrow), and the results should be faxed to your
primary care provider (fax number: ___ or the result
can be called in (___) by the lab. Return to the ED if
you have any dnager symptoms (listed below). You will follow up
in stroke clinic.
It was a pleasure meeting you!
Your ___ Neurology Team | On admission, Mr. ___ had an ___ of 3 (1 pts right arm, 1 pt
sensory for right arm, 1 pt dysarthria). ___ was without
acute stroke, but CTA initially concerning for a left carotid
dissection with possible intra-arterial thrombus (final read
describes 50% narrowing of left ICA secondary to soft plaue with
distal intramural thrombus and relative preservation of distal
flow. Labwork was benign. He was started on a heparin gtt given
the possible thrombus.
He was admitted to the ICU where MRI showed acute infarctions
involving the left parieto-occipital,left temporal, and left
frontoparietal lobes as well as the right centrum semiovale. A
filling defect in the left priximal internal carotid artery,
initially thought to be a dissection, was also seen. MRA of the
head was normal. He was eventually transferred to the acute
stroke service floor. An MRA of the neck with fat saturation
confirmed a filling defect in the left proximal internal carotid
artery, reflecting an intraluminal thrombus per the formal read
(could represent dissection per our read). He has some
improvement in his right hand deficit. A carotid US revealed
1.5cm free-floating hyperechoic material within the proximal
left ICA with surrounding flow, likelyrepresenting a
non-occlusive thrombus or plaque with <40% stenosis of the left
ICA. Vascular surgery was consulted and recommended lifelong
therapeutic anticoagulation and decided that no surgical
intervention was indicated.
His work-up included an EKG that did not show any evidence of
ischemic changes. CXR showed left pleural effusion and chronic
underlying disease. A1c was 5.6. LDL was 90.
The exact underlying etiology remains unclear and could
represent dissection versus in situ thrombus with ruptured
plaque. He was discharged on Lovenox bridge to coumadin. | 159 | 281 |
16040458-DS-6 | 21,018,027 | Dear Mr. ___,
It was a pleasure taking care of your during your
hospitalization. You were admitted with low red blood cell
counts (anemia), weakness in your legs, and swelling in your
lower legs. We believe that your low red blood cells counts were
caused by your recent chemotherapy. We gave your blood to
improve your anemia. We believe that your weakness and swelling
is because of progression of your tumors which are compressing
your nerves and veins. We hope that the radiation that you are
receiving will help the swelling in your legs improve.
We wish you the best,
Your ___ team | ___, a ___ yo M PMHx Metastatic Prostate Cancer
(lumbar/cervical spine, right hip) on treatment with radium 223
recently admitted with pathologic right subtrochanteric femur
fracture now readmitted with anemia, worsening lower extremity
edema and fevers/chills. | 103 | 38 |
15002062-DS-20 | 28,515,248 | Ms. ___,
You were admitted to ___
because you had fluid in your abdomen.
While you were here:
-We drained the fluid. There was no infection in this fluid.
-You had an upper endoscopy to evaluate for something called
varices (dilated blood vessels that can happen in liver
disease). Those blood vessels were clipped, please talk to Dr.
___ repeating your upper endoscopy in a few weeks as
follow up.
When you go home:
-Please continue all medications as directed.
-*We increased your Lasix so that you will take 60 mg in the
morning and 40 mg in the evening.
-*We decreased your Lantus because you were taking 50 units in
the morning, but your blood sugars were low with this. We
changed it to 38 units. Please speak with your primary care
doctor about this, as you may require higher dosing once you go
back home and eat different food than in the hospital.
-Please follow-up with the below doctors.
-___ weigh yourself daily, call your doctor if your weight
goes up by more than 3 pounds in one day or 5 pounds in three
days.
-Please call your doctor if you have: fevers, chills, confusion,
more yellowing of the skin, abdominal pain, more fluid in the
abdomen, more swelling in the legs, or decreased urine output.
We wish you the best,
Your ___ care team | Ms. ___ is a ___ year old woman with Type 2 DM, NASH
cirrhosis (dx ___ presenting with ABD distension and dyspnea,
found to have recurrent ascites.
#Recurrent ascites:
Second occurrence of ascites without evidence of trigger. Not
suggestive of infection or bleeding from history. Micro negative
to date. She has been compliant with meds. RUQUS unrevealing.
AFP within normal limits. She underwent a large volume
paracentesis with 12L off on ___ and received albumin
repletion. She remained stable and was discharged. Discharge
Lasix regimen increased: 60AM/40PM. As this is second occurrence
of ascites, held off TIPS for now. Recommend transplant workup.
Please follow-up pending blood cultures and ascitic fluid
cultures and cytology in clinic.
#Varices:
Banded varices on EGD ___. EGD also revealed small ulcers
in the antrum. She was started on PPI twice daily. She should
continue Carafate for 1 week. She should have a repeat EGD to
evaluate banding in ___ weeks. H. pylori serology was pending
and should be followed up after discharge. Nadolol was
considered but deferred given low blood pressures and recurrent
ascites.
# Hepatic cirrhosis, diagnosed ___, documented on liver biopsy:
Underlying etiology likely ___, NaMELD on admission: 10.
Complicated by ascites and esophageal varices. She had inpatient
EGD on ___ with varices at the lower third of the esophagus
(ligation) as above.
# T2DM on insulin - continued Lantus but decreased to 38 Units
as night given low blood sugar with 50U. Add insulin sliding
scale while inpatient but she did not require it.
# H/o CVA - continued ASA 81 daily and Atorvastatin 40mg daily | 217 | 260 |
18562129-DS-10 | 22,764,355 | Dear Mr. ___,
You were admitted to the cardiology service at ___ due to your
decreased appetite, nausea, vomiting, weight loss, and fatigue.
For this, you received IV fluids and a number blood tests, which
were all normal. | Hospital course by problem:
# FAILURE TO THRIVE: Pt has been living in ECF since his AVR
___. Per report from patient and his daughter, he has been
having decreased appetite +/- nausea for several years with a
worsening in his condition since the AVR. He also states that
he has a persistent issue with dry mouth for the past several
years attributable to his SSRIs. He has a history of depression
and alcohol abuse in the past. His wife has died in the past
year. Infectious workup negative (WBC WNL, no fevers). Albumin
3.8. TSH normal. Cortisol stim test normal. Cardiac echo with
only mild increased LV filling pressures, EF 55% (full report in
results section). CT/ABD/CHEST/PELVIS head with no acute
process. Patient was given IV fluids with improvement in energy
level. Speech/swallow and nutrition saw patient, and their
recommendations were followed (see results section). An UGI
study was done showing some dysmotility (see results section).
Our differential included depression, amiodarone side effects,
dementia, adrenal insufficiency (ruled out). Amiodarone was
stopped during this admission, but will take up to a week to
clear from system. GI biopsy showed inflammatory foci consistent
with eosinophilic infiltrates consistent with either reflux or
eosinophilic esophagitis.
# ___: Pre-renal based on FeNa 0.28%. Patient was given IVF. Cr
on admission 1.6, returning to baseline (around 1.0) by HD 2. We
held glipizide on this admission. Renal ultrasound with some
simple cysts, but nothing else significant. Cr corrected back
down to 1.4 by time of discharge. This should be monitored
closely upon discharge.
# EOSINOPHILIA: Moderate to severe. DDx: neoplasia, AIN,
allergy, adrenal insufficiency (ruled out) rare GI causes,
amiodarone side effect. No adrenal insufficiency. GI and heme
onc consult were placed. An EGD was done (see results section)
with no apparent cause, bx was taken to rule out eosinophilic
esophagitis. Patient will follow as outpatient with heme/onc for
possibly diagnosis of hypeosinophilic syndrome vs. esophageal
eosinophilia suggested by biopsy.
# PAROXYSMAL AFIB: Patient in sinus rhythm on this admission
with rates ___. His INR trended down likely ___ to increased PO
intake/dietary changes. Home dose 0.5mg was increased to 1mg.
Patient will need INR followed closely and warfarin readjusted.
Discontinued amiodarone for the reasons listed above.
# CAD: Patient is s/p CABG 4vessel, s/p 2 stents to SVG to RCA
___, s/p stent at anastomosis of SVG to LAD and stent to
proximal SVG to LAD ___, s/p LCx/?OM stent and LM stenting
___. Many of his cardiac medications had been discontinued by
his cardiology several days prior to this admission. He was
continued on ASA, which was the only CAD med still on his med
list. His previous dose of amlodipine 5mg daily was restarted
___ mild HTN (SBPs 140s-150s).
# DM: non-insulin dependent. Held glipizide given his elevated
Cr on admission. He was managed on RISS.
# OSA: continued on CPAP at night
# DEPRESSION: The patient has a history of depression on an SSRI
(Zoloft) that was recently increased to 125 mg. Here, he
endorses depression with a Geriatric Depression Scale score of 7
(> 5 suggests depression). The patient does have significant
stressors (wife's death and recent surgery) and has not had
appropriate grief counseling. Denies any suicidal or homicidal
ideation. The patient has agreed to outpatient talk therapy for
his depression in an outpatient setting. | 37 | 555 |
12384056-DS-23 | 27,622,538 | Dear ___,
___ were hospitalized due to symptoms of left sided weakness
resulting from an acute hemorrhagic stroke, a condition where a
blood vessel providing oxygen and nutrients to the brain is
damaged asnd bleeds. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain can result in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
We are changing your medications as follows:
START lisinopril 5mg daily
CHANGE metoprolol to carvedilol 2.5mg BID
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing ___ with care during this
hospitalization. | Patient was seen and evaluated after being transferred from an
outside hospital to ___. She was admitted to the intensive
care unit because of a right frontal IPH for further management
and care. A repeat CT scan of the head was done which was
stable.
#Neuro:
A non-contrast head CT was stable with slightly more edema
surrounding the bleed. She was continued on Mannitol 12.5 IV Q6
following serum osmolality and sodium levels until ___.
AN MRI/MRV showed no AVM, aneurysm or tumor. The most likely
origin of the bleed is amyloid angiopathy. Her neurologic
examination remained stable and improved slightly thorughout her
stay, with her being able to spontaneously move her left foot.
She did not have seizures, and her antiepileptic medication was
continued at the same dose.
#CV:
SBP goal was 120. We initially treated her with metoprolol and
hydralazine iv, and then switched her to lisinopril and
carvedilol.
Her echo and EKG were stable compared to previous exams.
#Pulm:
Her CXR showed some atalectasis and streaky opacities suspicious
for pneumonia. She was started on levofloxain iv whioch was
discontinued after her follow up CXR did not confirm the
diagnose. She did not have fever or and elevated WBC and
remained stable regarding her respiration at all times.
#GI:
She failed the initial speech and swallow evaluation, and had an
NG tube placed, but passed the follow up evaluation on ___,
and was started on pureed foods and nectar thick liquids.
#GU:
Foley catheter in place. Creatinine rose to max 1.4, and was at
1.1 before discharge.
#BMT:
She was continued on her maintenance prednisone.
#Prophylaxis:
Heparin prophylaxis, bowel regime. | 290 | 256 |
17784248-DS-17 | 29,731,065 | Ms. ___,
You were admitted for your shortness of breath. You were found
to be fluid overloaded and given medicines to help you lose
fluid. Please continue to take your oral diuretic (torsemide) as
prescribed. This has been recently increased and you should
continue to take the increased dose.
You also had a rash on your arm and you were given medicine for
this. Please continue this until the itching and redness
resolve.
If you have worsening chest pain, shortness of breath, or new
symptoms, please return for immediate evaluation.
It was a pleasure taking care of you!
Your ___ Team | Ms. ___ is a ___ with PMH of CHF, CAD s/p DES to RCA, GERD,
Depression, COPD, HTN, HLD, h/o breath cancer s/p mastectomy,
chemo and XRT, osteoporosis who presents with dyspnea, found to
have CHF exacerbation.
# Acute on Chronic Systolic Heart Failure: EF per most recent
stress test showed EF 35-40%, though last TTE in ___ system
___ shows EF 50%. Patient with dyspnea and weight gain at
home, found to have markedly elevated BNP on admission to ___
from prior 400. Dyspnea and O2 sat improved s/p IV diuresis.
Unclear precipitant of CHF exacerbation. Patient w/o evidence of
cardiac ischemia or infection. She reports medication and
dietary compliance. Continued on home metop while inpatient.
Diuresed with IV Lasix 80mg x 2. Transitioned to oral torsemide
20mg.
Weight at discharge 63.4kg
Creatinine at discharge 1.3
# Eczema: Pt's hospitalization course complicated by large
tri-focal erythematous patches on humerus. Has happened before
and treated fro cellulitis. Started clindamycin and then
vancomycin here but worsened
with severe itching. Never had fever/leukocytosis. Discussed
with ID and derm. Derm recommended clobetasol and noted this was
not c/w cellulitis. On day of discharge, markedly improved
erythema and itching. Pt given hydrocort 2.5%, sarna, clobetasol
(pt instructed to discontinue clobetasol in 1 week).
# Flank Pain: patient with flank pain in the ED, per her
description occurs whenever she is given high dose IV diuretic.
CTU in the ED w/o evidence of nephrolithiasis or acute process.
Pain has resolved by time pt was on floors.
# Alkalosis: on initial presentation pH 7.5, likely primary
respiratory in the setting of tachypnea
# CAD: ECG w/o changes and troponin negative x2, Continued
___, Plavix.
# COPD: lower index of suspicion for COPD exacerbation.
Continued albuterol, benzonatate, fluticasone.
# Depression/Anxiety:
Continued home diazepam and clonazepam.
# Allergies:
continued loratadine
# GERD:
continued home omeprazole
# Osteoporosis:
continued home Ca/Vit D
# Med Rec: continued B12, Fe
TRANSITIONAL
============
-Continued on torsemide 20mg.
-Pt discharged on hydrocortisone 2.5, clobetasol (will
discontinue after 1 week), sarna lotion.
-Pt to follow up with PCP and dermatology for her issues within
1 week.
-Pt will get call from heart failure nurse to arrange
appointment with possible BMP check and fluid status check. | 96 | 368 |
11296936-DS-98 | 28,991,585 | Dear Mr. ___,
You were admitted to the hospital for confusion and were found
to have a low oxygen level. It appeared that you were somewhat
fluid overloaded and had pulmonary edema (fluid in your lungs)
when you arrived. Alternatively, you could have had low blood
sugar. You underwent dialysis and your symptoms improved. You
should be careful not to drink too much fluid after you leave
the hospital and to monitor your blood sugars in order to avoid
this problem in the future. Weigh yourself every morning, call
MD if weight goes up more than 3 lbs. Physical therapy
recommended ___ rehab for you to regain your strength, but
since you declined this, you will need physical therapy at home.
Since this week is a holiday, you got dialysis this morning in
the hospital and should go to your dialysis center on ___
___.
You should continue to take all of your medications as
prescribed and follow up with primary care at the appointment
scheduled below. | ___ yo male with history of ESRD on HD, CHF, DM2, polysubstance
abuse, hx SI admitted for altered mental status and hypoxia.
#MICU COURSE: The patient's vital signs were stable throughout
his MICU course with vitals T 97.7 HR 84-102, BP 111/60-163/87,
RR ___, SaO2 93-100%. The patient denied lightheadedness,
dyspnea, or chest pain. He did complain of pruritis which he
reports is common for him after dialysis. It responded to sarna
lotion, diphenhydramine, and hydroxyzine. His antibiotics were
discontinued since he did not appear to be infected.
#AMS: Per report, pt was found wandering in a store, confused,
found to have low O2 sat by EMS. ___ have been secondary to
hypoxia in the setting of pulmonary edema as described below.
Other possiblities include substance use, which patient denied
(serum tox negative, unable to obtain urine tox as pt is
anuric), and hypoglycemic episode as pt reported to health care
providers that he recalled "passing out" in the store, but
improving after someone gave him chocolate Glucose and
electrolytes were within normal limits. No fevers or
leukocytosis to suggest infection. Mental status returned to
baseline after HD and he remained AAOx3 for the rest of his
admission.
# Hypoxia: Pt with lowest documentated oxygen saturation to 88%
on room air, likely secondary to worsening pulmonary edema as
seen on exam and chest xray. Pt denied missing HD. A fib
effectively rate controlled. Troponin and MB elevation raised
concern for ACS, but pt denied cardiac symptoms and no there
were no EKG changes. No fever, leukocytosis or focal
consolidation to suggest PNA. Respiratory status improved after
HD; pt noted to desat to 89% with ambulation; he was discharged
without supplemental O2.
# ESRD: ___ dialysis. Pt denied missing any dialysis
sessions and electrolytes were within normal limits. HD intially
continued according to his regular schedule until morning of
discharge (___) when he received dialysis due to
anticipated change in schedule of HD center given ___
___.
# substance abuse: Prior history of crack cocaine, EtOH, and
tobacco abuse per OMR, though only endorses cocaine use, unclear
when last used and unable to obtain urine tox screen. | 164 | 359 |
14445029-DS-11 | 26,445,299 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ y/o M w/ PMH significant for HTN and HLD, who presented with
epidural abscess with spinal cord compression now s/p L1-L4
laminectomies with washout on ___ by neurosurgery,
transferred from MICU to floor for further management.
ACTIVE ISSUES
=============
#MSSA bacteremia
#Epidural Abscess s/p drainage
#Spinal Cord Compression s/p Laminectomies and Washout
#Left mid-back skin abscess s/p I&D on ___
#Concern for septic emboli: multifocal opacities in lungs, L
renal wedge-shaped infarct
#Embolus in distal L brachial artery - s/p thrombectomy by
vascular surgery
#L renal infarct, likely from septic embolus
#Endocarditis with two >1cm vegetations on mitral valve
complicated by perforation
Presented with decreased strength and weakness bilaterally
(___), decreased sensation ~L4/L3 to L1, incontinence of urine
and stool. MRI ___ concerning for epidural abscess with
evidence of cord compression. Blood cultures positive for MSSA.
Started on IV nafcillin. Neurosurgery performed L2-L5
laminectomy and washout on epidural abscess. Also found to have
a left mid-back sebaceous cyst/abscess with sinus tracts to skin
(evaluated by U/S), felt to be the possible original source of
infection. Skin abscess was I&D'ed by MICU team. TTE negative.
Otherwise, patient does not have typical risk factors denying
IVDU, penetrating injuries, surgeries, diabetes, or alcoholism.
Of note, patient later revealed he is a ___ and
has had multiple accidents on the job due to carelessness and/or
being under the influence of alcohol. Has acquired a number of
rib fractures as a result. Normal upper extremity exam and CN
exam. Following transfer to floor after spine surgery, patient
continued to have fevers, white count continued to uptrend, and
blood cultures were persistently positive until ___. Blood
pressures consistently thready in ___ systolic and HRs
persistently ___. There was concern for inadequate source
control and CT torso was obtained which showed showed
multiloculated fluid collections in retroperitoneum, pelvis, and
R buttock, concerning for abscesses. Also seen were multifocal
peripheral opacities in the lungs and a wedge shaped infarct in
the L kidney, concerning for septic emboli. Additionally,
patient started developing ischemic signs in left forearm (cool
to touch, cyanotic fingertips, absent radial pulse on exam and
Doppler, ulnar pulse still dopplerable). Retroperitoneal and
pelvic abscesses were drained by ___. R buttock abscess was too
small to drain and improved on repeat imaging. Vascular was
consulted for ischemic signs in left arm, heparin gtt and
aspirin/plavix started with improvement in symptoms. Left arm CT
showed brachial artery embolus at about the level of the elbow,
s/p thrombectomy by vascular surgery with return of L arm radial
pulse. New murmur was noted on exam and TEE showed 2 vegetations
>1cm on mitral valve with perforation and severe MR.
___, patient had minimal respiratory symptoms and lungs
were clear. Did have an O2 requirement of ___ liters. Had 2+
pitting edema in all 4 extremities, however this was felt to be
due more to third spacing from low albumin/malnutrition than
from heart failure. Cardiac surgery was consulted for valve
repair, Plavix was discontinued (remained on ASA and heparin
gtt), and patient was transferred from the floor to cardiac
surgery service.
#Intermittent hypotension
Systolics persistently in ___ to 100s, has remained fluid
responsive. Had episode of hypotension to ___ on ___ iso
ongoing skin bleed from I&D wound on L back while being on
heparin gtt. S/p sutures placed by ACS. Likely related to a
combination of sepsis and third spacing from low albumin. Being
cautious with fluids given acute and severe MR on TEE associated
with endocarditis, as well as third spacing. However, continued
to tolerate mIVFs given for kidney contrast injury prophylaxis
as well as 2 units of pRBC for pre-op prep.
___
#L renal infarct
#Hyperphosphatemia
Developed ___ following episode of hypotension on ___. Likely
prerenal vs ATN from ischemia. DDx includes AIN from nafcillin,
CIN from recent contrast studies. CBC w/diff negative for
eosinophilia, though this doesn't definitively rule out AIN.
Urine microscopy did not reveal granular casts, but did show
many RBCs. Consistent with known L renal infarct. However given
continued Cr rise, multiple potential sources for renal injury,
and tricky-to-manage volume status given sepsis, third spacing,
and acute MR, was considering nephrology consult. On the day
patient was transferred from floor, Cr had peaked.
#Third spacing
#Volume overload
Edema in all 4 extremities iso clear lungs. R arm edema > L, R
arm U/S negative for DVT. Albumin persistently low around 2, INR
mildly elevated since admission, has LFT abnormalities,
suggestive of malnutrition. Though he has acute and severe MR
from endocarditis, he is surprisingly stable in terms of
respiratory status, and it does not appear that he is developing
pulmonary edema or heart failure. Patient has no teeth and owns
dentures but feels they are a hassle to use, asking for soft
foods. This is one potential precipitant of poor PO at home.
Started compression stockings. Changed diet to soft foods and
following nutrition recs of adding ensures to diet. Recommend
further clarifying how much PO patient is taking. If inadequate,
consider feeding tube following his surgery. Diuresis was
avoided given the suspected etiology of his edema, as well as
his soft blood pressures. | 104 | 829 |
12633029-DS-19 | 27,448,944 | Dear Mr. ___,
You were admitted to ___ on ___
because you were having headaches and changes in your vision as
well as fevers and chills. The rheumatology team saw you was
concerned about inflammation in your body, although the specific
cause is not certain. A CT scan of your body was done and showed
a region in your left lower lung lobe that may be a pneumonia.
For this, you will be given a 5 day course of antibiotics. You
will need repeat imaging to ensure that the pneumonia has
resolved.
With regards to the redness in your eyes and blurriness in your
vision, you received an eye exam which showed you had uveitis
(an inflammation of your eye). You received prednisone eye drops
which you will take according to the instructions given by your
ophthalmologist.
You will have out-patient follow up with the Rheumatology team,
your ophthalmologist, and your primary care doctor to better
find out the cause of the inflammation in your body. In the mean
time, you may take Tylenol (acetaminophen) for your headaches
and/or fevers, but do not take ibuprofen (NSAIDs) which may
affect your kidney function.
It was a pleasure taking care of you.
Your ___ Medicine Team | ___ yo male with history of CAD s/p CABG (___), NHL s/p BACOP
(___), HTN, HLD, obesity who presents with headache and
bilateral temple pain a/w visual changes as well as fevers and
chills.
ACTIVE ISSUES
==============
# Headache, temple pain: Presentation concerning for giant cell
arteritis (GCA), given pain in temples, acute visual
disturbance, normocytic anemia, unexplained fever, &
significantly elevated CRP at 159.8. Was treated with prednisone
40mg x 1 on ___ with improvement of symptoms - improved
headache, no fevers/chills, improved eye redness. Rheumatology
was consulted and thought that pt likely does not have temporal
arteritis give age, lack of claudication, and no decrease in
temporal artery pulse. Pt's elevated CRP may be due to other
etiologies such as infection and malignancy (eg lymphoma).
Recommended CT neck, chest, abdomen and pelvis, which was
negative for malignancy or infection, though CT abdomen and
pelvis was limited by poor contrast bolus timing and small
volume of contrast used due to pt's poor renal function. Chest
CT showed consolidation in the left lower lobe that could
reflect
pneumonia or aspiration. The patient was not tachypneic, and did
not have cough or sputum production to suggest pneumonia.
However, given pt's fever and elevated WBC (12.6), the patient
was started on levofloxacin 750mg for a course of 5 days. For
the patient's bilateral eye redness and self-report of blurry
vision, rheumatology recommended an ophthalmology slit lamp
exam; the exam showed bilateral uveitis, and the patient was
started on prednisone eyedrop taper starting at 4 drops a day
for one week. The exact etiology of pt's headache, vision
changes, fevers and chills would require out-patient follow up.
The patient will have follow up as an out-patient with the
Rheumatology team, the ophthalmology team upon completion of his
prednisone eye drop taper, and his primary care doctor. We
recommend a repeat CXR to evaluate the resolution of his lower
lobe consolidation after he completes his levofloxacin course.
We recommend pain and fever control with acetaminophen as
opposed to NSAIDs in light of pt's diminished kidney functions.
# Acute kidney injury: Cr 1.6 on initial presentation from
baseline of 0.8-1. Likely from regimen of motrin 800mg TID x 1.5
weeks coupled with acute illness and decreased PO intake.
Creatinine initially downtrending in response to 2L NS in ED,
though increased back to 1.6 despite IV fluids. Elevated BUN
suggesting a component of pre-renal etiology. However pt has not
fully responded to fluids. UA and urine sediment were
inconsistent with ATN, AIN. UCx ___ showed <10,000
organisms/mL. Pt's increased BUN and creatinine may be a
manifestation of the etiology causing pt's
headaches/fever/uveitis. As the etiology is unclear at this
moment, we recommend further elucidation of his underlying
etiology with the rheumatology team out-pt as per above, and
out-pt PMD f/u of his kidney function as necessary.
# Uveitis: Pt underwent ophthalmology slit-lamp exam consistent
with mild-moderate non-granulomatous anterior uveitis
bilaterally in the setting of his systemic inflammatory disease.
Pt was started on prednisone eye drop taper. Pt will have out-pt
ophthalmology f/u at the completion of his prednisone eye drop
course. Rheum f/u for possible underlying inflammatory etiology
as per above.
#Anemia - pt with Hgb pf 12.5 on admission which has been
downtrending. MCV of 87 suggestive of normocytic anemia. No
obvious source of bleeding, denies BRBPR or melena, and LDH,
bili WNL, suggesting absence of hemolysis. Iron studies showing
high ferritin, low transferring and TIBC, consistent with anemia
of chronic disease. The pt will have out-pt f/u with
rheumatology for elucidation of underlying etiology per above
with PMD f/u as necessary.
#Elevated ___: at 14.2 on admission and 14.6 on discharge;
patient not on Coumadin. AST ALT relatively benign, suggesting
no decrease in synthetic function. Likely in response to acute
illness. We recommend out-pt PMD f/u as necessary.
CHRONIC ISSUES
===============
#HLD: ___ atorvastatin 80mg was continued
#HTN: ___ HCTZ 12.5mg daily was held during hospital course and
at time of discharge given ___. BP on day of discharge was
138-145/67-68. We recommend PMD f/u to assess restarting the
medication when appropriate.
#CAD s/p 4v CABG (___): continue ___ metoprolol succinate 25
mg daily and aspirin 81 mg daily.
#h/o lymphoma: no active issues
#obesity: no active management
#Erectile dysfunction: hold Cialis inpatient
Transition Issues
==================
- CT imaging was limited due to the small volume of contrast
used (given ___ and poor contrast bolus timing. He would
benefit from repeat imaging once Cr returns to baseline
- Please recheck Cr in one week to confirm resolution ___
- Left lower lobe consolidation seen on chest CT - pt treated
with levofloxacin - recommend repeat CXR to confirm resolution
of consolidation after completion of levofloxacin course
- ___ HCTZ 12.5mg daily was held given ___ and normotension;
recommend PMD f/u to assess restarting the medication when
appropriate.
- discharged on pred forte taper:(4x day 1 week, then 3x day 1
week, etc) with close ophthalmology follow up
- Timing of his return to work to be determined by his
outpatient Rheumatologist | 205 | 825 |
10286521-DS-15 | 28,984,130 | Dear Ms. ___,
You were admitted with worsening shortness of breath and chest
pain. You were found to have a left sided pneumothorax most
likely due to your COPD. You had a chest tube placed and were
monitored for 72 hours. Your symptoms improved and we were able
to send you home after pulling out your chest tube. Please
continue the prednisone taper as prescribed by your primary care
doctor. We wish you all the best.
Sincerely,
Your ___ team | ___ with severe COPD/emphysema on 3 L NC at baseline s/p
Spiration endobronchial valve placement LUL x5 on ___
presenting with worsening dyspnea found to have left sided
pneumothorax with resolution s/p chest tube placement ___.
ACTIVE ISSUES
# Left sided pneumothorax in the setting of recent copd
exacerbation: Pneumothorax resolved on repeat cxr after chest
tube was placed. Patient passed clamping trial on day of
discharge and was without any shortness of breath. She had
minimal chest pain at prior site of chest tube for which she was
given 5 tab of oxycodone at discharge. She was discharge home
with follow-up with Dr. ___ in 6 weeks (with repeat CXR prior
to that).
# Severe COPD: enrolled into the EMPROVE trial s/p LUL 5 EBV
placement on ___. No signs or symptoms of recurrent COPD
exacerbation, and she has now completed appropriate treatment
for her recent COPD exacerbation. Patient was continued on
current prednisone dose 55mg daily with plan to taper in the
outpatient setting with taper plan provided by her PCP. She was
also maintained on her home azithromycin, alb nebs/tiotropium,
and medications equivalent to her home qvar and
mometasone-formoterol that were on formulary. Patient did not
require increased oxygen from her baseline (3L NC) after chest
tube placement.
# H/o adrenal insufficiency: Likely secondary chronic steroid
use. Patient had previously been on prednisone 10mg daily but
was uptitrated more recently in the setting of copd
exacerbation.
Patient was continued on current prednisone dose 55mg daily with
plan to taper in the outpatient setting with taper plan provided
by her PCP.
CHRONIC ISSUES
# GERD: Continue home omeprazole.
# Osteoporosis: continued equivalent dose home vitamin D
# HTN: Continued home diltiazem.
# Transitional issues
- complete prednisone taper as prescribed by outpatient
pulmonologist/primary care doctor
- Please consider need for initiating PCP prophylaxis if patient
remains on long steroid taper
- She should follow-up with Dr. ___ in 6 weeks with a CXR to
be performed prior to appointment.
# CODE STATUS: FULL CODE
# CONTACT: Husband ___ ___ | 78 | 335 |
13119908-DS-4 | 21,993,387 | Dear Mr. ___,
You were hospitalized due to symptoms of speech difficulty and
facial droop resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. Damage to the brain from
being deprived of its blood supply can result in a variety of
symptoms. Stroke can have many different causes, so we assessed
you for medical conditions that might raise your risk of having
stroke. In order to prevent future strokes, we plan to modify
those risk factors. Your risk factors are:
- diabetes
- atherosclerosis (hardening of the arteries) in vessels
supplying blood to your brain
- high blood pressure
- high cholesterol
We are changing your medications as follows:
- starting aspirin to thin the blood
- starting plavix (clopidogrel) to thin the blood
- starting atorvastatin to lower cholesterol
- increasing the glimeperide dose for your diabetes
- starting insulin (lantus) for your diabetes
Please take your other medications as prescribed.
Please followup with Neurology, Neurosurgery, vascular surgery,
and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Sincerely,
Your ___ Neurology Team | ___ is a ___ speaking man with a history of
diabetes and HTN who presented with subacute confusion and L
facial droop. Imaging revealed a meningioma and strokes.
# Acute Ischemic Stroke: MRI/MRA head and neck showed acute and
subacute infarcts of the right middle cerebral artery territory
involving the right basal ganglia, insular region, and temporal
lobes. MRA showed an abrupt termination of the distal M1 segment
of the right middle cerebral artery, which is likely etiology of
the strokes. LDL was 108 and Hb A1c was 9.3. Echo did not reveal
a cardiac source. He was started on dual antiplatelet therapy
with asa 81 daily and plavix 75mg daily for secondary prevention
given intracranial stenosis as etiology. He was also started on
statin therapy with atorvastatin 40mg daily.
# Diabetes: A1c was high at 9.3 and blood glucose levels were in
the 200s. He was seen by ___ consult. He continued his
Januvia at 100mg daily. His glimeperide was increased to 4mg BID
and when he continued to have uncontrolled blood glucose, he was
started on 10 units of lantus at night. He was discharged with
close PCP follow up of his diabetes. He had diabetes education
while intpatient.
# Right Leg Wound: Mr. ___ has a chronic wound on his right
leg that appears vascular in etiology. Per son has been stable x
1 month and he has an upcoming vascular appointment in 1 week.
He was seen by wound care consult and discharged with bandage
supplies.
# Hypertension: Held home Imdur and halved home propranolol to
allow for permissive hypertension in the setting of acute
stroke. His home doses were resumed at discharge.
# Liver Disease: Held home spironolactone 25 mg Daily for
permissive HTN, restarted at discharge.
# Airway Disease: Continued home albuterol. | 366 | 296 |
15428913-DS-17 | 20,083,634 | Mr. ___,
You were admitted to the hospital because you had lightheadness
and were found to have a heart rhythm that was not normal.
What was done while I was in the hospital?
============================================
- You were given a medicine to slow your heart rate
- You had a paracentesis to remove fluid in your abdomen caused
by cirrhosis. 9L were removed and you were given albumin.
- You also got antibiotics to cover any potential infection in
your abdomen.
What should I do now that I am going home from the hospital?
===============================================================
- Continue a low sodium diet (<2 g/day)
- Take all medicines as prescribed
- Follow-up with hepatology for planned EGD
- Follow-up with dermatology regarding a medicine that you can
tolerate for your leg infection. Please discuss whether you need
further antibiotics.
- Follow-up with cardiology for further assessment of SVT
Per the liver doctors, please get labs drawn prior to hepatology
visit with Dr. ___ on ___. You will be given a
script to get your labs drawn, you should be able to go to any
clinic to have this done.
Thank you for allowing us to participate in your care!
Your ___ Cardiology Care Team | Mr. ___ is a ___ male with history of alcoholic
hepatitis and alcoholic cardiomyopathy (EF 35%), who presents
with tachycardia and lightheadedness/weakness over previous 5
days.
# Supraventricular tachycardia
# Mildly Elevated Troponins
Patient tachycardic with rates in 120-130s on admission. SVT on
EKG with resolution during carotid massage. Etiology unclear but
differential includes PE vs. infection vs. structural
abnormalities vs. hyperthyroidism. CTA and infectious workup
negative thus far though. TSH normal. Rates have improved to
90-100s w/ metoprolol XL 100 mg BID. Trops mildly elevated to
.12. Likely in the setting of demand ischemia. Remains chest
pain free and HDS. No concerning ischemic changes on EKG. No TTE
done as inpatient. Can consider TTE as outpatient. Please
consider cardiology f/u as outpatient.
# Alcoholic cirrhosis
# Refractory ascites requiring intermittent paracentesis
# Hepatic encephalopathy
Patient had not had paracentesis in almost 3 weeks on
presentation. He reported abdominal fullness similar to how he
feels when he needs a paracentesis. Hepatology was consulted who
recommended abx for SBP, although likelihood of SBP low and a
diagnostic and therapeutic para. 9L were removed with tProtein
1.8, WBC 132, 7 poly, SAAG 1.5. Of note, para was done after
initiation of CTX. 6g albumin/L off was given post tap. Patient
completed 5 day course of 2 g IV CTX Q24H (___).
Spironolactone and Furosemide initially held in setting of
concern for infection, but resumed on day of discharge, with
stable renal function. Continued lactulose and rifaximin
(however, patient regularly refusing lactulose).
#Alcoholic cardiomyopathy: Most recent EF 55% in ___. Currently
appears euvolemic on exam and is asymptomatic. Continue beta
blcoker, therapeutic taps PRN as above.
#Ecthyma: Patient had seen dermatology as outpatient, who
recommended Keflex ___ mg BID x 14 days after patient had failed
doxy due to GI distress. Patient unable to complete Keflex
regimen due to GI upset. ___ clinic addendum note rec:
amoxicillin suspension 400mg/5ml, 7.5ml BID (___). Ursodiol
500 mg BID for pruritis. Continued mupirocin to lesions BID.
Patient will follow-up with derm ___ and will discuss treatment
options at that time. | 190 | 341 |
15089390-DS-6 | 20,591,260 | 1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Mrs. ___ presented initially to ___ with chest
pain. At OSH, EKG demonstrated STE in inferior leads with
reciprocal TWI in I and aVL. Labs were notable for troponin
0.013, CK-MB 6.1, MB index 6.7. Cardiology was consulted who
recommended transfer to ___. Cardiac catheterization at ___
revealed 3 vessel CAD with mid LAD stenosis and stenosis at the
bifurcation of the LAD and diag. No interventions were
performed, and pt was referred for CABG given favorable anatomy.
Initially, given her psychosis, pt was deemed to not have
capacity per psychiatry. In addition, she was started on
Olanzapine for psychosis NOS. A left foot cellulitis was noted
which was treated with vancomycin initially and then Keflex. It
improved with treatment. After few days, she was able to
communicate about surgery and it was discussed with patient,
husband and daughter with Cardiac surgery team and all were in
agreement to pursue CABG. Pre-op, she was treated medically with
ASA 325, Valsartan 160 BID and Atorvastatin 10. Metoprolol 25mg
QHS was not started given allergic reaction as hives in the past
per records. CABG was initially postponed over concern for
heparin induced thrombocytopenia dating back to ___. Upon
review of discharge summary and records from this admission in
___ ___, there were multiple factors that may
have contributed to thrombocytopenia including a balloon pump,
an H2 blocker and heparin. However, it did seem that
thrombocytopenia improved after discontinuation of heparin. She
did have an episode of asystole during that admission that was
attributed to RCA spasm. After consultation with hematology
oncology, cardiac anesthesia, allergy and cardiac surgery as
well as a review of the literature, it was deemed that if a
heparin-PF4 antibody ___ was negative, it would likely be safe
to proceed with intraoperative heparin. This assay was negative.
Therefore, she underwent three vessel coronary artery bypass
grafting on ___. Please see operative note for details. Post
operatively, she was taken to the intensive care unit for
monitoring. Over the next several hours, she awoke
neurologically intact and was extubated. Dilaudid was used for
her postoperative pain with fair effect. On postoperative day
one, she was transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. Chest
tubes and epicardial pacing wires were removed per protocol. She
requested to not be given statin drugs due to myalgia's. She was
noted to have mild leukocytosis however this was trending
downward. As mentioned below in her chronic issues, she
continued to refuse her psych medication post-op. Her mental
status remained stable (at baseline) with occasional paranoid
thoughts. She continued to make steady progress post-op and on
post-op day four she was ready for discharge to ___
___. Rehab stay will be less than 30 days. All
appropriate medications and follow-up appointments were given. | 140 | 484 |
10507647-DS-14 | 26,638,523 | Dear Ms. ___,
It was a pleasure to care for you at ___
___. You were admitted with right hip pain and found
to have a fracture of your hip. The orthopedic surgeons repaired
the fracture and stabilized your right leg to prevent fractures
in the future. You will receive radiation treatment to your
right leg about 2 weeks after your surgery date. You received a
dose of Doxil (chemotherapy) on ___.
Please see below for instructions from you orthopedic surgeons:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight Bearing as Tolerated.
- Range of motion as tolerated. | Ms. ___ is a ___ yo F with a history of metastatic
leiomyosarcoma presenting with lytic R hip lesion and associated
pathologic fracture of R iliopsoas. | 205 | 27 |
10027602-DS-8 | 28,166,872 | Medications:
Take Aspirin 325mg (enteric coated) once daily.
Take Plavix (Clopidogrel) 75mg once daily.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (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! | Ms. ___ was transferred to ___ for neurosurgical
evaluation. She was admitted to the Neurosurgical ICU and a
right frontal EVD was placed. A CTA was done that showed no
evidence of a vascular lesion. She remained stable overnight
into ___.
On morning rounds on ___ she was noted to be following commands
with all 4 extremities, as well as opening her eyes to voice.
Her ICPs remained less than 20, her EVD remained at 15, and she
was awaiting an MRI for prognostication. Her son was consented
for a diagnostic cerebral angiogram and she was pre-oped for it
with plan for it to be done on ___. Later in the day she had a
loss of 25cc of CSF during positioning for a procedure which was
aborted and EVD leveled appropriately. Later on she was noticed
to have horizontal nystagmus and some LUE twitching. She
received ativan with good effect. Neurology was consulted and
EEG was started. Her keppra was increased to 1000mg BID. She was
noted to be posturing intermittently and a STAT CT was obtained
which was stable. Later in the evening her exam improved and she
was localizing with her uppers and withdrawing her lowers.
On ___ she was awaiting MRI and angiogram. Her exam remained
stable and per neurology her Keppra was increased to 1500mg BID.
On ___, she was unchanged on exam. She awaits angiogram.
On ___, she was stable.
On ___, she was taken to angiogram for partial embolization of
the posterior meningeal branch. Post operatively, she was not
moving her BUE to noxious, BLE w/d to noxious and EO to stimuli.
Her EVD remains at 15.
On ___, on examination, patient spontaneous with LUE and
extending RUE. BLE w/d briskly to noxious stimuli. She was made
NPO in preparation for angiogram on ___. EVD was raised to 20
in attempts to wean.
On ___, the patient was febrile, cultures were sent and patient
was given Tylenol. CSF was also sent and showed no growth at
this time. Her exam was poor and EVD output was very low, a stat
head CT was done which showed that the EVD catheter was placed
in the correct position and the IVH was redistributed. A clamp
trial was attempted and her ICP elevated to 38 and drain was
opened. No output was seen from the EVD and the EVD was
replaced. Repeat head CT showed good position of EVD.
On ___, the patient's examination improved. Her EVD was left
open at 20 and ICPs were within the normal range. The EVD
drained briskly throughout the day. She will undergo an
angiogram tomorrow. She was extubated in the afternoon but
became stridorous and required re-intubation.
On ___, the patient's neurologic examination remained stable.
She spiked fevers to 102 overnight. Her EVD remained open at 20
and her ICPs were all within normal limits. Her urine was
positive for Enterococcus and her antibiotic regimen was changed
to Ampicillin. She underwent a BAL and the cultures remain
pending at this time. The patient was taken back to the angio
suite for further embolization of her Dural AV Fistula and
collateral vessels were noted. It was determined further
intervention will be necessary in the near future.
On ___, the patient was extubated and EVD was clamped.
On ___, the patients neurologic status has improved, external
ventricular drain remained clamped. The patient was slightly
confused, and repeat head CT suggests slightly larger ventricles
On ___, the patient was alert, neurological exam was improved.
A repeat non contrast head CT was stable. The patient's external
ventricular drain was removed, and a sample of CSF fluid was
sent for culture routinely. The patient was mobilized out of bed
to the chair. The daughters were updated at the bedside by the
neurosurgical team.
On ___, the patient was alert, eyes open to voice, EOMs grossly
intact, patient localizes bilateral upper extremities, and
withdraws BLE to pain, patient non verbal. The patient was
called out to the step down unit, awaiting a bed. ___/ OT
evaluated the patient and recommended rehab. Speech therapy
consult was placed to evaluate the patients swallow mechanism.
The patient completed a course of ampicillin for UTI today.
Foley catheter was changed today.
Mrs. ___ was transferred to the step-down unit on ___.
Both physical and occupational therapy were consulted and
recommended discharge to a rehabilitation facility. The patient
was found to have a urinary tract infection and was started on a
course of ampicillin. Her Foley catheter was changed.
Between ___ and ___, Mrs. ___ continued to recover
well. Because the patient was unable to swallow and therefore,
had a PEG inserted by ACS on ___. Tube feeds were started the
following day.
On the early morning of ___, the patient sustained an
unwitnessed fall out of bed. A non-contrast head CT was
obtained and showed no acute intracranial process. A
non-contrast C-spine CT was also obtained and showed no acute
fracture or subluxation. Incidentally, however, that exam
showed a concerning lesion in the apex of the left upper lung.
As a result, a CT torso was obtained to assess for any possible
metastatic disease.
Mrs. ___ was discharged to a rehabilitation facility on
___. She was afebrile, hemodynamically and neurologically
stable. Her course of vancomycin used to treat MRSA pneumonia
was completed (7 day course). Her CXR showed no infiltrates and
the patient was afebrile for at least 72 hours. Per discharge
instructions, the patient should follow up with Dr. ___
service in approximately one month. At that time, planning will
be discussed for surgical resection of her dural AV fistula. | 297 | 939 |
16411926-DS-23 | 22,389,095 | Dear Mr. ___,
IT was a pleasure taking care of you here at ___
___.
WHY YOU WERE ADMITTED:
- You presented to the ___ emergency department due to altered
mental status from serotonin syndrome developed in the setting
of concurrent use of psychiatric and pain medications. You were
admitted for further monitoring and care.
WHAT HAPPENED WHILE YOU WERE HERE:
- You were initially treated for your serotonin syndrome with
medications and IV fluids.
- Your home psychiatric and pain medications were discontinued.
Towards the end of your admission we restarted your home
clonazepam and a low dose of your Effexor.
- Endocrinologists evaluated you for your Addison's disease and
hypothyroidism. You received an initial stress dose of steroids
for your Addison's disease and thereafter received your normal
morning and evening doses for the remainder of the admission.
You received your daily medication for hypothyroidism, which was
adjusted to be slightly lower in accordance to test results by
the endocrine team. You have a test for your Addison's disease
(21 Hydroxylase antibody) pending.
- You received lab studies investigating for possible celiac
disease which resulted negative.
- You were evaluated by the neurology team for several brief
shaking episodes and received an EEG and a CT-Head which both
resulted clear.
- You were evaluated by the psychiatry team for management of
medications for anxiety/depression in light of your serotonin
syndrome diagnosis and due to your history of anxiety and
depression.
- You received several medications to help treat your left sided
abdominal pain. We obtained a stomach x-ray and CT Abdomen which
both resulted clear.
- You were started on a new medication, pregabalin, which treats
both your stomach symptoms as well as helps to treat your
anxiety.
- You received medicines to help you sleep.
- You were maintained on a bowel regimen to help treat your
constipation while admitted.
WHAT YOU SHOULD DO WHEN YOU LEAVE:
- Continue taking all your medicines as you were prescribed.
- Follow up with all your physicians as listed below
- Obtain a follow up TSH blood test in 2 weeks.
WHEN YOU SHOULD COME BACK
- If you are experiencing a change in your mental status,
coordination, speech, vision or hearing, palpitations,
dizziness, nausea, vomiting, diarrhea, abdominal pain, or any
other symptom that concerns you.
We wish you the ___!
Sincerely,
Your ___ Care Team | SUMMARY:
Mr. ___ is a ___ man with hx of Addison's disease,
hypothyroidism, duodenal ulcers, pancreatitis, gastritis, and
recurrent C. diff s/p vanc (2 wks ago) presenting to ___ ED on
___ with sudden onset AMS. Pt was at baseline until the ___
when he developed symptoms of serotonin syndrome in setting of
venlafaxine, mirtazapine, abilify, and tramadol polypharmacy.
His admission course is notable for several of these brief
shaking episodes with negative EEG and CT-Head workup, and
severe LUQ pain with negative abdominal XR and CT, now largely
resolved with medical therapy. | 391 | 93 |
12499922-DS-20 | 23,383,097 | Thank you for letting us take part in your care at ___
___. You were transferred to our hospital
because you had a fracture in your neck and you were
hypoglycemic. You were evaluated by an orthopedic spine
specialist who recommended wearing a soft neck brace. Your
blood sugar was monitored while you were here and your evening
dose of insulin was lowered. You should follow up with your
primary care doctor for further management of these issues.
The following changes were made to your medications:
- DECREASED Humulin N to 15 units every morning and 20 units
every night.
- STARTED Humalog Insulin Sliding Scale
No other changes were made to your medications. Please be sure
to take them as directed | ___ yo F with ___ transferred from OSH where she was evaluated
s/p fall, loss of consciousness, and neck fracture found to be
hypoglycemic on EMS arrival.
# hypoglycemia: Thought to be secondary to poor po intake vs
inappropriate medication administration. No WBC count on
admission and u/a, blood cultures, urine cultures, and CXR were
negative for infection. considered prolonged immobilization but
CK was WNL. Kept patient on sliding scale insulin; she ran low
overnight so decreased her ___ NPH dosing and her blood sugars
were more stable.
# syncope: pt had lightheadedness and bathroom use prior to
episode which suggested vasovagal episode. Pt also admitted to
feeling thirsty which suggested component of volume depletion.
Could also have been secondary to hypoglycemia, though this may
have occurred after the fall, as pt reports not knowing how long
she was out or how long EMS took to get to her. checked AM
cortisol to rule out adrenal insufficiency and it was normal.
EKG was negative for ischemia or arrythmia; no murmur on exam
suggestive of valvular disease. Gave IV fluids over first night
with good UOP but this later dropped off. She then responded
well to a second liter of IV fluids. Pt reported feeling
improved and her BP was stable throughout admission. ___ was
consulted and recommended rehab but pt refused, so she was sent
home with ___.
# neck fracture: pt found to have neck fracture on imaging at
OSH. per ortho pt has been stable with the fracture and it
appears old/chronic. She was without pain or neuro deficit.
they recommend soft collar and ortho spine follow up as
outpatient.
# hematuria: pt with large clots in foley bag after admission.
initial u/a was negative and without blood, so this was thought
to be secondary to traumatic foley placement. foley was removed
and pt voided on her own.
# Hypertension: continued home meds
# Depression: continued home meds | 122 | 337 |
19508928-DS-10 | 24,209,755 | Dear Ms ___,
It was a pleasure taking care of you at ___. You were admitted
for diarrhea. You improved rapidly at the hospital and no longer
had any diarrhea. We suspect this was related to your IBS as
well as medication effect.
We discussed your care with your GI physician Dr ___. We are
going to stop a number of your GI medications. Please carefully
review your new medication list. Please refer questions on your
GI medications to Dr ___. You are also being started on
twice daily Miralax.
We also want you to follow-up with Nutrition as an outpatient. | ___ with history of IBS, gastroparesis, hypothyroidism,
prolactinoma, and extensive previous GI work-up who presents for
abdominal pain and diarrhea.
# N/V/diarrhea: Patient's abdominal distention and constipation
likely ___ to known gastroparesis, polypharmacy with
anticholinergic effects, and recent completion of ciprofloxacin
regimen for small intestinal bacterial overgrowth. An abdominal
CT revealed significant fluid and air in the large bowel,
consistent with diarrhea. During this admission, multiple
anticholinergic and recently started agents (solifenacin,
lubiproston, vesicare, topamax, and linaclotid) were held. Her
diarrhea resolved (she had 0 episodes in the hospital) and she
improved with IV hydration and electrolyte repletion. Based on
absence of diarrhea and return of appetite, her diet was
advanced and she was able to tolerate PO. Given hx of
endocrinological disorders, along with worsening anorexia,
weakness, nausea/vomiting and mild eosinophilia, an AM cotisol
was obtained to assess for adrenal insufficiency, which was
normal. She was discharged off of many of her typical bowel
meds, and will f/u with Dr ___ as an outpatient. Miralax BID
was started because of her history of constipation. Dr ___
will restart medications as needed in the outpatient setting.
Patient will also be seen by Nutrition and followed in the
outpatient setting.
# Hypokalemia/Hypophosphatemia: K 3.1 and Phos 2.3 in the
setting of significant losses from diarrhea. Her electrolytes
were repleted.
# Hypothyroidism: Continued home levothyroxine.
# Migraines: Continued home acetazolamide and verapamil. | 100 | 231 |
14308143-DS-20 | 22,648,104 | Dear MS. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You are admitted to the hospital because there was concern that
there was infection in the fluid that they drained from your
lung recently
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-You received 1 dose of antibiotics in the emergency department
to treat this possible infection.
-The bacteria that was seen growing in the fluid from your lungs
came back from the lab consistent with most likely a
contamination from the needle passing through you skin and not a
true infection
You are not having any fevers, were feeling well, and your labs
did not show any evidence of ongoing infection so were felt safe
to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
Ms. ___ is a ___ woman with HTN, HLD and recently diagnosed
metastatic breast cancer who presented originally to the ED 2
days prior to admission for drainage of a loculated R pleural
effusion. She was found to have 1 colony of GPCs growing from
pleural fluid and was sent to the emergency department for
further evaluation. While in the emergency department she
received 1 dose of vancomycin to treat potential infection. She
also underwent chest x-ray revealing a residual small
right-sided pleural effusion with possible lower lobe
opacification. On further review of prior imaging opacities seen
at right base were felt to represent collapse in the setting of
metastases which had been previously visualized on CT imaging.
Culture from pleural fluid further speciated to
coagulase-negative Staphylococcus, felt to represent
contaminant. Antibiotics were discontinued. Patient remained
afebrile throughout admission, had no complaints, lab testing
without evidence of systemic infection. She was felt safe to
discharge home with close follow-up. | 166 | 161 |
19094446-DS-6 | 27,503,119 | ___ Sra. ___,
Te vieron en ___ para ___, dolor en las articulaciones,
y erupcion cutanea. Hemos enviado muchas ___, muchos de ___ sido negativos. Hubo un estudio que sugiere que ___
___ una infección estreptococica. Hemos enviado mas
___. Tambien se obtuvo una resonancia magnetica ___.
Por favor, ___ reumatologia proxima semana para
obtener ___.
Tambien se encontro un nodulo ___. Esto ___ es de
importancia ___. Por favor, ___ con ___ medico primaria sobre
obteniendo imagenes de repetición.
Fue un placer cuidar de ___
___ de ___ | ___ year old ___ woman from ___ with
PMH of HTN, GERD, depression who presents with 3 weeks of
bilateral leg and arm swelling, rash, and fevers.
# ___:
The patient reports joint swelling, rash, fevers, and weakness
for several weeks. Exam was significant for transient migratory
joint pains/swelling, macular (fading) rash on palms and soles,
and a heart murmur. Differential for palmar rash includes:
syphilis (RPR w/prozone negative), rickettsia (RMSF pending),
HIV (negative), Q fever (negative). Lyme and anaplasma were
negative. TTE (___) showed ___ evidence of valvular disease
and patient did well off antibiotics. Viral hepatidites,
EBV/CMV, monospot, toxoplasma were negative. Plastics evaluated
patient's R wrist on admission, and did not think it was
infected. Patient has not been to ___ ___ husband has
been there in ___. Parasite smear was negative x3.
Inflammatory/autoimmune disorders also possible, especially
given severely elevated ESR and CRP and complaint of arthralgias
and myalgias, so Rheumatology was consulted. ___,
RF, ___ negative. SPEP was negative. She had ___ evidence of
cholecystitis or cholangitis on RUQ US. She was initially
treated with vancomycin, ceftriaxone, and doxycycline, but these
were discontinued without change in clinical staus. Tests
pending at discharge include ANCA, ___, RMSF ___,
coxscackie virus, parvovirus, chikungunya, toxoplasma, CMV
antibody, Adenovirus PCR, HSV 1 and 2 IgM, leptospira antibody,
Hepatitis E IgM/IgG, throat culture & strep test, and blood
cultures. Her ASO titers were positive, but this was of unknown
significance and should be repeated in 1 week. An MRI of her
wrist was performed to evaluate for synovitis; this test will be
followed up by rheumatology. She was started on 20 prednisone
qday for 7 days pending Rheumatology and Infectious Disease
Clinic ___.
# Hypoxia: Transient episode of hypoxia in the ED, ___ evidence
of PE, pneumonia on CTA. ___ evidence of bronchospasm. On morning
of ___, patient endorsed normal breathing even after
discontinuing 2L oxygen by nasal cannula. She had ___ further
events
# Anemia: Decreased from 10.4 1 week prior to presentation.
Ferritin elevated at 1000, Iron 20. Likely anemia of
inflammation. ___ signs/symptoms of bleeding.
# Hyponatremia: Noted to be mildly hyponatremic. Stable w/ 500cc
NS. Labs should be repeated as outpatient.
# Lung nodule: 4 mm nodule within the right lower lobe.
Recommend outpatient follow up, repeat imaging in 12 mo
Transitional Issues:
====================
- tests pending at discharge: ANCA, ___, RMSF ___,
coxscackie virus, parvovirus, chikungunya, toxoplasma, CMV
antibody, strep & throat culture, adenovirus PCR, HSV 1 and 2
IgM, leptospira antibody, hepatitis E IgM/IgG blood cultures
- patient with transaminitis, slightly uptrending today at
discharge; to have LFTs rechecked with primary ___ physician
week of ___
- Patient noted to be mildly hyponatremia, with discharge sodium
of 132, Should have repeat Chem 7 at primary ___ visit the week
of ___
- Consider MRI hand at rheumatology followup appointment
- acute anemia of inflammation noted during this
hospitalization; to be monitored as an outpatient by primary
___ physician as well
- patient should have repeat chest CT in 12 months to monitor 4
mm nodule within the right lower lobe; to be arranged by primary
___ physician
- also noted to have ___ axillary lymphadenopathy on
chest CT; should be followed up by primary ___
- HCTZ held in the setting of normotension while inpatient; can
be restarted by primary ___ as outpatient if needed
- Started on prednisone 20mg qday pending rheumatology ___
- Recommend outpatient OT for hand swelling
- Final read of MRI wrist pending at time of discharge | 85 | 574 |
16370758-DS-8 | 23,353,209 | Dear ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital for neck swelling. You had a
biopsy of your neck mass ___ that showed lymphoma. We
started you on a regimen of chemotherapy. After discharge,
please follow up with your oncologist for further management.
While you were in the hospital you were having some more
constipation. We are sending you home with prescriptions for
docusate, which you should take twice a day, and senna, which
you can take ___ times a day. Other things that can help with
constipation are to eat more foods with fibers, such as fruits
and vegetables, and to exercise. You can also buy fiber
products, such as Metamucil, at most pharmacies. You can also
try MiraLax, which you can also buy at most pharmacies. We have
also given you a prescription for lactulose - if you are still
feeling constipated, please feel free to fill this prescription
and use it as well. If you are still having constipation at your
next doctor's appointment, please let them know, and they can
prescribe you more medications or give you more ideas.
It was a pleasure taking care of you, and we wish you all the
best.
Sincerely,
Your ___ team | Mr. ___ is a ___ year old gentleman with history of HTN,
HLD, DM2 presenting with 3 months of neck swelling found to have
large neck mass found to be grey zone lymphoma, treated with
CHOP
# Lymphoma: The patient presented with 3 months of neck swelling
and change in voice. He was evaluated with a CT neck and chest
on admission which showed diffuse cervical and mediastinal
lymphadenopathy concerning for lymphoma. He was evaluated with
an excisional biopsy on ___, the results of which showed gray
zone lymphoma, intermediate between Hodgkin's and Non-Hodgkin's
Lymphoma. The patient was treated with CHOP C1D1 = ___ which
he tolerated well. He was dosed with rituximab on ___.
Despite his initial extensive lymphadenopathy, the patient never
had signs of airway compromise or SVC syndrome during admission.
The patient was started on prophylactic allopurinol ___ PO
daily. He was discharged home with a followup appointment
scheduled for the following week.
# Acute on Chronic Kidney Injury: The patient presented with Cr
2.2 from baseline 1.4-1.6, thought to be pre-renal in origin.
This down trended to 1.3 with IVF hydration. Calcium and uric
acid were mildly elevated on admission and downtrended to within
normal limits with IVF. The patient was started on allopurinol
dose adjusted for Cr at 100mg PO daily. On discharge, his Cr was
1.3, which was at his baseline of 1.3 to 1.5.
# Normocytic Anemia: The patient presented with Hgb 9.3 thought
to be secondary to malignancy or chronic disease. This remained
stable from 8 to 9, requiring no transfusions.
# HTN: Initially held lisinopril 40mg given ___. He was
continued on amlodipine 5mg and Metoprolol XL 50mg. His
lisinopril was restarted prior to discharge.
# DM2: Initially held Janumet. He was continued on lantus 50
units QAM with HISS. However, upon initiation of steroids, the
patient began to have increased levels of blood glucose. His
lantus and sliding scale were increased during this regimen. On
discharge, he was restarted on his home insulin sliding scale.
# Overactive bladder: Patient's home medication of Toviaz was
nonforumalary, not continued on admission. It was restarted on
discharge.
# HLD: Held simvastatin 20mg PO daily due to interactions with
chemotherapy. Restarting this medication was deferred to the
outpatient setting. | 209 | 377 |
11909502-DS-14 | 20,103,686 | You were brought to medical attention due to having right sided
abdominal pain. You were found to have a renal (kidney)
hemorrhage on the right side and what is called a vascular
endoleak from the AAA repair.
Most renal hemorrhages stop on their own as yours has done.
They often occur spontaneously. You should have a CT of the
abdomen to re-evaluation the area of the kidney in 4 weeks to be
sure that there are not signs of a tumor in this area that
started the bleed. (this would be unusual for you as you have
had imaging and never noted to have an abnormality there in the
past).
You should see your vascular surgeon in ___ weeks to be
evaluated further for the endoleak and to determine if any thing
should be done about it vs continue to monitor.
You developed a cough after eating and a pneumonia. This was
treated with levofloxacin and clindamycin. Your oxygen levels
improved. Due to having some blood come up with the sputum, a
scan was done to look for blood clots. this was negative for any
blood clot.
Physical therapy will be very important to help get your
strength and balance back after being sick and in the hospital.
The rehab facility might consider testing your ability swallow
to be sure that food is going down to your stomach and not your
lungs. | ___ male with hx of aaa here from OHS with right sided abd
pain, found to have subcapulsar R renal hemorrhage. | 238 | 22 |
16610414-DS-19 | 25,058,434 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You
sustained rib fractures which caused you to have severe pain.
You should take your pain medicine and ensure to use your
insentive spirometer. If the pain medication is too sedating,
take half the dose and notify your physician. You were also
found to have a urinary tract infection during this
hospitalization and were treated with antibiotics. In addition,
you had pain and spasms in your left leg, making it difficult
for you to walk. Please follow up with your primary care doctor
and with your neurologist. Best Regards.
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.
We wish you all the best. | Ms. ___ is an ___ with a hx of HTN, HLD who presented s/p
mechanical fall on ___ and was found to have R posterior rib
9&10 fractures. She was initially admitted to the surgery
service for management of pain and was transferred to the
Medicine team for continued pain control and control of
hypertension
# Hypertension:
Patient's blood pressure was poorly controlled in the outpatient
setting with recent uptitration of her anti-HTN regimen. In the
setting of pain, her blood pressure was further increased. On
presentation, her BP was found to be 220/110. Her hospital
course was also complicated by poorly controlled HTN with BP
range: 132/55-250/90. She initially received home dose valsartan
120mg and required PO (50mg) and IV hydralazine (___). On
___, patient was started on amlodipine 5mg po qd, and valsartan
was increased to 320mg po. She received diltiazem 60mg po x 1.
She was later transitioned to Valsartan 320mg and Labetalol
(uptitrated to 400mg po bid). Amlodipine 5mg was added.
Given difficulties in BP control, she underwent renal artery US
for evaluation of secondary cause of HTN. There was no evidence
of hyperthyroidism, no evidence of infection or ischemia to
account for sx, no intracranial processes to explain HTN as
neuro exam is wnl. Renin/Aldosterone were pending at time of
discharge.
# Delerium:
Patient developed hypoactive delerium during the
hospitalization. Causes included hospitalization, pain and
pain/sedating meds. There was no evidence of infection. Delerium
resolved spontaneoulsy.
# Bacteruria - multiple colonies
Pt reports occasional dysuria and had + UA but organisms
appeared to be contaminant. NSG reported sample may not have
been clean. She recevied Bactrim 500mg DS BID (___) x 1d.
# Pain Control/Rib Fx:
Pain control was achieved with tylenol, tramadol, oxycodone prn
and morphine prn. There was no evidence of pneumothorax, no
crepitus on exam. Patient continued to use incentive spirometry.
# Leukocytosis
Please see labs section. UA negative on ___ and no resp sx.
Likely ___ stress response in setting of rib fx. Resolved
spontaneously.
#Depression: The pt with hx of depression and has a depressed
mood during the hospitalization. Continued Bupropion to 75 mg
qam and citalopram 20mg po qd.
# Hypothyroidism: TSH was found to be elevated. Levothyroxine
was increased to 100mcg po qd.
# Neuropathic ___ pain
Pt complained ___ L>R. This limited her mobility.
Low-dose gabapentin was inititated for management of this pain. | 192 | 401 |
16621413-DS-6 | 24,143,734 | You were admitted with gallstones, and underwent laparoscopic
removal of your gallbladder. You are recovering well and are now
ready for discharge with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | On arrival to the ED the patient underwent CTA of the chest for
rule-out of PE given his report of shortness of breath and
recent Orthopedic surgery in addition to report of worsening
pain with deep inspiration. The CTA was negative for evidence of
PE. RUQ ultrasound was also obtained and demonstrated a 1.2cm
stone in the gallbladder neck though no secondary signs of acute
cholecystitis were immediately evident. Surgery consult was
obtained for evaluation of possible biliary etiology of pain.
After the appropriate pre-operative work-up, the patient was
taken to the operating room where he underwent an uncomplicated
laproscopic cholecystectomy. He was transferred from the
operating room to the PACU and then to the floors in good
condition. He was admitted for overnight observation and pain
management, and was able to tolerate a regular diet by
post-operative day 1.
Also by post-operative day 1 the patient's pain was well
controlled on oral pain medications, and it was determined
surgically appropriate to discharge him home without need of
services.
At the time of discharge the patient was tolerating a regular
diet without any nausea, vomiting, or increase in abdominal
pain. He was ambulating independently, his pain was
well-controlled, and he had remained afebrile throughout the
entirety of his hospital course | 285 | 212 |
17042207-DS-19 | 21,992,801 | Dear Ms. ___,
You were admitted for management of headache. Our evaluation
showed that your headaches are due to elevated fluid pressure in
your head called Idiopathic Intracranial Hypertension. You were
started on a medication called Acetazolamide (Diamox) to treat
this condition. Your laboratory tests also showed that your
Phenytoin (Dilantin) level was quite low, which explains your
recent seizures. You were given a dose of Phenytoin through your
IV. Follow up with Neurology will be arranged.
You also had vaginal bleeding during this admission. We obtained
records from ___ and discussed this matter
with our ___ team. Given that you were stable and your red
blood cell measurements were stable as well, you were discharged
with a plan to follow up with your Gynecologist ASAP. Please
call your Gynecologist to schedule an Urgent follow up
appointment.
Please follow up with your Primary Care Provider in one week as
well. Lab tests will likely be drawn.
It was a pleasure being part of your care team.
Sincerely,
___ Neurology | Patient was admitted in stable condition. Given elevated opening
pressure (38) and normal neuroimaging, a diagnosis of idiopathic
intracranial hypertension was felt to be most appropriate.
Patient was started on Acetazolamide, which was later uptitrated
with good effect. Patient's Phenytoin level on admission was
quite low (1.1) which is the likely explanation for her recent
seizures. She received an IV bolus and repeat level was within
normal limits (10.2). Patient had no seizures during this
admission.
Patient had vaginal bleeding during this admission. Records from
___ were obtained and the case was discussed
with ___ ___. Despite bleeding, patient was clinically
stable and hematocrit/hemoglobin remained stable as well
(9.2/31.2). She was therefore discharged and agreed to call her
Gynecologist the day after discharge to schedule an urgent
follow appointment. Neurology follow up will be arranged.
Appointments with Hematology and Cardiology for workup prior to
hysterectomy are already arranged. | 163 | 148 |
12495749-DS-6 | 29,507,590 | Dear Ms ___,
WHY WERE YOU ADMITTED
- You had a fast heart rhythm called atrial flutter.
WHAT HAPPENED DURING YOUR HOSPITALIZATION
- We performed a special ultrasound of your heart through the
esophagus to see if there is a blood clot in the heart, which we
did not find.
- We then shocked your heart to get it back into a normal heart
rhythm.
- Because of your fast heart rhythm, you developed fluid in your
lungs, which we treated with medication.
WHAT YOU SHOULD DO AT HOME
- Please keep all of your doctor appointments.
- Take your medications as directed. We have made changes to
your medications, so be sure to verify with the discharge
medication list.
- Your potassium level was low while in the hospital. We are
sending you home with potassium supplementation. Please have
your potassium level checked with your PCP 1 week after
discharge.
It was a pleasure taking care of you at ___.
Best,
Your ___ Team | ___ yo female with PMHx afib s/p ablation and moderate aortic
stenosis who presented with fatigue and urinary symptoms, found
to have a regular, wide complex tachycardia on EKG
# Tachycardia.
Patient presented with 3 days of increased fatigue and SOB,
found to have a wide complex tachycardia on initial EKG. She has
a history of aflutter s/p DCCVx2 and MAZE procedure. EKG
findings on admission most consistent with atrial flutter in
setting of known left bundle branch block. It is unknown how
long she was in this current rhythm. Patient had been on rate
control at home and had been well controlled per outpatient EP
and reveal device. Patient also had not been on anticoagulation
for many years second to a spontaneous retroperitoneal bleed
while on coumadin. On ___ pt underwent TEE to exclude thrombus
from left atrial appendage remnant and then underwent DCCV. She
remained in normal sinus rhythm after the procedure, up through
discharge on ___. Patient's aspirin and plavix were continued
through the course of the hospital stay.
# Pulmonary Congestion. Ms. ___ developed increased fluid on
pulmonary exam as well as new small effusions noted on CXR after
DC cardioversion. This was deemed most likely second to
post-cardioversion myocardial stunning. She was diuresed with IV
lasix and improved greatly. She was sent home on furosemide 20
mg PO as well as KCl 20 mEq daily. She will need follow-up
metabolic panel drawn one week after discharge to assess for
electrolyte abnormalities related to furosemide use.
#HTN: Patient normotensive at CCU. Home meds were initially held
but eventually restarted losartan but at a lower dose (25mg from
home 50mg). Her Metopolol Tartrate 50mg PO QAM and 25 mg PO QPM
was changed to long-acting Metoprolol Succinate XL 37.5 mg PO
Daily.
#Depression: Citalopram 20 mg daily
#Intertrigo: Apply ketoconazole 2% to affected area daily.
#HLD: Simvastatin 80 mg daily.
TRANSITIONAL ISSUES
=====================
- NEW medications: furosemide 20 mg daily, potassium chloride 20
mEq daily
- CHANGED medications: losartan 50 mg daily to 25 mg daily;
metoprolol tartrate 50 and 25 mg in AM and ___ to metoprolol
succinate 37.5 mg daily
- Patient required significant potassium repletion with diuresis
during this hospitalization, and she was started on potassium
chloride repletion with discharge on oral diuretic. She will
need a repeat chemistry panel in 1 week to assess ongoing need
for repletion. | 152 | 386 |
18389073-DS-29 | 20,599,400 | Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted after having a fall. Multiple x-rays a fracture of
your clavicle and the orthopedic doctors recommended ___ a
sling at rest for 2 weeks. We were concerned about your falls
and had the physical therapists see you and they recommended
rehab to optimize your strenght and mobility.
Please see the attached medications list. | Ms ___ is a ___ with history of dementia, recent PE on
coumadin presenting s/p mechanical fall.
# Fall. Admitted after fall, likely mechanical in nature as
patient reports slipping in bathroom. Syncope work-up negative
(CE negative, tele without event, CTA without PE). Trauma
work-up revealed distal clavicular fracture and small subgaleal
hematoma; otherwise negative. ___ evaluated the patient and
recommended rehab to optimize strength and mobility. Seen by
Orthopedics Consult, non-operative management. | 69 | 76 |
17400716-DS-28 | 21,083,449 | Dear Ms. ___,
You were admitted to the hospital with hypoglycemia (low blood
sugar). We decreased your insulin regimen to help protect you
from low blood sugar, which can be very dangerous.
Because you have heart failure, it is very important that you
weigh yourself every morning. Call your physician if your
weight goes up more than 3 lbs.
Please see below for an updated medication list.
It was a pleasure caring for you here at ___. | 880F with PMH HTN, HLD, hypothyroidism, OSA (on CPAP), ESRD s/p
renal transplant in ___, CAD s/p ___ 2 to RCA in ___,
recently medically managed NSTEMI ___, CHF (LVEF 50-55%),
with recent discharge ___ after 1 week hospitalization for
medically managed NSTEMI in the setting of having renal
transplant and acute on chronic CHF as well as treatment of
presumed CAP, now admitted with hypoglycemia.
# Hypoglycemia: Likely due to change in diet; she has been
eating very healthfully. No change in renal function. Low risk
of inadvertent overdose, given insulin pen. Patient's insulin
regimen was decreased (glargine was decreased from 25 to 15 and
then to 10). Repaglinide was discontinued. Blood sugars during
hospitalization and insulin doses are included below. ___
was consulted. Patient will follow up with ___ in outpatient
setting.
-- | 77 | 141 |
15131736-DS-14 | 29,361,108 | Dear ___,
It was a pleasure taking care of you during your stay at the
___. We admitted you because
you were short of breath. We think your shortness of breath is
due partially to too much fluid on your lungs, which we treated
with diuresis (IV lasix). We also think you were having a COPD
flare, now improved with prednisone, azithromycin, and
nebulizers. We also found that you had a urinary tract infection
for which you are currently taking an antibiotic, Macrobid.
It is important that you continue using your nebulizers and
finish taking the prescribed course of prednisone and
azithromycin that you are currently on. Please continue taking
your other medications as they were initially prescribed to you
prior to this admission.
Thank you and best wishes to you! | Pt is a ___ y/o F with history of COPD, extensive history of
smoking, OSA and dCHF who presents from a subacute SNF with
2-day history of worsening shortness of breath. | 131 | 31 |
11879397-DS-20 | 25,832,375 | Dear Ms. ___. You were admitted to evaluate ankle
painafter imaging at another hospital was concerning for a
possible soft tissue mass. The MRI was reviewed by our team
here. They felt the MRI results were consistent with arthritis.
You were treated for pain with oxycodone. You were evaluated by
physical therapy and provided with a brace. We recommend
repeating the MRI in a couple of month. Our orthopedics group
will continue to follow you. | Brief Hospital Course:
Ms ___ is a ___ yo old patient with a history of a solitary
plasmacytoma in ___ s/p XRT. She has been having intermittent
left ankle pain for about one year. Pain is worse for the past 3
weeks. Most recently, she had an MRI on ___ at an outside
facility that showed a bony abnormality of the calcaneus, with a
rounded lesion in the ___ this concerning for bone tumor,
lipoma w/fat necrosis or edema. Since ___, she has been
having
increasing pain and edema of this ankle, and is now having
difficulty ambulating with crutches. She was being admitted for
an
expedited work up. Review of ankle MRI here was felt to be most
consistent with degenerative joint disease. Her pain was
controlled with oxycodone and Tylenol given NSAID intolerance.
She was seen by orthopedic who recommended weight bearing as
tolerated and a ___ brace with repeat MRI and follow-up in 3
months. She will work with outpatient ___. | 81 | 156 |
12005748-DS-30 | 28,946,354 | Dear Mr. ___,
It was a pleasure to take care of you during your
hospitalization at ___. You were admitted to ___ for
abdominal pain and found to have a serious kidney infection and
admitted to the ICU and treated with intravenous antibiotics.
After you were stable from your infection, you were found to
have decreased function of your heart with a blood clot in one
of the chambers of your heart. You were started on blood thinner
called heparin and coumadin. You were also found to have
narrowing of one of your heart valves, which should be evaluated
by your outpatient cardiologist after you leave the hospital.
You were also found to have a small ulcer on your left big toe.
This was evaluated by podiatry in the hospital and they are
recommending you see your vascular surgeon within the next few
weeks to discuss this issue, as it could be due to peripheral
vascular disease.
You are being discharged with follow-up appointments with your
PCP/ cardiologist and vascular surgery.
Your medications and follow-up appointments are summarized
below. | SEPSIS from a urinary source: The patient presented on ___
with fever, non-radiating periumbilical pain, and acute onset
rigors. He was febrile, tachycardic, and hypoxic with bilateral
pleural effusions and positive urinalysis concerning for
sepsisfrom urinary versus pulmonary source. Patient recieved
broad spectrum antibiotics, fluids and was transferred to MICU
for sepsis, where he received vasopressors and aggressive fluid
resuscitation. He was responsive to fluids and weaned off
vasopressors on ___. Although intially hypoxic, he had
progressively decreasing O2 requirements. Urine culture and
blood cultures were positive for highly resistant E. coli, for
which he was switched from 2 days of azithromycin to cefepime on
___. Patient will continue on cefepime for a total of 14d
course (last day ___.
CARDIOMYOPATHY WITH LEFT VENTRICLE THROMBUS: Patient was found
on ___ ECHO to have a newly depressed ejection fraction of
20% down from 35-45% in ___, with associated left ventricle
thrombus. He was transferred to the Cardiology service for
management. Given concern for heparin-induced thrombocytopenia
(see below), he was started on argatroban per ___ protocol.
When PF4 antibody returned negative, he was started on
intravenous heparin on ___ and coumadin 3mg to be uptitrated
to an INR of ___. He was continued on prior lasix dose of 20mg
PO daily, was relatively comfortable and euvolemic on day of
transfer. Will need further titration of lasix dose:PRN volume
status.
THROMBOCYTOPENIA: The patient's platelet count on admission was
164k, which decreased to a nadir of 74k in the setting of
sepsis. The differential included drug-induced thrombocytopenia
(antibiotics) as well as heparin-induced thrombocytopenia given
the patient's exposure to heparin products and a greater than
50% decline in platelet count. As such, the heparin products
were discontinued and argatroban was started on argatroban on
___ as anticoagulation for left ventricle thrombus (see
above). The Hematology team was consulted, and they did not
think that patient's thrombocytopenia was consitient with
heparin induced thrombocytopenia. A PF4 antibody was sent and
came back negative, so argatroban was discontinued and heparin
re-started as a bridge to coumadin. At the time of discharge,
the patient's platelet count was steadily rising to 102k.
AORTIC STENOSIS: The patient was also incidentally found on
___ ECHO to have moderate-to-severe aortic stenosis. The
patient denied any prior episodes of syncope. Given his ECHO
parameters were more consistent with moderate AS, and he was
relatively asymptomatic at this time, further workup and
management of this issues was deferred to his outpatient
cardiologists.
CORONARY ARTERY DISEASE STATUS POST NON-ST ELEVATION MYOCARDIAL
INFARCTION: The patient developed elevated cardiac biomarkers
including troponinemia during this hospitalization from 0.06 on
admission to 1.14. This corresponded elevated CK-MB level as
well as some ST-depression and T-wave inversion while
tachycardic. While there was initially some concern for non-ST
elevation myocardial infarction, this troponinemia was
attributed to demand in the setting of sepsis, as the patient
never developed symptoms (denied chest pain, palpitations,
shortness of breath) and troponin levels began to decline after
resolution of sepsis. The patient was continued on his home
coronary artery disease medications of clopidogrel,
rosuvastatin, metoprolol. Lisinopril was held in the setting of
kidney failure and may be restarted prior to discharge. Of
note, patient has an allergy to aspirin (rash) so this was not
started.
ACUTE-ON-CHRONIC KIDNEY DISEASE: Thought secondary to acute
tubular necrosis given the presence of muddy brown casts in
urine and clinical picture of hypotension. Nephrotoxic
medications were avoided during this admission. As urosepsis
was treated, the patient's kidney function improved with
creatinine recovered to his baseline of 1.3-1.7. Home
lisinopril was held pending resolution of blood pressures and
kidney function.
HYPERTENSION: His home metoprolol and lisinopril were held in
the setting of urosepsis, and low blood pressure, metoprolol was
restarted as low dose tartrate with holding parameters.
LEFT TOE ULCER: patient noted chronic left toe ulcer with mild
erythema, reported that it had been debrided by podiatry in the
past. Podiatry was consulted in house, felt etiology was
related to peripheral vascular disease and that it was not
infected (plain film negative for osteo). He was scheduled with
close follow-up with his vascular surgeon for further management
of this issue.
POLYMYALGIA RHEUMATICA: Managed with patient's home prednisone
6mg PO daily.
BENIGN PROSTATIC HYPERTROPHY: Managed with patient's home
tamsulosin ER 0.4mg PO daily
DEPRESSION: Managed with patient's home citalopram | 180 | 741 |
18032787-DS-12 | 24,017,967 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay.
You came to the hospital because you were having a rash. We
initially thought this was from an infection and you were given
antibiotics to which you had a reaction. You were seen by our
dermatologists who did a biopsy of your skin. It showed
something called eosinohillic cellulitis". This is not an
infection, therefore you do not need to take antibiotics. You
will be treated with oral and topical steroids.
Your discharge follow up appointments and medications are
detailed below.
We wish you the best!
Your ___ Care team | ___ woman who presented with for arm rash. She says two weeks PTA
she developed itching and pain over her third L toe, which
blistered after putting antibiotic ointment on it. She went to
her PCP and received course of Keflex with resolution of rash.
Then 3 days PTA she had a similar episode of redness and itching
on her L posterior arm. This was predominantly itchy and swelled
rapidly, so she presented to her PCP who prescribed
___ for cellulitis. She took these for 1 day and
developed blistering on rash and extension of erythema and
represented to her PCP who referred her to ED.
In our ED her arm was evaluated by dermatology, who felt it most
likely represented cellulitis, though itchiness and blistering
unusual with ddx of eosinophilic dermatitis, bug bite reaction,
and erythema migrans. Lyme serologies were sent and a skin
biopsy was performed. She received Vancomycin with rapid
improvement of her arm. However, she developed Red Man Syndrome
which persistent despite premedication and dose reduction of
Vancomycin infusion. She also developed a diffuse itchy
maculopapular rash concerning for true allergy to Vancomycin.
She received one dose of linezolid IV with significant
improvement in rash and was switched to Bactrim DS 2 tabs.
The patient's biopsy results showed Eosinophilic cellulitis. Her
antibiotics were discontinued and she was started on oral
prednisone (___) and topical Fluocinonide.
=========================
Transitional issues:
=========================
[] Started prednisone on ___. 40mg PO QD x7 days, then 20mg PO
QD x 7 days
[] outpatient follow up with dermatology and allergy
[] Vancomycin reaction likely secondary to Red Man syndrome.
[] follow up lyme serologies
[] L Arm bunch biopsy sutures to be removed ___
Per Dermatology Note regarding Vancomycin reaction
" Her manifestations with this medication were most consistent
with "red man syndrome",
developing a red rash on the upper trunk during infusion, that
on repeat slowed infusion was less severe. Close monitoring
should obviously be undertaken using this medication, but in the
event of a life-threatening MRSA infection this medication
should not
be strictly contraindicated."
- Full code presumed
- Emergency contact: mom ___ ___ | 101 | 343 |
16781914-DS-3 | 26,171,590 | Dear ___,
Your were admitted to ___ due to symptoms of left sided
weakness, which were a result of a bleed in your brain. This
most likely happened due to uncontrolled blood pressure and
increased risk of bleeding from your blood thinner, Eliquis.
While you were in the hospital, we worked to control your blood
pressure. We also stopped your Eliquis to prevent the bleed from
expanding.
The following changes were made to your medications:
1. Stop Eliquis
2. Start Aspirin 81 mg daily. This will help thin your blood and
help prevent strokes due to your abnormal heart rhythm
3. Start chlorthalidone. This medication helps control blood
pressure
4. Start felodipine. This medication helps control blood
pressure
5. Start fluoxetine. This medication helps with depression.
6. we stopped donepezil which your PCP can decide whether to
restart.
Your imaging had a couple of findings that will need to be
monitored over time by your PCP. This includes a small aneurysm
on your aorta and a small nodule on your thyroid.
You should follow up with you PCP, ___, and
already established neurologist as below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is an ___ year old woman with hypertension,
paroxysmal atrial fibrillation on eliquis, diabetes, prior TIA,
suspected dementia, recent diagnosis of
seizure disorder on keppra with reported side effect of
increased sleepiness presenting as OSH transfer with new right
frontal IPH.
# Right frontal IPH
Patient received Kcentra (on Eliquis) and labetalol (SBP >200)
at OSH prior to transfer to ___. On arrival to ___, exam
notable for left facial droop, L arm > L leg weakness, and right
leg weakness (baseline). Her interval head CT on arrival showed
bleed to be stable. Her SBP goal was <140, gradually liberalized
to <150. This required nicardipine gtt and antihypertensives as
below. Her Eliquis was held, but ASA 81 mg was restarted on
***** for anticoagulation given history of afib.
Attempted to obtain MR brain, but patient did not tolerate
despite premedication with seroquel. Review of MR ___ brain from
OSH from ___ does not reveal large underlying lesion. GRE
with blood products in same area of current bleed and her
history of cognitive decline suggests a history of amyloid.
Etiology of her IPH most likely amyloid compounded by
anticoagulation for atrial fibrillation and uncontrolled
hypertension.
#Epilepsy
Concern that increased sleepiness could represent nonconvulsive
seizures. cVEEG with right frontal slowing. Her home keppra 500
mg BID was continued without change. Review of OSH GRE
(performed ___ on presentation for first time seizure)
reveals blood products in area of current bleed. This is
concerning for an underlying amyloidosis leading to ___,
resulting in seizures.
#Dementia
Home donepezil held during hospitalization, but should be
resumed at time of discharge.
#Hypertension
Goal blood pressure on admission of systolic less than <140.
Required a nicardipine gtt to achieve blood pressure goal as
well as continuation of all her home antihypertensives and the
addition of 2 new antihypertensives, chlothalidone and
felodipine. Her systolic blood pressure goal was liberalized to
less than 150. At time of discharge her blood pressure regimen
is as follows:
- Clonidine 0.2 mg BID (Home medication)
- Atenolol 100 mg qAM, 50 mg qPM (Home medication)
- Hydralazine 100 mg TID (Home medication)
- Losartan Potassium 50 mg BID (Home medication)
- Chlorthalidone 25 mg PO/NG DAILY (started ___
- Started Felodipine 5mg (started ___
#Atrial Fibrillation
Eliquis held in setting of IPH. ASA restarted for
anticoagulation on ___. It was felt that patient is not a good
candidate for resumption of oral anticoagulation given the
presence of superficial siderosis on MRI from OSH.
# Mood
Concern for depression during hospitalization. Started
fluoxetine 20 mg daily ___.
# Diabetes
No changes to home mediations upon discharge. Home meds were
held during hospitalization and blood sugar was controlled with
sliding scale insulin.
================================
Transitional Issues:
[ ] Stroke Neurology Follow Up
[ ] Established Outpatient Neurologist: continued management of
cognitive decline, epilepsy
[ ] PCP: perform thyroid ultrasound to assess interval increase
in size of hypodense thyroid nodules noted on ___ ___
CTA head/neck.
[ ] PCP: follow 4.3 cm fusiform ascending aortic aneurysm over
time.
[ ] PCP: ___- chlorthalidone and felodipine
added to home antihypertensive regimen
[ ] PCP: ___ depression. Fluoxetine 20 mg daily started ___
[ ] PCP: consider restarting donepezil
===============================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) | 295 | 629 |
16598160-DS-20 | 25,036,408 | You presented to ___ Emergency Department after your recent
gallbladder surgery (which was complicated by a bile leak
requiring an ERCP with stenting), complaining of fevers. A cat
scan was obtained, which showed a fluid collection in the
gallbladder fossa. You were started on antibiotics and taken to
Interventional Radiology to have a drain placed in the fluid
collection. After the drain placement, a gallbladder scan showed
no evidence of bile leak. You tolerated the procedure well and
are now being discharged home to continue your recovery. You
will be given a prescription to complete a 7-day course of
antibiotics. We are setting you up with a Visiting Nurse to come
help with ___ drain care.
You will still need a repeat ERCP in ___ weeks for pancreatic
and biliary stent removal and re-evaluation by the GI doctors.
___ will call you to schedule this appointment.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of fevers. The patient is
POD11 from lap CCY which was complicated by a bile leak
requiring an ERCP with stents. Admission abdominal/pelvic CT
revealed
a rim enhancing organized collection of complex fluid density in
the gallbladder
fossa measuring 5.9 x 5.1 cm with fat stranding, concerning for
biloma. The patient was started on IV antibiotics and underwent
a CT-guided drain placement, which went well without
complication. Gallbladder study post drain placement revealed no
evidence of a leak. The patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
for drain care. Drain teaching was started with the patient and
his family in the hospital, and the patient's wife demonstrated
proper technique in flushing and emptying the drain. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
The patient was given prescriptions to complete a 7-day course
of antibiotics and for pain medication. He had follow-up
scheduled in the ___ clinic. | 475 | 270 |
19623595-DS-14 | 24,018,718 | Dear Ms. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you had low sodium
and high potassium levels in your blood. In the hospital, we
gave you some fluids and stopped your diuretics. We also started
you on a low dose of steroids because your body was not
producing enough steroids. This will help correct your sodium
and potassium.
You should follow-up with your endocrinologist Dr. ___
___ a week.
We wish you a speedy recovery,
Your ___ Care Team | ___ yo w with PMHx of pituitary adenoma s/p resection in ___
with good residual pituitary function, breast cancer (___), DM,
COPD, who presented with 2 days of diffuse abdominal pain found
to have hyponatremia with Na of 120.
# Hyponatremia/Hyperkalemia:
Patient found to have a sodium of 120 on admission. Likely a
combination of factors including CHF, increased free water
intake and low solute intake, as well as an element of
iatrogenic secondary adrenal insufficiency given the patient's
history of steroid injections for hip osteoarthritis. Urine
lytes with Na>40, UOsm>100 in line with SIADH vs. adrenal
insufficiency. TSH normal. Chest CT done not suggest a pulmonary
source for SIADH. Potassium also uptrending during this
admission reaching a high of 6.0. Corticotropin stimulation test
was performed with adequate response. ACTH measured before stim
test was 6, lower limit of normal. Na measured at the end of the
stim test showed an increase in sodium from 125 to 130 (highest
the patient had been since admission). Patient was started on a
trial of prednisone 3mg PO daily with improvement of her sodium
and potassium (Na 120 and K 5.3 at discharge). Plan for
discharge with prednisone 3mg PO with possible taper and
follow-up with Dr. ___ as an ___.
# Abdominal Pain:
Patient presented with diffuse abdominal pain. CT not remarkable
for acute process. Description of pain suggestive of excessive
gas. Improved with simethicone. At discharge, patient was not
complaining of any residual abdominal pain.
# L-hip osteroarthritis
Patient with known severe osteoarthritis, slowly worsening,
having difficulty moving hip with severe pain. Patient not a
surgical candidate. History of cortisone injections. Maintained
on tramadol for pain. Evaluated by ___ who suggested discharge to
rehab facility.
***TRANSITIONAL ISSUES***
# Patient discharged on prednisone 3mg PO daily. Requires
follow-up with endocrinologist Dr. ___.
# Lisinopril dose reduced and furosemide was held. Blood
pressures inpatient stable. Would evaluate need for continued
therapy or alternative blood pressure management given
hyperkalemia/hyponatremia on admission
# Patient started on vitamin D and calcium on discharge.
Consider addition of PPI if continued steroid therapy.
# CODE: Full (confirmed)
# Emergency Contact: Daughter (______ | 84 | 342 |
17479853-DS-3 | 21,645,079 | Dear Ms. ___,
You were admitted to ___ because of uncontrollable
abdominal pain.
While you were here, we did some testing. Your CT scan was
normal. Your lab tests did not show any cause of the abdominal
pain. Your endoscopy and colonoscopy were normal.
We think a possible cause of your abdominal pain is
endometriosis, and have prescribed you birth control pills to
help with this. We controlled your pain using oxycodone.
Hopefully the birth control pills will help and you will not
need to keep using the oxycodone. We have prescribed you some
oxycodone at your discharge, but if you need more, you will need
to see your primary care doctor. Oxycodone can cause
constipation, so it is important to take your stool softeners
when taking the oxycodone.
Your follow up appointments and discharge medications are below.
It was a pleasure taking care of you!
Your ___ Medicine Team | Ms. ___ is a ___ woman with h/o angioedema, idiopathic
urticaria, anti-TPO antibodies, and depression who presented
with 2 weeks of abdominal pain with nausea, vomiting and
inability to tolerate PO intake for 5 days.
# ABDOMINAL PAIN
This is Ms. ___ first episode of severe abdominal pain,
which she described as diffuse and associated with nausea and
vomiting and inability to tolerate PO intake. Initially, pain
was controlled with IV opioids, but she was transitioned to PO
oxycodone. The patient did not tolerate Bentyl. GI was consulted
and workup was non-revealing: CT A/P negative and LFTs, lipase,
and lactate were normal, negative urine porphobilinogen, and
EGD/colonoscopy were normal. Given that her pain was worsened
with her period, recent discontinuation of OCPs with increased
cramping, and pain with defecation, most likely diagnosis was
thought to be endometriosis and the patient was discharged on
OCPs for a trial, to be followed up with PCP and OB/GYN.
- F/u pain while on OCPs, and f/u with OB/GYN regarding
endometriosis
- F/u EGD/colonoscopy biopsy results
- F/u pending labs: heavy metal screen, urine total porphyrins,
urine aminolevulinic acid.
# DEPRESSION/ANXIETY
Ms. ___ has a history of depression on Lexapro. Her
abdominal pain is also associated with significant anxiety. She
follows with outpatient psychiatrist Dr. ___. Psychiatry was
consulted for assistance in managing anxiety related to
abdominal pain, and potential concern for functional abdominal
pain (abdominal pain discussed above). She was started on Ativan
0.5mg BID prn prior to eating, which helped the patient
dramatically. Additionally, prazosin 1mg qhs was started for
insomnia/nightmares. Home Lexapro was continued while in house
- Continue to follow with outpatient psych
# H/o Angioedmea and chronic idiopathic urticaria
Ms. ___ has C1 esterase deficiency per ___ records as well
as chronic urticaria, followed at ___. Complement levels in
house were not reflective of hereditary angioedema (C3 83, C4
18). No episodes of angioedema or urticaria on this admission.
CODE: Full (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: Husband (___): ___ Mom
(___) ___
TRANSITIONAL ISSUES
===================
- Follow up on any biopsies from EGD/colonoscopy
- Follow up pain while on OCPs
- Follow up with OB/GYN regarding dx of endometriosis
- Pending labs: heavy metal screen, urine total porphyrins,
urine aminolevulinic acid. | 144 | 371 |
16299664-DS-17 | 23,737,411 | Dear Ms. ___,
You came into the hospital because you had a seizure in the
setting of alcohol withdrawal. You were given medicines to help
with the symptoms of alcohol withdrawal. You were started on a
medication to help prevent alcohol craving (naltrexone) and a
medication for anxiety (sertraline).
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all clinic appointments.
- It is very important that you attempt to stop drinking
alcohol. If you continue to drink, you may continue to have
seizures and your liver will continue to get worse, which can
lead to death.
- You should see a liver specialist for your liver cirrhosis.
Please call to make an appointment (___)
It was a pleasure taking care of you,
Your ___ Care Team | Ms. ___ is a ___ woman with alcohol use disorder,
alcoholic cirrhosis (compensated), who presents as a transfer
from ___ with concern for seizure in the setting of alcohol
withdrawal.
ACUTE/ACTIVE PROBLEMS:
======================
# EtOH use disorder
# EtOH withdrawal
# Seizure:
Patient presented with episode of loss of consciousness after
abrupt decrease in alcohol consumption. S/p 15 mg/kg
phenobarbital load on ___, self-tapering. Intermittently
required benzodiazepines, clonidine, and quetiapine post
phenobarbital load. Started MVI, folic acid, and high dose
thiamine repletion (D1 = ___. SW consulted for alcohol
cessation resources. Started Naltrexone 50 mg PO DAILY started
for EtOH cravings.
# EtOH cirrhosis:
Per ___ Atrius records, patient visited GI and was diagnosed
with compensated alcoholic cirrhosis. Evidence of synthetic
dysfunction with elevated INR, thrombocytopenia. Currently no
sign of decompensation (ascites, HE, bleed,
infection). RUQUS showed e/o steatosis, but cannot exclude
cirrhosis.
# UTI
Patient noted dysuria and foul-smelling urine. UCx from BI-M
growing E.coli ___ to nitrofurantoin). S/p one dose of
ceftriaxone in ED. Nitrofurantoin ___ for total 3 day
course.
#Generalized anxiety disorder
Patient describes significant worry about many things in her
life (her health issues, dentist, living situation, etc.). This
is sometimes a trigger for alcohol use. Started sertraline 25 mg
daily.
CHRONIC/STABLE PROBLEMS:
========================
# Psoriasis
Held ammonium lactate 12 % topical DAILY. Started Clobetasol
Propionate 0.05% Ointment 1 Appl TP BID
# Diabetes
HbA1c 6.3. ISS while inpatient.
# Hypertension
Lisinopril 10 mg daily while inpatient (home benazepril 10 mg
oral DAILY not formulary)
# Neuropathy
Increased gabapentin to 300 mg PO BID and 600 QHS given
persistent pain and paresethesia.
# Lower extremity edema
Home Furosemide 40 mg PO DAILY
# GERD
Continue Omeprazole 20 mg PO DAILY
# CONTACT: Room ___, ___
TRANSITIONAL ISSUES
===================
[]Patient has evidence of cirrhosis. Please continue to
emphasize the importance of alcohol cessation.
[]Started naltrexone to help with alcohol cravings
[]Please ensure Hepatology follow up for fibroscan and
management of likely cirrhosis.
[]Patient describes significant generalized anxiety. Started
sertraline 25 mg daily. Please monitor anxiety and titrate
sertraline. Consider psychiatry follow up for anxiety and
substance use.
[]Started betamethasone Ointment for psoriasis.
>30 minutes spent on complex discharge | 130 | 349 |
15584173-DS-9 | 20,017,749 | Dear Ms. ___:
You were hospitalized at ___.
You were found to have a type of blood cancer known as acute
myelogenous leukemia (AML). You were treated with chemotherapy
to destroy the cancer cells. While you were hospitalized, we
also adjusted your anxiety meds and changed it to a medicine
known as seroquel. You should stop taking your klonopin. We also
added a medicine known as acyclovir which will prevent the
shingles virus from reactivating. We held your warfarin because
your plt count was so low you were liable to bleed. You should
stay off the warfarin until your oncologist says it is ok to
restart.
You will follow up with your primary oncologist in ___, Dr
___ on ___. You will require frequent blood draws
and chemotherapy as an outpatient.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team | ___ year old woman with smoldering IgA kappa multiple myeloma,
left iliac and femoral vein DVT on warfarin, temporal arteritis
on prednisone, osteoarthritis, chronic pain, depression, and
hypothyroidism who presented to ___ on ___
with the chief complaint of abdominal pain, and was found to
have severe anemia, thrombocytopenia, and leukocytosis with 80%
blasts in peripheral blood. | 138 | 57 |
11095918-DS-18 | 20,688,527 | You were admitted for persistent abdominal pain, nausea,
vomiting and difficulty eating. You had a CT scan of your
abdomen which did not show any significant changes and your
blood work was normal. You were seen by the chronic pain team,
your medications were adjusted and you were given a trigger
point injection with some improvement in your pain. | ___ s/p CCY, s/p RNY gastric bypass, acute on chronic abdominal
pain thought to be recurrent biliary colic, s/p ERCP with sludge
extraction, sphincteroplasty, and, most recently, CBD stent
placement, admitted with recurrent abd pain, inability to take
PO. Most recent EGD ___ with no findings to explain pain. All
labs currently were normal. Etiology of her recurrent pain
remains unclear and her LFT abnormalities are not present
currently. She does not feel she has had any benefit after
recent ERCP and stent placement.
# Abdominal pain
# Anxiety
# GERD
# Constipation
The chronic pain service was consulted. Her pain was the same
as prior admissions. Her gabapentin was discontinued and she
was started on Lyrica 25 mg BID. She was started on a Lidoderm
patch. She underwent abdominal wall trigger point injections on
___ with significant improvement in her symptoms. Her PO intake
improved.
-F/u with pain clinic as scheduled on ___
- D/c gabapentin, start Lyrica
- Lidoderm patch
- Continue home hydroxyzine, duloxetine, amitriptyline,
oxycodone
- Continue bowel regimen
- FULL CODE
- HCP: sister, ___ ___
___: Home without services | 61 | 182 |
15677663-DS-6 | 24,427,797 | Dear Ms ___,
You were hospitalized due to symptoms of dizziness and
difficulty walking. You had imaging done that showed your
symptoms were not due to acute ischemic stroke. We think that
your symptoms were likely due to multiple factors including
Benign Paroxysmal Positional Vertigo (BPPV), and cervicogenic
headaches.
BPPV is a type of vertigo that develops due to collections of
calcium in the inner ear. These collections are called
canaliths. This vertigo is typically brief in people with BPPV,
lasting seconds to minutes. Vertigo can be triggered by moving
the head in certain ways.
Cervicogenic headaches are caused by tightness of the muscles in
your neck that cause tension headaches.
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:
-CKD
-Diabetes
-High blood pressure
-High lipids
We are changing your medications as follows:
- Start taking flexeril 5mg at night for 14 days. This
medication can cause drowsiness so you should only take at night
and if you do take during the day, please avoid driving.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ woman with PMH for IDDM, CKD stage
IV, hypertension, hyperlipidemia presenting to the emergency
department from urgent
care for evaluation of transient episode of vertigo followed by
unsteady gait, nausea, head "heaviness".
#Vertigo
#Headaches: Lab work up was benign. Exam was nonfocal. She had
MRI that was negative for any acute ischemic stroke or other
possible causes of vertigo. Given very brief episode of true
"room spinning" vertigo after bending over this was felt to
represent BPPV. Her headaches were felt to represent
cervicogenic headaches given exam findings of tight cervical
muscles. Her unsteadiness, vertigo, and headaches improved
during hospitalization. She was given heat packs and started on
cyclobenzaprine 5mg qhs for cervicogenic headaches. She also was
given prescription for vestibular ___ that she can use if
vertiginous symptoms improve. Stroke risk factors were checked:
HbA1c 7.5, LDL 120.
# CV: Patient was monitored on tele during admission without any
brady or tachyarrhythmia noted.
#ESRD: Patient recently had fistula placed that has subsequently
clotted. Not currently getting HD but plan in the future. Cr was
2.1 on admission. No acute indication for HD while admitted.
#Insulin dependent Type 2 Diabetes: HbgA1C was 7.5. Though
elevated is at goal for patient with long standing diabetes and
complications from diabetes.
She was continued on home insulin of Lantus 18units in ___ and 22
units ___ with sliding scale with meals.
Transitional Issues
====================
[] discharged with flexural for 2 weeks for cervicogenic
headaches. Please follow up headaches and assess for resolution.
Consider ___ referral if continued pain.
[] If patient's symptoms of vertigo recur please refer to
vestibular ___
#Contact:
___
Relationship: WIFE
Phone: ___ | 350 | 277 |
14309399-DS-11 | 23,100,617 | You were admitted with an infection in your abdomen near the
surgical site from your prior surgery. This required drainage in
interventional radiology. You have had significant nausea during
your admission however, this seems to have improved now. You
will take the antibiotic Augmentin at home and the drain will
remain in place. You will need to continue to flush and care for
the drain however, the drain will only need to be flushed once
daily. Otherwise, it should be secured so it does not fall out
and we will take it out in clinic. Continue to wash around the
incertion site daily as instructed by the nursing staff and
apply a new dry sterile gauze dressing and secure with paper
tape. Keep track of any output and being these numbers to clinic
with you. Continue to titrate your ileostomy with the
medications and care for it as you have been.
Please call us with any of the following symptoms:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
if the drain falls out. | Ms ___ was readmitted with an abdominal abscess. This was
drained in interventional radiology. She was treated with broad
spectrum antibiotics and her white count returned to normal. Her
diet was advanced. Her ostomy output was high and she was
started on a regimen to slow the output. At the time of
discharge, the drain was no longer putting out and it was now
only flushed daily. She was discharged home to complete a course
of augmentin and the drain will be removed in clinic. | 204 | 86 |
11982428-DS-22 | 21,489,295 | Dear Ms. ___,
You were admitted with chest pain. You chest pain had resolved
shortly after your arrival in the hospital. You underwent stress
testing which was reassuring for no signs of damage of your
heart.
Please follow up with your primary care physician ___ 7 days
of discharge.
It was a pleasure providing care for you! We wish you the best
in your health!
Your ___ | Ms. ___ is a ___ yo woman with a H/O hypertrophic
cardiomyopathy, hypertension and mitral regurgitation who was
admitted after an episode of chest pain.
ACTIVE ISSUES:
# Chest pain: Ms. ___ presented after a single episode of
chest pain at rest which had resolved after aspirin and
nitroglycerin administration. Her CAD risk factors include
hypertension, hyperlipidemia, family history and obesity.
Coronary angiography in ___ showed no flow-limiting CAD and
stress echocardiogram in ___ had no objective evidence of
ischemia. Most recent echocardiogram in ___ showed no regional
wall motion abnormalities. Her EKG at presentation did not show
ischemic changes and serial troponins were negative. She was
continued on aspirin and was started on atorvastatin. She was
continued on her home metoprolol. She didn't experience anymore
episodes of chest pain during her admission. She underwent
pharmacologic nuclear stress testing which was negative for
evidence of ischemia. | 67 | 147 |
11413236-DS-124 | 27,935,947 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted for abdominal pain
and concern for exacerbation of your Mast Cell Degranulation
Syndrome. You were treated per the protocol for your Mast Cell
Symptoms and your abdominal pain ultimately improved. You were
able to eat and drink without difficulty. We highly encourage
you to follow up with the appointments listed below.
We wish you the best.
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old female with a PMH significant for
mast cell degranulation syndrome, CAD s/p CABG ___ (2v
disease), PCI w/ stent placed ___, GERD, achalasia, diffuse
esophageal spasm, RA, inflammatory polyarthritis, hypothyroidism
who is presenting with dyspnea and abdominal pain concerning for
her known mast cell degranulation syndrome. | 80 | 54 |
16285428-DS-20 | 29,557,259 | You were admitted after a fall. You sustained a fracture to
your nose and right arm. You had a splint placed on your arm
and you will follow-up with the Orthopedic service. You had a
large amount of bleeding from your nose and required monitoring
in the intensive care unit. The nasal packing was removed and
you have had no further bleeding. You have had difficulty with
swallowing and you were evaluated by Speech and Swallow who
cleared you for food. You were seen by physical therapy and
recommendations made for discharge to a ___ facility. | The patient was admitted on ___ after a fall onto her face.
She was found to have a right distal radius fracture, which was
casted by ortho. She also had bilateral nasal bone fractures.
Her nose was packed by ENT for significant nasal bleeding. The
patient was very agitated and pulled the packing out. She
required restraints for agitation. She was also started on 1
week course of bactrim for a urinary tract infection.
During the night, she had profuse epistaxis, requiring posterior
packing in the right nare and anterior packing in left nare,
warranting admission to the intensive care unit for close airway
monitoring. Within several hours of arrival to the intensive
care unit, the patient experienced re-bleeding around the nasal
packings. She was re-evaluated and re-packed by ENT who deferred
surgical intervention, however the patient was intubated for
airway protection with plans to remain intubated until most of
her packing was removed. She was kept on vancomycin while the
nasal packing was in place. Her left nasal packing was removed
on ___ and right anterior packing was removed on ___. She was
extubated on ___.
Her pain was controlled on acetaminophen and she continued on
her home dose of methadone. She continued on a nasal cannula and
her oxygen saturation was closely monitored. She had isolated
episodes of arrythmia attributed to her posterior nasal packing
that was non-sustaining. A bedside speech and swallow was done
on ___. The Speech Therapist's recommendation was that the
patient be kept NPO due to oxygen desaturation and coughing with
oral intake. A foley was kept in place for UOP monitoring while
she was intubated and on ___ because she had minimal mobility.
Physical therapy worked with her in the ICU on ___. She was on
vancomycin BID while her nasal packing was in place.
Subcutaneous heparin was held initally due to her epistaxis but
was resumed on ___. SCDs were used as well for DVT
prophylaxis. The patient was transferred to the surgical floor
on ___.
Because of the medical history of the patient and the associated
problems, the Geriatric service was consulted. They recommended
increasing her pain regimen because she continued to be
agitated. She had bouts of desaturation and there was concern
for aspiration. She underwent a video swallow evaluation which
revealed normal passage of barium through the oropharynx and
esophagus, but aspiration was observed with thin liquids and
penetration with thickened liquids. When discussed with the
patient's family, they chose to allow the patient to eat with
the knowledge that there was a risk for "silent" aspiration.
The patient was therefore allowed to drink nectar-thick liquids
and a pureed diet. The patient's medications were crushed and
given with the pureed food. She was switched from vancomycin to
bactrim for packing prophylaxis. On ___, her telemetry was
discontnued per ENT recommendations. The patient desaturated to
the ___ and was put on a 10L face mask. A chest x-ray was done
which was slightly improved, but her white blood cell count had
increased from 8 to 12.8. She had no fevers during this time.
Over the next ___ hours, her white blood cell count was monitored
and it began to normalize. Her white blood cell count upon
discharge was 8.
The posterior packing was removed from the nose on ___ and
there was no further evidence of bleeding. The patient did
report clear drainage of fluid from the nose. ENT were
consulted and reported that this may have resulted from afrin
use and should subside. After the packing was removed, the
patient was again evaluated by speech and swallow. She was
cleared for thickened nectar and pureed food with aspiration
precautions. Her vital signs remained stable and she was
afebrile.
The patient was evaluated by physical therapy and
recommendations made for discharge to a ___ facility
because of her continued immobility. The patient was discharged
on HD #15 in stable condition. Follow-up appointments were
scheduled with ENT, orthopedics, and plastic surgery. | 102 | 682 |
11531320-DS-15 | 22,957,791 | Dear Mr. ___,
You were admitted to ___ on
___ for swelling and possible infection of your
scrotum/groin. The Urology team evalulated you during your
admission. The swelling was likely due to infection of the
deeper skin tissues, causing the swelling, warmth, and redness.
You were discharged with an antibiotic, Clindamycin to treat
this infection. You should continue the Clindamycin for 5 more
days for a total of 7 days. Also, the swelling is likely caused
by extra weight and weight loss will help prevent this from
happening again. You should elevate your scrotum while laying
down and wear supportive undergarments while walking.
We scheduled an appointment to follow up with Dr. ___
urologist on ___.
We also scheduled you for an appointment with your primary care
provider, Dr. ___ on ___ at 10:00 AM.
Additionally, you have a follow up appointment for pulmonary
function test on ___ at 7:40AM.
It was a pleasure taking care of you at ___. If you have any
questions about the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team | ___ year old gentleman with h/o morbid obesity, lower extremity
venous insufficiency, presenting w/ several days of scrotal
swelling and erythema, w/out significant tenderness, concerning
for scrotal cellulitis.
ACTIVE ISSUES
==========
# Scrotal Cellulitis: Pt presented w/ scrotal swelling,
erythema, and warmth to the touch w/out significant pain,
consistent w/ scrotal cellulitis. Pt has been treated for an
episode of scrotal cellulitis in ___, which resolved w/
amoxicillin ___ days. During this episode, pt was treated w/
Clindamycin 450mg TID. Urology was consulted and recommended
urology out-pt f/u w/ no immediate urology needs while in-pt.
The pt was discharged w/ improvement of his scrotal erythema and
swelling, w/ continuation of PO Clindamycin 450mg for another 5
days, for a total of 7 days. Urine culture from ___ was
negative, and blood culture was pending at time of d/c.
# Anemia: Patient has history of Vitamin B12 deficiency, but
presented w/ microcytic anemia from not taking home iron due to
side effects of constipation. On admission: H/H: 11.4/39.6; MCV
of 77. Colonoscopy ___ was normal. Iron studies ___ showed
Ferrtin 11 (normal: 30 - 400), iron 41 (normal: 45-160),
consistent w/ iron-deficiency anemia. Pt was started on ferrous
gluconate 324mg every other day since admission, and was
encouraged to take his home iron and colace for associated
constipation. Vitamin B12 was 335 (normal: 240-900); as pt was
due for his monthly vitamin B12 injection, an 100mcg B12
injection was given prior to discharge.
CHRONIC ISSUES
===========
# Dyspnea: on 2L home O2. Progressive over the past 8 months.
Admitted ___ due to dyspnea. Seen by Pulmonary with Dr. ___
___ as outpatient. Thought to be component of asthma given
improved response to inhaled steroids. Obesity also likely
leading to restrictive lung disease as well as component of
obstructive lung disease (COPD). Seen by Cardiology who cannot
perform stress test given patient's weight. Also likely
component of pulmonary hypertension. Home regimen of Advair,
Combivent, Montelukast, were continued throughout hospital stay.
As well, pt was encouraged to use CPAP which he tolerated while
hospitalized.Pt will have pulmonology f/u out-pt.
# Hypertension: Home regimen of amlodipine 10 mg PO daily,
chlorthalidone 25 mg PO daily , losartan 100 mg PO daily were
continued.
# Depression: Home escitalopram 20 mg PO daily
# Obstrucitve Sleep Apnea: has not been using CPAP at home.
During hospital stay, continued home regimen of 2L nasal cannula
with head of bed elevated. Encouraged CPAP use at home.
Transitional Issues:
===========================
- Has CPAP at home, but says the mask does not fit properly.
Used CPAP in the hospital and took mask home. Please follow up
to ensure he has a proper mask for his home CPAP.
- We gave his monthly dose of 1000mcg Vitamin B12 in hosptial on
___.
- has Pulmonary follow-up in place to further characterize his
severe restrictive lung disease as well as probably OSA.
- started on ferrous gluconate for iron-deficiency anemia-
likely secondary to gastric bypass surgery. Had a normal
colonoscopy in ___ with recommended followup in ___ due to hx
of polyps. | 178 | 516 |
18563813-DS-11 | 26,900,264 | Dear Ms. ___,
It was a pleasure to care for you at ___
___. You were admitted because you had abdominal
pain. We were concerned about your history of ischemic colitis
and performed a CT-Scan of your belly. We found no
abnormalities on this scan and determined that your belly pain
is more due to straining the muscles of your abdomen. (This may
be as result of your recent Adult Center excercises).
.
We recommend you avoid any strenuous excercises on those muscles
until the pain improves. Heat pads may also help with the
discomfort.
.
Your blood tests showed that your kidney labs (creatinine) was
slightly higher than usual, possibly because of dehydration and
your decreased food intake recently. Your kidneys were
improving when you were discharged.
.
We controlled your blood sugar with insulin while you were in
the hospital.
.
We have not made any changes to your medications and you may
resume them at your usual home doses. | Ms. ___ is an ___ year old woman with a history of
ischemic colitis, CAD, and dyastolic CHF who presented with
musculoskeletal abdominal pain and ___. | 158 | 28 |
16073325-DS-37 | 27,779,614 | Dear Mr. ___,
You were admitted to ___ after
you developed drooping in your face. This resolved by the time
you came into the emergency department. We think this could have
been because your blood pressure was low or because you had
something called a transient ischemic attack (TIA). You should
speak with your primary care physician about restarting ___ drug
called warfarin (coumadin), which is used to thin your blood.
You had previously been taking this medication, but stopped
because of your falls. To help prevent strokes, we increased
your dose of aspirin.
We also found that you had an infection in the soft tissues of
your leg and the bones of the foot. You will need to continue
taking an antibiotic called vancomycin, which you will be given
at hemodialysis for six weeks. You were also seen by our
vascular surgeons and podiatrists who did not feel that you
needed an amputation of your toe at this time.
You should follow up with your primary care physician, and we
have set you up with an appointment to see her. You should also
follow up with podiatry, and you already had a follow up
appointment scheduled.
It was a pleasure to help care for you during this
hospitalization, and we wish you all the best in the future.
Sincerely,
Your ___ Team | PATIENT:
___ yo M with extensive past medical history including ESRD on HD
MWF, atrial fibrillation, and LLE cellulitis who presents with
new onset facial droop this morning.
.
.
ACUTE ISSUES
# ___ facial droop: Pt was felt to have TIA vs.
hypotension causing recrudescence of old stroke. Patient did not
have any focal neurologic deficits on admission, and his
neurologic exam remained stable. Pt had a carotid duplex series
which showed significant carotid stenosis with some element of
subclavian steal. Vascular surgery felt that patient was not a
candidate for vascualar interventions and no procedure was
performed. Patient notably had a CHADS2 score of 5 (if evidence
of prior stroke is counted toward score). We discussed
anticoagulation with him, but he reported that he wanted to
think about this and discuss with his PCP in the future. PCP was
contact this admission who strongly recommended against starting
any oral anticoagulation as patient been taken off warfarin
given recurrent falls. Started on full strength aspirin prior to
discharge.
.
# ___ hallux osteomyelitis: Pt's ___ great toe was noted to be
gangrenous, likely stable from prior. He was seen by vascular
surgery, who did not feel that a revascularization procedure was
indicated this admission. He was also seen by podiatry, who did
not feel that toe amputation was indicated at this time, given
severity of PVD. MRI foot/ankle was consistent with hallux
osteomyelitis. Patient was started on HD-dose vancomycin. ID
consulted and OPAT scheduled to follow Ptient after inpatient
discharge.
.
# Cellulitis: On admission, pt was noted to have worsening
erythema/warmth of his LLE. LENIS were negative. He was started
on vancomycin on ___. Per previous HD center, he had not
received vancomycin for unclear reasons. Pt was maintained on
vancomycin with HD while hospitalized. He was seen by ID, who
felt that patient should continue vancomycin as detailed above.
.
# Bilateral opacities: In the ED, pt was felt to have possible
bilateral opacities, but was otherwise asymptommatic. His
levaquin/flagyl were discontinued, and patient did not develop
any symptoms of pneumonia.
.
# Hypotension: Pt's SBP was low on presentation to the ED,
likely from worsening infection and recent HD. Pt's SBPs were
generally >90 while he was admitted.
.
. | 217 | 361 |
16142940-DS-17 | 23,717,411 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital after a fall
at home. You were found to have low sodium levels in your blood
and fluid in your lungs. Scans of your head and your body did
not show any bleeding or fractures. You were seen by the
interventional pulmonary team who were able to drain the fluid
from your lungs. Your sodium levels improved after receiving
diuretic medication. It is very important that you take your
diuretic (torsemide) daily and weigh yourself daily.
Additionally you will continue to take one diuretic medication
weekly: metolazone. If your weight should go up by more than 3
pounds for 3 days please contact your primary care physician or
your cardiologist. Your weight on discharge is 64 kg. You were
weak at the time of discharge and we felt you could benefit from
rehabilitation.
Please follow-up with the appointments listed below and take
your medications as instructed below.
Wishing you the best,
Your ___ Care team | ___ with hx of amyloid cardiomyopathy (EF 55%), permanent Afib
on apixaban, severe TR and CKD who presents s/p mechanical fall
found to have hyponatremia and ___.
# Acute on chronic decompensated dCHF: EF 55% ___ senile amyloid
s/p EMB. Patient came in 7 pounds above dry weight of 135-138
pounds, elevated proBNP 5187. He was admitted on bumex 4 mg BID
with metolazone 2.5 mg every other ___ at home. TTE showed
depressed EF 40-45%. Patient was diuresed with lasix gtt with
boluses. Patient was transitioned to PO torsemide initially BID,
however he was urinating at night which negatively affected his
quality of life and prior to discharge was transitioned to 80 mg
PO torsemide daily, 12.5 of spironolactone daily, and 2.5 mg of
metolazone q week (___). Discharge weight 64 kg.
# Hyponatremia: Patient presented asymptomatic with Na of 126
from baseline mid ___. Volume status appeared hypervolemic.
Etiology most likely in setting of chronic dCHF with decreased
effective intravascular volume leading to appropriate ADH
response with UNa < 10. Patient was placed on free water
restriction and diuresed as above. Discharge Na 133.
# R pleural effusion: Patient has a chronic R pleural effusion.
Per patient, has been drained before at OSH (about a year ago).
Patient has DOE at baseline per his report, but oxygen
saturations remained stable on room air. Patient had therapeutic
thoracentesis by IP on ___ draining 2L serous fluid with
chemistries suggesting transudative fluid, preliminary fluid
cytology negative for malignancy, fluid appeared bland. Possibly
secondary to heart failure, though would expect to see
unilateral effusion. Subsequent XXR revealed re-accumulation of
the pleural effusion without a change in his respiratory
symptoms, unlikely re-expansion effusion as pleural pressures
became low during procedure and only 2L removed. At the time of
discharge it was felt that the patient's respiratory symptoms
were stable and there was no indication for urgent repeat
thoracentesis. If his symptoms of dyspnea increase he may
benefit from pleural drain placement by Interventional
Pulmonology. He will follow up in ___ clinic in 4 weeks to
determine further management.
# Acute on Chronic Kidney Disease: Admitted with Cr 2.0 with
baseline 1.6-1.8. Most likely pre-renal in setting of diastolic
heart failure with decreased forward flow. Cr improved with
diuresis. Discharge Cr 1.7.
# s/p fall: Likely mechanical with tripping over objects going
to the bathroom at night. Extensive head, spine, and bone
imaging in the ED negative for acute processes. Patient
sustained bruises on left side with left upper extremity
swelling though upper extremity ultrasound negative for DVT.
Pain was controlled with tylenol and tramadol as needed. | 175 | 436 |
15814642-DS-18 | 29,971,563 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with bleeding from your GI
tract. You had a colonoscopy which showed internal hemorrhoids.
We monitored your blood counts and your symptoms closely. You
will need to take stool softeners while you are home to prevent
constipation. It is very important that you do not strain while
having a bowel movement.
You will need to have follow-up in Dr. ___
clinic early next week (either on ___ or ___. They
should contact you with the appointment information. If they do
not contact you by this weekend, please call their clinic at
___.
We wish you the best,
Your ___ Team | Mr. ___ is a ___ y/o male with a past medical history of
metastatic lung adenocarcinoma (EGFR-/ALK-) currently on C4 of
carboplatin/pemetrexed who presented with BRBPR. Hospital course
is outlined below by problem:
# BRBPR ___ internal hemorrhoids: Patient was hemodynamically
stable and was admitted to the floor for further workup of his
BRBPR. GI was consulted for colonoscopy and his Hct was
monitored closely. He did not require blood transfusions. A
colonoscopy was performed on ___ which showed evidence of
internal hemorrhoids and there were no interventions. His
bleeding resolved and he was discharged home with a bowel
regimen. His Hb on discharge was 9.2 (baseline Hb ___.
# Metastatic lung adenocarcinoma (EGFR-/ALK-) currently C4
carboplatin/pemetrexed. His ANC was 660 the day of discharge.
The patient did not receive neupogen per discussion with his
outpatient oncologist. The patient will have repeat labs
performed on ___. He was also seen by social work during his
hospital stay. Of note, a CT abdomen pelvis was performed which
showed multiple sclerotic bony lesions which were unchanged from
prior imaging.
CHRONIC ISSUES
# BPH: held tamsulosin during hospitalization. This was
restarted at discharge.
# GERD: continued PPI
# Presumed COPD: continued spiriva, albuterol
CODE: Full (confirmed)
EMERGENCY CONTACT HCP: ___ (wife) ___
TRANSITIONAL ISSUES
========================
- patient will have repeat CBC/diff performed on ___ given
neutropenia and anemia at the time of discharge
- patient was discharged on a bowel regimen | 115 | 232 |
15173562-DS-3 | 27,937,963 | Dear Ms. ___,
You were admitted to the gynecology service for pain control
following a left sided rupture hemorrhagic ovarian cyst. Imaging
was obtained showing no concern for ovarian torsion. Your pain
has now improved and we feel that it is safe for you to go home.
Please follow the instructions below:
- Do not exceed 4000mg of acetaminophen in a day.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol. | Ms ___ is a ___ year old G1P1 a history of recurrent UTI and
known left adnexal cyst who was admitted to the gynecology
service on ___ with nausea and acute on chronic LLQ and back
pain.
Upon presentation in the ___, patient complained of abdominal
pain and diffuse itching. She underwent a transvaginal
ultrasound that demonstrated a 6.2 x 4.4 x 4.9 cm hemorrhagic
cyst in the left ovary, normal flow, with IUD in correct
position, and normal uterus. A follow up CT scan demonstrated a
5.7 x 4.7 cm cyst in the left ovary, no free fluid, no other
acute findings. Patient's hematocrit was trended as follows: Hct
34 (___) -> HCT 29 ___ AM) -> 28.5 (repeat ___. Her urine
hcg was negative. Gonorrhea and chlamydia tests were negative.
Findings pointed towards a painful left sided hemorrhagic cyst.
Lower suspicion for torsion at the time. Given abdominal pain,
however, patient was advised not to eat or drink and was started
on IV fluids in case of impending need for surgery. She was
given morphine IV 4mg three times in the ___. She also endorsed
itching for which she received IV Benadryl. She had a history of
a prior urinary tract infection for which a urinalysis was sent.
This returned negative. She also endorsed yeast vaginitis for
which she was given one time dose of diflucan 150mg.
On admission to the floor, patient was transitioned to PO
Tylenol and dilaudid ___ Q4H PRN. She had an improved exam and
was switched to a regular diet. She also continued to endorse
pain and itching and therefore she was given IV Benadryl with
the specific instructions not to overlap with narcotics. She was
also given a one time dose of 2mg morphine IV. Patient was
unable to recall the hospital site where she went for a
transvaginal ultrasound this past month and therefore the
gynecology team was unable to obtain records.
On ___, patient was continued on her pain regimen. Her pain
improved and she was tolerating a regular diet. Patient reported
that her pain had mildly increased in the afternoon and
therefore she remained an extra night.
On ___, patient was in stable condition with stable vitals,
benign exam and improved pain. She reported nausea with one non
recorded episode of emesis. She was later able to tolerate
crackers and clears and was thus discharged to home with follow
up and pain medications. | 88 | 405 |
14124404-DS-4 | 25,342,429 | Dear Ms. ___,
You were hospitalized due to symptoms of Rt sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Atrial Fibrillation
Hypertension
High cholesterol
We are changing your medications as follows:
Started Eliquis 2.5 mg BID on ___
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Neurology Stroke Team | ___ is an ___ year-old female with history of atrial
flutter/fibrillation s/p ineffective ablation ___ off
anticoagulation due to anemia, HTN, HLD, and CHF who presented
___ after collapsing at home. She initially presented to
___ and head CT showed a left ICA/proximal M1 clot. NIHSS
was 20 at presentation and she was intubated due to inability to
protect airway. She received tPA at 10:08a and was transferred
to ___ for endovascular treatment. She urgently went to the
angio suite and underwent thrombectomy; the clot was removed
successfully with a TICI 3 reperfusion score. She was then
admitted to the neurologic ICU for further monitoring and
management.
Following her procedure, she had a routine head CT which
revealed a small amount of hemorrhagic conversion versus
contrast extravasation. Blood pressure was controlled within a
goal of SBP 100-140. She underwent routine post-tPA precautions
(frequent blood pressure checks, avoidance of arterial puncture
and antiplatelets/anticoag for 24 hours). Stroke was felt to be
cardioembolic as pt had atrial fibrillation and was off
anticoagulation.
Patient was transferred to the floor for further management.
__________________________________________________________
FLOOR COURSE: During her floor stay Ms. ___ she had some
issues with fluid management given her history of CHF which
responded well to extra doses of diuretics. She was started on
NGT feeds given her inability to swallow. Speech therapist
evaluated her and recommended to pursue PEG placement. PEG was
placed on ___ without any complications. She was also evaluated
with ___ who recommended transfer to rehabilitation facility
for continued therapies. During her PEG it was noted that she
had very numerous gastric polyps (did have biopsy sent with path
pending at the time of discharge). If appropriate for goals of
care, may consider endoscopy in the future. | 278 | 288 |
18397567-DS-16 | 29,160,138 | Dear Mr. ___,
You were admitted to ___
because you were found on the floor of your home.
In the hospital, you were noted to have low blood sugar, a low
heart rate, difficulty breathing, severe anemia and a very low
body temperature. Because of these problems, you required a stay
in the Intensive Care Unit.
Fortunately, many of your symptoms improved. We gave you
medication to improve your breathing. You were given 3 blood
transfusions and had a colonoscopy and endoscopy to help
evaluate the source of your anemia. You were followed by the
diabetes specialists to help better control your blood sugar.
You also had a steroid shot in your right knee to help with some
of the pain due to your osteoarthritis.
When you go to rehab, please take all of your medications as
prescribed. It is also very important that you go to your follow
up appointments (see below).
It was a pleasure taking part in your care. We wish you all the
best with you health.
Sincerely,
The team at ___ | SUMMARY:
====================
___ with hypertension, diabetes and CKD was brought in by
ambulance after being found down in his apartment for an unknown
period of time. He was hypothermic, bradycardic, hypoxic and
confused. | 170 | 32 |
13375158-DS-14 | 27,252,048 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
were having fevers. After an extensive diagnostic evaluation,
we ultimately determined that your fevers were most likely from
a worsening pulmonary emboli (clots in the vessels of your
lungs); your cancer and a bacterial infection of your lung may
also have contributed. You also had a chest tube placed to
drain fluid from your lungs, which improved your breathing. You
were given a course of antibiotics to treat any possible
undetectable bacterial infection. You were discharged on a new
blood thinner (fondaparinux) to slowly decrease the size of the
pulmonary embolism. Best of luck to you in your future health.
Please take all medications as directed, attend all doctors
___ as ___, and call a doctor if you have any
questions or concerns.
Sincerely,
Your ___ Care Team | Prima ___, a ___ yo F PMHx Metastatic Renal Cell Carcinoma
presented with fever/tachycardia and chronic dyspnea. She was
found to have worsening pulmonary embolism despite warfarin
treatment. Otherwise her infectious workup was unrevealing.
UA/UCx significant for Enterobacter but no urinary symptoms and
continued to spike fevers even after days of appropriate
antibiotics and resolution of bacteriuria. Chest Imaging showed
pleural effusion without bacteria. Abdominal Imaging showed no
focus of infection. Infectious Disease felt that the fevers were
secondary to significant pulmonary embolism with evolving
pulmonary infarction with a possible element of paraneoplastic
syndrome and less likely due to occult bacterial infection (but
recommended 7 total days of vancomycin/cefepime). She had her
___ pleural effusion drained by Interventional Pulmonology
(exudative effusion, negative culture, cytology negative for
malignancy). She was discharged on fondaparinux for her
pulmonary emboli (had several subtherapeutic INRs with
progression of emboli on warfarin, not tolerating BID
enoxaparin). At discharge, patient was cleared for home by ___,
had mildly reduced dyspnea, and was having reduced frequency of
fevers (last fever >48 hours prior to discharge).
# FEVERS / OCCULT BACTERIAL INFECTION:
Patient presented with fever/tachycardia, no focal symptoms
aside from dyspnea (had been ongoing since pulmonary embolism
diagnosis in ___. Labs showed urinalysis with
positive ___, urine cultures grew
broadly-sensitive Enterobacter, and pleural fluid labs showed
exudative pleural effusion without bacteria. Imaging showed
worsening pulmonary emboli in right lung (extension of thrombi,
evolving pulmonary infarctions) along with large ___ pleural
effusion but no other sources of infection on chest or abdominal
imaging. She was started on ceftriaxone (for UTI despite lack
of urinary symptoms), broadened to cefepime on ___, and
broadened to vancomycin/cefepime/azithromycin on ___ due to
continually spiking fevers. An Infectious Disease consult was
obtained on ___ which felt that her symptoms were likely
secondary to large pulmonary embolism burden, ___ paraneoplastic
fever, and less likely an occult bacterial infection (given 7
days of vancomycin/cefepime). Her last fever was ___.
# PULMONARY EMBOLISM WITH WARFARIN FAILURE: Patient had
bilateraly pulmonary emboli diagnosed in ___ at the time of
oncologic diagnosis and was on warfarin as an outpatient with
some subtherapeutic INRs. CTA-Chest this hospitalizatoin showed
worsening of existing pulmonary emboli with proximal extension,
vascular occlusion, and evolving pulmonary infarction (less
likely infectious consolidation but superinfection cannot be
ruled out). She was initially changed to heparin drip to
facilitate procedures and was discharged on fondaparinux due to
possible warfarin failure and prior inability to tolerate BID
subcutaneous shots (patient has little subcutaneous tissue much
of which is concentrated around tender abdominal surgical
sites).
# EXUDATIVE PLEURAL EFFUSIONS STATUS-POST THORACENTESIS AND | 153 | 439 |
12136594-DS-17 | 24,986,228 | Dear Mr. ___,
You were admitted to the hospital for throwing up blood.
In the hospital, we checked your blood levels and found that you
were also having signs of infection, both in your urine and in
your lungs. To treat this, we gave you antibiotics to help clear
the infection from your body. Because you were having
substantial difficulty breathing, we also gave you medications
to help your body get more oxygen.
You also underwent a video study of your swallowing to help you
prevent further aspiration. We discussed with your family that
you were having some swallowing, but we decided that we would
let you eat softer foods with a lot of supervision.
You were found to have a blood clot associated with the
catheter. You were started on a blood thinner and your catheter
was removed. The hematology team saw you after you developed a
reaction to the blood thinner and you were switched to a new
blood thinner. We monitored your blood levels closely to make
sure that you were not continuing to throw up blood or bleed
from anywhere else in the body.
Now that you are out of the hospital, please continue taking
rivaroxaban (new blood thinner) for ___ weeks and follow up
with the hematology team. Please also continue taking omeprazole
(to prevent further throwing up of blood).
Please make sure you maintain regular bowel movements to help
prevent you from vomiting.
Please also follow up with your primary care physician to
discuss this admission.
Please also keep your follow up with the Hematology doctors.
It was a pleasure to be a part of your care!
Sincerely,
Your ___ Care Team | Patient Summary
===============
___ yo M w/ a PMH of dementia, HTN, neurogenic bladder, ___
degree AV block who presented with high volume coffee ground
emesis and concern for urosepsis, now with imaging concerning
for aspiration pneumonia and new respiratory distress.
Acute Issues
============
#Thrombocytopenia (HIT):
#Heparin induced thrombocytopenia
Started heparin drip for RUE DVT on ___, AM ___ Plt down to
79 with 4HIT score 5, now confirmed HIT. Heme Onc consulted,
recommend starting rivaroxaban 15mg PO BID. Plt count improving
on ___. PF4 Heparin Antibody found to be positive, heme-onc
signed off, will plan to continue rivaroxaban for ___ weeks.
H/H remained stable on blood thinners without signs of active
bleeding during the days leading up to discharge. H/H at
discharge 9.___.4.
#RUE DVT. ___ concern for more pain, got U/S which showed small
thrombosis/air concerning for abscess/infection in RUE. got
repeat U/S on ___, no abscess/septic thrombophlebitis. briefly
got one dose of Vanc, tip cultures NGTD. PICC now removed. on
rivaroxaban per above and will continue for ___ weeks.
___. Cr up 1.3 from 0.9 on ___, given 500 NS bolus with no
improvement. Likely due to poor PO intake given caution with
aspiration. Improved to 1.2 on ___ on day of discharge.
Recommend ongoing monitoring (especially in setting of poor PO
intake, and use of rivaroxaban which is CrCl dependent.)
# Respiratory distress
# Acute hypoxic respiratory failure:
The patient at baseline does not have respiratory issues and has
never been on home O2. Upon admission, however, he had a new
oxygen requirement, hoarseness, and oral secretions. Blood and
urine cultures showed no growth while imaging from ___ showed a
left lower lobe opacification concerning for aspiration
pneumonia. He was subsequently started on vancomycin
(___) and zosyn (___) as well as albuterol
nebulizers to help breathing. After MRSA swab returned negative,
Vancomycin was discontinued. Zosyn was continued to complete a
full course for his prior E coli/ Pseudomonas UTI (diagnosed
previously at ___ and was discontinued after his
final dose on ___. His subsequent U/A did not show evidence of
infection and his foley catheter was exchanged. With incentive
spirometry and pulmonary toilette his respiratory status
improved, and he was discharged stable on room air.
# Sepsis of unclear etiology:
# Suprapubic Pain:
The patient at admission had tachycardia, tachypnea, and
leukocytosis with concern for aspiration pneumonia vs. UTI given
suprapubic tenderness and neurogenic bladder. He underwent CT
abdomen/pelvis on ___ which found no no growth and he was
treated with empiric vancomycin (___) and Zosyn
(___). Zosyn was continued to complete a full course for
his prior E coli/ Pseudomonas UTI and was discontinued after his
final dose on ___. His subsequent U/A did not show evidence of
infection and his foley catheter was exchanged.
# Upper GI bleed: Patient had ongoing intermittent vomiting for
months and per nursing home, two buckets of coffee ground emesis
on ___. No episodes of emesis were witnessed during his
hospitalization, but close monitoring of blood counts showed a
stabilization of the patient's hemoglobin levels. Based on his
history of retching and nausea for months, a ___ tear
was suspected. Prior to discharge, the patient's hemoglobin
levels remained stable at H/H 9.1/28.4. He was initiated on IV
PPI initially, which was transitioned to PO PPI; this should
eventually be reevaluated after he has finished course of
rivaroxaban.
# Abdominal pain
# Constipation: On ___, the patient presented with a rigid
abdomen that was promptly evaluated by ACS. A KUB was obtained
which did not show any sign of free air or perforation. Instead,
the patient was found to have significant stool burden and his
bowel regimen was subsequently escalated. He was given PR
bisacodyl, miralax, and senna while inpatient with normalization
of BMs (last BM on ___. He should have careful monitoring of
BMs given his risk for severe constipation and nausea/vomiting.
Chronic Issues
==============
#HTN: Mechanical blood pressures taken on L arm have been
persistently
elevated (up to 190s-200s systolic). Highest suspicion for
elevated blood pressures given modified technique (upper left
arm) where BPs are taken mechanically given placement of 2 PIVS
in left arm I/s/o recent GI bleed and not being able to take BPs
on R arm given RUE
thrombosis. BPs continue to be elevated to 180-190s on
___, no signs of headache. Lisinopril increased to 30 mg
daily, added amlodipine 5mg daily. Improvement of BPs on day of
discharge to 160-170s (improvement from 190s-200s).
#Visual symptoms
Patient has reported history of glaucoma and macular
degeneration, unclear vision baseline. reported ___ "difficulty
seeing" though appears to have vision in both eyes, though with
some challenge in R eye reading words on paper. Remainder of
neuro exam WNL, and this improved on ___ examination (but
patient reports it has been going on "a long time."
Continued home dorzolamide/timolol eye drops BID. Will need
close outpatient monitoring going forward.
Transitional Issues
===================
New medications:
- rivaroxaban 15 mg BID
- amlodipine 5 mg daily
- miralax
- bisacodyl
- senna
- Tylenol (PRN)
- omeprazole
- lidocaine patch | 271 | 812 |
10462916-DS-8 | 27,489,711 | You were admitted to the inpatient Colorectal Surgery Service
with Diverticulitis for which you are scheduled for surgery on
___. Until that time, you will take the antibiotic
Augmentin for a total of two weeks. Our hope is that the
antibiotics will decrease the inflammation in your abdomen
enough to give you the optimal result from surgery. Please
continue to eat a low residue diet. Please monitor your bowel
function closely. If you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you develop constipation please
take an over the counter stool softener such as Colace, and if
the symptoms do not improve call the office. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
extended constipation.
Our office will be in contact with you to give you instructions
related to your surgery. | ___ was admitted to the inpatient colorectal surgery
service with diverticulitis despite being treated with
Cipro/Flagyl. The CT scan did not show any large perforation or
abscess. She was conservatively treated and received IV Cipro
Flagyl which did improve her symptoms however, she was changed
to Augmentin which she tolerated well. Her white blood cell
count improved from 13 to 8 prior to discharge. Her pain was
significantly improved and she was able to tolerate a regular
diet. She will return home to complete a course of Augmentin
prior to returning for surgery at the end of this month. She was
given appropriate discharge instruction. | 188 | 106 |
19113440-DS-18 | 29,475,809 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing right lower extremity in unlocked
___ brace
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add tramadol as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please resume your home Eliquis at the same dosing
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Touchdown weightbearing right lower extremity in an unlocked
___ brace
No range of motion restrictions
Okay to remove ___ brace while in bed
Treatments Frequency:
Incision closed with staples
Dry sterile dressing as needed for wound drainage | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right periprosthetic femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for less invasive surgical fixation
plating, right periprosthetic distal femur fracture, 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
remarkable for hematocrit of 21.9 on postoperative day 1 for
which she was transfused 2 units of packed red blood cells.
Patient's hematocrit remained stable at the time of discharge.
She had a transient creatinine rise which peaked at 1.6 on
___ which subsequently came down to 1.5 and then 1.4.
Patient was asked to follow-up with her PCP ___ 1 week for repeat
creatinine check.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the right lower extremity in an
unlocked ___ brace, and will be discharged on her home dose
of Eliquis 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. | 596 | 336 |
14868219-DS-21 | 27,046,867 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were transferred here for
confusion and evaluation of your change in mental status. You
were seen by our Neurosurgery team and were not having an active
bleed in your head. You also were seen by the neurology and
psychiatry teams, who determined that you did not have a new
stroke and you were sad after recent tragic events in your life.
You were thought not to need any medical treatment for this.
While you were in the hospital you were diagnosed with a urinary
tract infection and were given antibiotics. Since you have been
having weakness and difficulty caring for yourself you will be
going to an acute rehab center to build up your strength. Please
continue to take your medications as prescribed.
We wish you all the best!
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Ms. ___ is a ___ old woman with history of multiple CVAs
(most recently ___ with residual L sided deficits),
hx of MI, HTN, polycythemia, p/w spiritual hallucinations and
confusion.
# Toxic Metabolic Encephalopathy: Patient presented to outide
hosptial with "hallucinations", confusion and family concern for
the patient not acting like herself. The patient underwent a CT
scan at the outside hospital that was concerning for possible
intracranial hemorrhage and the patient was transferred to ___
for evaluation. She was evaluated by neurosurgery and thought to
not have hemorrhage. The patients confusion improved however she
continued to intermittently be confused in regards to
orientation to place/time. In terms of medical work up, the
patient's hyponatremia (outside hospital 130), corrected on
admission to ___. UA had small leuks and WBC. Culture had
mixed contaminent flora. The patient did have a WBC count of
___ however was afebrile, started to report increased
frequency so she was treated for a UTI with fosfomycin. TSH,
RPR, Vit 12 were normal. The patient had been on oxycodone and
alprazolam for pain and anxiety at home, these were discontinued
given her acute change in mental status. The patient was
evaluated by neurology and thought it was less likely she had an
acute stroke and this was a chronic process secondary to
previous strokes. The patient was also evaluated by psychiatry
who deemed that the patient was not suffering from psychosis.
The "hallucinations" were thought to be more likely spirual
thoughts and the patient reports not having those thoughts in
the hospital and does not remember having them. Patient was
diagnosed with adjustment disorder with low mood. Medical
therapy for depression was deferred to outpatient management.
#Urinary Tract Infection- given leukocytosis, increased
frequency, confusion the patient was treated with fosfomycin x1
for UTI. Repeat UA and culture were sent prior to administration
and results were pending on discharge.
# Adjustment reaction with low mood- Patients son recently died
and it was difficult for the patient to cope. She has had
decreased appetite and changes in her mood. Family and nursing
have noted she is occasionally sobbing. Patient was seen and
evaluated by psychiatry. Her hallucinations were thought to be
spiritual thoughts and normal for her culture and beliefs. The
psychiatry team did not think she needed medical treatment at
this time. If the patients symptoms worsen she can follow up
with ___ Mental Health Clinic at ___ she was
given the following contact info prior to discharge:
___ Mental Health Unit
___, MD and ___ Director
___ Floor
___
Tel: ___
Fax: ___
#Decreased mobility, weakness, and inability to care of herself-
family states this has been worsening for past couple weeks.
Physical therapy was consulted and it was deemed that the
patient would need acute rehab. | 158 | 459 |
18630905-DS-16 | 27,302,383 | Dear Ms. ___,
You were admitted to ___ because you were having chest pain.
You were found to have a heart attack and underwent called a
cardiac catheterization. They placed a stent in one of the
arteries that supplies your heart.
You were started aspirin and clopidogrel after the procedure.
You will take aspirin for life. You will need to continue
clopidogrel (Plavix) for at least 12 months. Aspirin and
clopidogrel are taken to decrease the risk for a blood clot from
forming in the stent. Do not stop aspirin or Plavix by Dr.
___. Stopping aspirin or clopidogrel prematurely may put
you at risk for a life threatening heart attack.
We also started you on pravastatin to reduce your cholesterol
levels and prevent build up in your arteries. We started this
medication at a low dose given your liver transplant. We
confirmed with the transplant clinic at ___ that they were ok
with starting this medication. You will need to have your liver
enzymes checked on ___. You should follow up with you
liver doctor to discuss the results of the testing. The statin
medication should be increased to 40mg daily if your liver
enzymes are stable. They should also start you on ezetemibe,
another medication to lower your cholesterol at a future date.
Do not lift any objects heavier than 10 lbs for the next 2
weeks. We have provided you were a referral for cardiac
rehabilitation. You should talk to your cardiologist regarding
obtaining a referral to one of these programs.
You were seen by rheumatology who recommended follow up after
you leave the hospital to send several additional tests. They
also recommended that you see a pulmonary doctor to follow up on
pulmonary nodules. You should also have your gastroenterology
doctor refer you for a colonoscopy given the bleeding you saw
with a bowel movement.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Cardiology Team | PATIENT SUMMARY:
=====================
___ yo F with h/o liver transplant for PBC in ___, Sjogren's,
breast cancer s/p bilateral mastectomy, SVT, who presented with
chest pain to ___, found to have a troponin elevation
with T wave inversions in the lateral leads, transferred to
___
for further evaluation and admitted to general cardiology for
NSTEMI workup, plan was initially made for catheterization on
___ with ECHO planned for ___ which showed globally
preserved biventricular systolic function. Subtle distal
inferolateral hypokinesis which was reassuring that cath on
___ may be appropriate, however shortly afterwards, the
patient complained of chest pain, was found to have ST
elevations in II,III,aVF, and TWI in v3-6 concerning for acute
STEMI at which time patient was taken to the cath lab for
intervention. After catheterization, the patient returned to the
floor chest pain free. The following two days the patient was
consulted on by hematology, rheumatology and plans were made for
outpatient follow ups for transitional issues.
# STEMI: Patient presented with acute chest pain with
development of ST elevations in V3-V6. She underwent cardiac
catheterization that demonstrated LCx with distal thrombotic
occlusion s/p DES. She was also found to have long-tubular 70%
stenosis of the LAD. She was started on aspirin and Plavix which
she will need to continued for at least 12 months. She should
continue aspirin indefinitely. She was also started on
Metoprolol 100mg daily. She was started on pravastatin after
discussion with her hepatology team at ___ given
interaction with immunosuppression. Initial dose was 20mg daily
and should be increased as tolerated provided LFTs stable. She
should obtain repeat LFTs on ___ using standing lab order from
___ clinic. ACE inhibitor was held given EF 48%. She will
follow up with Dr. ___ at ___ per her preference.
# Diarrhea: Patient with chronic diarrhea. C diff sent and was
negative and her symptoms improved.
# BRBPR: Small amount, one episode. No e/o hemorrhoids. She
should have colonoscopy as outpatient arranged by her PCP as she
is ___ for repeat screening.
# ___ s/p living donor transplant (___): Follows at ___
___. Goal tacro level ___. She was continued on cellcept 500
BID, tacrolimus 1 mg BID, colchicine 0.6 BID, ursodiol 300 TID.
She will have repeat LFTs and labs drawn on ___ per her
hepatology team. ___ also need reevaluation of tacrolimus dosing
as two levels were sub-therputic during admission.
# High inflammatory state:
CRP: 112.7, platelets high, night sweats mentioned for years
with small pericardial effusion. Unclear etiology may be ___
psudorejection/recurrent PBC given low levels of tacro vs other
immune modulators. Seen by rheumatology who recommended follow
up with outpatient rheumatology and testing repeat CRP, ___,
RO/La, RF, complement and UA.
#Acute heart failure with preserved EF: NTBNP severely elevated.
No DOE and no oxygen requirement. Patient with signs of mild
overload. She was given 1 dose of IV Lasix. Patient declined
staying in the hospital for an additional day for observation,
so she will be discharged on ___. She should continue to take
torsemide 10mg daily for the next several days and weight
herself daily. If her weight decreased by more than ___, she
was told to stop the torsemide. If her weight increased by more
than ___, she should follow up with her cardiologist. | 330 | 539 |
15484879-DS-8 | 22,471,495 | Dear ___,
You were admitted to the hospital because you were withdrawing
from alcohol.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- Your withdrawal was treated with medications
- You also had significant electrolyte abnormalities which were
repleted
- You were found to have inflammation of your liver (alcoholic
hepatitis), which was monitored closely and began to improve at
time of discharge.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or you will die
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober\
- You will need to continue eating >2500 kcal/day to help your
alcoholic hepatitis
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | ___ w/ PMHx EtOH use disorder, possible prior episode of EtOH
hepatitis p/w EtOH intoxication and alcoholic hepatitis. He was
monitored and treated for withdrawal with Ativan. He improved
over the next few days and was no longer requiring treatment on
day of discharge. His LFTS were monitored closely and began to
improve at the time of discharge.
=========================== | 177 | 58 |
18217711-DS-11 | 22,073,023 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated L lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take 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.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
WBAT and ROMAT LLE
Treatments Frequency:
Wound monitoring
Wound care: DSD daily and prn L hip wound
___: WBAT LLE | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF Left subtroch femur fracture , 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. She was noted to have post operative urinary
retention and a foley was placed on ___ for PVRs of 900cc. She
will complete a void trial at rehab.
Medicine also followed her during her stay as part of medical
comanagement. 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. The
patient is WBAT on the LLE, 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. | 194 | 285 |
17648869-DS-18 | 25,628,670 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for severe wrist
pain. You were diagnosed with Gout. You were started on
treatment with steroids. You will need to continue steroids as
prescribed. Please monitor your blood sugars. You will need to
follow up with your doctor and continue to take your medications
as prescribed. Please weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
Sincerely,
Your ___ Team | ___ year old gentleman with history of renal tx ___, ___, CAD,
DM, HLD, stroke with residual right sided weakness, A fib
presenting with bilateral wrist pain and swelling concerning for
gout flare.
#Gout - presenting with acute onset bilateral wrist pain with
taps concerning for inflammatory process that is likely gout
given monourate crystals. Infectious etiology less likely given
negative gram stain, however his immunosuppression would make
him more likely to get an infection. Gram stain was negative and
cultures were pending. Patient was started on 40mg daily for 5
days followed with taper down to baseline of 5mg daily.
Avoid NSAIDs, and colchicine given advanced CKD
# ESRD from cholesterol emboli, s/p Living unrelated renal
transplant in ___ with allograft dysfunction baseline Cr
1.7-2.2. Patient was continued on tacrolimus 2mg BID and Bactrim
SS daily for PPX. Cr on d/c was 2.0.
#Chronic diastolic heart failure - appears euvolemic, continued
on home torsemide, metoprolol. Metoprolol was ultimately stopped
due to bradycardia below, and for hypertension management
replaced with hydralazine 10 tid.
# Hypertension: Patient sys BP increased from 150's to 180's
after holding home metoprolol for bradycardia. started
hydralazine 10 mg tid on ___
# Bradycardia: Patient had bradycardia in setting of afib
overnight (Hr dipped as low as 30's, asymptomatic). Tele review
was concerning for AV block with aflutter, given flutter waves
on tele and irregular RR interval. Given it was difficult to
determine degree/location of block with aflutter, and degree of
bradycardia consulted cardiology. Two repeat EKG showed HR in
50's, and likely intermittent conduction delay in setting of
slow afib. Patient HR increased appropriately (to 50's and 60's)
after stopping metoprolol. Patient will follow up with Dr. ___
to have 24 holter monitor to monitor for bradycardia/possible
block. Of note patient had prior episode of bradycardia with
labetalol and at that time was switched to metoprolol.
# Anemia: Likely multifactorial, at recent baseline, continued
on Ferrous Sulfate 325 mg PO DAILY
#DM - Increase NPH to 30 from 15 Units Breakfast and 5 from 3
Units Dinner as patient was on steroids. Consulted endocrine
given remarkably elevated suagrs on steroids (300's), was put on
following scale:
Blood Glucose Breakfast Lunch Dinner HS
100-150 3 0 5 0
151-200 5 2 7 0
___
___ 4
___ 6
Patient will have F/U with ___ on discharge as well.
#Atrial fibrillation- hx of stroke - CHADS2 of 6 continued on
coumadin.
#CAD continued on Atorvastatin 40 mg PO QPM
#Depression continued on Fluoxetine 40 mg PO DAILY
#GERD continued on Omeprazole 20 mg PO Q12H
#Recent cataract surgery continued PrednisoLONE Acetate 1%
Ophth. Susp. 1 DROP LEFT EYE BID and Ciprofloxacin 0.3% Ophth
Soln 1 DROP LEFT EYE QID
TRANSITIONAL ISSUES
-Patient discharged with prednisone taper of 3 days (D1 = ___
of 35 mg prednisone, 3 days 30 mg prednisone, 3 days 25 mg
prednisone, 3 days 20 mg prednisone, 3 days 15 mg prednisone,
and 3 days 10 mg prednisone before resuming home prednisone dose
of 5 mg. Slow taper chosen given risk of recurrence and
inability to trial colchicine in ___ due to renal transplant
history.
- Due to bradycardia in ___, home metoprolol stopped; replaced
with 10 tid hydralazine for blood pressure control.
-Discharged on insulin regimen above; please titrate while at
rehab accordingly as steroid taper decreases.
-Discharged on home warfarin, INR on d/c 2.3, recheck INR in 5
days | 80 | 581 |
12300094-DS-13 | 22,667,213 | You were admitted for abdominal pain and underwent an ERCP. This
showed scar tissue, which was stretched with a balloon.
Afterwards your liver function tests improved and your pain also
improved.
You also developed right lower quadrant pain. This was likely
due to constipation. With an aggressive bowel regimen this pain
improved.
You will follow up with Dr. ___ in clinic in two days. You
should follow up with your outpatient physicians as needed.
Of note, you were given a small prescription for dilaudid for
pain. If you continue to have pain or it becomes more severe you
may need to be evaluated. If you are unable to tolerate food
notify your physician. | # Epigastric pain
Likely secondary to stenosis of prior sphincterotomy site. She
presented with elevated lfts which downtrended after the
procedure. In addition, her epigastric abdominal pain also
improved afer the procedure. She notes that she feels "a quiver"
at the site where she would get SOD pain. She was given a
limited prescription of dilaudid (she was warned against driving
as this could make her drowsy). She was tolerating a low fat
regular diet at the time of discharge. Of note, she had self
discontinued the urosdiol. This was not restarted at discharge.
# Constipation:
She had constipation on LLQ pain. She was initially concerned
that this was due to diverticulitis. However, she did not have
fevers, chills, leukocytosis or other worrisome symptoms. She
was treated with aggressive bowel regimen with improvement in
her symptoms. At the time of discharge she was moving her bowels
and was pain free in this area. She was encouraged to maintain
adequate hydration and limit narcotics as much as possible. In
regards to her prior diverticulitis, she is scheduled to follow
up with Dr. ___ on ___.
# Epilepsy
- continue lamotrigine
# ADD
- continue Adderall
# Active smoking
- nicotine patch while here | 110 | 193 |
10956699-DS-16 | 23,135,943 | Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- Swelling in your leg
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were treated for a blood clot in your leg with blood
thinners
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team | ASSESSMENT AND PLAN:
====================
___ female with history of chronic immobility due to
severe multiple sclerosis, history of cerebral venous sinus
thrombosis status post 6 months warfarin, and dementia,
presented
with left lower extremity swelling, found with extensive left
lower extremity DVT. | 87 | 37 |
11245028-DS-8 | 27,889,421 | Dear ___,
You were admitted at the Acute Care Surgery unit at ___
following a motor vehicle accident. You were found to have a
right grade IV renal laceration and a retroperitoneal hematoma.
You have been recovering well and are now ready for discharge.
Please keep the following in mind
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
It has been a pleasure looking after you and we wish you all the
best. | The patient was admitted to the trauma surgery service after
suffering a motor vehicle accident. His injuries included: right
renal laceration with adjacent retroperitoneal hematoma and
right collecting duct system injury. He was hemodynamically
stable but monitored overnight on hospital day 1 in the ICU with
hematocrits measured every six hours given the renal laceration.
He remained hemodynamically stable and his hematocrit remained
stable, so he was transferred to the floor on hospial day two.
He had hematuria with clots so a three-way foley was placed for
irrigation. Urology was consulted given concern for a collecting
duct injury but felt no urgent intervention was needed. After 48
hours, he underwent repeat CT imaging that showed:
"Re-demonstrated right renal lacerations as on prior imaging,
now with definite evidence of contrast extravasation from the
interpolar right posterior calyx, consistent with renal
collecting system injury. Redemonstration of right perinephric
hematoma and urinoma extending into the pelvis, as on prior
exam."
The urology team indicated that no intervention was necessary
given this event is small and will likely heal on its own
without intervention. They recommended follow up in ___
clinic in 3 months to check
blood pressure, urine analysis and basic metabolic panel. | 144 | 203 |
18189951-DS-7 | 24,543,740 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted for bruising on your left side and concern for fall.
Imaging showed you did not suffer any fractures. Your INR was
found to be elevated and you were thought to have a bleed. You
received blood transfusions, after which your blood levels
normalized. You will need to start lovenox injections until
your INR returns to therapeutic range. Your blood sugar was
also noted to be somewhat low so we are adjusting your diabetes
regimen.
Please make the following changes to your medications:
Please START lovenox injections once daily.
Please take lovenox until your INR is therapeutic. You will
need to have your INR checked more frequently over the next
week.
Please STOP glipizide. You no longer need this medication. | ___ year old male with hx. afib on coumadin, CAD, chronic
systolic CHF (EF 45%), vascular dementia, presenting from home
with c/o left sided pain and bruising, admitted for concern for
bleed in setting of supratherapeutic INR.
# ?Bleed: Patient's hematocrit fell from 29 to 27 overnight in
the ED. Given his supratherapeutic INR, he was reversed with 10
units vitamin K IV, given 2 U pRBCs and admitted to the floor
without further cycling of his hematocrit. Guaiac was negative.
Patient's hematocrit bumped appropriately to transfusion and
remained in the mid ___ and stable for the rest of his
hospitalization. Slight decline in hematocrit initially is
explainable either by his left sided hematoma or by inherent
variability in CBC testing.
# ?Fall: Patient had no witnessed or reported fall. As per
discussion with son, patient walks with cane at home
independently. Recent note from ___ mentions gait difficulty.
Extensive imaging was conduected to rule out fracture. Syncope
was considered and patient was placed on tele overnight with no
events. As per son, patient spent a fair amount of time sitting
(5 days straight) recently, possibly contibuting to bruising.
___ was consulted who evaluated the patient and felt he would
benefit from home ___. He will be going home with home ___ to
work on gait and mobility.
# Afib: Patient is on coumadin for CHADS-2 of 4. He is s/p
pacemaker for sick sinus syndrome. Unclear etiology of
supratherapeutic INR, possibly due to poor nutrition. Coumadin
held and INR reversed (as above). Lovenox was started when INR
became subtherapeutic. Education was provided to patient's
family on proper use of lovenox and he will be going home on
once a day dosing to bridge until his INR becomes therapeutic
again.
# T2DM: His oral diabetic agents were held and he was placed on
a ISS overnight. ___ were noted to be low (in the ___ overnight)
on hospital day 1 in the setting of receiving no insulin. ___
continued to be on the low side on hospital day 2 without
anti-hyperglycemics. The decision was made to discontinue his
glipizide upon discharge and have him follow-up with his PCP for
further management.
# CAD: Remained stable, continued atenolol, aspirin,
simvastatin.
TRANSITIONAL ISSUES
1. Patient's glipizide was discontinued altogether for low ___
readings in house, needs further monitoring of blood sugars
going forward.
2. Patient was started on lovenox for bridging to coumadin,
needs close monitoring of INR.
3. Patient will have home ___ to help with gait training. | 138 | 447 |
19638438-DS-10 | 26,644,545 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for shortness of breath. The shortness of
breath was due to fluid accumulating around your left lung.
WHAT HAPPENED IN THE HOSPITAL?
-You were evaluated by the lung doctors.
-___ drained the fluid around your left lung using a chest tube.
-We removed the tube after knowing that there is no more fluid
left to drain.
-We sent a sample of the fluid for analysis. The fluid contained
cancer cells likely from the breast. This indicates that fluid
accumulation occurred because of your breast cancer.
WHAT SHOULD YOU DO AT HOME?
-You should continue to take your medications as prescribed.
-You should follow-up with your doctors as ___ below.
-Please report any shortness of breath, chest pain, any other
concerning symptom.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | Ms. ___ is an ___ F with a history of stage III
hormone receptor-positive breast cancer in ___ s/p lumpectomy
and chemo, currently on anastrazole, T1N0M0 oral squamous cell
carcioma s/p R hemiglossectomy in ___, who presents with acute
onset dyspnea, found to have a large L pleural effusion,
re-demonstrated pulmonary nodules c/w lymphangitic
carcinomatosis, and hyponatremia. | 151 | 58 |
15704029-DS-11 | 23,216,117 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. As you know, you were admitted
with pain in your thumb and toe. The hand surgeons drained the
swollen area in your thumb, which was most likely caused by
gout. The podiatrist treated the infection in your left big toe
nail, and you should complete a 14-day course of antibiotics.
You have also had a cough recently, which is most likely from a
viral illness. You used nebulizer treatments and your wheezing
improved. We recommend you take your albuterol and your new
inhaler, ipratropium, every 6 hours for the next 2 days and then
as needed until you see Dr. ___.
During your admission, we restarted your water pill. You were
evaluated by our physical therapists who recommended that you
have home physical therapy and occupational therapy.
We made the following changes to your medications:
- START Keflex (cephalexin) 250 mg three times a day. This is
the antibiotic to treat your foot infection. You should continue
taking it until ___.
- START Lasix (furosemide) 40 mg daily
- START ipratropium 1 puff every 6 hours
- START Tylenol ___ mg every 6 hours as needed for pain | Ms. ___ is a lovely ___ woman with DMII, dCHF, gout,
and a recent admission for L toe cellulitis. She presents with
cough, R thumb gouty abscess, and L toe paronychia.
ACTIVE ISSUES
1. Thumb Pain/Gout: Patient's thumb pain is most likely
secondary to gout based upon chalky appearance of fluid drained.
Her pain was well controlled with Tylenol. NSAID's were avoided
due to renal function and colchicine and allopurinol were
avoided due to allergies. A bacterial culture was sent to
further rule out bacterial abscess, and culture was still
pending at time of discharge (prelim negative). She was
instructed to follow-up with the hand clinic as an outpatient.
2. Left Toe Paronychia: Patient was seen and paronchia incised
by Podiatry in the ED. They recommended oral antibiotics for two
weeks and follow up in clinic. Pain was well controlled with
Tylenol. ___ evaluated patient and recommended home with ___.
She will be discharge to complete a 14-day course of Keflex
(___).
3. Cough/Asthma: Patient's cough is most consistent with a viral
URI vs. bronchitis +/- mild asthma exacerbation. She does not
appear signficantly volume overloaded on exam and is not short
of breath, but CXR did note mild pulmonary edema. Patient's
lasix was stopped during prior admission for ___, but Cr has
improved, so Lasix was restarted. She received standing duonebs
and cough/wheezing improved.
4. CKD: Patient has chronic stage 4 CKD. Her recent Cr baseline
has been in the low 2's. Cr is now 1.9. Given mild pulmonary
edema on CXR, furosemide was restarted at 40 mg PO daily.
5. Chronic Diastolic CHF: Last EF > 70% ___. Currently not
showing evidence of volume overload on exam, but CXR does show
mild pulmonary edema. Given aparent stability in Cr, furosemide
was restarted as above. She was continued on valsartan.
CHRONIC ISSUES
1. Hypertension: Continued home amlodipine, valsartan, and
metoprolol.
2. Hypothyroid: Continued levothyroxine.
3. HLD: Continued atorvastatin.
4. DM II: Patient's diabetes is diet controlled. She was
monitored with QID fingersticks.
TRANSITIONAL ISSUES
1. Will need electrolytes and creatinine checked at next
appointment as lasix is being restarted
2. Follow-up with Ortho Hand
3. Follow-up with Podiatry
4. Would likely benefit from increase in home care services | 202 | 366 |
13833118-DS-8 | 27,973,939 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
after a fall with elevated muscle tests ("rhabdomyolysis") and
elevated kidney tests ("creatinine"). You were treated with
fluids and you improved. You are now ready for discharge. | This is a ___ year old female with past medical history of breast
cancer, DVT on Coumadin, diabetes type 2 and hypertension
presenting after a fall, found to have rhabdomyolysis and ___,
now resolved and ready for discharge to rehab
# Fall - patient found down after reported mechanical fall.
Trauma workup did not reveal any acute pathology. Patient seen
by ___ and recommended for ___ rehab. No events were
observed on telemetry monitoring
# Rhabdomyolysis secondary to Fall - Admitted with CK 2187.
Improved to 1156 without intervention. Does not require
additional trending
# ___ - secondary to rhabomyolysis and dehydration; Cr peaked at
1.3 from baseline 1.0, resolved with IV fluids and good PO
intake
# Chronic Lower extremity DVT - continued on home warfarin
dosing; INR 2.5 at time of discharge. Would continue to monitor
daily
# Hypertension: continued home captopril, amlodipine and
hydrochlorothiazide
# Diabetes type 2 with neurology complications - continued home
glipizide.
# Diabetic Neuropathy - continued home gabapentin
Transitional Issues
- Would monitor INR daily for now and adjust Coumadin for goal
INR ___
- Follow fingersticks--can consider sliding scale Humalog if
persistently elevated
- Found to have dysphagia this admission and placed on dysphagia
diet; would consider swallow therapy and reassessment | 44 | 207 |
11662302-DS-13 | 20,272,097 | Dear ___
___ were admitted to ___ for
small bowel obstruction. ___ are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ 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.
___ 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
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | The patient presented to Emergency Department on ___. Upon
arrival to ED, he had high grade SBO and imaging identified a
possible closed loop. He was admitted to ___ for NPO, IVF, and
NGT maintenance. His coumadin was also held because of a need
for possible surgical intervention. After 6 hours of NGT
decompression, he was administered gastroview with a repeat CT
abdomen to evaluate obstruction that revealed resolution of
obstruction, and he also began having bowel movements.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV medications
and then transitioned to oral medications once tolerating a
diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___ the NGT
was removed; therefore, the diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored. CT scan also revealed evidence of
fatty liver changes.
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. His Coumadin was
restarted at discharge.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 224 | 308 |
18182458-DS-10 | 28,109,603 | It was a pleasure looking after you, Mr. ___. As you know, you
were admitted with fever and abominal pains. You had evidence
of bacteria (E Coli) in your blood as well. These symptoms were
attributed to a stricture in your hepatic duct along with an
obstructing stone(s) - leading to infection of your biliary
ducts. ERCP was attempted with replacement of the older stent
with a larger stent - but the stone was not able to be
extracted.
In the meantime,you were treated with antibiotics and given
pain medications. You are expected to complete at least 2 weeks
of intravenous antibiotics. For this reason, a PICC line was
placed. You will be seen again on ___ for a reattempt of stone
removal (by Dr. ___ after you have received a good course
of antibiotics. | ___ old male h/o HTN, s/p chole ___, recurrent pancreatitis
presumably ___ to choledocholithiasis admitted for fever, RUQ
abd pain, and positive blood cultures.
# GI: s/p chole with choledocholithiasis. On abd CT, Mr. ___
had evidence of L hepatic duct stricture with associated
___ biliary dilatation - likely chronic given liver
parenchymal loss. He underwent a recent ___ ERCP with
stricture plasty, stent placement, but incomplete removal of
stones. He was admitted fever, midepigastric abd pain, + ESBL
EColi bacteremia consistent with cholangitis - again likely
within the region of the L hepatic duct obstruction/stricture.
He was initially treated with zosyn but then switched iv
meropenem once the bacterial sensitivities returned
(demonstrating ESBL Ecoli).
He underwent an ERCP on ___ - which revealed mild diffuse
dilation of the CBD/CHD and left intrahepatic duct. There was
slow filling of contrast across a stricture in the left
intrahepatic duct. A remaining large stone was noted at
approximately the level of a ___ order branch which did not
appear to be endoscopically removable, at the time. A larger
stent was placed with the distal portion over the strictured
region.
Initially, the plan was to consider surgery with possible
resection of the L liver lobe and hepatic duct resection to
address the area of obstruction and infection. But the decision
was to reattempt an ERCP to remove stone, after a 2 week course
of abx was given to cool the area (in order to avoid a
potentially major surgery).
Mr. ___ was given iv meropenem, morphine PRN, zofran PRN,
and noted improvements in his overall improvement. He was
afebrile and there was no increase in LFTs or WBC. He was able
to tolerate PO without difficulty and adequate control of pain
with morphine ___ PO. After his blood cxs were negative for 48-72
hrs, a PICC line was placed for home administration of iv
ertapenem.
ERCP brush bx and stent cytology was negative for malignancy.
The cause of L hepatic stricture is unclear: no evidence of
malignancy on prior brush bx. ? trauma from past chole or ERCP
or alternatively biliary infection of parasites while in
___? HIV or PSC were also considered unlikely.
In the future, Mr. ___ may consider actigall in long run to
avoid future stone. Given low suspicion for cholangioCA, ___
and CEA were not sent.
# SOB - Mr. ___ had mild hypoxia on 2L NC O2 on Hosp day 2.
This was attributed to getting aggresive iv fluids. Port CXR
showed mild interstitial edema c/w fluid overload, atelectasis.
It completely resolved on its own and Mr. ___ had good O2 sats
on RA, on the day of discharge. He was given incentive
spirometry and pain control to minimize splinting
# Headache - noted while getting iv morphine. It was relieved
with fioricet PRN and interestingly did not occur with oral
MSIR.
# HTN
- on norvasc
# Depression/anxiety
- on cymbalta and wellbutrin, xanax PRN
# OTHER ISSUES AS OUTLINED.
.
# DVT PROPHYLAXIS: [X]heparin sc []SCDs
# LINES/DRAINS: [] Peripheral [x] PICC [] CVL [] Foley
# PRECAUTIONS: [] Fall [] Aspiration [X]
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
# COMMUNICATION: patient. Sister ___ ___
# CODE STATUS: [X]full code []DNR/DNI | 143 | 564 |
14148873-DS-2 | 25,057,889 | ___,
You were admitted for an abscess in your throat. The ear, nose,
and throat (ENT) surgeons tried to drain this, but failed in the
ER. Instead, you were admitted for antibiotics through the IV.
Your pain and swelling improved and you were transitioned to
oral antibiotics. Please continue taking these, as well as a
course of steroids, upon discharge. Please follow-up with your
primary care physician and make an appointment with the ENT
doctors ___.
It was a pleasure caring for you,
-___ medical care team | Ms. ___ is a ___ year old healthy female college student with 4
days of sore throat, ear pain, jaw swelling and fevers who was
found to have a peritonsilar phlegmon/abscess on CT and mild
epiglottic swelling per ENT scope who failed drainage in the ED
and was admitted for IV abx and steroids.
#PERITONSILAR PHLEGMON:
Ms. ___ is a previously healthy ___ with 4 days of sore
throat, mandibular swelling, and ear pain. CT showed
peritonsilar abscess with associated soft tissue swelling and
scope showed mild epiglottic swelling. Patient ultimately could
not tolerate aspiration. The diagnosis was peritonsillar
phlegmon and patient was admitted for IV antibiotics for 40
hours and steroids to prevent it turning into an abscess.
Patient received clindamycin, unasyn, and vancomycin, as well as
steroids with improvement. She was discharged with augmentin and
a steroid taper.
#HYPONATREMIA:
She also had Na 133 and Cl 92 at intake, in setting of poor
intake by mouth due to difficulty swallowing. Her electrolytes
improved and she was able to transition to eating soft foods. | 84 | 172 |
19760933-DS-12 | 23,552,799 | You were admitted for concern that you had a tear in your
esophagus. An esophogram showed no such tear. You were started
on prophylactic antibiotics and your diet was gradually advanced
to regular . You are know read for discharge. Complete your
antibiotic course and you will be called with a follow up
appointment.
Please come to the ED or call our office at ___ if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. | ___ was transferred from ___ on ___. In the
ED an esophgram was obtained which was negative for a leak. He
was admitted for observation, made NPO and started on augmentin.
His diet was advanced to clears after a negative esophagram and
was well tolerated. On ___, he was advanced to a regular
diet and again, tolerated it well. A repeat CXR showed no
pneumothorax and a small amount of mediastinal air, his WBC was
5K and he was afebrile. He did have some diarrhea after
starting Augmentin but was encouraged to take yogurt over the
next few days. He will call us if it becomes problematic. After
a ubeventful stay he was discharged to home on ___ and will
follow up with Dr. ___ in a few weeks. | 83 | 132 |
11927419-DS-22 | 25,806,159 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
You were admitted to the hospital because you were feeling
dizzy. Your blood pressure was also very low.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
In the hospital, you received fluids, which improved your blood
pressure. We also checked for possible causes of your dizziness,
including infection, which we did not find. We stopped one of
your medications, called TAMSULOSIN (FLOMAX), which may be
making your dizziness worse. We started you on a separate
medication, called MIDODRINE, which can help treat your
dizziness and low blood pressure.
WHAT HAPPENS WHEN I LEAVE THE HOSPITAL?
=======================================
-You will be discharged to a rehabilitation facility, where you
will have physical therapy to get stronger before going home.
-Please stop taking TAMSULOSIN, as this medication may worsen
your dizziness and blood pressure. You may be restarted on this
medication at a later date with your primary care provider.
-Please continue MIDODRINE 7.5 three times a day, which will
help your dizziness and blood pressure.
-You will have a repeat blood test in ___ weeks to check your
thyroid function.
-Please use caution when you go from sitting to standing, and
get up slowly to prevent dizziness and falls.
-Please continue to wear compression stockings to help with your
dizziness and blood pressure.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY:
================
___ male with history of ___, dementia,
hyperlipidemia, mitral regurgitation, presenting with dizziness,
found to have significant orthostatic hypotension. He was
started on midodrine with improvement in orthostatics. | 227 | 29 |
18305656-DS-7 | 29,030,324 | You came to the hospital with swelling of the pre-patellar
bursa, which is a fluid space that is located over the knee cap.
You were found to have an infection of the pre-patellar bursa
with associated cellulitis (skin infection) of your leg.
.
You had fluid removed from the bursa, which grew a type of
bacteria called Staph epidermidis. You were started on an IV
antibiotic called nafcillin to treat the infection. You will
receive infusions of nafcillin through an IV called a PICC. You
will have a visiting nurse to help you manage the PICC. The PICC
should be removed after your course of IV antibiotics is
complete ON ___, but NOT before your infectious disease
appointment, as the duration of therapy will be determined at
that time.
.
You will need to have some labs monitored weekly while on
nafcillin, with results faxed to the infectious disease clinic.
.
You developed an area of swelling on your left arm, which may be
related to inflammation of a vein from a prior IV. You had an
ultrasound of this area, which showed a possible foreign body
close to the surface of the skin, with some tubular inflammation
that was not clearly a vein. An x-ray showed an area of soft
tissue swelling. As the are of swelling was already improving,
we did not pursue and further imaging while you were in the
hospital. You should discuss further evaluation with MRI with
your primary care doctor if this area is worsening or fails to
resolve.
.
Please apply warm compresses to the area of swelling on your
left arm for ___ minutes three times daily.
.
There are some changes to your medications:
1. START nafcillin (IV antibiotic) | ___ yo M presenting with with pre-patellar bursitis and
associated cellulitis, found to have MSSA in pre-patellar joint
fluid.
.
# Pre-patellar bursitis/cellulitis: The patient presented with
left pre-patellar bursa swelling and associated cellulitis of
the left lower extremity. He was started on IV vancomycin.
Rheumatology was consulted and tapped the bursa, as well as the
left knee joint (although orthopedics thinks that both taps may
have come from the bursa). Orthopedics was also consulted and
tapped the bursa. All of the bursa/joint fluid grew MSSA, at
which point vancomycin was changed to nafcillin. After much
discussion amongst the primary team, orthopedics, rheumatology,
and infectious disease about whether this was septic bursitis,
or also arthritis. Ultimately, it was decided that this was just
bursitis. A PICC was placed but fell out. A second PICC was
placed, and the patient was discharged on nafcillin, with a plan
to complete a 2-week course on ___. At that time, the
patient will follow up in infectious disease clinic, and a
decision will be made about whether IV antibiotics need to be
continued. Once the course of IV antibiotics is complete, the
PICC should be removed. The patient will need weekly laboratory
monitoring while on nafcillin (CBC/diff, complete metabolic
panel, ESR, CRP), with resulted faxed to the infectious disease
clinic, attention Dr. ___, ___.
.
# Nodule on left forearm: The patient developed a nodule on his
left forearm. Ultrasound showed a solid tubular echogenic
structure within the superficial tissues at the site of the
patient's palpable nodule. Clinically, this appeared to be a
phlebitis, but no clear vein was visualized on ultrasound. The
patient was treated with warm compresses with markedly reduction
in the swelling. His was discharged with primary care follow-up.
He was instructed to talk to his primary care doctor about
further imaging (i.e. MRI) if the nodule grows or fails to
resolve. The patient was offered inpatient MRI given the vague
appearance of the lesion, but he opted to monitor it and
declined further inpatient evaluation.
.
# Communication: friend, ___ ___
.
# Code status: Full code | 278 | 348 |
17123455-DS-20 | 23,135,019 | Dear Ms. ___,
You were admitted to ___ after you
were found to have several areas of bleeding in your brain,
which were likely causing some of your memory problems. We are
still not exactly sure what caused this bleeding, however we are
concerned for spread of your cancer. Therefore, we had you seen
by our neuro-oncologist and radiation oncologist while you were
here. We will be getting something called a PET scan, to see if
your lung cancer is active.
We STOPPED your aspirin, as it puts you at increased risk of
bleeding. Please do NOT take this medication. You should also
avoid NSAID medications such as ibuprofen, motrin, advil,
naproxen, aleve.
We started you on a new medication called Keppra, which prevents
seizures. You should take 500mg twice daily.
You will need to undergo a PET scan, which has been ordered, and
needs to be scheduled.
You will also need a repeat MRI scan in one month.
You have some labs pending, including CEA and LDH, which will be
followed up by your neurologist Dr. ___.
It was a pleasure taking care of you during this hospital stay. | Ms. ___ ___ year old female with history of lung cancer,
was admitted to the stroke service for further workup of
multiple hemorrhagic lesions seen on MRI brain performed by her
PCP as outpatient, as described in the HPI.
She underwent a CTA which showed an incidental 7mm aneurysm in
the left vertebral artery, which is unrelated to her
hemorrhages. Her outside MRI was reviewed extensively, and it
was decided that given the enhancement and position at the
grey-white junction, these lesions were most likely to be
metastatic. There were no microhemorrhages which would have been
indicative of amyloid angiopathy. Her recent cancer screening
was investigated - she had undergone CT torso within the past
month which was, per report, stable since ___. Mammogram ___ year
ago was normal and colonoscopy had shown a benign colonic polyp.
LDH and CEA serum tests were sent, per recommendation from
neuro-oncology, who was consulted. Neuro-onc also recommended
outpatient PET scan, which was ordered, as well as radiation
oncology consultation, which was obtained (will consider whole
brain radiation pending PET scan and further outpatient workup).
Her exam remained stable, and she was discharged home following
the above workup.
Her aspirin was stopped, as this was only in place for
prevention, and she is at risk for further bleeding, given her
likely metastatic disease.
OUTSTANDING ISSUES
[ ] F/U CEA, LDH
[ ] Outpatient PET ordered, to evaluate for active lung cancer,
in which case diagnosis of metastatic disease would be more
certain.
[ ] Would repeat mammogram this year as planned given breast
lump per PCP
[ ] Will follow up in stroke clinic, and will likely be referred
for neuro-oncology appointment pending results of PET
[ ] Has PCP follow up | 183 | 280 |
17603980-DS-15 | 24,734,264 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted with worsening liver function, acute
kidney injury, and confusion. We treated your renal function
with fluids and held your diuretic medications. We gave you
lactulose and rifaxamin which improved your confusion. During
admission, you were also found to have a UTI and were started on
treatment for your infection.
Please take your medications as prescribed and follow up with
your doctors as ___. | ___ F with recent diagnosis of alcoholic cirrhosis presents with
decompensated cirrhosis manifesting as acute hepatic
encephalopathy, and acute kidney injury in the setting of
several days of N/V and inability to take PO (including meds.) | 82 | 39 |
11618270-DS-7 | 24,924,277 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having pain and
swelling in your legs, and weight gain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given Lasix through an IV to help remove the
additional fluid that had built up in your body.
- The IV lasix worked at first, but eventually did not make much
change in your leg swelling, as you were still taking in a large
amount of fluids by mouth.
- You were started on a strict 1.5L oral fluid restriction,
which allowed you to prevent fluid from reacummulating, and you
were able to restart your home oral diuretics.
- You were also started on insulin while in the hospital,
because your blood sugars were noted to be elevated.
- Your legs were feeling and looking much better than when you
came to the hospital, and you were ready to go home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- It is very, very important to stick to your 1.5L fluid
restriction while out of the hospital. This prevent the fluid
from reaccumulating, as before. The lasix medication (80mg,
twice per day) will also help.
- Please take the Potassium supplements every day. You will take
40mg in the morning and 20 mg in the evening.
- You will need good follow up with the liver doctors for your
liver disease, which has not been fully treated. Please see
below for instructions regarding your liver appointment.
- You will need to follow up with your primary care doctor after
you leave the hospital, within ___ days. They should check your
electrolytes (especially your potassium), and discuss the best
plan going forward with your diabetes management.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY:
================
___ is a ___ year old female with a history of
polysubstance use disorder including alcohol, benzodiazepines,
heroin, and cocaine, now on methadone, also with PTSD, and a
recent admission with new diagnosis of cirrhosis who presented
to the ED with a weight gain of 25 pounds and lower extremity
edema and pain. She was first treated with IV diuresis, which
was initially effective but limited by electrolyte abnormalities
and inadherance to fluid restriction. A 1.5 L fluid restriction
was initiated with good effect, and she was able to be
maintained on her home oral diuretic regimen. Eventually, the
pain in her legs improved secondary to a combination of
compressive wrapping, frequent ambulation, fluid restriction,
and diuresis. The etiology of her leg swelling is likely
secondary to her underlying liver disease, but significantly
exacerbated by chronic venous stasis.
TRANSITIONAL ISSUES
===================
[] It is very important for ___ to continue with a 1.5L
fluid restriction while out of the hospital, as this will help
prevent her from accumulating fluid, leading to the swelling in
her legs.
[] She was discharged on 80mg PO Lasix twice per day, along with
potassium repletion of 60mEq daily (40 mEq in the morning, 20mEq
in the evening). She will need follow-up within ___ days, in
order to check her potassium levels and adjust repletion. Last
potassium: 4.1 ___ AM)
[] She has not seen a hepatologist as an outpatient for her
newly diagnosed liver disease; an appointment request was made
to be evaluated at the ___.
[] HCV viral load was detectable (4.9 log10) this admission. She
should follow up with hepatology for treatment for her HCV.
[] ___ was noted to be Hep B non-immune on laboratory
testing. She should be vaccinated for Hepatitis A and B, given
her underlying liver disease.
[] She presented to the hospital without any medications to
treat her diabetes; a HgbA1c was 7.5%, up from 6.4% on ___.
She was maintained on long-acting and mealtime insulin while
in-hospital, with a sliding scale. She will be discharged on
metformin 500mg BID, which she was previously prescribed. Her
outpatient provider should continue to titrate her medications
to ensure adequate blood sugar control.
# CODE: Full Code
# CONTACT: ___) ___ | 311 | 362 |
14726985-DS-15 | 24,016,088 | Dear Ms. ___,
You were admitted to the hospital for concern of cellulitis of
your legs. You did well with IV vancomycin and you remained well
without fevers and the swelling and redness improved. We
ultrasound scanned your legs and did not find clots in your
veins. Your swelling was also improved with IV Lasix. Your
diarrhea also resolved and was negative for C. difficile on
stool testing. You are to take Bactrim and Keflex for 5 more
days which are antibiotics for your cellulitis. The last day you
will take the oral antibiotics will be ___. Please
follow-up with OB/GYN and with your primary care doctor and
hepatologist.
Please be sure to have your labs drawn before your appointment
with your primary care doctor on ___ since we started you
on oral Lasix and spironolactone to help you remove fluid from
your legs and abdomen. We are providing you a prescription for a
lab draw. | ___ yo F w/ cirrhosis who presents volume overload with
cellulitis of her lower extremities and acute hepatic
decompensation in postop setting.
#Lower extremity edema: Patient had increased erythema, warmth
and swelling of her lower extrmeities with more on the right
compared to the left. She has a history of pasturella cellulitis
in a similar distribution previously that was fully treated with
imipenem. DDx for this could include erythema from worsening
peripheral edema from her decompensated liver failure in postop
setting (after abdominal hysterectomy and hernia repair) vs
cellulitis vs DVT. LENIs were negative for DVT. Patient's lower
extremity swelling and edema improved significantly with IV
vancomycin and IV diuresis with Lasix. Patient did not have
documented fevers during hospital stay and was without
leukocytosis. On day of discharge, patient was switched to PO
antibiotics: Bactrim and cephalexin to complete a 7 day course
with end date on ___. She was also discharged with PO
diuretics: Lasix and spironolactone. She was instructed to have
labs drawn at PCP appointment on ___.
#Pannus pain- Her surgical wound did not appear infected,
although she was at risk for infections in the area given the
surgical manipulation. Likely dependent postsurgical edema vs
hepatic decompensation fluid retention. Pain improved with IV
diuresis and swelling around surgical site improved. Gyn
oncology followed the patient and surgical wound while she was
in house and patient has follow-up with OB/GYN scheduled.
#Diarrhea- ddx included withdrawal from narcotics (pt had
stopped using her dialudid), Cdiff (given recent hospitalization
and her presumed antibiotic received in the setting of her prior
surgery, lactose intolerance (pt reports just eating a lot of
dairy. C. diff was negative and diarrhea resolved completely on
day prior to discharge.
#Cirrhosis- patient has cirrhosis (unclear etiology) and is
followed by Dr. ___ started seeing him as an
outpatient. She reports being on furosemide prior but was no
longer taking it. Patient was put on low sodium diet and was
diuresed with IV Lasix. On discharge, she was started on 80mg PO
Lasix and 100mg spironolactone.
#s/p hysterectomy and ventral hernia repair- no signs of
infection on the surgical wound itself. Patient received PO
Dilaudid for pain control. | 156 | 357 |
14168528-DS-21 | 28,871,620 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had symptoms that were concerning for influenza. We
tested you and you were found to be negative for influenza. You
also had an abscess on your scrotum that was drained by Urology.
You received a 5-day course of antibiotics (completed on ___.
You will also have to change your dressing every day.
We noticed that your blood sugar levels were very high (over
400) during your hospitalization. We adjusted your Lantus dose
to 35 units at breakfast and 15 units at bedtime. We recommend
that you follow up with your PCP to follow an insulin regimen
that better controls your sugars.
We also observed that your oxygen level decreased considerably
while you were sleeping. This happens with Obstructive Sleep
Apnea (OSA), which you have as a diagnosis from many years ago.
We recommend that you have a sleep study and use CPAP, since OSA
can lead to many medical conditions, including high blood
pressure, high pulmonary pressure, and the risk of stroke.
You had high potassium, and we gave you medications to treat it.
We had EKGs done to see the rhythm of your heart, and ran blood
tests that were concerning for possible lack of oxygen to the
heart. We placed you on a new medication: aspirin 81 mg daily.
Your kidney function worsened when we restarted your home
torsemide. Please continue to hold your home torsemide as well
as your lisinopril (because they can negatively affect your
kidneys as they recover). Please check with your PCP as to when
you can re-start torsemide and lisinopril.
Your weight on discharge is 210.6 kg. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
We wish you the best,
Your ___ team | Mr. ___ has a history of HTN, DM II with retinopathy/
nephropathy, hypertensive heart disease, dCHF, OSA, obesity, and
history of prior abscesses requiring surgical intervention, who
presented with rhinorrhea, congestion, ear aches, subjective
fevers/chills, and painful scrotal abscess now s/p I&D and ruled
out for influenza. | 298 | 48 |
18255718-DS-8 | 24,956,641 | - You have headaches, we recommend that you take you take
tylenol. Although narcotics such as dilaudid will improve your
headaches, tchronic use of narcotics for headaches will cause
rebound and worsening headaches
- Your sutures were removed in routine fashion. It is ok to
shower and pat dry you wound. Please do not touch. Keep wound
clean and dry
- If you develop worsening symptoms, please call our office at
___ | Patient was admitted to neurosurgery for pain management. She
was started on her home oxycodone and then changed to dilaudid.
She reported improvement of her headaches. Her symptoms have
improved and she is back to her baseline neurologic status.
Mrs. ___ was afebrile, hemodynamically and
neurologically stable. | 74 | 51 |
18339865-DS-39 | 23,702,309 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having difficulty
breathing and because you had stomach pain. You were found to
have extra fluid in your lungs because of worsening kidney
function causing extra fluid to build up in your body.
What did you receive in the hospital?
- You were given a water pill through the IV to help get rid of
the excess fluid. You were still having some lightheadedness and
trouble breathing when you were walking, but we continued giving
you a water pill, and those symptoms resolved. You should
continue to take this water pill (torsemide) every day. The
water pill helps to make sure that you can still breathe well.
- You were found to have a possible urinary tract infection, for
which you were treated with antibiotics.
- Your iron levels were noted to be low, likely causing your red
blood cells to be low as well. Because of your constipation, we
stopped the iron that you take at home (which can worsen
constipation) and instead gave you iron through your IV.
- You had one episode of having very low blood sugars and not
being able to wake up. We gave you extra sugar. Your blood
sugars jumped around a lot. You were seen by the ___ team,
who recommended an insulin regimen that helped control your
blood sugar better.
- Your stomach pain was thought to be due to constipation, and
we gave you laxatives to help relieve that.
- We discussed the risks of you leaving the hospital. You
decided to leave the hospital against our medical
recommendations. Please come back to the hospital if you have
ANY symptoms of confusion, difficulty breathing, or more
swelling in your legs or stomach.
What should you do once you leave the hospital?
- Please come back to the hospital on ___, to start
dialysis or earlier if you have ANY symptoms of confusion,
difficulty breathing, or more swelling in your legs or stomach.
- Please use your continuous glucose monitor at all times to
avoid low blood sugars.
- Please continue taking the water pill (torsemide) every day to
avoid having extra fluid build up in your lungs and the rest of
your body. This water pill will help make sure that you can
breathe.
- Please continue your Toujeo at 6 units daily (decreased from
before), your sliding scale insulin, and your carb-counted
insulin at a 1:20 ratio of insulin units to carbohydrates. If
your blood sugars are greater than 400, please call the ___
doctor.
We wish you all the best!
- Your ___ Care Team | ___ with history of poorly-controlled T1DM c/b neuropathy,
achalasia/gastroparesis, and CKD stage IV, and MELAS who
presented with SOB, found to have acute hypoxemic respiratory
failure in the setting of pulmonary edema likely ___ worsening
renal failure. Her course was c/b hypoglycemia ___ severely
brittle diabetes. She was also found to have fecal incontinence,
likely overflow from significant stool burden. She was seen by
the inpatient Nephrology team, who recommended placement of a
tDC for HD initiation on this admission for worsening renal
function. However, the patient decided to leave against medical
advice. She was counseled around the risks of leaving the
hospital and was able to reiterate those risks. | 441 | 110 |
19835796-DS-12 | 28,641,985 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you overdosed
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We gave you naloxone to reverse the overdose
- We did tests on your blood which showed that your heart was
mildly injured, most likely because of your recent cocaine use
- A social worker met with you, and was able to put you on a
waitlist for an outpatient addiction program at the ___
___
- You were started on two new medications, called aspirin and
atorvastatin, to help protect your heart
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | BRIEF HOSPITAL COURSE:
====================
Mr. ___ is a ___ gentleman w/ hx of bipolar
disorder, PTSD, & polysubstance use disorder who initially
presented after an overdose after having taken crack cocaine,
heroin, and clonidine. He received one dose of naloxone and bag
valve mask respirations in the field with good response in his
mental status. Subsequently required two doses of naloxone here
in ED. He was found to have mildly elevated troponin to 0.02,
which down-trended to 0.01. ECG was difficult to interpret given
LVH, but had low suspicion for ischemia as he remained CP free
throughout. Suspect that he may have had transient vasospasm
from recent cocaine use. Social work was consulted, and placed
him on a waitlist for an intensive outpatient addiction
treatment program at ___.
TRANSITIONAL ISSUES
====================
FOR PCP:
[] Recommend referral to addiction psychiatry for ongoing
treatment of patient's substance use disorder.
[] On review of PMP, patient has been prescribed suboxone by Dr.
___). We did not prescribe any
psychiatric medications here, as pt insisted on leaving before
addiction psychiatry could evaluate him (and he was deemed to
have capacity to leave)
[] Patient was placed on waitlist for intensive outpatient
addiction treatment program at ___.
[] Consider stress test if pt c/o chest pain.
MEDICATION CHANGES:
- NEW: aspirin 81 mg daily + atorvastatin 40 mg daily
# CODE STATUS: Full (presumed)
# CONTACT: ___, mother, ___
ACTIVE ISSUES:
===============
# Overdose
# Polysubstance use disorder:
Patient presented after an overdose on cocaine, heroin, and
clonidine. He required treatment with Narcan and bag valve mask
respirations with recovery of mental status. Patient has a
longstanding psychiatric history, and had no acute safety
concerns this admission. Patient denied suicidal ideation. He
had no evidence of withdrawal. Social work was consulted, who
placed patient on a waitlist for an intensive outpatient
addiction treatment program at ___.
We did not prescribe any psychiatric medications here, as pt
insisted on leaving before addiction psychiatry could evaluate
him (and he was deemed to have capacity to leave)
# Elevated troponin
Patient's troponins were mildly elevated (0.02>0.01) with no
chest pain, no shortness of breath. EKG with nonspecific T wave
changes. Elevated troponins occurred in the setting of cocaine
use, and therefore likely due to vasospasm. AIC 5.7%, Cholest
136, LDL 66, HDL 60, ___ 50. Patient was started on aspirin 81 mg
daily and atorvastatin 80 mg QHS. Beta blocker contra-indicated
iso recent cocaine use.
# Neutrophilic Leukocytosis
Patient was noted to have WBC 22.7 on admission, which
downtrended to 13.1. Suspect reactive iso overdose. Afebrile &
no localizing s/s to point to infection. | 162 | 430 |
19059343-DS-9 | 29,177,595 | Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop similar abdominal pain
to this episode, a fever greater than 101.5, chest pain,
shortness of breath, severe abdominal pain, pain unrelieved by
your pain medication, severe nausea or vomiting, severe
abdominal bloating, inability to eat or drink, or any other
symptoms which are concerning to you.
Diet: Please refrain from eating large or fatty meals. Your band
has been loosened, but you must try to continue eating similar
portions sizes as when the band was tight.
Stay on Stage VI diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
2. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
3. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
As tolerated. | The patient presented to the Emergency Department c/o right
upper quadrant ab. pain X 1 day. The bariatrics team was
consulted and Dr. ___ her gastric band in the
Emergency Department. This did not help relieve her pain
symptoms. A RUQ ultrasound was conducted which showed
cholelethiasis, but no evidence of cholecystitis.
Due to continued pain, a CT scan was conducted to evaluate for
other causes of pain. The CT showed no cause for her pain,
specifically the read was:
1. No acute findings. No evidence of obstruction or
inflammation. Gastric band in unchanged position from
prior exam.
2. Hepatic steatosis.
The patient was admitted to the bariatric service overnight for
monitoring, IV hydration and was made NPO. All home medications
were continued. On hospital day one her abdominal pain had
resolved and she was feeling well. Her diet was advanced from
Bariatric I to Bariatric III throughout the course of hospital
day one and the patient was discharged.
The diagnosis is presumed biliary colic. She has a followup
appointment with Dr. ___ and is tentatively scheduled for an
elective cholecystectomy in ___ with Dr. ___. | 189 | 207 |
17851173-DS-21 | 28,899,520 | You were admitted this hospitalization for a heart attack. You
underwent a procedure called a cardiac catheterization to
explore the blockages and open a blockage in the left anterior
descending artery that supplies the front portion of the heart
muscle. We placed a bare metal stent where the blockage is
during this procedure.
We also found that the pumping function of your heart is
depressed. This is called heart failure. It is of the utmost
importance that you watch your sodium intake, do NOT drink or
smoke and weigh yourself daily. Taking in too much sodium and
alcohol makes the heart have to work harder and harder and can
lead to hospitalization and death. Weighing yourself daily will
allow you to see if you are retaining too much fluid thus making
your heart work harder than it needs to. Please call you doctor
Dr. ___ your weight goes up more than 3 lbs in two days.
You will need an echocardiogram to reassess your heart function
in ___ months.
We also discovered a stable focal infrarenal aortic dissection
that needs ongoing monitoring with a vascualr surgeon and
imaging ( a cat scan in 6 months)
We have made the following medication changes:
START: Plavix 75mg daily
START: Aspirin 81mg daily
START: Atorvastatin 80mg daily
START: Metorpolol Succinate 25 mg daily
STOP: Pravastatin
STOP: Propranolol
It is of the utmost improtance that you take your Plaviox and
Aspirin every day. Failure to take these medications could lead
to a life threatening heart attack and death.
The Atorvastatin and metoprolol also owrk on your heart and
taking then will decrease your risk of having another heart
attack.
Please keep your appointment as scheduled with Dr. ___ at the
___. You will need to be seen by a cardiologist, please discuss
with Dr. ___ you see him. | ___ yo M with PMH HTN and HLD presenting with acute STEMI s/p
cardiac catheterization with BMS to LAD. | 297 | 20 |
10122182-DS-19 | 22,489,381 | Mr. ___,
You were ___ to the surgery service at ___ after
pancreaticoduodenectomy with symptoms of sepsis. CT on admission
revealed pancreaticojejunostomy leak and large intra abdominal
abscess. You were treated with antibiotics and bowel rest. You
underwent multiple CT-guided procedure by ___. You were started
on long term antibiotics and provided with TPN for nutrition.
You are now safe to return home to complete your recovery with
the following instructions:
.
Please ___ Dr. ___ office at ___ option 4 if you
have any questions or concerns. During off hours: please ___
operator at ___ and ask to ___ team.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
JP Drain x 2 Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
___ the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions. | The patient s/p pancreaticojejunostomy was readmitted to the
Surgical Oncology Service with increased abdominal pain and
tachycardia. On admission patient was afebrile, his HR was 155,
WBC ___ and lactate at 7. Abdominal CT scan on admission
demonstrated large irregular collection with debris and gas
adjacent to the presumed site of the pancreaticojejunostomy,
concerning for anastomotic leak or perforation. Patient was
started on broad spectrum antibiotics and ___ was consulted for
possible drainage/aspiration. Patient received 1L fluid bolus
and one unit of RBC. On ___ patient underwent CT guided
placement of ___ pigtail catheter into the collection.
Post procedure patient was transferred in ICU for further
management. He was started on Octreotide, continued on
Meropenem/Vancomycin. Blood cultures were positive for GPCs. On
___: PICC line was placed, TPN was started. Patient remained
afebrile, WBC down to 13K. On ___: Repeat CT scan demonstrated
significant decrease in the peripancreatic collection containing
the
pigtail drain; increase in smaller rim enhancing collection
adjacent to the hepatic
caudate lobe and significant increase in extensive rim enhancing
fluid associated with anterior small-bowel loops just deep to
the abdominal wall, much of which
appears to be communicating (please see Radiology report for
details). ___ was consulted for additional drain placement. On
___: patient underwent placement of ___ and ___ drains into
abdominal wall fluid collections. Vancomycin was discontinued,
NGT was removed. He continued on TPN and IVF.
On ___ Patient's diet was advanced to clears. he was
transferred to the floor on Meropenem, Octreotide and clears. On
the floor patient continue to progress with recovery. ID was
consulted and recommended to continue Meropenem. He was
transitioned to oral medications from IV. On ___: Octreotide
was discontinued as drains output decreased. On ___: Repeat CT
scan demonstrated decreased size in all intraabdominal fluid
collections. Two drains, which were placed in ___ were removed.
Diet was advanced to regular. Patient was transitioned to Zosyn
per ID recommendations. Patient developed nausea with small
emesis on ___ and diet was downed to clear liquids. Infectious
Diseases recommended continue Ertapenem after discharge for ___
weeks (course will be determine during follow up appointment).
On ___ patient JP 1 was discontinued. TPN was cycled for 12
hours overnight. On ___ patient was discharged home in stable
condition. Patient was instructed to check his blood sugar twice
a day; once before bedtime when on TPN; and second time 2 hours
after discontinue TPN in AM. He was provided with prescription
for glucometer and supply. | 453 | 416 |
11146680-DS-7 | 20,779,500 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
were having extreme pain in your left groin area because of your
metastatic melanoma. Your pain medication was adjusted to
minimize this and you received radiation to the area to further
reduce pain and local disease. You were discharged with home
hospice care. Best of luck to you in your future health.
Please take all medications as prescribed, and call a doctor if
you have any questions or concerns.
Sincerely,
Your ___ Care Team | ___, a ___ yo F PMHx Metastatic Melanoma (abdominal,
inguinal, chronic lymphedema) recently on pembrolizumab
complicated the inguinal metastases eroding onto the skin
presented with pain crisis and altered mental status secondary
to excessive opioids. She was evaluated by Palliative Care, her
opioid regimen was changed to fentanyl patch, standing morphine
liquid, breakthrough morphine liquid, gabapentin, and lidocaine
with good results, and she received palliative radiation therapy
___. She was discharged with good pain control to home
hospice.
# Metastatic Melanoma - Most recently with progressive disease
on ipilimumab, switched to pembrolizumab, now completed cycle ___ which is last cycle. Got first of 5 treatments with
radiation on ___ for symptom relief and is currently pursuing
comfort-focused care with the help of Palliative Care and
Hospice; patient and HCP do not want further disease-oriented
therapies
# Hypoactive Delirium / Pain Control:
Was reportedly confused/pinpoint pupils on arrival to ED after
getting ___ MSIR benadryl and 100 fentanyl patch. She was started
on Fentanyl patch 100 mcg but remained overly sedated on arrival
to floor thus fentanyl patch removed at risk of re-exacerbation
of pain. Pt also noted to have clonus and decreased ___ strength
although exam difficult due to sedation. Brain MRI ___ negative
other than calavarial lesion, head CT w/o acute process and
repeat MRI on ___ also normal. Almost certainly due to over
medication at home with rapid stacking of prn medications. Her
pain regimen was adjusted to PO/TD only on ___ with good
results. She required only transdermal and oral medications,
with ___nd at most ___ pain with ambulation
# Mobility: Given femoral disease, pain, and delirium issues,
there was some concern about the ability of hospice-scheduled
nursing to attend to her needs. However she has been able to
ambulate to commode with ___ assistants. Hospice and family feel
able to care for her at home.
# Nutrition: Patient has very poor nutritional status, low
albumin; family does not want feeding tube. Nutrition Consult
gave recommendations to inpatient team and family.
# Hyponatremia: Mild, most likely from hypovolemia as her Hct
and WBC are also increased. Completed 2L NS in ED and
transferred on 150cc/hr. Held off on further fluids as will
could exacerbate lymphedema but has had urine output on the low
side. No further daily labs around time of discharge. Patient
was encouraged to take PO and she did not receive further
IVF/diuresis after admission.
# Lower Extremity Edema: Lymphedema for almost a decade
secondary to lymph node exploration/debridement. Family had
wanted Pneumoboots but these are prohibitively expensive.
Patient was discharged with TEDS.
# Constipation: Narcotic and possible mass effect. Had bowel
movements on senna, colase and miralax. | 97 | 446 |
13022039-DS-20 | 20,136,856 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because you are having
shortness of breath and chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You received an EKG and blood tests, which showed that you were
not having a heart attack.
Your shortness of breath was found to be due to fluid in your
lungs, which can happen when your heart gets backed up with
fluid due to heart failure.
-You were also treated for a pneumonia, which may have been
caused by choking on food, given your problems with swallowing.
You were given a water pill to remove the extra fluid from your
lungs to make you feel better.
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.
-Please weigh yourself daily after you are discharged, and call
your primary care provider or cardiologist if your weight goes
up by 3 or more pounds.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
========
___ (___) with autonomic failure (c/b orthostatic
hypotension, bowel dysmotility, atonic bladder/recurrent UTIs),
COPD, HFpEF, afib who presented from rehab facility with
concerns
for shortness of breath and chest pain. | 189 | 27 |
10394817-DS-17 | 21,026,693 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You are admitted with pain in your back and your legs.
- There was concern that you are not able to care for yourself
adequately at home.
- You had swelling in your legs that was caused by a condition
called heart failure, which is when your heart isn't as strong
as it used to be.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were given water pills to decrease the swelling in your
legs, and started on medications to help your heart
- You were started on paliperidone, a medication to help you
take care of yourself.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
- Your ___ Care Team | Transitional issues:
====================
[] DIURESIS: repeat complete metabolic panel on ___ to
assess potassium and magnesium levels after starting torsemide
80mg daily.
[] NEW HEART FAILURE: follow up with cardiologist and obtain
stress test
[] PRE-DIABETES: HgA1c 6.2, follow up closely with primary care
physician
[] LIKELY OSA/OHS: polysomnogram as outpatient
[] PALIPERIDONE DOSING: next dose due on ___
[] PCP: please refer pt. to ___ within one month
and please call ___ Psychiatry @ ___ for
an Intake.
Any questions, please call ___ @ ___.
Ms. ___ is a ___ year old woman with history of morbid obesity
complicated by likely obstructive sleep apnea, and bipolar
disorder who originally presented with failure to thrive and
lower back pain, and was subsequently found to decompensated
heart failure and likely obstructive sleep apnea. Her hospital
course was notable for significant diuresis (50lbs) and
initiation of long-acting paliperidone. | 174 | 137 |
18208827-DS-3 | 22,748,352 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had pain and
redness and swelling of your left leg.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have an infection of the skin called
cellulitis on your left lower leg.
- You were started on IV antibiotics and pain medications to
treat your cellulitis.
- You had an ultrasound which showed that you do not have any
blood clots in your left leg.
- Lab tests showed that you have very low blood counts (anemia)
and severe iron deficiency. This is most likely due to heavy
menstrual cycles. Your outpatient hematologist at ___, Dr.
___ that you may also have thalassemia trait which
could be contributing to your anemia.
- You received transfusions of red blood cells and IV iron to
help get your blood counts back to normal.
- You improved and 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 should continue to take two oral antibiotics (Keflex and
Bactrim) through ___. This will fully treat your
cellulitis.
- For pain control, take ibuprofen and use cold or warm packs on
your left leg.
- If you experience worsening pain, redness, or swelling of your
left lower leg you should seek medical attention immediately.
- You should take oral iron supplements every day until you see
your Hematologist Dr. ___ on ___.
- Using compression socks or stockings or wrapping your lower
legs tightly with ACE bandages can help to reduce leg swelling.
We wish you the best!
Sincerely,
Your ___ Team | P - Patient summary statement for admission
==============================================
Ms. ___ is a ___ with a history of iron deficiency anemia and
dependent lower extremity edema now presenting with ___ months
worsening weakness and new left lower leg pain, swelling, and
erythema.
A - Acute medical/surgical issues addressed
==============================================
# Acute on chronic iron deficiency anemia
# Menorrhagia
Hgb 6.1 on presentation with MCV 48, Tsat 2.5% and retic count
1.8%, c/w microyctic, hypochromic anemia, most likely ___ severe
menorrhagia and lack of adherence to home iron supplements (1
month supply last filled in ___, per patient she has not been
taking iron pills because they were too large). Has a history of
microcytic anemia with prior smear demonstrating poiklocytes,
ovalocytes, target cells, tear drop cells, schistocytes, and
anisocytes. Heme/onc was consulted during a previous hospital
admission and noted that severe iron deficiency anemia can cause
these atypical morphologies. Per ___ records, her Hgb was 7.3
with Tsat 3% in ___. She was seen by Dr. ___ in
___ clinic at ___ in ___, who thought that pt most
likely has iron deficiency anemia ___ menorrhagia and possible
thalassemia trait. Pt was lost to follow up and ordered studies
were never obtained (hemoglobin electrophoresis, peripheral
blood smear, retic count and iron studies). During this
admission, smear of pre-transfusion blood demonstrated 2+
hypochromia, 3+ anisocytosis, 3+ poikilocytosis, 1+ macrocytes,
3+ microcytes, 2+ target cells, 2+ schistocytes, and 2+ teardrop
cells. Pre-transfusion haptoglobin 153, platelets 497. Low
suspicion for GU or GI bleed given no hematuria, melena, or
hematochezia and negative FOBT in ED. S/p transfusion of 2 units
pRBC with Hgb bump from 6.1 to 7.4. Received IV ferric gluconate
250mg x1.
# Cellulitis
# Leukocytosis
Presents with left lower leg erythema, pain, warmth, and
swelling consistent with cellulitis. Appears non-purulent.
Reassuringly, pt was afebrile and HDS with only mild
leukocytosis, however given hyperesthesia and exquisite
tenderness to palpation of left lower leg and exposure to MRSA
in hospital job, covered with IV vanc/ceftriaxone ___
with improvement in pain and erythema. She was then transitioned
to PO cephalexin and Bactrim to complete 7 day course with
empiric MRSA coverage (___). Left leg more swollen than
right, US negative for LLE DVT. ED UCx negative, blood cultures
x2 no growth to date. For pain she initially received IV
acetaminophen and morphine in the ED, then IV ketorolac on the
floor, transitioned to PO ibuprofen prior to discharge.
C - Chronic issues pertinent to admission
==============================================
# Lower extremity edema
Pt has a history of lower extremity swelling around her ankles,
thought to be ___ venous insufficiency. No history of heart
failure or renal disease. S/p 40mg IV lasix in the ED. Currently
appears euvolemic. Has not been taking home lasix 40mg QD
recently due to
side effects of heart palpitations, frequent urination, and
occasional lightheadedness. Held home home lasix given that pt
appears euvolemic. Recommend compression stockings or ACE
bandages for ___ swelling.
T - Transitional Issues
==============================================
[] F/u resolution of cellulitis after 7 day course of
antibiotics (vanc/ceftriaxone ___, cephalexin and
Bactrim ___.
[] F/u anemia: check CBC and f/u H/H in 1 week, scheduled for
Hematology follow up on ___. Consider additional IV iron
repletion.
[] F/u lower extremity dependent edema: pt encouraged to use
compression stockings and ACE bandages. Home lasix held in
setting of anemia and symptoms with home lasix in the past
(heart palpitations, lightheadedness).
#CODE: Full (presumed)
#CONTACT: No HCP chosen | 293 | 554 |
18223539-DS-37 | 21,678,146 | Mr. ___,
You were admitted to the hospital for evaluation and treatment
of a COPD exacerbation which was causing you severe shortness of
breath both at rest and with minimal exertion. This was treated
and gradually improved in some ways, but you continued to have
cough and shortness of breath. A repeat chest X-ray showed a
new pneumonia, for which you were started on antibiotics. This
helped your cough and breathing improve.
You were also found to have iron deficiency, which was treated
with iron infusions.
In order to minimize the chances that you would develop urinary
retention with starting one of your new lung medications
(Tiotropium - Spiriva), your tamsulosin (Flowmax) dose was
increased. If you start to have difficulty urinating over the
next couple of weeks, please pause the Spiriva and touch base
with your pulmonologist.
Over the next couple of weeks, you will take a tapering dose of
prednisone:
take 30mg from ___ to ___
take 20mg from ___ to ___
take 10mg from ___ to ___
take 5mg from ___ to ___
Please make sure to see your pulmonologist in about 2 weeks, or
sooner if there are issues.
It was a pleasure caring for you while you were in the hospital
and we wish you the best.
Sincerely,
Your ___ Medicine Team | TRANSITIONAL ISSUES:
[] consider additional IV Fe supplementation (got 5 doses here);
redraw CBC in 4+ weeks to monitor recovery of blood counts after
repletion
[] monitor for resolution of respiratory Sx on prolonged taper
pred + new Spiriva + 3x/weekly azithro
[] monitor for recurrent urinary retention on Spiriva
[] please obtain ___ to assess for any signs of subacute lower
GIB given microcytic anemia
# Moderate-to-Severe COPD with acute exacerbation
Patient recently discharged from the hospital for COPD
exacerbation, now presenting again with dyspnea and wheezing
consistent with COPD exacerbation. Given chronicity of symptoms,
suspect related to discontinuation of prednisone. No evidence of
infectious trigger or volume overload at the time of admission.
Patient had completed a 7-day course of levofloxacin on ___.
Of note, patient has history of BPH with urinary retention
triggered by anti-muscarinics in the past, so has not been on a
LAMA such as tiotropium.
- Initially he was treated with PRN albuterol nebs, but on a
PRN-only basis he did very poorly and symptoms were worsening.
We avoided nebulized ipratropium given his hx of acute urinary
retention with that medication.
- Gave stacked albuterol nebs followed by standing albuterol
nebs q4h with some improvement in symptoms and on lung exam
- Started Levalbuterol nebs q2h PRN (to try to minimize impact
on his HR)
- Discussed with his PCP & primary Pulmonologist re: trial of
increasing his home tamsulosin followed by initiation of
tiotropium. Mr. ___ was amenable to this trial in the
supervised setting of the hospital. Tiotropium was initiated on
___ with no evidence of urinary retention and seemed to help
play a role in improving his lung exam & symptoms. He will
continue this medication on discharge. Of note, pt states that
the last time he was on tiotropium, urinary retention started
after a couple of weeks; he will monitor for this, cont the
higher Tamsulosin and DC the Spiriva if having Sx and contact
his pulm
- Initiated azithromycin 250 mg 3x/week MWF ___- ), this will
be continued indefinitely
- Initiated prednisone 40 mg daily with plan for a prolonged
taper given failure of 5-day course of prednisone and relatively
slow improvement with resumption of steroids and max medical
therapy for his COPD flare during this hospitalization; will
decreae by 10 at 5-day intervals, to go through ___
- His home Symbicort is NF and patient has had adverse reaction
to Advair in the past so he did not receive inhaled
corticosteroids but he will resume these on discharge
- prior to DC pt ambulating up full length of hall, round trip
without stopping, which he felt was baseline; comfortable with
plan to DC home
# Pneumonia
Diagnosed on ___ CXR showing new retrocardiac opacity obtained
in setting of ongoing productive cough and symptoms of
pronounced dyspnea despite marked improvement in his lung exam
findings.
- treated w/ Ceftriaxone ___ - ) and symptoms improved; sent
home on 3 additional days of cefpdoxime; frequency of coughing
was down considerably prior to DC and pt felt breathing was much
improved
# Iron deficiency anemia
Microcytosis with ferritin 110, TSAT < 10%.
- initiated repletion of iron stores w/ IV ferric gluconate 125
mg daily on ___ received total of 5 doses
[] We recommend that Dr. ___ outpatient iron infusions
given the poor efficacy profile of oral iron supplementation,
particularly in the elderly
[] Given that his microcytic anemia was not present to this
degree in ___, may warrant outpatient evaluation
for sources of occult GI bleeding | 208 | 569 |
10164309-DS-6 | 25,927,595 | Dear Ms. ___,
You were admitted to the gynecology service with right sided
abdominal pain and concern for ovarian torsion and underwent
surgery. You have recovered well and the team believes you are
ready to be discharged home. Please call the OB/GYN office
___ with any questions or concerns. Please follow up
with Dr. ___ for your dialysis care and for your high
blood pressure. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 6
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology service
for management of her likely right ovarian torsion. Her ovary
likely spontaneously de-torsed as her pain had resolved by the
time she arrived to the ___ emergency department. Repeat
pelvic US showed right pelvic mass with only peripheral flow and
no demonstrable internal flow, concerning for a right adnexal
neoplasm versus a residual broad ligament fibroid. Follow up MRI
showed possible degenerated or torsed broad ligament fibroid or
degenerated ovarian fibroma or other neoplasm. Given the
possibility of torsion and in order to prevent infectious
sequelae of torsion, decision was made to proceed to the OR
___ for removal of the mass with laparoscopic RSO, possible
laparotomy.
Renal and transplant surgery were consulted for optimization of
her ESRD in the setting of requiring surgical intervention. Her
creatinine remained stable. She received peritoneal dialysis
starting the evening of ___ until her surgery. She also
received an right IJ tunneled dialysis line ___ by ___ for
planned hemodialysis after her operation. She continued her home
losartan and had asymptomatic, elevated blood pressures to the
180s/110s overnight on ___. She was restarted on labetolol
150mg PO BID per renal recommendations with improvement of her
blood pressures.
On ___, she underwent laparoscopic right ovarian cystectomy.
Please see the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV Dilaudid and Zofran for
narcotic related nausea.
On post-operative day 1, she was voiding spontaneously. Her diet
was advanced without difficulty and she was transitioned to PO
Dilaudid/Zofran/acetaminophen. She was followed by Renal and
Transplant surgery and she received her first hemodialysis on
___ and is scheduled for her next dialysis on ___. Her
hematocrit and electrolytes remained stable. She declined social
work consultation for resources during her stay.
By post-operative day 2, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. She
will follow up with Dr. ___ for her ESRD, anemia and
blood pressure management. | 230 | 345 |
17329921-DS-12 | 29,326,959 | You were admitted to the hospital after having a seizure. You
had a CT scan of the head given your recent fall and it did not
show any acute or new findings. You were seen by Dr ___
were given ativan and keppra and your seizures stopped. Dr
___ that we continue the keppra for now and for
your to follow up with him in clinic. | #Seizures
Patient with history of seizures but could not tolerate Depakote
___ thrombocytopenia or keppra ___ mood changes, so had recently
been tapered off, now presented with seizure likely as a result
of being off of prophylactic AEDs. Concussion possible
contributor given recent headstrike, but patient is without
headache. Patient is also with recent local recurrence of his
glioblastoma which is likely also contributing. Fortunately, CTH
without acute changes
compared to prior (no hemorrhage or worsening edema or trauma
___ recent headstrike).
Dr ___ patient ___ 2g keppra load in ___
be started on 1g q12h afterward He was seen by ___ given his
recent fall who recommended that pt continue with his outpt
regimen of ___ as previously directed.
#Right parietal-temporal glioblastoma (s/p debulking, adjuvant
chemoradiation, now with local recurrence s/p cyberknife PAtient
recently completed cyberknife without adverse effects and CTH on
admission without acute changes WIll f/u with Dr ___ as
outpatient.
#HTN
Carries diagnosis but is not on any controller medications.
Normotensive during admission.
time spent on DC related activities >30 min
pt seen/examined and stable for DC | 68 | 178 |
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