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13879853-DS-26 | 20,828,817 | You came to the hospital with pain in your abdomen and back, as
well as some vomiting with blood. You were found to have a
urinary tract infection, that may have spread to your kidney.
You were discharged against medical advice in order to care for
your cat. You were advised to seek urgent medical attention as
soon as possible as there is a risk of death if the infection
goes untreated. | Patient is a ___ F with a history of of male to female
transgender, paraplegia secondary to MVA, neurogenic bladder s/p
ileo conduit/urostomy, COPD (on 2L home ___), and history of PE
not on anticoagulation who presents with hemetemesis, right
flank
pain, nausea, and right sided abdominal pain. Spiked a fever and
found to have a pseudomonas UTI. Her abdominal pain and back
pain now appeared to be secondary to likely pyelonephritis.
There were no further episodes of hemoptysis. She was treated
with several doses of cefepime, prior to leaving the hospital
against medical advice to care for her cat. She was advised to
immediately come to the ER as soon as possible due to the risk
of death if this infection goes untreated. She endorsed
understanding and acknowledged the risk of death and still
decided to leave the hospital AMA.
[ ] When she re-presents to the ED, please restart cefepime.
[ ] pain was controlled with oxycodone prior to leaving | 72 | 157 |
10745745-DS-24 | 20,908,082 | Dear Mr. ___,
You were hospitalized with progressive sensory symptoms of lower
leg heaviness. You had an MRI of the dorsal spine performed
which showed a fluid collection. This fluid collection grew a
yeast called ___, which you had previously been infected
with. You were treated with micafungin, an antifungal agent
with the guidance of our infectious disease colleagues. You will
continue micafungin until ___ at which point you will be
switched to oral fluconazole. We do not feel that the fluid
collection caused your sensory symptoms. You did appear to
become weaker, which is concerning for Guillain-Barré syndrome.
Your EMG/nerve conduction study test did not show any clear
evidence of GBS, but can be normal early in the course of
things. Normally we will perform a lumbar puncture or spinal
tap to assess for this, but this was not felt to be safe from an
infectious standpoint because of the fluid collection, so we
empirically treated you with IVIG (immune globulin). This
medication often takes several weeks to take full effect, but
shortens the duration of the GBS and causes the peak symptoms to
be milder than they would be otherwise. You were followed by
physical therapy to who recommended discharge to rehab to work
on your strength.
Sincerely,
Your ___ neurology team | Mr. ___ is a ___ man with past medical history
notable for multiple spinal surgeries complicated by infections
including discitis and osteomyelitis, eosinophilic PNA, and ILD
on slow steroid taper admitted with ascending BLE "heaviness".
He was found to have a fungal infection and paraspinal fluid
collection and treated with micafungin. He was empirically
treated for GBS with 5 days of IVIG, given ascending sensory
symptoms and weakness, unable to perform lumbar puncture due to
paraspinal fluid collection and concern over infectious
concerns.
#presumptive GBS s/p IVIG treatment -patient admitted with
symptoms of ascending sensory changes, described as
numbness/heaviness of the lower legs. These symptoms remained
stable during the hospital course. His clinical exam was
monitored. He had an EMG which showed sensorimotor
polyneuropathy with both axonal and demyelinating features. And
a R L5-S1 radiculopathy. Not able to rule out GBS, as EMG was
still early in his course. His strength subsequently was noted
to decrease on exam which prompted presumptive treatment for
GBS. A lumbar puncture was not able to be safely performed, due
to his paraspinal fluid collections, and concern for spreading
infection due to their location. Cervical puncture is not
available at this institution. He was treated with 5 days of
IVIG for a total of 2 g/kg, which he tolerated without
difficulty. His respiratory status remained stable. his strength
has improved as of the day of discharge. See discharge exam for
details. At its worst strength was 4 out of 5 in affected
muscles. His workup was negative as follows: GQ1b negative;
neuropathy labs negative (B12 552, folate 6, A1c 5.2%, TSH 3.4,
ANCA negative, ___ negative, SPEP/UPEP (no monoclonal band),
lyme negative, RPR negative)
#elevated lactate -he had elevated lactate of 3 on admission
which peaked at 5, this was fluid responsive and improved to 3,
however did not clear with repeated fluid boluses. Medicine was
consulted, given that he was clinically stable despite elevated
lactate, no further lactates were checked. There did not appear
to be any other causes of elevated lactate like medications on
his medication list. Blood cultures were negative.
#Rim enhancing fluid collection at T12-L2, growing yeast.
-Infectious disease was consulted for this fluid collection.
They recommended ___ aspiration, this was performed under CT
guidance. ___ grew from this fluid collection, the same
species that he had previously grown on another admission as
such this was considered relapsing infection by infectious
diseases he was started on micafungin and his fluconazole
discontinued. Ortho spine did not recommend I&D given patient's
poor wound healing from previous surgeries, and relatively
stable clinical status at the time. He will continue a
micafungin course until ___, at which point he should
start oral fluconazole 400 mg daily again. He has infectious
disease follow-up scheduled. PICC was placed on ___ for IV
abx. He was continued on his doxycycline and atovaquone
prophylaxis.
#depressed mood -he had notably depressed mood during this
admission. Psychiatry was consulted and his sertraline, which
was being tapered previously was increased back to 100 mg daily.
This can be further uptitrated as needed. Hydroxyzine which
she had been on for sleep at rehab was stopped and ramelteon as
needed was started.
#ILD -he continues on his prednisone taper, which is as follows:
40 mg starting ___ to ___, then 30 mg starting ___ to ___,
then 20 mg from ___ to ___, then 10 mg ___ to ___, then off.
Continued Azathioprine uptitration 100 mg starting ___ ending
___, then 150 mg starting ___. Continued protonix,
montelukast, home nebs, glucose monitoring, sliding scale
insulin, Fosamax, and vitamin D. He had no respiratory issues
during this admission and continued on his baseline level of
oxygen.
#RLS
-continued home primidone
#anxiety
- Continue home Xanax 0.5mg TID PRN
#pain
- Continue home gabapentin, Pregabalin
#Hypothyroidism - Continued home levothyroxine 88 mcg
#HTN -increased HCTZ to 25 mg this admission for better BP
control. | 217 | 650 |
18143326-DS-11 | 26,657,028 | You were admitted to the hospital on ___ with perforated
appendicitis as confirmed by CT scan. Because you had continued
pain and the CT scan demonstrated reduction in the inflamation
you were taken to the OR for a laproscopic appendectomy. You
tolerated this procedure well. You tolerated a regular diet and
had pain well controlled with oral medication. Please follow up
with the ___ clinic in two weeks. Please call to make an
appointment at ___. | ___ was admitted on ___ under the acute care
surgery service for interval appendectomy after two weeks of
antibiotic treatment for a ruptured appendix. He was taken to
the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. He
tolerated the procedure well and was extubated upon completion.
He was subsequently taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of ___
to regular, which he tolerated without abdominal pain, nausea,
or vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic. | 76 | 177 |
15216917-DS-17 | 21,091,774 | Continue outpatient ___ for shoulder
Tylenol for pain
Follow-up with Orthopedic Sports Medicine Clinic in 2 weeks | Mr. ___ is a ___ with HTN, HLD, DM, CAD, h/o LV thrombus s/p
CABGx3(LIMA-LAD,SVG-RCA,SVG-OM)and LV thrombectomy with Dr.
___ on ___ who presents with
one day of left shoulder pain. He reported to ___ E.D. per
private car. Upon arrival to E.D. EKG revealed NSR with no acute
changes. Cardiac enzymes negative (CK-MB 2, Trop <0.011).
Shoulder x-ray no acute fracture or dislocation. Chest x-ray no
focal consolidation or pleural effusions. No evidence of deep
venous thrombosis in the left lower extremity veins. He was
admitted for observation to ___ 8 to await orthopedics consult.
Patient was found to have a L rotator cuff
tear. He was instructed to continue outpatient ___ for shoulder,
use Tylenol for pain, and to follow-up with Orthopedic Sports
Medicine Clinic in 2 weeks. Patient was discharged in good
condition with proper discharge and follow-up instructions. | 16 | 141 |
11925350-DS-10 | 24,768,076 | Dear Mr. ___,
You were hospitalized for likely seizures resulting from a
hemorrhage (bleeding) in your head. This could be due to high
blood pressure, as you had very high blood pressure when you
were brought to the hospital. Or there could be some vascular
abnormality that could have led to bleeding. Unfortunately,
cerebral angiogram could not be performed as your kidney
function was poor during this hospitalization. This may need to
be done as outpatient.
PLEASE get an MRI with and without contrast as outpatient in
about 1 month to figure out whether there is some underlying
structural problems for the bleeding. Please call ___
(#1) to schedule MRI for end of ___.
Prior to getting the MRI, you will need to get your BUN and
Creatinine (measure of your kidney function) checked. Please
make sure you go to the ___ and get
your blood checked couple of days before the MRI.
We have started you on multiple blood pressure medications.
Please take them as instructed to prevent high blood pressure.
This is VERY important as you have already had bleeding in your
brain.
1. Take amlodipine 10 mg daily
2. Take hydralazine 50 mg every 8 hours
3. Take labetalol 800 mg every 8 hours
4. Take clonidine tonight and tomorrow morning and then STOP.
Please obtain a primary care physician as soon as possible, so
your blood pressure can be managed in long term. Please followup
with Neurology as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () 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 (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Mr. ___ is a ___ yo M who p/w an episode of LOC (?seizure)
and found to have L temporo-occipital hemorrhage, ___ PRES with
seizure/hemorrhage vs. cavernous hemangioma. Hospital stay c/b
difficult to control BP requiring nicardipine gtt in the ICU. He
was started on multiple medications for his blood pressure and
was transferred to the neurology floor when he was more stable.
# Neuro: Patient found to have L temporo-occipital hemorrhage
with unclear etiology, thought to be ___ PRES vs. cavernous
hemangioma. MRI/MRA was done and did not show underlying mass
but conventional angiogram could not be done in setting of his
acute kidney injury (as below). He was kept in neuro-ICU for
blood pressure control with nicardipine gtt and was started on
multiple medications for blood pressure control including
labetalol, clonidine and hydralazine. Amlodipine was also added.
Risk factors for stroke were checked showed TC=162 ___ HDL=42
LDL=109 and A1C of 5.7%.
For the question of seizures, he was started on Keppra 500 mg
BID (renally dosed) and there were no further episodes
concerning for clinical seizure and his EEG also did not show
epileptiform acitivities. He was monitored in the floor and
evaluated by physical therapy who recommended that he does not
need rehab and can be d/c home.
# Cardiovascular: malignant hypertension with SBP up to 220s,
possible cause of PRES and intracranial hemorrhage. No other
known cardiac risk factors. His troponins became elevated to
0.06 on admission then trended down. When it was rechecked, it
did increase to 0.08, but as his CK-MB was flat, it was thought
to be more likely related to his ___ and decreased excretion of
troponin. His blood pressure was initially controlled with
nicardipine gtt as above and he was started on PO medications
including labetalol, hydralazine and clonidine. As there was
concern for rebound hypertension with clonidine, it was weaned
and amlodipine was started.
Patient does not have a PCP and has not seen a doctor in some
time, but his MRI and TTE did show some evidence of likely
chronic hypertension with white matter changes likely related to
small vessel disease and echocardiogram with LVH consistent with
hypertension. Renal ultrasound was done to look for any vascular
abnormalities that could account for secondary hypertension and
was normal.
# Renal: patient developed ___ during this hospitalization and
nephrology was consulted. It was thought to be due to ATN,
possibly from hypertensive emergency vs. ? hypotensive episode
during his episode of unresponsiveness. Creatinine was 1.5 on
admission, peaked at 4.3 and downtredned to 1.7 at the time of
discharge. Patient has unknown baseline for creatinine given his
lack of PCP.
His CK was also elevated for unclear reason and patient was
given IVF to help clear CK. Rheumatology was also consulted for
elevated CK, ESR and CRP for question of myositis vs. myopathy
vs. systemic rheumatologic disease and did not see evidence of
systemic disease. Per recommendation from renal and
rheumatology, he was treated with IVF and his CK trended down.
# Endo: His A1C was normal at 5.7%.
# Pulmonary: He was intubated initially for ? seizure, but he
was able to be extubated in the ICU and there were no active
respiratory issues after the extubation. | 396 | 622 |
10581221-DS-9 | 24,313,676 | You were hospitalized at ___ for suicidal ideation with a plan
in the setting of acute escalating anxiety.
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way, including having suicidal ideation,
planning, or intent, and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you, and we wish you the
best of health. | This is as ___ year old single Caucasian man, previously
diagnosed with depression, anxiety, currently a senior at ___
___, who presented to ___ as a referral from
his outpatient psychiatric provider with worsening depression,
anxiety, chest pain and suicidal ideation with plan to cut his
wrists or overdose on propranolol.
.
Upon interview, patient reports longstanding history of
depression and anxiety beginning in childhood with recent
worsening of symptoms in the setting of academic stressors,
conflict with family. Given subjective symptoms with low mood,
poor sleep, energy, poor concentration, suicidal ideation,
anhedonia, he likely meets criteria for major depressive
disorder without psychotic features. Also likely meets criteria
for generalized anxiety disorder. However, given the chronicity
of his depression with chronic suicidal ideation, I am also
suspicious of underlying cluster B traits with recent
decompensation. I cannot rule out underlying substance use,
given reports of cannabis use perhaps overuse of Ativan,
although tox screen was notably negative.
.
#. Legal/Safety: Patient admitted on a ___, upon
admission signed a CV, which was accepted. Stating he did not
want to be in the hospital, he also signed a 3 day notice on
___ that expired on ___. Given improvement in
depression, adherence with treatment, denial of suicidal
ideation and good behavioral control, I did not believe he met
criteria to file 7&8b at this time.
Of note, Mr. ___ maintained his safety throughout his
psychiatric hospitalization on 15 minute checks and did not
require physical or chemical restraints.
.
#. MDD, recurrent, severe, without psychotic features/GAD
- Patient was compliant in attending some groups and maintained
good behavioral control throughout his admission. He was active
in treatment and demonstrated improved insight, discussing his
perfectionistic tendencies and how this may affect his mood and
anxiety. Patient allowed the treatment team to contact his
parents, who were supportive in his care.
- After discussion of the risks and benefits, we continued
Sertraline 200 mg po qd, which he tolerated well with no
complaints of side effects. Discussed the risks and benefits of
augmenting this SSRI, and patient agreed to a trial of
risperidone which was started at 0.5 mg po qhs and 0.5 mg po bid
prn agitation. He tolerated the risperidone well with
improvement in mood and anxiety with no unwanted side effects
- For anxiety and insomnia, we discussed the risks and benefits
of Valium, which was started at 5 mg po bid. However, patient
required few doses, and given his overuse of the Ativan, this
was tapered off prior to discharge with no worsening of anxiety
or depression
- Given concern for overdose, propranolol was tapered off prior
to discharge. In addition, patient allowed friend to remove
propranolol from the apartment, which was confirmed by the
treatment team.
- By time of discharge, patient was notably consistently denying
thoughts of suicide or self harm and reported improvement in
mood. He was notably linear, goal and future oriented with plan
to return to ___ and follow up with outpateint treaterse.
#. Hypertension: as above
- Patient weaned off propranolol as noted above with BP's that
remained stable throughout his admission
- Recommend continuing to monitor as an outpatient
.
#. High Cholesterol
-Lipid Panel during admission was elevated, no pharmacologic
intervention initiated
-Recommend re-check Lipid Panel as outpatient | 120 | 540 |
16425412-DS-56 | 25,563,232 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were here because of shortness of breath. We gave you
medications to make you pee out extra fluid. You were seen by
our physical therapists who thought you were safe to go home.
After you leave the hospital, please continue to take all of
your medications as prescribed and attend all of your scheduled
appointments.
Please weigh yourself every day. If your weight goes up by more
than 3 lbs in one day or more then 5 lbs in three days, please
call your doctor.
We wish you the best in the future!
Sincerely,
Your ___ care team. | ====================
PATIENT SUMMARY:
====================
Ms. ___ is an ___ with ESRD s/p renal transplant (___),
rectal cancer s/p abdomino-perineal resection now with ostomy
(___), CAD, DM2, HTN, HFpEF, hepatic fibrosis with biliary
obstruction, and DVT s/p IVC filter who presented with abdominal
pain and decreased ostomy output. In the ED she had a BM that
resolved her abdominal pain. However, she was noted to be SOB
and was therefore admitted for dyspnea on exertion concerning
for heart failure exacerbation. She had a TTE with >65% EF and
mild-mod pulm artery systolic HTN. She was treated with IV
diuresis, which resulted in mild creatinine bump, and
transitioned to back her home Lasix 20mg PO with good response.
She was seen by transplant nephrology for assistance with volume
management. Her dyspnea improved, although it was unclear
whether this was from the additional diuresis she received. She
worked with ___ on day of discharge who recommended that she go
home with home ___.
====================
TRANSITIONAL ISSUES:
====================
[ ] Please continue to monitor volume status as outpatient and
titrate diuretics accordingly.
[ ] She developed swelling in LUE thought to be from blood
draws, which improved. Please assess arm and ensure that the
swelling has improved.
[ ] Please check electrolytes in 1 week ___. Started
on sodium bicarbonate 650 mg PO BID per inpatient renal
transplant team.
[ ] Please continue to monitor ostomy bag and assess for
constipation.
Discharge weight: 118 lbs
Discharge Creatinine: 1.6
Discharge HCO3: 18
Discharge Diuretic: Lasix 20mg PO daily
====================
ACUTE ISSUES:
====================
# Dyspnea on exertion
# Acute on chronic HFpEF (EF 73% in ___
She presented with worsening dyspnea on exertion over past month
and 10 pound weight gain. BNP elevated beyond prior levels. She
appeared mildly volume overloaded on exam. No pulmonary edema on
CXR. Her dry weight was unclear, as she reported 112 pounds a
month ago although it looked like she was standing weight 108
pounds in ___. She had a TTE this admission that showed EF
>65%, mild LVH with normal cavity size and global biventricular
systolic function. No valvular pathology identified.
Mild-moderate pulmonary artery systolic HTN. She was treated
with IV diuresis, after which creatiine trended up slightly from
1.5 to 1.7, at which point lasix was held for one day. She was
then transitioned to her PO Lasix 20mg on ___, which she
tolerated well. She was continued on her home carvedilol,
diltiazem, and hydralazine during her admission. She was 118 lbs
on ___ (standing weight) and thought to be euvolemic.
Ultimately it was uncertain whether or not volume overload was
the cause of her presenting dyspnea, but fortunately her
symptoms improved.
#Subacute on ESRD ___ s/p DDRT ___ w/ CKD stage 3 of renal
allograft
#Metabolic acidosis
Previous baseline was Cr 0.9 - 1.3, which worsened over the past
few months, thought to be secondary to progression of renal
allograft dysfunction. Last admission transplant u/s showed
increasing resistive indices but no acute process. New baseline
appears to be approximately 1.5. Her creatinine on presentation
was 1.5. Transplant nephrology was consulted during her stay for
management of her volume status. She was diuresed as above. She
was continued on her home MMF, prednisone, and prophylactic
bactrim and valacyclovir. Her Creatinine on discharge was 1.6.
She was started on sodium bicarb on the day of discharge as per
renal transplant recs.
#decreased ostomy output
On admission she noted decreased ostomy output and abdominal
pain. However, she had a large BM shortly after admission and
her abdominal pain resolved. She continued to have bowel
movements during her stay and was not constipated. Her
constipation on admission was thought to be from dehydration
given decreased PO related to her dypsnea. However, she should
have careful monitoring of ostomy on discharge for adequate
output.
#LUE swelling
Thought to be secondary to blood draw. LUE US ___ showed no
DVT. Full ROM and sensation in the arm. No evidence of
arthropathy or infection on exam.
====================
CHRONIC ISSUES:
====================
# Hypertension
Continued home hydralazine 10mg PO TID, carvedilol 6.25mg PO
BID, home diltiazem 180mg PO daily.
# Macrocytic anemia
Likely secondary to chronic kidney disease though last admission
it was noted that her B12 had been downtrending over years, most
recently in 500s. Continued home ferrous sulfate.
# Type 2 Diabetes
Continued home repaglinide + ISS
# CAD
Continued home atorvastatin 20mg PO QHS and aspirin 81mg PO
daily
# COPD
Continued home tiotropium and ipratropium albuterol inhalers
# h/o disseminated aspergillosis
With CNS, lung, and mediastinal involvement. No longer on
suppressive antifungal therapy. Continued home Keppra 750mg PO
BID | 106 | 740 |
19787519-DS-7 | 20,127,337 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple 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 could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mr. ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. He tolerated the procedure well and was extubated
upon completion. He we subsequently taken to the PACU for
recovery.
he was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of
___ to regular, which he tolerated without abdominal pain,
nausea, or vomiting. he was voiding adequate amounts of urine
without difficulty. he was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic in ___ weeks. | 777 | 175 |
10554112-DS-17 | 26,641,002 | Dear Ms. ___,
You were admitted to ___ because of leg pain, similar to a
presentation that you've had in the past. You were initially
started on antibiotics but these were stopped because you were
stable and we weren't convinced that you had an infection. We
had consulted our infectious disease and rheumatology doctors to
___ to help figure out your lab abnormalities and muscle pain.
As part of our workup, we checked a toxicology screen, which was
positive for cocaine. Cocaine can sometimes lead to problems
with muscles. As a result, we felt obligated to perform a room
search to protect your safety and for the safety of other
patients. You chose to leave the hospital against medical
advice. You were informed of the gravity of this situation and
understood.
If at any time you start feeling worse and choose to come back
to care, please do not hesitate to come to the ED.
- Your ___ Team | ___ with complex PMH including childhood CML s/p HSCT, RCC s/p
nephrectomy, HCV cirrhosis s/p TIPS and Harvoni, uterine rupture
c/b cardiac arrest (EF recovered >55% in ___, moderate-severe
pulmonary HTN, multiple prior admissions for myositis (believed
to be infectious), admitted for recurrent severe bilateral leg
pain x 3 days consistent with her prior episodes of myositis.
She presented with leukocytosis to 30 and elevated lactate to
3.5, but with stable hemodynamics. Although she had been treated
with antibiotics on previous presentations, infection may be
less likely as pt has never had a positive blood culture. She
did have a positive urinalysis with GNRs in culture, although
she was not having urinary symptoms. Rheumatology was consulted
and did not feel that her presentation was an
inflammatory/autoimmune phenomenon and did not recommend
steroids. A tox screen was added on during admission, which
noted a positive cocaine level in urine from admission,
concerning for a possible cocaine-induced myopathy. A routine
bed search was performed after this was explained to the
patient. She insisted on being discharged AGAINST MEDICAL
ADVICE. She was not discharged on any new medications.
An MRI of the thigh and calf was ordered for further evaluation
of myositis but not completed prior to discharge. Multiple labs
tests were also pending upon discharge (see Results section). | 156 | 216 |
13243285-DS-20 | 27,785,662 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted after a fall that we think
was caused by losing your balance because of your chronic right
knee pain. We also think that you were also more likely to fall
because of the martini you had. You struck your head and
suffered a cut that was stapled in the emergency department.
While this stopped the bleeding, you lost a significant amount
of blood, so we gave you IV fluids and blood. Your blood
pressure was low likely because of this bleed so we reduced your
metroprolol dose and held your lasix. You should restart your
lasix if you noted increased swelling in your legs or if your
weight goes up by more than three pounds. Given your fall, our
physical therapists saw you and recommended that you go to rehab
to regain your strength.
We wish you the best,
Your ___ team | Mr. ___ is a ___ with a history of atrial fibrillation
(not on AC) who presents following an unwitnessed fall with
headstrike in the setting of alcohol intoxication.
# MECHANICAL FALL WITH HEADSTRIKE, LACERATION, and ACUTE BLOOD
LOSS ANEMIA: Likely mechanical in nature given patient's account
of falling ___ to right knee pain with likely significant
contribution from alcohol intoxication given positive serum tox.
He noted no loss of consciousness but had significant bleeding
noted by EMS and was slightly hypotensive on presentation.
Trauma scan in the ED showed no evidence of any acute fracture
or intracranial bleed. Only significant finding on trauma eval
was posterior scalp laceration which was stapled in the
emergency room. Hct on presentation was 27 for which he was
transfused 2U pRBC w/ discharge HCT 24. Diuretic held in setting
of acute bleed. Seen by physical therapy and felt to be a fall
risk and recommended ___ rehab. Admission Hct was 27 in
setting of bleeding from scalp laceration and underlying chronic
anemia (myelodysplastic syndrome). Discharge Hct was 22.7,
likely to dilutional effect of volume resuscitation. He was
given 2U PRBC w/ discharge HCT 24. He has a known baseline
anemia ___ to myelodysplasia thought baseline was unknown. A
reticulycte index showed appropriate RBC production and ferritin
was 58, indicating mild iron deficiency anemia.
# ETOH INTOXICATION: Serum etoh level of 121 on admission. Daily
drinker. No history of withdrawal or seizures. No evidence of
withdrawal during hospitalization.
# ATRIAL FIBRILLATION: not on anti-coagulation for unclear
reason. Home dose of metoprolol is 100mg BID. However, given
hypotension this was changed to 50mg BID. Rates well controlled
in hospital. | 159 | 272 |
18086373-DS-19 | 20,939,507 | Dear Mr. ___,
You were admitted to ___ because you briefly lost
consciousness. We believe this was due to a combination of
dehydration and the beta-blocker medication you are on. We
monitored you overnight and you felt better after some
re-hydration. We talked to your PCP and ___ follow-up with
you within the week regarding this hospitalization.
.
The following medications have been changed:
1. STOP metformin until you talk to your PCP
2. STOP atenolol until you talk to your PCP
3. STOP hydrochlorothiazide until you talk to your PCP
4. STOP captopril until you talk to your PCP
.
Please continue taking your other medications as previously
prescribed. | ___ with history of afib on coumadin, CKD, HTN, DM2 presenting
with syncopal event.
.
# Syncope: Presentation, orthostatic vital signs and slight ___
on presentation is most consistent with some element of
dehydration, likely in setting of minor alcohol intake.
Orthostatics here indicated inappropriate heart rate response to
low blood pressure so element of excessive beta-blockade is
possible as well. Neurogenic causes were not supported by
history so were not pursued. There is no indication of valvular
disease on exam or history that could be contributing. Troponins
were negative and EKG showed only some interventricular
conduction delay and bradycardia. Patient was given 1L normal
saline and his creatinine returned to baseline. He was able to
walk around the unit without recurrence of his symptoms. His
beta-blocker was held at the time of discharge.
.
# Hypokalemia: No signs of GI or renal losses. He was
bradycardic on telemetry but no signs of ectopy. His K was
repleted and was 3.7 at the time of discharge. His HCTZ was held
at discharge given his initial hypovolemia.
.
# ___: Baseline creatinine is 1.6-1.9. Presented with elevation
to 2.2 and FeNa<1. Resolved with fluids so suggestive of a
prerenal picture. Captopril was held.
.
# DM/IGT: Metformin held on presentation given his ___. Per PCP,
___ HBA1c has been in the ~6 range for the past year and
he has never had problems with hyperglycemia. Metformin was held
at discharge until patient can discuss further glycemic
management with his PCP.
.
# Anemia/Thrombocytopenia: Hct was 33.5, Plt 118 which is
approximately ___ baseline. Patient was hemodynamically
stable with no signs of active bleeding.
.
# Hypercalcemia: Presented with a mildly elevated calcium of
10.4 which corrected after normal saline. Per PCP, patient has
history of mild calcium elevation in the past with workup
including PTH, vitamin D, and total protein levels being
unrevealing.
.
# HTN: Patient was normotensive throughout his stay and
hypotensive on admission. His amlodopine was restarted at
discharge but his other anti-hypertensives were held.
.
CHRONIC ISSUES
# Atrial Fibrillation: Remained in sinus bradycardia (HR 35-50)
with therapeutic INR on warfarin. His INR was rising so his
coumadin was decreased to 4mg on day of discharge with plan to
resume regular home dosing and check INR later this week.
Atenolol was held at discharge.
.
# Hyperlipidemia: Simvastatin 40mg was continued.
.
# Gout: Continued allopurinol
.
TRANSITIONAL ISSUES
- Given ___ persistent bradycardia and its potential
contribution to his presentation, patient should continue to
discuss with his PCP and outpatient cardiologist as to whether
1) change in beta-blocker is indicated or tolerated 2) if
beta-blockade fails, a pacemaker might be indicated
- Patient will need careful re-evaluation of his volume status
and clinical picture before re-starting his including HCTZ,
beta-blocker, and captopril
- Glycemic control with metformin should be readdressed given
___ kidney disease and his low HbA1cs
- Patient should have a repeat CBC to evaluate his anemia and
thrombocytopenia
- Iron studies were pending at the time of discharge
- Consider decreasing simvastatin to 20mg QHS due to potential
interactions with amlodipine | 104 | 494 |
12568708-DS-21 | 21,115,561 | Dear Ms. ___,
It was a pleasure taking care of ___ during ___ recent admission
to ___ came to us because your lab work
at Dr. ___ showed that your potassium level was high
and your kidneys were not working as well as they should. We
gave ___ medications to lower your potassium. We also stopped
your medication called lisinopril, which we think may have
caused your high potassium. Your blood pressure was low so we
gave ___ fluids that improved your blood pressure and also
helped your kidneys. We also stopped your water pills called
Lasix and spironolactone.
Weigh yourself every day. If your weight increases by more than
3 pounds, call Dr. ___ (___). We also increased your
lactulose to four times a day. Please make sure ___ are having
___ bowel movements a day. If ___ are having more than this,
please decrease lactulose to three times a day.
We wish ___ the best of health.
Sincerely,
Your ___ Team | Ms. ___ is a ___ y/o woman with history of NASH cirrhosis
c/b Grade I esophageal varices and hepatic encephalopathy, HTN,
DM, hypothyroidism who presented with ___ (creatinine 1.2 from
baseline 1.0) and hyperkalemia (K+ 5.7) found on routine
outpatient lab work. For her hyperkalemia, she was given
insulin, dextrose, kayexalate, and calcium gluconate to good
effect. Her home lisinopril was held. When she was admitted, she
was found to be somnolent with systolic blood pressure in the
___. She was given 1L of IV fluids with improvement in her blood
pressure and her mental status. She was also given albumin 25%
50 g x1, with resolution of her ___. Her creatinine on discharge
was 0.8. The patient's Lasix and spironolactone were held. She
had an anemia below her baseline that was thought to be
dilutional. She did have an episode of small-volume bright red
blood per rectum. She remained hemodynamically stable and her
H/H after the episode was 7.8/24.4.
============== | 159 | 160 |
14709510-DS-6 | 29,342,491 | Dear Mr. ___,
You were admitted to the neurology service because of your new
weakness and trouble with vision. We performed an MRI of your
brain which showed that cancer has spread to your brain. The
radiation oncology team discussed treatment options with you. We
understand that you would like to receive 10 days of radiation
therapy beginning on ___ prior to your return to
___.
We have given you prescriptions for Decadron 4 mg po Q6h, Keppra
1000 mg BID, with daily PPI and Bactrim ___ for prophylaxis.
It was a pleasure to care for you.
Best regards,
The ___ Neurology Team | Mr. ___ was admitted for imaging of his head and chest/abdomen
given known metastatic lesions in lungs and liver in the context
of 1-week of ataxia and left-sided symptoms.
Head MRI with and without contrast on ___ showed innumerable
and predominantly parenchymal enhancing lesions in a peripheral
distribution compatible with multiple metastatic foci throughout
cerebral and cerebellar hemispheres. The majority of the masses
are hemorrhagic. The disease burden is worse in the left frontal
and parietal lobes, where there is significant surrounding
vasogenic edema resulting in diffuse sulcal effacement, mild
leftward 3 mm midline shift and effacement of the anterior and
posterior horns of the right lateral ventricle. In addition,
there is a predominately right-sided falcine lesion and there is
a right posterior parietal lesion that is extra-axial and dural
based.
Abdominal CT with and without contrast on ___ showed:
1. Indeterminate left adrenal lesion concerning for metastatic
disease
2. Several liver lesions are consistent with cysts however a
lesion in segment
___ has a thickened somewhat nodular wall and is concerning for
metastasis.
3. Bladder wall thickening consistent with known history of
bladder cancer
4. Enlarged prostate gland
5. Subcentimeter hypodense lesions in the kidneys are too small
to characterize but statistically most likely represent cysts
Chest CT with and without contrast on ___ was difficult to
interpert due to respiratory motion. Unusual pulmonary lesions
were noted, some of which were thought to possibly be
metastases, although they were not characteristic appearing. The
differential for these findings was felt to include reactivation
of TB, in addition to known metastases.
Given the high number of hemorrhagic masses found on head MRI,
it was concluded that the patient's symptoms were due to
metastatic lesions from either bladder or lung (lung being
statistically more likley and possible given heavy smoking
history, but bladder being more likely given that pulmonary and
hepatic lesions were previously found to be metastasized from
bladder). Neuro-oncology and radiation oncology were both
consulted, and treatment options were discussed. Ultimately it
was decided that Mr. ___ will receive 10 days of radiation
therapy beginning on ___. Following a one week period
of recuperation he will return to ___, per his wishes.
He was discharged home with prescriptions for Decadron 4 mg po
Q6h, Keppra 1000 mg BID, with daily PPI and Bactrim ___
prophylaxis. | 100 | 386 |
13370248-DS-21 | 23,983,022 | Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
with abdominal pain and found to have a bowel obstruction. You
were taken to the operating room and had a piece of intestine
removed and your intestines put back together. You are now doing
better, tolerating a regular diet, and ready to be discharged to
rehab to continue your recovery from surgery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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. | ___ Course:
The patient presented to the hospital with closed loop
obstruction and underwent Ex-lap SBR of necrotic bowel and
reanastomosis (___). She tolerated the procedure well and
was transferred to the ICU intubated on pressors. During her ICU
course she was slowed weaned off the ventilator and extubated on
POD 3.Her pain was well controlled with IV pain medication. She
was weaned off pressors on POD 2 and remained hemodynamically
stable. She was noted to have RLE swelling and concern for
hematoma of the R femoral CVL. Duplex and CT of the lower
extremity done that demonstrated common femoral vein thrombus.
The CVL was subsequently removed on POD 2 and she was started on
heparin gtt. She had mutliple bowel movemnts on POD 3 with low
NGT output. She was transferred to the floor on POD 4. | 362 | 139 |
17452052-DS-20 | 26,889,086 | Dear Ms. ___,
Why you were here?
- You came in to ___ because you had a GI bleed with blood in
your stool.
What we did while you were here?
- You had a procedure with interventional radiology to stop the
bleeding.
- We monitored your blood counts after the procedure.
What you should do when you go home?
- You should take all of your medications as prescribed
- You should continue to not smoke cigarettes
- You should follow up with colorectal surgery
- You should follow up with the liver doctors ___ your
___ of hepatitis C and evidence of cirrhosis on imaging.
It was a pleasure taking care of you!
Your ___ Team | This is a ___ year old woman with a chronic hepatitis C with
possible cirrhosis, bipolar disorder, heterozygous prothrombin
gene mutation, history of spontaneous hematomas, and history of
CVA on Plavix who presents with large volume lower GI bleed
requiring 4u pRBCs and pressors, now s/p embolization with ___.
Her CBC was monitored and she remained hemodynamically stable
with no additional evidence of bleed. | 107 | 65 |
14553598-DS-19 | 23,439,649 | Dear Ms ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a pneumonia from a bacteria called MSSA
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You went to the hospital and went to the ICU
- You had a tube down your throat to help you breath
- You did well and were transfer to the ___ floor
- You were found to have a clot in your neck from the IV
catheter
- You will need t continue antibiotics until ___
- You will not need any blood thinners for your blood clot, your
body will absorb it naturally.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you notice neck swelling, contact your pcp or come the
emergency room to have and ultrasound of the right neck to see
if the clot is getting worse..
- The infectious disease doctors ___ contact ___ to make a
follow-up appointment.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old female with a history of tobacco
use, gastric bypass, biliary dilation s/p
PTC/sphincteroplasty/delayed cholecystectomy, who was admitted
to the MICU with multifocal cavitary pneumonia, found to have
MSSA on bronchoalveolar lavage. She was continued on nafcillin,
with good response. Her ICU course was complicated by prolonged
AMS. Her CT brain showed an incidental small subarachnoid
hemorrhage which was stable on further imaging with no evidence
of aneurysm on CTA, however did show a Right IJ non occlusive
thrombus at the site. She was stared on heparin drip. Hematology
and neurosurgery were contacted for help in deciding
anticoagulation. Ultimately, hematology oncology recommended no
further anticoagulation as patient had a provoked DVT and now no
longer has the right IJ line in place.
#Septic Shock
#MSSA-associated necrotizing pneumonia complicated by abscess
The patient was admitted for pneumonia and transferred to the
ICU in septic shock and was intubated and sedated. MSSA was
isolated on BAL and blood culture. She was found to have
cavitating lesion diagnosis with MSSA-associated necrotizing
pneumonia. ID was consulted on admission to the ICU and
continued to follow the patient. The patient was narrowed to
nafcillin 2g IV Q4H with excellent clinical response. She will
continue antibiotics Start Date: ___ until End Date:
___. ID will contact the patient to coordinate follow up
appointment and imaging as well as determine if further
antibiotics are necessary.
#Diarrhea:
Patient with diarrhea since starting nafacilin. C diff was
checked on ___ at was 463. Diarrhea likely due to side effects
from antibiotics. She was stared on loperamide with good effect.
# R proximal IJ nonocclusive thrombus:
The patient was found to have a nonocclusive right proximal IJ
thrombus on CTA of head and neck due to her central line
placement. She has no previous history of blood clots. She was
stared on heparin drip. Given her subarachnoid hematoma, she
had serial Ct scans and neruo checks. CT scan once therapeutic
on heparin did not show worsening of sub arachnoid hemorrhage.
Ultimately, neurosurgery was contacted and cleared the patient
for oral anticoagulation if indicated. Given the lack of data in
this circumstance hematology was consulted recommended no
further anticoagulation as patient had a provoked DVT and now no
longer has the right IJ line in place.
#Subarachnoid Hemorrhage
The patient was found to have an incidental small left SAH
discovered on CT head for workup of AMS in the ICU. Repeat CT
scan showed that the SAH was stable. The patient denied any
recent falls. Neurosurgery evaluated the patient and recommended
no further workup or management of subarachnoid hemorrhage.
#QTC prolongation:
Patient with long QTC on EKG. Medications reviewed. Methadone
and
PPI are most associated with elevated QTC. Pantoprazole was
discontinued and methadone was reduced to 40mg. On discharge QTC
on ___ was 464
#Opioid dependence
The patient was continued on 40mg methadone daily with good
effect. She will continue to follow with ___.
# Bradycardia:
Cardiology consulted for asymptomatic bradycardia while sleeping
and toileting and concern for AV block. Both episodes of
bradycardia captured on telemetry were reviewed and most likely
consistent with a vagal etiology, with gradually increasing PP
and PR intervals. Supporting this is also the fact that the
patient was sleeping and asymptomatic during these episodes.
Endocarditis has also been ruled out with TEE earlier this
admission. The patient has no cardiac history. Cardiology
recommended that pacemaker was indicated at this
time, and she would also be a poor candidate for one in the
setting of her recent bacteremia. No follow-up was recommended.
CHRONIC ISSUES
==============
#Hypertension
-Home lisinopril was increased from 20 mg daily to 40mg daily.
-Home HCTZ was discontinued.
#GERD
-Pantoprazole was discontinued in setting of prolonged QTC. QTC
at discharge on ___ was 464. The patient was started on
ranitidine with good effect.
#Asthma
-Continue inhalers | 176 | 626 |
17636971-DS-13 | 20,927,831 | Dear Mr. ___,
You were hospitalized due to symptoms of stuttering, imbalance
and vertigo resulting from a TRANSIENT ISCHEMIC ATTACK (TIA), a
condition where a blood vessel providing oxygen and nutrients to
the brain are temporarily decreased. The brain is the part of
your body that controls and directs all the other parts of your
body, so a TIA can result in a variety of symptoms.
TIA's can have many different causes, so we assessed you for
medical conditions that might raise your risk. In order to
prevent future strokes and TIAs, we plan to modify those risk
factors. Your risk factors are: high blood pressure, high
cholesterol, and atrial fibrillation.
You will continue your home dose of pravastatin, metoprolol, and
warfarin.
We also had to put a foley catheter in you because you were
unable to urinate and ended up retaining a lot of urine. Your
primary care doctor ___ remove this foley in 1 week.
Please take your other medications as prescribed. Please ensure
that you continue to get regular INR checks with your ___/
___ clinic.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization. | #TIA
Mr. ___ is a delightful ___ gentleman with h/o AFib on
Coumadin, s/p PPM for bradycardia, HTN and HLD who presented to
our ER with 2 days of stuttering, severe gait imbalance (falling
backward) and dysarthria. Also had transient room-spinning
vertigo and pulsatile tinnitus in the left ear. While may
features of his vertigo appeared to be suggestive of a
peripheral process, the associated dysarthria was very
concerning for a central process such as a small cerebellar
infarct or TIA. A CT/CTA was done in the ER which showed
athersclerotic changes but no occlusion, stenosis or dissection.
He was admitted to the stroke service for further workup and
monitoring.
While admitted, an MRI was unable to be performed because of his
pacemaker. He did have recurrence of his vertigo overnight;
however, his exam improved significantly to the extent where he
was able to stand up and get to his chair and walk (with
assistance) without the marked ataxia noted on initial exam. He
has known Afib and is already on warfarin; his INR was
therapeutic during admission. Therefore, we continued it at his
current home dose of 2.5 mg 4 times a week, and 3.5mg 3 times a
week. His INR will be followed by the ___
clinic (every ___ and ___. We spoke to your clinician
___ ___ ext 7) who confirmed this.
Risk factor screening revealed an LDL of 60 and he was continued
on his Pravastatin 60 mg PO DAILY . His HbA1C was found to be
6.0.
#PERIPHERAL NEUROPATHY
Mr. ___ was noted to have decreased sensation and
proprioception in a distal symmetric pattern (notable in b/l
lower extremities) and screening labs including vitamin B12,
folate and TSH were sent. These were all normal.
#REHABILITATION
___ was consulted who felt he would be safe to go home and will
benefit from home ___ to address lack of pacing insight and to
progress pt to regular home
exercise regiment in this baseline very active elderly male.
#ATRIAL FIBRILLATION
He has known Afib and is already on warfarin; his INR was
therapeutic during admission. Therefore, we will continue it at
the current dose. He will require regular INR checks as prior.
#URINARY RETENTION
Mr. ___ was noted to have urinary retention during his
admission and a foley was placed. A trial of void was attempted
prior to discharge, and while he initally did well, he again had
retention. Urology was consulted, who placed another foley and
recommend that the foley be in place for ___ days for bladder
rest and urethral trauma. They also recommended discharging him
with the foley with a plan that it be removed in 1 week by his
PCP. We called his PCP's (Dr. ___ office and were informed by
one of the Nurse Practitioner's at the office that this will be
feasible and that they will call him after discharge and set up
a time for him to come in for foley removal. If his urinary
retention continues, you can consider starting tamsulosin 0.4mg
qHS.
Mr. ___ will follow up as outpatient with Stroke Neurology as
well as his primary care doctor. He will get INR checks through
his ___ service/ ___. | 196 | 522 |
11592968-DS-10 | 25,692,931 | Dear Mr. ___,
It was a pleasure being part if your care at ___. You were
admitted to the intensive care unit due to a lung infection
(pneumonia) and difficulty breathing. You required intubation to
help you breathe. You were also treated for a rapid heart rhythm
which required cardioversion (electric shock). You subsequently
recovered.
After discharge, please follow up with your providers at your
rehab facility.
It was a pleasure being part of your care.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with history of prior CVA and
resulting right hemiparesis and aphasia, insulin dependent
diabetes, dysphagia with g-tube dependence, and recent
admissions for PNA ___ ___ and ___ who presented from ___
with altered mental status, ___ shock (likely pulmonary source)
with course c/b respiratory failure requiring intubation,
hypernatremia, hyperglycemia and ___.
# Hypoxic respiratory failure:
Initially secondary to healthcare associated pneumonia. He was
extubated ___, but required re-intubation ___. Acute
precipitant for recurrent hypoxia appeared transient,
potentially mucus plug ___ setting of initially decreased right
sided lung sounds which cleared with positive pressure
ventilation. He was noted to have pulmonary edema on CXR after
initial fluid resuscitation. Details of subsequent diuresis as
below.
# Shock (resolved):
# Healthcare associated pneumonia:
He presented with imaging concern for pneumonia and sputum
culture revealed coag+ staph and GNRs. Likely secondary to
aspiration of secretions. He initially required phenylephrine
and vasopressin for BP support (ended ___. Finished 7 day
course of vanc/meropenem (initially vanc/cefepime) as of ___.
Scopolamine patch was started for secretion management.
# Toxic metabolic encephalopathy:
Likely due to sepsis and ICU delirium. This improved markedly
after extubation.
# Abnormal CT head:
CT head showed subtle hypodensity ___ the left cerebellum,
suggestive of acute or subacute infarct. He is already on
medical therapy for CVA and was not a TPA candidate. Consider
brain MRI if further evaluation is indicated ___ outpatient
setting.
# Hypernatremia:
He had hypernatremia on admission likely secondary to free water
deficit, which fluctuated during his admission and was
controlled with D5W infusion and tube feed free water flushes.
#Hyperglycemia:
He had hyperglycemia on admission with anion gap, likely
triggered by infection and dehydration. Suspect worsened by
dehydration, ___ and decreased urine output causing decreased
clearance/increased concentration of blood glucose. He was
briefly on insulin gtt and transitioned to SC Lantus / Regular
scheduled insulin per ___ diabetes consult. See medication
list for discharge insulin dose.
# History of subsegmental PE:
He was continued on home warfarin which was adjusted as needed.
# SVT:
He had multiple runs of SVT on ___ which were accompanied by
hypotension. This was potentially triggered by sympathetic surge
due to concurrent fever. He was cardioverted a total of 5 times
on ___, with return to sinus rhythm each time. He was placed on
amiodarone load with no recurrence of his SVT. Amiodarone was
subsequently continued for several days, and stopped on ___ per
cardiology recommendations given acute stressors leading to SVT
are thought to be resolved.
# Anemia:
He required 1u PRBCs on ___ and ___, with no evidence of gross
clinical bleeding. Anemia likely secondary to marrow suppression
from acute illness, and ongoing phlebotomy. Hemoglobin responded
appropriately to transfusion.
# Thrombocytopenia:
Likely secondary to sepsis vs medication side effect from
cefepime. Cefepime was switched to meropenem to complete
antibiotic course and platelet count recovered.
#History of CVA:
- Aspirin was held when platelets were below 50 and restarted
when platelet count recovered as above.
#Dysphagia, Malnutrition:
He was continued on tube feeds.
#GERD: Continued PPI | 76 | 492 |
16447263-DS-20 | 21,102,565 | You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple 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 could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute appendicitis. She was taken
to the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She was subsequently taken to the PACU for recovery. She was
hemodynamically stable. Her vital signs were routinely monitored
and he remained afebrile and hemodynamically stable. She was
initially given IV fluids postoperatively, which were
discontinued when she was tolerating PO's. Her diet was advanced
on the morning of ___ to regular, which he tolerated without
abdominal pain or vomiting. She had one episode of nausea, which
was likely caused from activity in preparing for discharge. She
felt better soon after. She was given one dose of oral zofran
and tea/crackers. She was voiding adequate amounts of urine
without difficulty. She was ambulating well independently. Her
pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, Mrs. ___ was discharged home with scheduled follow
up in ___ clinic. | 777 | 189 |
10020852-DS-21 | 23,905,070 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were evaluated for shortness of breath. You were seen
by the pulmonary team and had a CAT scan and a bronchoscopy in
addition to a number of lab tests.
You were treated for pneumonia with antibiotics while you were
hospitalized.
The results of your studies indicate you likely have
Eosinophilic Granulomatosis with Polyangitis (EGPA). You were
started on steroids which will treat this condition. You have
also been given new inhalers to help your breathing. It is
important that you stop smoking and vaping. You were started on
Chantix to help with this. While you take steroids, you should
take a medication to protect your stomach and calcium with
vitamin D to protect your bones. You have also been started on
an antibiotic to prevent an infection while you are on steroids.
You were found to have high blood pressure during your
hospitalization. You have been started on new blood pressure
medications.
It is important that you follow up with your PCP and with the
pulmonary team on discharge. Your primary care doctor ___ refer
you for an echocardiogram.
We wish you the best,
Your ___ Care team | Ms. ___ is a ___ female with the past medical
history of tobacco use, THC vaping, exercise induced asthma and
DVT/PE (one in ___ and another in ___ post-surgery
immobilization) who presents with worsening cough and SOB x 1
week.
#Eosinophilic Granulomatosis with Polyangitis
#Pneumonia
#?Asthma Exacerbation
The patient presented with worsening cough and shortness of
breath. CT scan on admission showed multifocal pneumonia. The
differential for the patient's presentation included EGPA vs AEP
vs Vaping related lung disease, with less likely APBA or
Coccidioides. The patient was also noted to have a significant
peripheral eosinophilia. She was initially started on
Ceftraixone/azithromycin for treatment of CAP. Which was
transitioned to Vancomycin when sputum from BAL was +for MRSA-
she was ultimately transitioned to clindamycin to complete a 5
day course of antibiotics. Following bronchoscopy, the patient
was started on Prednisone 60mg daily, She had a CT sinus which
did not show evidence of EGPA. She was also evaluated by
dermatology who found no skin lesions to biopsy. Ultimately,
the patient's ANCA (PR3 antibodies) returned positive. In
addition she was found to have a significantly elevated IgE. The
combination of ANCA positivity, eosinophilia, lung findings are
consistent with EGPA. The patient was discharged on Prednisone
40mg daily to continue until close pulmonary follow up. She was
continued on a PPI and started on atovaquone for PJP ppx. She
was also started on Advair. ECG was without significant
abnormalities. The patient will need an echocardiogram as an
outpatient to asses for cardiac involvement of EGPA. The patient
had significant improvement in her symptoms prior to discharge.
#Hypertension
The patient was noted to have significantly elevated blood
pressures. She was started on HCTZ which was uptitrated to 50mg
Daily and then amiodarone was added. Blood pressures not
optimally controlled on discharge. Will likely require
additional titration
#Vulvovaginal candidiasis:
- Patient was given Fluconazole x2 | 197 | 308 |
18653102-DS-8 | 26,077,729 | Dear Mr. ___,
You were admitted to ___ on ___ after you had worsening
left flank pain and found to have kidney stones there, which
also were worsening your kidney function.
You were given IV fluids with pain medications, and had a stent
placed on ___. You were monitored post-operatively for
bleeding, kidney function. Your kidney function is returning to
your baseline now.
We held your medication called "Plavix" as it can increase
bleeding and you dont have a absolute condition to be on it.
Your losartan was also stopped given your kidney function was
lower and your blood pressures were stable without Losartan so
it was not restarted. Please discuss this with your primary care
doctor whether you should resume these medications.
PLEASE CALL ___ at the ___ clinic for follow up in
2 weeks. They will do a non-contrast CT scan at that time to
assess residual stone burden and make plan for definitive
treatment then.
We wish you the ___
Your ___ care team | ___ yo M with history of prior nephrolithiasis w most recent
episode ___ years ago, BPH, CAD s/p PCI, DMII, HLD presenting
with left flank pain, ___, nephrolithiasis w/ hydroureter, with
urological stent placement ___.
# Nephtolithiasis
# Acute renal failure
He had L sided nephrolithiasis with hydroureteronephrosis, given
no stones passed and no change in renal function, he had stent
placed on ___ for 2 ureteral stones. He had a foley catheter
placed after procedure and had some bladder spasms as well as
prostatic bleeding, improved with irrigation. Renal failure
improved with IV fluids. Pain control done initially with IV
medications, transitioned to oral medications with good effect.
He was started on tamsulosin daily. Plavix was held given no
clear indication for him to be on this medication given no
recent coronary stenting. Creatinine was improving on discharge,
foley removed and patient was voiding well. Plan for follow up
in ___ clinic in 2 weeks for non-contrast CT scan to assess
residual stone burden and make plan for definitive treatment.
# Abdominal distension: No tenderness, likely from stool
content. Started and improved on bowel regimen.
CHRONIC ISSUES:
# DMII: held metformin, glipizide and liraglutide while
inpatient and given renal failure. Continue on home insulin
regimen.
# OSA: CPAP
# CAD: ASA, metoprolol, Lipitor continued, Plavix held
# BPH: continued finasteride
# HTN :continued amlodipine, hydralazine. Held losartan given
acute renal failure, BPs remained stable without it.
# HLD: continued ezetimibe and lipitor | 163 | 247 |
16859501-DS-15 | 27,253,344 | Estimada ___ Hernández,
Fue admitido ___ hospital ___ y dolor
abdominal, así como el empeoramiento del dolor y ___ depresión de
nuevo. Nos encontramos con ___ de pruebas,
___ de imágenes del interior ___ abdomen y el
___ no mostró ninguna anormalidad. Creemos ___ dolor
de ___ surgió de los músculos ___. Mientras estaba ___
___ hospital, nos ___ y paracetamol para ayudar con
___ y dolor de espalda. También ___
casa.
También hablamos ___ de ánimo deprimido. Te vieron
por ___ psiquiatría, ___ pensaron ___ podría ___
a un psiquiatra, además ___. También hablamos con ___
___ para ___ de ánimo ___
y lo ___ había ___ hospital.
También nos ha dicho ___ usted ha ___ teniendo caídas
repetidas en casa. Creemos ___ esto se debe en ___
___ de sus problemas de espalda baja y ___ disminución de
___ de líquidos. Tuvimos nuestros fisioterapeutas ___
___ el fin de ___ y resistencia. Con el fin
de garantizar ___ son ___ en casa, usted está ___ de ___
___ centro de rehabilitación aguda para ayudarle a obtener más
___ y ser más estable en sus pies.
___ vez ___ esté ___, usted debe asegurarse de ___ el
seguimiento con ___ y el PCP, con ___ citas
programadas.
Si usted encuentra ___ usted está pensando en hacerse daño o
___, usted debe venir directamente de vuelta al
servicio de urgencias.
Fue un placer cuidar de usted.
___ de ___
=============================
Dear ___,
You were admitted to the hospital due to new chest and abdominal
pain, as well as worsening back pain and depression. We ran a
lot of tests, including taking pictures of the inside of your
abdomen and chest, which did not show any abnormalities. We
think that your chest pain arose from the muscles in your chest.
While you were in the hospital, we gave you ibuprofen and
acetaminophen to help with your chest and back pain. We also
continued your home gabapentin.
We also discussed your depressed mood. You were seen by
psychiatry, who felt you could benefit from seeing a
psychiatrist in addition to your therapist. We also talked to
your therapist to update her on your mood recently and what had
brought you into the hospital.
You also told us that you have been having repeated falls at
home. We think this is in part due to weakness from your lower
back problems and decreased fluid intake. We had our physical
therapists see you in order to assess your stability and
strength. In order to insure that you are safe at home, you are
being discharged to an acute rehab facility to help you get
stronger and become more stable on your feet.
Once you are home, you should make sure to follow-up with your
therapist and PCP, with whom we have scheduled appointments.
If you find that you are thinking about hurting or killing
yourself, you should come straight back to the ED.
It was a pleasure taking care of you.
Your ___ team | Patient is a ___ year old woman with a history of HTN, cervical
and lumbosacral radicular pain, unconfirmed report of recurrent
pericarditis, and depression who presents with new chest and
abdominal pain in the setting of chronic back pain, recurrent
falls, and depression with passive SI.
ACTIVE ISSUES
============
#Depression with passive SI: The patient reported anhedonia,
depressed mood, and passive suicidal ideation consistent with
major depression, with strong contributions from death of her
daughter, recent death of partner, and chronic pain severely
limiting her activity. She was evaluated by psychiatry, who
determined that her suicidal ideation was passive with no need
for ___ or a sitter, but recommended a ___ speaking
PHP after discharge from rehab and ultimately a psychiatrist.
She was also continued on her home escitalopram and trazodone.
Her outpatient therapist, ___ (___)
was contacted regarding her hospitalization.
# Falls, Weakness and Orthostasis: The patient reported
recurrent falls, which she attributed to weakness in her left
leg as well as dizziness. She was found to be orthostatic on
physical therapy evaluation, with high risk for falling. Her
falls were ultimately thought to be multifactorial in etiology,
with contributions from neuropathic pain, deconditioning, and
orthostasis secondary to poor PO intake. Her pain was managed as
decsribed above and her home antihypertensives were held. She
was given IV fluids, and her orthostatics were rechecked, with
normal pressures. She was discharged to rehab.
# Chronic back and neck pain with left sided sciatica: The
patient presented with worsening chronic back with left sided
sciatica, for which she has been seen in an outpatient pain
clinic. She had no urinary retention, constipation, or saddle
anesthesia to suggest cauda equina syndrome. Her pain was
managed with ibuprofen 400 mg Q6H alternating with acetaminophen
650 mg Q8H, with gabapentin 600 mg QHS. She was seen daily by
physical therapy, who recommended discharge to rehab.
# Musculoskeletal chest pain: The patient presented with chest
pain, reportedly similar to prior unconfirmed episodes of
pericarditis. On physical exam, she had a normal rate and
regular rhythm with normal S1, S2 and no murmurs/rubs/gallops,
and her lungs were clear. Her pain was reproducible with
palpation of her sternum. She had a normal CXR, and her EKG was
similar to prior. Her labs revealed a normal CRP, negative
troponins x 3, and normal lytes. There was no evidence for
pericarditis, ACS, or PE, and ultimately her chest pain was
thought to reflect a musculoskeletal etiology, such as
costochondritis. Her pain was managed with ibuprofen and
acetaminophen.
# Abdominal Pain: The patient presented with diffuse abdominal
pain. A liver ultrasound was normal with no evidence of
cholecystitis. An abdominal CT with contrast was reassuring,
with no acute abnormalities. Her labs showed a normal lipase and
bilirubin with mildly elevated transaminases that downtrended to
normal over the hospitalization. She was continued on her home
omeprazole.
CHRONIC ISSUES
==============
# Hypertension: Given the patient's dizziness, her home
antihypertensives (chlorthalidone and atenolol) were held during
hospitalization. Her blood pressures remained normal throughout
hospitalization(SBP 110s-130s) so she was not restarted on her
home antihypertensives for discharge. | 489 | 508 |
18784275-DS-13 | 27,302,617 | Dear ___,
___ was a pleasure participating in your care at ___. You were
admitted for a Left fractured tibial plateau fracture which was
treated by the orthopedics department using an external fixator.
The next phase of your tibial fracture operation will be
schedueled.
While you were here you also began experiencing atrial
fibrillation and atrial tachycardia. We gave you medication
which slowed your rate and normalized your heart rhythm which
returned and stayed in a normal pace. | ___ y/o woman with history of dementia and a baseline of AOx2 who
recently suffered a L tibial plateau fracture s/p fall, and was
discovered to be experiencing multiple random unsustained bouts
of tachycardia/a-fib.
#Ortho: After the patient was cleared from the recovery room she
was transported to the floors, where her leg was elevated and
pain was controlled with morphine. The final external fixator
construct was highly satisfactory to the surgeons and the
proximal tibia will most likely require fixation in a staged
manner once the soft tissue edema improves. Pt. received lovenox
qd as she has been NWB for DVT ppx. Doppler checks were
performed daily to rule out compartment syndrome. DP pulses were
palpable B/L and ___ pulses were dopplerable on the L initially
and palpable after resolution of edema, and palpable on the R.
Pin care and Silver Sulfadiazine 1% Cream have been applied by
the nursing staff daily. Pt. will need to return to the
___ clinic in one week (rehab needs to make appointment)
for a skin check and to follow up with the staged reduction of
the tibial plateau fracture and removal of ex fix.
Noted that patient had a right tibial fracture which was
examined under fluoroscopic
imaging and was tested under significant valgus stress in the
operating room. The proximal tibia plateau fracture did not
depress any further during manipulation suggesting that it is
likely an old fracture with a new tibial eminence fracture which
does not require surgical intervention. CT scanning confirmed
the chronicity of this fracture. The patient is weightbearing
as tolerated in the right leg, and can wear a brace for support.
While recovering from surgery the patient developed anemia and
was transfused 1 unit of PRBC. This anemia was most likely due
to bleeding from the pin sites. The patients hematocrit
stabilized after the infusion and the bleeding from the pin
sites ceased.
#Leukocytosis: The patient presented with a white count of 19.8.
She had an infectious workup which was negtive. We followed her
WBC and watched as it down trended over the course of her stay.
We believe the leukocytosis was due to the trauma and resolved
with the ongoing stabilization of her fracture.
#Hyponatremia: The patient also experienced hyponatremia which
was most likely from pain and hypovolemia, and the continued
stress from surgery. Morphine was used to treat her pain and
normal saline was also given, which normalized her sodium.
#Aspiration: As we attempted to give the patient PO meds the
nurse noticed that she was having great difficulty swallowing
her pills by mouth. For that reason we did not progress her diet
and consulted the speech and swallow service. She had a video
swallow study performed which confirmed that patient is grossly
aspirating everything including all liquids. It was their
recommendation that nothing is safe by mouth at this time. If
however, the family wanted to accept these risks, then the
safest diet would consist of nectar and puree. If the patient
were to refuse this, it was mentioned that regular liquids do
carry a higher risk of aspiration. After the risks of aspiration
and dangers associated with eating/drinking by mouth were
discussed with the family, the family accepted the risks and
decided to allow the patient to gather her nutrition by mouth
using a nectar and puree diet. Speech and swallow gave further
recommendations including encouraging the patient to be seated
as upright as possible during feeding and strongly suggested
against the use of straws. While within the hospital she has
been eating a puree diet with her PO meds crushed within and has
been tolerating it without evidence of aspiration.
#Tachy-brady syndrome: The patient began to experience sudden
bouts of tachycardia about ___ days post op. During these bouts
she was asymptomatic and hemodynamically stable. This abnormal
rhythm was captured on EKG which was reviewed with cardiology.
She would intermittently experience atrial fibrillation with RVR
to 140 alternating with sinus with frequent PACS. As well, she
experienced two times a sustained regular narrow complex
tachycardia felt likely to be either AVNRT or atrial tachycardia
by cadiology. During bouts of tachycardia, she was given 5mg of
Lopressor IV and 2g magnesium with good rate control. She was
placed on metoprolol PO first TID then switched to BID after
about 3 episodes of her rate dropping to the low ___ for a few
beats then normalized to the 60's. After stabilizing her heart
rate we closely monitored it before considering discharge.
Because of the fluctuations of her heart rhythm we discussed the
case with cardiology who agreed that the patient might have
tachy-brady syndrome and could possibly benefit from a pacemaker
if indeed her fall was due to symptomatic
bradycardia/tachycardia. This option was discussed with the
family, who due to the patient's poor likelihood of return to
baseline after surgery wanted to first deal with her leg surgery
before making a follow up appointment with electrophysiology to
further discuss her rhythm abnormalities. After discussion with
cardiology, she should have a cardiology pre-op consult upon
readmission to the hospital for orthopedic surgery if she has
issues with heart rate at that time, otherwise she should be
given follow-up with EP here. | 78 | 870 |
14388510-DS-18 | 29,530,141 | Dear Ms. ___,
You were admitted to the hospital for heavy vaginal bleeding in
the setting of a likely miscarriage. Because of your blood loss
you were started on iron supplements which you should continue
twice per day. Although this is a likely miscarriage, because no
pregnancy was ever seen on ultrasound it is important for you to
continue to monitor your HCG (pregnancy hormone level) until it
is zero. This can be done either in our clinic or with your
midwife. You have elected to follow-up with your midwife.
Please make an appointment to be seen later this week. If you
have any questions or concerns you can call ___ and the
on-call physician ___ call you back.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Monitor your vaginal bleeding
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was admitted to the GYN service for observation given
her heavy vaginal bleeding in the setting of a likely
spontaneous but incomplete abortion.
Her vaginal bleeding decreased while in the hospital. Her
initial HCT was 40 and on follow-up her HCT was noted to be
26.6. Given the large drop we decided to repeat her HCT later
that day and it was found to be 25.1 and then 24.6 and felt to
be stable. While in the hospital the patient considered
watching and waiting, cytotec use, MVA or D+C for her incomplete
abortion. After lengthy discussion the patient elected to watch
and wait and follow up with her midwife to ensure dropping HCG
levels and appropriate bleeding. Initially upon admission her
heart rate was noted to be in the 120-130s but after fluid
hydration and decreased bleeding it was in the ___. While in
the hospital she did not experience any dizziness, palpitations,
chest pain or shortness of breath. She was started on iron
supplements. Given that her hematocrit stabilized, her bleeding
decreased she was discharged at the end of hospital day 1 in
good condition with plans to follow-up with her midwife.
Warning signs were extensively reviewed. | 189 | 208 |
19625808-DS-32 | 23,834,188 | Dear Ms ___,
WHY DID YOU COME TO THE HOSPITAL?
You came to ___ because you were nauseous and had a migraine.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
We gave you medications to treat your nausea, abdominal pain,
and migraine. You had dialysis overnight. You improved
considerably and were able to eat. You were ready to leave the
hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please resume your home insulin regimen
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see
below).
- Seek medical attention if you are so nauseous you cane eat or
have other symptoms that concern you.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | ====================
This is a ___ F with PMH of T1DM (c/b neuropathy, gastroparesis),
ESRD (on PD c/b recurrent culture-negative peritonitis),
fibromyalgia, and migraines who is presenting with
nausea/vomiting c/f hypoxemia, now resolved. Patient improved
significantly with supportive care. | 154 | 37 |
18926021-DS-3 | 28,057,759 | 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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | She was admitted to ___ on ___. At presentation, she
developed worsening shortness of breath with CXR demonstrating
bilateral pulmonary edema. BNP > 12,000. An echocardiogram
demonstrated a new reduction in ejection fraction from >55% in
___ to 20% now with apical akinesis. TSH within normal
limits. SPEP/UPEP unremarkable. Given apical akinesis, a cardiac
catheterization was obtained. The study was significant for 90%
stenosis of mid LAD, along with significant disease in the RCA
and LCx. Cardiac surgery was consulted for consideration of
CABG. She developed acute kidney injury with peak creatinine of
4.5. Given time course, occurring two days after CT
abdomen/pelvis, she likely had contrast-induced nephropathy
exacerbated by concurrent diuresis. Nephrology was consulted,
and ___ and diuresis were held. She started auto-diuresing and
Creatinine continued to downtrend to 1.0 on ___. At
presentation to ___ she was found to have Hemoglobin of
5.5. No recent PCP labs to compare, but likely chronic given no
subjective bleed or melena. She was transfused 4 units of PRBCs.
In setting of weight loss and smoking history, high concern for
malignancy but CT torso negative. Colonoscopy in ___
with multiple diverticula. EGD this admission with gastritis,
which may possibly explain a chronic bleed. She was treated with
four days of ferric gluconate. Capsule endoscopy without any
significant source of bleeding. She had superficial
thrombophlebitis with two palpable cords in her right forearm,
inflamed and painful. A preoperative urine culture was positive
for pan-sensitive E. Coli which was treated with IV ceftriaxone
for five days.
======================================== | 117 | 252 |
19136248-DS-12 | 20,437,489 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing RLE in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 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.
- 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
Physical Therapy:
NWB RLE in splint
Mobilize
Treatments Frequency:
Staples to be removed on POD14 at first postoperative visit in
clinic.
Maintain in splint | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF right ankle, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to <<>>>>>> was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in splint in the right lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 288 | 253 |
15397456-DS-10 | 29,954,357 | You were admitted to ___ for possible pneumonia and a new lung
mass. You underwent bronchoscopy and biopsy of that mass. You
were treated with antibiotics for a possible pneumonia. You will
need to follow up in pulmonology clinic in ___ weeks for review
of your results. | ___ year old nonsmoker F with a PMH of HTN, HLD, hearing loss who
presents with 3 weeks of a productive cough in the setting of a
10lb weight loss, found to have a new RUL mass and possible
post-obstructive PNA, now s/p bronchoscopy with biopsy ___.
#Cough
#RUL mass (8.5cm)
#RUL consolidation
#Leukocytosis
Patient presented with cough x 3 weeks. CT chest showed an 8.5cm
mass in the RUL of the lung with narrowing of the RUL airways by
the mass and consolidation of the RUL concerning for
post-obstructive pneumonia. Mass most concerning for malignancy,
although patient is a non-smoker. TB and fungal infection
thought less likely, although patient is originally from ___.
No fevers, but given leukocytosis Unasyn was initiated
(___) for possible post-obstructive PNA. Interventional
pulmonology was consulted and the patient underwent bronchoscopy
with EUS and biopsy of the mass on ___. Bronchoscopy revealed
extrinsic compression of the bronchus without an endobronchial
lesion; the airway was patient, however, and there was no clear
evidence of a post-obstructive PNA. The procedure was
complicated by intra-operative laryngospasm, for which the
patient was briefly intubated (extubated uneventfully prior to
completion of case). Post-procedure CXR showed no e/o PTX, and
there was no clinical evidence of hemoptysis or laryngospasm/
bronchospasm. Tissue growing GNRs, sensitivites pending, from
broth only at the time of discharge. Washings without organisms,
culture NGTD. AFB stains/culture and pathology pending at time
of discharge. Ms. ___ was transitioned to Augmentin on
___ to complete a 7d course of antibiotics (through ___.
Her leukocytosis improved from 12.5 on ___ to 10.7 at the time
of discharge and remained afebrile while in hospital. Should her
gram negative rods prove to be Unasyn/Augmentin resistant, she
will be contacted for initiation of an alternate antibiotic. She
will f/u in pulmonology clinic (to be arranged by the
interventional pulmonology service) to review results of the
biopsy and to determine next steps (including referral to
thoracic oncology if appropriate). Ms. ___ and ___
daughter were advised to present to the ED for any fevers,
hemoptysis, stridor/wheezing, or shortness of breath and
expressed understanding of these instructions. She was
prescribed an albuterol inhaler on discharge in the event of
wheezing, although none was present at discharge.
___ Edema: ___ noted on presentation. LENIs negative for DVT.
#Normocytic anemia: Hct 35.8 on presentation, downtrend to 31.7
on ___ in absence of hemoptysis or other evidence of active
bleeding. Ferritin 80 with TIBC 216, more c/w anemia of chronic
inflammation. Hct 35.9 at discharge. | 47 | 411 |
15971330-DS-18 | 24,772,338 | Dear Mr. ___,
It was a pleasure taking care of you at the ___. You came in
with chest pain and were found to have in-stent restonosis of
the vessel of your heart. You will need a CABG procedure and
will need to follow up with the cardiac surgeons for this
procedure as an outpatient. | Mr ___ is a ___ h/o CAD (11 total stents) most recently s/p
LAD stent c/b in-stent stenosis and stent exchange ___, DM,
HLD, HTN, stable angina presenting with chest pain and concern
for unstable angina taken for cardiac catheterization.
# Chest pain:
Patient's chest thought to be secondary to unstable angina.
Patient with previous stable angina that was very predictable
that has become increasingly unstable since patient was admitted
after epinephrine administration and subsequent NSTEMI 1.5 weeks
ago. Patient started on heparin drip, not noted to have
ST-segment changes on EKG, and troponins trended X 3 were
negative. Patient was continued Plavix, Atorvastatin, Aspirin,
Metoprolol, and Losartan. Patient taken for cardiac
catheterization on ___ and found to have in-stent
restonosis of LAD that required ballooning. OM-2 also found to
be "tight" and required ballooning as well. Patient will see Dr.
___ in follow-up to discuss CABG in the event he has ISR
again of the LAD at which time LIMA bypass would be a much more
durable solution.
#Urinary frequency
Patient denies dysuria currently and denies previous history of
BPH. UA checked and within normal limits. Some concern for
urinary retention though no history of BPH. Patient should
follow up closely with PCP.
# Anxiety/Stress: Under significant amount of stress at work,
often exacerbates angina. Patient should be considered as
candidate to start SSRI as outpatient.
- Consider SSRI
#Diabetes:
Metformin held. Home insulin and sliding scale continued.
#HLD:
Patient continued on atorvastatin 80 mg daily.
#HTN: Patient hypertensive in ED with systolic of 200's that
resolved upon transfer to the floor and continuation of home
medications. HCTZ, losartan potassium, and metoprolol continued.
# GI bleed ppx: Patient was on Omeprazole for ppx of previous GI
bleed which was stopped for possible interaction with Plavix.
This has been an in ___ concern that has not been demonstrated
clinically as far as I'm aware. That being said, patient has
significant CAD and repeated stents despite optimal medical
management. For now, would prefer a medication that does not
inhibit CYP2C19 (Ranitidine) but if felt he would benefit in the
future from a PPI, "of the PPIs, pantoprazole has the lowest
degree of CYP2C19 inhibition in ___ This issue
should be discussed with patient's outpatient cardiologist. | 54 | 370 |
12542274-DS-13 | 20,745,607 | Dear Mr. ___,
You came to the hospital because you felt fatigued, "off," and a
little short of breath. We found that you had a pneumonia, and
we treated you with an antibiotic called levofloxacin. You will
need to take this antibiotic until ___.
On your chest x ray we noted a new density, which we wanted to
evaluate further with a CT scan. The CT showed only pneumonia in
your lungs. This was reassuring to us. You still need a repeat
chest x-ray in about 6 weeks to ensure resolution of your
pneumonia.
The CT also showed thyroid nodules. You will need an ultrasound
of your thyroid gland in the future to further assess these
nodules. Your TSH was 1.1, which is normal.
We also noticed that you had a worsening anemia (a low red blood
cell count). We want you to follow up on this with your primary
care doctor, as low blood counts can make you feel tired, or can
be a sign of other diseases.
We also stopped your warfarin (Coumadin) while you were in the
hospital, because your INR was too high when you were admitted.
Levofloxacin also makes you need less warfarin. We restarted
your warfarin at a lower dose, and you will take 3mg until you
complete your antibiotics. After you finish your antibiotics,
you should take your original 5mg dosing (so this would be on
___. You should get follow up in your ___
clinic soon. We have notified them of these modifications.
It was a pleasure taking care of you during your inpatient stay.
Best,
Your ___ Care Team | ___ with COPD not on home O2, T2DM, HTN, HLD, and hx of DVT on
Coumadin who presents with several disease of malaise, cough,
and dyspnea on exertion as well as 2 episodes of diarrhea, found
to have a CAP on CXR, being treated with levofloxacin, and also
found to have a new density concerning for underlying mass which
was only revealing for PNA on CT Chest.
ACTIVE ISSUES
# Community acquired pneumonia: Presented with 2 weeks of
malaise and associated cough and dyspnea on exertion. In ED,
found to have low-grade fever and CXR with new right middle lobe
infiltrates. Overall, picture consistent with pneumonia, viral
vs. bacterial. Administered CTX/azithro in ED, switched to
levofloxacin on the floor. Plan is four a five day course
through ___. Patient had no fevers, no leukocytosis, no
altered mental status, and had no O2 requirement while in house.
He underwent CT chest for further evaluation of findings on
chest x-ray and it was unrevealing for anything other than a
pneumonia. He does require a follow-up CXR in 6 weeks (early
___ to ensure resolution.
# PE/DVT: INR goal 2.5-3.5 per anticoagulation sheet in OMR. INR
3.6 on admission, warfarin held in the context of
supratherapuetic INR and levofloxacin administration. Restarted
at 2.5mg then increased to 3mg for discharge (INR 2.3).
Anticoagulation team aware of changes.
# POSITIVE BLOOD CULTURE: Coagulase negative staphylococcus in
___ bottles, thought to be a contaminant given hemodynamic
stability and that it is coagulase negative staphylococcus.
# COPD: Patient without wheezes on exam, not thought to be
having an exacerbation of his COPD. Continued home medications.
# T2DM: HISS while in-house.
# HTN: SBP 130s-140s. Continued home medications (Dilt XR 240mg
daily, doxazosin 4mg daily, losartan 40mg daily)
# HLD: Continued home atorvastatin 10mg QHS
# Hx thyroidectomy: Continued home levothyroxine 50mcg daily.
TSH 1.1. See transitional issue of thyroid nodule as below.
# GERD: Continued home omeprazole 20mg dailiy
# BPH:Continued home medications (Tamsulosin 0.4 QHS, oxybutynin
5mg TID)
****Transitional Issues****
#CT Finding of right thyroid lobe nodules, largest approx. 1 cm.
- Will need thyroid ultrasound in ___ months. TSH normal during
this admission. Patient informed of these findings.
#Pneumonia
-Will need repeat CXR in 6 weeks to assess for resolution of
pneumonia.
#Anticoagulation
-Decreased warfarin from 5mg to 3 mg in setting of levofloxacin
use. Will need close follow up in ___ clinic to
adjust dose after completion of antibiotic therapy.
___ clinic aware. | 265 | 408 |
15593172-DS-28 | 20,964,249 | Mr. ___,
.
It has been a pleasure taking care of you at ___
___. You were admitted for abdominal pain
and ___, both of which improved. You were able to tolerate
food as well as your tube feeds before leaving. We think you
likely had a viral infection that caused your symptoms. | ASSESSMENT/PLAN: ___ M with concurrent stage IIB NSCLC and
laryngeal CA with multiple brain ___ C3D15 taxotere who
presents with abd pain, emesis, and CT scan showing colitis.
.
# Colitis resulting in abdominal pain, nausea, vomiting and one
episode of loose stool in the ER was felt to be most likely from
a viral gastroenteritis. Abx were d/ced the morning after
admission. Pt had no further fevers for > 24 hours prior to
discharge. He initially got some IVF, but the morning after
admission was asking for food, which he was able to tolerate, so
fluids were stopped. Tube feeds were resumed on HD2 per
nutrition recommendations and well-tolerated for 24 hours prior
to discharge. He had no diarrhea, nausea, or vomiting on the
floor.
.
# Anemia: Hct at baseline on admission, but decreased to 29 on
HD2. There was no obvious bleeding source. Pt did not have a BM
for stools to be guiaced. He remained HD stable and Hct was
stable for > 36 hours prior to discharge. This could be due to
cumulative chemotherapy toxicity vs dilutional. Home Fe, folate,
and B12 were continued. CBC should be re-checked ___.
. | 51 | 196 |
14373141-DS-19 | 21,546,931 | Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be TOUCHDOWN weight bearing on your right leg with
range of motion from 0 to 40 degrees in knee brace and
weightbearing as tolerated on your right arm with active/passive
range of motion as tolerated to your right little finger.
- You should not lift anything greater than 5 pounds.
- Elevate right arm/leg to reduce swelling and pain.
- Do not remove brace. Keep brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
RUE: AROM/PROM to ___ finger, NWB to ___ finger, WBAT to other
joints
RLE: TDWB, ROMAT
Treatments Frequency:
Wound Care:
- Keep Incision clean and dry.
- Keep pin sites clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. | Ms. ___ was admitted to the Orthopedic service on ___
for right hip/finger/knee fracture after being evaluated and
treated with closed reduction in the emergency room. She
underwent open reduction internal fixations of the acetabular
and finger fracture without complication on ___ and
___, respectively. Please see operative reports for full
details. She was extubated without difficulty and transferred to
the recovery room in stable condition. In the early
post-operative course she did well and was transferred to the
floor in stable condition.
She had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and she is being discharged to rehab in
stable condition. | 411 | 118 |
10187422-DS-12 | 22,024,813 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Mr. ___ is a ___ year-old-M who was admitted to ___ on the
night of ___ after having five days of RUQ
abdominal pain. He went to his PCP on ___ who sent
labs and an abdominal x-ray which were normal. He came to the ED
after a bout of severe pain, nausea, and anorexia. A abdominal
US was performed at the ED demonstrating a distended gallbladder
with lodged gallstone in the neck with positive sonographic
___ sign consistent with acute cholecystitis. The US showed
splenomegaly measuring 15.2 cm as well. Mr. ___ was admitted
to the Acute Care Surgery service. He was placed NPO with IV
fluids and IV antibiotics (ciprofloxacin and flagyl), pain
control, and added on to the OR schedule for laparoscopic
cholecystectomy. On admission his WBC, liver function tests, and
lipase were WNL. WBC = 8; Tbili = 1.1; AST = 36; ALT = 42; ALP =
77; Lipase: 19. His pain was treated with IV Dilaudid and
received Zofran single dose for nausea.
In the morning of ___, Mr. ___ was taken to the
OR for laparoscopic cholecystectomy. A foley catheter was
placed. The postoperative diagnosis was advanced acute on
chronic cholecystitis with early necrosis of the gallbladder.
The patient tolerated the procedure without any incident and was
returned to the PACU in a satisfactory condition. He was later
on transferred to the floor in a stable condition. His pain was
adequately controlled with oxycodone q3 PRN ,standing tylenol
q8, and IV breakthrough Dilaudid. IV Zofran q8 PRN was
prescribed for nausea. His Foley catheter placed in the OR was
removed that same day at 14:43 and was due to void at
___. The patient voided twice (100cc and 250cc) with a
post void residual of 715 at 20:21. We waited one more hour
within which he voided two more times (175cc and 175cc) but had
a post void residual of 840 at 21:37 and a Foley catheter was
replaced given his urinary retention and inability to empty the
bladder. 700cc came out after replacing the Foley catheter. At
22:30 the Foley was removed and he was due to void at
___. He was taking adequate amount of POs and IV fluids
were discontinued.
On ___ he voided 350cc at midnight but kept
retaining urine with bladder scan showing 455cc. He was straight
cath at 07:07 for 625cc and was due to void at ___. He
kept voiding 100-300cc throughout the day retaining smaller
amounts as the day went by. He voided 300cc at 16:18 with post
void residual of 248. He was then sent home with Phenazopyridine
and tamsulosin (Flomax) and asked to return to the Emergency
Department in case of urinary retention. | 729 | 448 |
16907705-DS-15 | 27,929,135 | You were admitted to the hospital with low blood levels. You
received several blood transfusions and underwent endoscopies
that unfortunately did not pinpoint the site of bleeding.
.
Please continue to take your medications and note the changes
that we have made to your regimen. We have started you on a
medication called Omeprazole 40mg that you should take twice a
day until instructed to decrease or stop by Dr. ___.
.
Please do not take aspirin until instructed to do so by your
doctors. | ___ yo M with rectal cancer s/p chemoradiation and resection,
chronic incontinence, afib, CAD s/p CABG, dCHF and severe AS,
presenting with 3 days of melena and a Hct of 16 from 30.
.
# GI Bleed: Pt presented with large amount of melena, and
incontinent due to surgery. Thought to be an upper GI bleed due
to presence of melena. Started on IV PPI and made NPO. Had an
EGD performed while in the FICU showing no evidence of bleeding
down to the jejunum. Received a total of 7 units PRBCs and 2
units of platelets. Hct remained stable post-EGD and patient was
called out to the floor. While on the floor had continued melena
and underwent an enteroscopy that was unrevealing. The patient
was then prepped for 2 days and underwent a colonscopy that
revealed radiation changes to the rectum but no source for brisk
bleed. The pt received 1pRBC prior to discharge. (His Hct was
mid ___ prior to the pRBC transfusion). The patient was
discharged with plans for a Hct check the day following
discharge and to follow-up with ___ (GI) for a
potential outpatient capsule endoscopy.
.
# Atrial fib: Pt currently in NSR on dofetilide and PRN
metoprolol at home. Dofetilide continued. Metop held due to GI
Bleed. Pt instructed to restart on discharge after discussion
with his PCP.
.
# CAD: Initially held metoprolol and aspirin. Pt instructed not
to restart ASA until instructed to do so.
.
# Hypokalemia: Pt noted to be hypokalemic to low 3s for 3 days
prior to discharge. This was repleted daily. The patient was
instructed to get his electrolytes checked the day after
discharge and have them repleted as needed. Etiology was likely
secondary to loose stools/diarrhea while in house. | 82 | 291 |
17234374-DS-11 | 29,040,960 | Dear Mr. ___,
You were admitted to ___ because
you had right upper extremity swelling and were found to have a
blood clot (also called a deep venous thrombosis or DVT) in your
right arm. For this clot you were started on lovenox 80mg twice
a day. This should be continued as an outpatient to prevent any
further clots from forming.
You were also found to have anemia. On admission your blood
count was low. This is probably due to your cancer. You were
transfused 2 units of red blood cells during your stay.
While you were in the hospital your urine catheter was changed
out and your home medications were continued.
We wish you the best in your health,
Your ___ Care Team | Mr. ___ is a ___ year old man with stage IV lung
adenocarcinoma, metastatic to the brain, TCC of bladder s/p
TURBT ___, HTN, BPH, who was transferred from ___
___, who presented with right upper extremity
swelling, found to have right upper extremity DVT, and
incidentally found to have anemia, Hgb 6.7, on admission labs.
# Right Upper Extremity DVT:
Exam notable for RUE edema, DVT was confirmed on ultrasound. He
had no evidence of PE on CTA. His DVT is likely secondary to
malignancy and prolonged immobility. He was started on Lovenox
80mg BID, he should continue this as an outpatient pending
further oncology followup.
# Anemia:
His hemoglobin was fairly stable around ___ as an outpatient
with low MCV. He presented with Hgb 6.7 in ED, which improved to
8.7 after 2u PRBCs. His MCV was also found to be low, but was
normal ___ years ago, likely suggestive of anemia of
inflammation. He also has history of iron deficiency anemia,
though most recent ferritin 354. His Hgb on day of discharge was
8.7. With his ___ transfusion he was found to have a fever to
101.2, this was treated with Tylenol. A transfusion reaction
workup revealed a negative direct coombs test. This likely
represents a febrile nonhemolytic transfusion reaction.
# Left lower extremity pain:
Patient has chronic left leg pain, secondary to his malignancy.
His home pain medications were continued, including his
oxycontin, lidocaine patch and ointment, dilaudid, and Tylenol.
# Pyuria:
He was found to have pyuria on admission, and grew E.coli,
however he had no evidence of active UTI including fever or
leukocytosis. He also has a chronic foley which is likely the
cause of this UA. His foley was changed this hospitalization.
# Stage IV lung adenocarcinoma, metastatic to the brain
Diagnosed ___, s/p 2 cycles on carboplatin/pemetrexed last
___, s/p cisplatin/etoposide with concurrent XRT in ___.
He has poor functional status. He has progressive metastatic
cancer to lung and increasingly large mass s/p 2 episodes of
significant hemoptysis previously. He had no hemoptysis this
hospitalization. Per Dr. ___, he is not a candidate
for any further therapy as he is not strong enough for a trial
of immunotherapy, and given that his performance status of 4 is
unlikely to change, this was deemed no longer appropriate. He
needs continual outpatient conversations for consideration of
hospice.
# Constipation:
Patient with chronic constipation. His home bowel regimen
including senna, Colace, miralax, bisacodyl, and lactulose was
continued. He had a bowel movement during this admission.
#Pressure ulcers:
Patient with unstageable ulcers to bilateral heel, as well as
healed skin/stage 1 ulcer to gluteal fold. In the hospital wound
care dressings were placed and he was repositioned frequently. | 122 | 439 |
17526975-DS-6 | 26,066,060 | Dear Dr. ___,
___ were admitted for arm and leg weakness after diarrheal
illness concerning for Guillain ___ Syndrome. ___ had an LP
with 0 WBCs and protein of 68 consistent with this diagnosis.
___ completed a 5 day course of IVIG without event and have
begun to gradually improve. ___ have never had any sensory
difficulties, but at your weakest, ___ could not move your
arms/legs against their own weight. On discharge, ___ are now
able to move your proximal arms and legs against their own
weight and have been able to move your fingers slightly.
Sleeping has been an issue secondary to your inability to adjust
your position causing frequent back pain. We have recommended
starting trazodone at night to help with sleep. ___ will follow
up with Dr. ___ with Neurology who may also recommend
additional neuromuscular follow up for ___. At this time, per
your request, we are deferring EMG scheduling. | Dr. ___ was admitted for arm and leg weakness after diarrheal
illness concerning for Guillain ___ Syndrome. Stool culture
was ultimately negative. He had an LP with 0 WBCs and protein of
68 consistent with this diagnosis. He completed a 5 day course
of IVIG without event and have begun to gradually improve. He
has never had any sensory difficulties, but at his weakest, he
could not move arms/legs against their own weight. On discharge,
he is now able to move his proximal arms and legs against their
own weight and has been able to move his fingers slightly.
Sleeping has been an issue secondary to his inability to adjust
his position causing frequent back pain. We have recommended
starting trazodone at night to help with sleep. He will follow
up with Dr. ___ with Neurology who may also recommend
additional neuromuscular follow up for ___. At this time, per
family request, we are deferring EMG scheduling. | 154 | 157 |
17472354-DS-7 | 24,710,307 | You were admitted to ___ following evaluation of your
abdominal CT scan. You were found to have coninutation of your
abdominal abcesses. You were given IV fluids, IV antibiotics,
and were taken to Interventional Radiology to have drain placed
replaced into the abscess. You tolerated this procedure well.
Your pain has improved.
1. We found a fistula in your sigmoid colon (a conection between
your bowel and the abdominal cavity. This fistula should close
on its own but it is important to keep monitoring the output of
your drainage daily as well as any change in color/consistence
of the output. For this reason you will be discharge home with
___ services (a nurse that will go to your home daily to monitor
and record your drain output and perform daily dressing.
2. You will continue to take augmentin for 10 more days.
3. You will follow up in clinic as instructed below
You are ready to be discharge home with the drain to continue
your recovery and to complete a course of oral antibiotics.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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).
*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 will have a nurse doing this for you
daily.
*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.
It was a pleasure taking care of you during this admission.
Your ___ team | Mrs. ___ was admitted to ___ follow evaluation in the ER for
hematuria. She had a CT scan which showed new intraabdominal
abscesses. She was taken by ___ for replacement of her ___ drain.
She tolerated the procedure well. She was continued on her home
abx which had been found to be effective based on her previous
abscess cultures. During her admission she did have pain around
the ___ drain site, which improved through out the admission. She
was discharged on ___. She will follow up with a repeat CT
of her abd and pelvis. She will continue to receive home ___
care as well. At the time of discharge she was doing well. She
was tolerating regular PO, voiding, and ambulating
independently. | 513 | 124 |
11182724-DS-14 | 27,963,799 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you had fevers, chills, and
right shin skin rash.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- Your blood was drawn and urine was collected for cultures.
These were negative.
- You were started on IV antibiotics called vancomycin and
ceftriaxone.
- Your chest x-rays were without abnormalities.
- You had ultrasound imaging for your chest, called
echocardiogram, which did not show evidence of heart valve
involvement.
- You skin rash appearance and history is suspicious for tick or
spider bite that is why you were covered with antibiotic called
doxycycline.
- Your fever improved and IV antibiotics were switched to
antibiotics by mouth.
- You were discharged on two antibiotics called doxycycline and
cephalexin.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Please follow-up with your doctors as ___.
- Please call your doctor or come to the emergency department if
you experience fevers, chills, worsening of skin rash, chest
pain, shortness of breath or any concerning symptom.
We wish you speedy recovery!
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history of HIV on ART (last
CD4 count 600-800), atrial fibrillation on rivaroxaban and
bicuspid aortic valve s/p AVR presents with fevers and likely
cellulitis vs. insect bite with possible tick-borne illness.
Fevers resolved on antibiotics. Patient was discharged on
doxycycline and cephalexin. | 213 | 51 |
16667570-DS-21 | 29,960,142 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You initially were seen in ___ where they placed a
breathing tube given your difficulty breathing. You were
transferred to the ___ cardiac intensive care unit where they
removed your breathing tube.
- You were found at ___ to be in a rapid abnormal heart
rhythm called atrial fibrillation (Afib) with rapid ventricular
response. They tried to convert you back to a normal heart
rhythm which was initially successful - but you went back into
Afib while you were in the hospital. We started you on a new
medication called amiodarone for your Afib and you will be seen
by the electrophysiology cardiologists to have a procedure
called a pulmonary vein isolation as an outpatient.
- You had an echocardiogram which showed that your heart is
pumping abnormally and less efficiently than it used to and you
were diagnosed with congestive heart failure. This heart failure
caused you to accumulate fluid in your lungs which was likely
contributing to your initial trouble breathing. We gave you a
medication called Lasix (furosemide) to help you pee off this
additional fluid and you felt better. You will need to continue
Lasix in order to prevent re-accumulation of fluid in your lungs
and the rest of your body.
- You had an exercise nuclear stress test which showed evidence
of an old heart attack. This is likely why you now have heart
failure. You did not have any signs of a new heart attack while
you were here in the hospital or any signs of reversible
coronary artery disease.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your cardiologist Dr.
___ at ___ if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 101.9 kg (224.65 lb). You should use
this as your baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[]New Systolic Heart Failure (EF 40%)
DISCHARGE WEIGHT: 101.9 kg (224.65 lb)
DISCHARGE CR: 1.0
DISCHARGE REGIMEN: PO Lasix 80 mg, lisinopril 2.5mg daily,
metoprolol XL 100 mg daily
[] Needs repeat CMP at PCP follow up on ___. Replete
potassium and magnesium as appropriate.
[] To continue amiodarone load of 200mg BID for 1 month from
___, with planned transition to 200mg daily afterwards. Will
need outpatient LFTs, PFTs, TSH check in ___ weeks.
[] Will be scheduled by EP with outpatient pulmonary vein
isolation.
[] Please ensure outpatient sleep study to screen for OSA given
recurrent Afib.
[] Noted incidentally on CTA chest with scattered tiny lucencies
within the ribs. In the setting of chronic anemia concerning for
possible myelodysplasia including myeloma. SPEP/UPEP sent and
normal.
[]Noted with isolated indirect hyperbilirubinemia on admission
that resolved - potentially ___. Would continue to monitor
BRIEF SUMMARY:
==============
Mr. ___ is a ___ year old gentleman with history of AF
(developed in ___, s/p DCCV x3 (___) and DM2,
presenting originally to ___ with URI symptoms and
subacute worsening dyspnea on exertion, found to have AFwRVR s/p
DCCV with respiratory distress requiring ___ -
transferred to ___ CCU on ___ for further management.
Extubated and weaned off pressors on ___ then transferred to
floor for further management of acutely decompensated heart
failure with newly depressed EF 40% and wall motion abnormality
as well as Afib.
#CORONARIES: mild 3-vessel disease: 20% ___ LAD, 20%
LCx, 30% ___ RCA
#PUMP: Normal in ___, EF 40% ___
#RHYTHM: Afib
ACUTE ISSUES:
=============
# Acutely decompensated heart failure with reduced EF (EF 40%)
# Hypoxemic hypercarbic respiratory failure s/p intubation
(extubated ___
Pt presenting initially to ___ in respiratory failure
likely in setting of newly decompensated systolic heart failure
and possible flash pulmonary edema in setting of Afib with RVR
and possible component of myocardial stunning after recent ___.
CTA was negative for PE and thought less likely PNA given rapid
resolution of a RLL consolidation with diuresis. Trigger of HF
exacerbation thought likely to be due to URI and resulting Afib
with RVR - he had no signs of active ischemia on arrival to
___ or ___. Etiology of systolic heart failure seems to
be ischemic cardiomyopathy given evidence of fixed large
perfusion defect in the territory of the LAD from prior infarct
as seen on nuclear stress test. Tachycardia-mediated
cardiomyopathy also possibly contributing given patient's high
burden of Afib. He was actively diuresed down to an estimated
dry weight of 101.9 kg (224.65 lb). He was discharged on Lasix
80 mg daily, lisinopril 2.5mg daily, and metoprolol XL 100 mg
daily.
#Coronary artery disease
#exertional dyspnea
Per history, patient complaining of progressively worsening
exertional dyspnea improved with rest. TTE on ___ was
concerning for ischemia given newly reduced EF of 40% and
regional wall motion abnormality in territory of PDA. He
underwent a nuclear exercise stress test on ___ which showed
fixed large severe perfusion defect involving the LAD territory
with moderate systolic dysfunction and regional akinesis
involving the LAD territory. He underwent cardiac
catheterization on ___ which showed mild 3-vessel disease
involving the LAD, LCx, and RCA with no culprit for the abnormal
stress test and therefore no intervention.
#Afib with RVR
Pt with a history of AFib since ___, s/p 3 ___, presenting
with AFwRVR at ___ where he underwent DCCV on ___ with
successful conversion to NSR for about 24 hours. He converted
back into Afib on evening of ___ and was persistently in Afib
until discharge, with rates controlled in the 70-80s. He was
evaluated by the EP consulting team who recommended rate control
with metoprolol and starting rhythm control with amiodarone. His
home sotalol was discontinued given his acutely decompensated
HF. He was discharged on metoprolol XL *** mg, amiodarone 200mg
BID x1 month and then 200mg daily. He was continued on his home
apixaban for anticoagulation. He will be scheduled by EP for PVI
as an outpatient and will need LFTs, PFTs, and TSH checked in
___ weeks in the setting of initiating amiodarone.
#Type II NSTEMI - resolved
Trop-T initially elevated on arrival to 0.06, likely in setting
of HF exacerbation and Afib with RVR. It trended downward to
0.03 with no concern for further ischemia throughout the rest of
his hospitalization.
He underwent cardiac catheterization on ___ which showed mild
3-vessel disease involving the LAD, LCx, and RCA with no culprit
for the abnormal stress test and therefore no intervention.
#Normocytic anemia - stable
Patient with chronic anemia Hgb ___ and noted with scattered
lucencies within ribs on his CTA concerning for possible myeloma
vs other myelodysplastic process. An SPEP/UPEP was sent which
was normal. He should continue further workup of his chronic
anemia with possible heme/onc referral if concerned for an
ongoing bone marrow process.
CHRONIC ISSUES:
===============
#T2DM
Patient's home Januvia and metformin were held in house and he
was maintained on ISS.
#Primary prevention
Continued home statin
CORE MEASURES:
==============
#CODE: Full code,confirmed
#CONTACT/HCP: Wife ___ ___
Greater than 30 minutes spent on discharge planning. | 400 | 829 |
19248660-DS-16 | 29,261,254 | Dear Mr. ___,
It was a pleasure taking part in your care. You were admitted to
___ with a itchiness, fatigue, decreased appetite and abnormal
liver function tests. It is unclear why you had the
abnormalities and this should be worked up further with your
primary care physician. While hospitalized we checked labs which
were elevated but stable, got an ultrasound which showed
possible fatty infiltration of your liver. At the time of
discharge you were doing well clinically.
The following medications were changed:
- Stop metoprolol until you see your PMD
- Stop Lisinopril until you see your PMD
- Stop atorvastatin until you see your PMD
- Stop levaquin | ___ yo M w/ hx of prostate cancer, DM type 2, CKD, and
orthostatic hypotension who presents with several days of
fatigue, nausea and worsening elevation in LFTs.
## LFT abnormalities: Patient had no complaints on admission,
although did note that about several days prior to admission he
had severe upper abdominal/flank pain with nausea that lasted
approximately 6 hours. Also with some nausea/fatigue in days
leading to admission. LFT's on admission 281/237 AST/ALT, alkP
643, Tbili 1.0. Also lipase 190. Mildly elevated WBC 11.8.
Elevated alk phos suggested obstructive pattern of cholestasis.
Initially concern for liver metastasis as patient with history
of prostate cancer, however, ___ U/S showed no significant
abnormalities/obstruction and CT a/p from ___ no evidence
of metastases. It is possible that alk phos elevated ___ bone
process, so GGT level drawn to help differentiate. History and
physical exam atypical presentation for viral hepatitis - viral
studies drawn at PMD - negative for acute hepatitis.
Pancreatitis possible given elevated lipase - while pt denies
ETOH use, certainly possible gallstone pancreatitis.
Additionally, history of upper abd./flank pain, nausea,
decreased PO intake also consistent with pancreatitis, although
no stones seen in U/S possibly ___ passed gallstone. Adverse
reaction to medication also considered, but has long been on
statin and only new med is levofloxacin which is rarely
associated w/ LFT abnormalities. At time of discharge, etiology
of elevated LFTs still unclear, however patient was asymptomatic
and repeat LFT levels were stable and patient told to follow-up
with PMD as outpatient. Statin was held during admission and
patient told to stop taking statin until advised by PMD.
## Fatigue: Patient reported fatigue much improved by arrival to
floor. Most likely fatigue due to decreased PO
intake/dehydration. Received IVF in ED and floor, and tolerated
PO intake on floor with no problems. Patient told to hydrate as
much as possible at home with pedialyte/gatorade and advance
diet as tolerated. BP meds were held as patient dehydrated and
BP's low in past few days per PMD report.
# CKD (stage III). Cr stable 2.0-->1.9 during admission.
# DM type 2: Last A1c 5.8 per Atrius records on ___.
Glucose controlled during stay - did not require insulin.
# Prostate cancer. No acute issues.
-- Transitional Issues--
# Patient instructed to follow-up with PMD on ___ for
repeat labs.
# GGT level pending at time of DC. Team will contact PMD with
results. | 106 | 416 |
16570062-DS-2 | 26,369,441 | Spine Fractures
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Wear your back brace for all activity with HOB greater than 30
degrees.
You may shower briefly without the back brace.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control). | ___ y/o M s/p fall on coumadin presents with back pain. CT torso
revealed L1 fracture and nondisplaced L3/4 facet fracture. He
was admitted to neurosurgery for further management. He was
neurologically intact on exam, but reported significant amount
of pain. An aspen quickdraw brace was ordered. On ___, patient
was unchanged on exam. ___ was consulted for the patient and
valium was added for pain management.
On ___ patient was discharged home with a rolling walker and
home ___. Patient stated that he wanted to follow up with Dr.
___. | 152 | 90 |
18508296-DS-6 | 21,118,722 | Dear Ms. ___,
You were hospitalized for a urinary tract infection (UTI),
candidiasis (fungal infection), and high blood sugars. Please
continue to take your antibiotics until you finish the entire
course. You should follow up with your diabetes doctor regularly
to make sure your insulin regimen is meeting your needs. Please
get your blood checked at this visit. | Ms. ___ is a ___ year old woman with poorly controlled type
1 DM presenting with hyperglycemia, recently diagnosed UTI, and
mucocutaneous candidal infections with nausea, vomiting, and
hyperglycemia.
#UTI: Recently diagnosed and started on ciprofloxacin on ___ at
urgent care. In ED, UA positive for leukocytes and bacteria.
Urine cultures were drawn and are pending at discharge. Urine
culture from urgent care visit last week grew multiple organisms
but sensitivities were not performed. She was started on IV
ceftriaxone on ___ and was transitioned to nitrofurantoin 100mg
twice a day from ___ until ___ for a total of 5 day course of
antibiotics.
#Type I diabetes, hyperglycemia: Patient presented with blood
glucoses in the 300s and fingersticks remained high likely in
setting of infection. UA negative for ketones, so unlikely DKA.
___ was consulted and recommended continuing glargine 28u
twice a day, humalog after each meal with carbohydrate count
scale, and follow up with Dr. ___ in one week.
#Chronic kidney disease with acute kidney injury: Creatinine was
elevated to 1.5 from baseline of 1.2-1.3. Most likely pre-renal
in setting of poor PO intake.
#Oral thrush and candidal vaginitis: Thrush on oral and pelvic
exam and patient reports dysphagia but no odynophagia. She was
started on nystatin swish and swallow. For candidal vaginitis,
she should continue taking fluconazole 150mg daily for one week.
=========================== | 57 | 225 |
17624238-DS-10 | 25,573,958 | Dear Mr. ___,
You were admitted to the ___ Cardiology Team on ___ after
finding that you had atrial fibrillation with very fast heart
rates. You were started on IV and oral medications to slow down
your heart rates. Your Pradaxa also was restarted as your blood
needs to be thin to prevent clot formation. You had a
cardioversion done on ___ with good effect.
It will be very important to continue your sotalol at 120 mg
twice a day and also the Pradaxa at 150 mg twice a day. Please
follow up closely with your doctors and ___ if you feel
you are back in atrial fibrillation.
While you were in the hospital, your blood pressure medications
were held given risk for low blood pressure with high heart
rates. Your blood pressures have been 110-140 without your
medications. Please resume amlodipine 5 mg daily. After ___ days
of being at a stable rate, check your blood pressures. If you
are running above 140 consistently, start back your Lisinopril
40 mg daily. We would also recommend closely following up with
your primary care doctor.
We are working on a follow up appointment with Dr. ___. You
will be called at home with the appointment. If you have not
heard within 2 business days or have questions, please call
___
We wish you the best
Your ___ Cardiology Team | ___ yoM with h/o Atrial fibrillation s/p multiple ___ in the
past, successful PVI (___) presented to the hospital with
palpitations, dyspnea on exertion and diaphoresis.
# Atrial fibrillation: Patient found to be in atrial
fibrillation, rates ranging from ___, with rates above 130s
showing rate related left bundle branch block, leading to
worsening symptoms. Of note, he decreased his Sotalol from 120
mg BID to 60 mg BID by himself this ___. HE also self
discontinued Dabigatran in ___ and did not seek any refill
given that he felt the ablation was successful. He was started
on IV diltiazem with modest response and also given PO
metoprolol. He also appeared to be mildly volume overloaded and
was given a one time dose of IV Lasix with good effect.
He was resumed on dabigatran and got 1st dose of sotalol prior
to TEE/___. TEE did not show any intracardiac thrombus. He was
anticoagulated with IV heparin with bridge to Dabigatran. is
rates after ___ were sinus ___, initial rate 35 for which
he received 0.5 mg atropine with improvement. After procedure,
he was asymptomatic and discharged.
# HTN: His antihypertensives (Lisinopril 40 and Amlodipine 5)
were held given tachycardia. He is to resume amlodipine 5 on
discharge. His SBP ranged 110-140s on discharge. He measures his
BP regularly at home, instructed to allow himself ___ days of a
stable rhythm, and measure his BP. If he is consistently above
SBP 130-140, he can resume his lisinopril 40. | 223 | 246 |
14342692-DS-42 | 24,530,708 | You were re-admitted from rehab for worsening of your foot
wound. IV antibiotics were given. You should continue IV
Ceftazedime for ___ weeks to be given after each dialysis
session via your dialysis cathether. You should follow up with
the Outpatient Antibiotic Therapy Clinic on ___. You should
have labs checked weekly while on antibiotics, including CBC,
Chem10, LFTs, ESR and CRP.
Your wound vac for your groin wound was changed ___,
___. This should continue on the same schedule.
Please keep your appointments as scheduled. Details are included
below.
Please work with a physical therapist daily.
History of heart failure - Weigh yourself every morning, call MD
if weight goes up more than 3 lbs. | Ms. ___ was transferred to ___ from rehab on ___,
where she had been since her last discharge on ___. She
presented with worsening of her left foot wound and increased
pain in that area. IV antibiotics and local wound care were
continued. She continued hemodialysis. Her dorsal foot wound was
sharply debrided at the bedside on one occasion. Wound cultures
and a single positive blood culture grew out the same E.Coli
previous wound cultures had grown with identical sensitivities.
A goals of care meeting was held and it was decided that
non-surgical management should continue for the present time
with the possibility of re-assessing for possible amputation if
circumstances were to change at a later time. A family meeting
was then held to determine whether the patient should be
discharged back to rehab or home with family. It was decided
that the patient should return to rehab with the goal of
ultimately transitioning home. The patient complained of some
increasing rectal pain and a colorectal consult was called. This
was felt to likely be due to a fissure, outpatient follow up and
symptomatic treatment with stool softeners, topical nifedipine
and hydrocortisone suppositories were recommended. The patient
was discharged to rehab. | 114 | 202 |
17552188-DS-3 | 27,366,012 | Hi Mr. ___,
You were transferred to ___ from an outside hospital because
you were bleeding in your gut. When you were transferred here,
you were not bleeding. You spent a day in the intensive care
unit under close monitoring. Eventually you were transferred to
a general medicine floor. In the early morning hours of ___,
you began having large bloody bowel movements, and it was felt
to be due to the outpouchings in your colon (diverticuli). You
were transfused with two units of blood and given intravenous
fluids. You went for a procedure with interventional radiology,
where dye was injected into the blood vessels of your colon
(mesenteric angiogram) to attempt to find the source of the
bleed. Unfortunately, during this time, you had stopped bleeding
and they were not able to find the source of the bleed. At your
request, we consulted the colon surgeons who came to see you.
Since the colonoscopy at the outside hospital showed diverticuli
in several areas of your colon, they recommended removing a
large portion of the colon (subtotal colectomy with temporary
ileostomy). At this time. you were not interested in pursuing
this intervention. Over the next several days you did not bleed
and blood counts stayed stable. You were a little dehydrated
after not eating or drinking around the procedure, and needed to
stay for a few days, while we gave you IV fluids On ___, it
had been several days since your last bleed, your blood pressure
was good, and your blood counts were increasing, so you were
allowed to go home. You should no longer take your daily aspirin
because it can increase bleeding and wait to take your Moexipril
15 mg until you follow up with your primary doctor because your
blood pressures have been good without it. If you should start
to bleed again, you should go straight to the emergency room at
___ or another hospital that has ___ so that they can do an
angiogram and locate the bleed.
It was a pleasure participating in your care. We wish you all
the best!
-Your ___ Care Team | ___ with PMHx of diverticulosis, HTN, DM2, and recent
hospitalization for diverticular bleed s/p colonoscopy with
clipping of bleeding diverticulum in sigmoid colon with
recurrent BRBPR, was transferred for BRBPR and ___ intervention.
On arrival pt was hemodynamically stable. CTA ___ showed
diverticulosis without evidence for active hemorrhage. On ___,
pt had several large BMs, grossly bloody, symptomatic with
presyncope, weakness, and tachycardia/ S/p 2 units PRBCs, IVF,
___ mesenteric angiogram found no source of bleed.
Colorectal surgery consulted and recommended subtotal colectomy.
Pt declined this intervention. On ___, Hgb increaseing at 9.2,
but patient was orthostatic likely in the setting of decreased
PO intake the previous 2 days. He was given IV fluids and
increased PO intake. Throughout the hospital stay, patient had
frequent episodes of atrial tachycardia/PACs (previously seen by
Dr. ___, but was asymptomatic and hemodynamically
stable. On ___, he had no signs of bleeding and Hgb was stable
for several days. He was discharged with instructions to follow
up with his PCP and return to ___ or another hospital with ___
services should he have any further bleeding.
=====================
TRANSITIONAL ISSUES
=====================
-If patient re-bleeds, he needs urgent mesenteric angiogram to
localize source of bleed. He should present to closest ___ if
unstable. If stable, he should present to ___ or other
___ ___. He was given a note with these instructions
-Holding ASA on d/c given GI bleed
-Holding Moexipril 15 mg PO QD on d/c given stable BPs. Can
consider restarting as outpatient if hypertensive
-Should follow up with cardiology given frequent periods of
atrial tachycardia/PACs on telemetry.
# CODE: Full Code
# CONTACT: HCP is daughter ___ ___
==================
PROBLEM LIST
==================
# Acute blood loss anemia: BRBPM likely ___ to recurrent
diverticular bleed. CTA ___ showed diverticulosis without
evidence for active hemorrhage. Patient with active BRBPR in AM
on ___. ___ angio found no source of bleed. Surgery consulted
and recommended subtotal colectomy. Pt declined. On ___ Hgb
increased to 9.2. On d/c no bleeds >48 hrs and VSS stable
# Orthostatic hypotension: Patient had symptomatic orthostatics
___ when rising from chair most likely ___ to dehydration in
setting of poor PO intake. S/p 1L NS and increased PO intake.
Repeat orthostatics before d/c were normal.
# Atrial Tachycardia- Hx of AT: ___ in ___ showed 12
minutes of symptomatic AT, saw Cardiology in ___, started on
metop. No recent symptoms, but evidence of unsustained runs of
AT on tele during bleed on ___. Started metop tartrate 12.5 BID
___. Switched to metop succinate 25mg daily on d/c
# HTN: chronic and stabl. Held home Moexipril and metoprolol
while bleeding. Started metop tart 12.5 mg BID ___. Switched to
metop succ 25 mg on d/c
# T2DM: chronic and stable. Held home Metformin and started on
insulin SS. restarted metformin on D/c
# HLD: chronic and stable. Held Aspirin 81 mg PO DAILY in
setting of GI bleed. Continued home Atorvastatin 40 mg PO QPM
# Anxiety and depression: chronic and stable. Continued home
ALPRAZolam and Citalopram
# BPH: chronic and stable. Continued home Tamsulosin and
Finasteride
# Glaucoma: chronic and stable. Held home Lumigan (bimatoprost)
and started latanoprost, which was on formulary. On discharge
re-started Lumigan | 351 | 519 |
19329795-DS-11 | 29,376,441 | Dear Mr. ___,
You were hospitalized due to symptoms of vision change,
language change, and confusion 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:
hyperlipidemia
We are changing your medications as follows:
Please take aspirin and statin.
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 | ___ with hx leaky bowel syndrome with transient changes
including vision, language (perseveration), and confusion. MRI
shows late acute L medial thalamic infarct. Found to have small
PFO during admission, and undergoing workup for paradoxical
embolus and hypercoagulability workup given young age and few
risk factors. The etiology of stroke is unclear at this point.
# Ischemic Stroke: Patient was found to have L medial thalamic
infarct on MRI. Initial CTA showed possible abnormality of left
vertebral artery; however MRA with fat suppression confirmed
normal vasculature without dissection. Hypercoagulability workup
was sent and was pending at time of discharge. Patient had
normal inflammatory markers and no D-dimer elevation.
Echocardiogram was positive for small PFO vs ASD. Lower
extremity ultrasounds were performed to evaluate for source of
paradoxical embolism but were negative. Given low likelihood of
venous clot with negative Ddimer, MRV abdomen pelvis for venous
clot was scheduled in the outpatient setting. Patient was
started on aspirin and atorvastatin during admission (LDL 147)
to minimize stroke risk.
=================== | 281 | 166 |
18682125-DS-14 | 29,019,544 | You were admitted to ___ with advanced gastric cancer. You
were prepped for surgery on the medicine service where your
Coumadin was held and you were on a heparin drip for
anticoagulation due to your mechanical valves in your heart. You
were taken to the operating room and underwent a subtotal
gastrectomy with a feeding tube placed. Post-operatively, you
developed a small bowel obstruction which necessitated
exploratory laparotomy, because you were not getting better with
conservative management. In the OR, it was found that your tube
feedings were backing up and these were cleaned out of your
small bowel.
You developed diarrhea, and stool studies came back positive for
Clostridium difficile (C. diff) infection. You have completed a
course of antibiotics and your last stool sample was negative
for C. diff. You also had a rising white blood cell count and
your urine culture was growing bacteria, for which you were
treated with appropriate antibiotics.
Your lab work is all normalizing now and your diarrhea has
resolved. You are tolerating a regular diet and your pain is
well controlled. You have been up ambulating with a walker, and
Physical therapy has cleared you for discharge home with home ___
and ___ services.
You will be discharged on lovenox for anticoagulation, an
injection to give yourself twice a day.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Mr. ___ is a ___ w/ a recent diagnosis of Stage 3B gastric
adenoma and a h/o of Afib, rheumatic heart disease (s/p AVR,
MVR)on warfarin, CABG, CVAx2 w/o residual deficits presenting
with dizziness and found to be anemic, likely due to bleeding
from gastric adenocarcinoma. Received 2U PRBC while awaiting
gastric resection and transitioned to heparin perioperativly
(Off Plavix since ___ and continued ASA).
He has been seen by oncology previously and refused neo-adjuvant
chemotherapy. He elected for surgical resection. Given risk of
thrombosis and need for transition to heparin gtt
___, he remained inpatient until Surgical resection
by Dr. ___ on ___.
On ___, he was taken to the Operating Room where he underwent a
subtotal gastrectomy with Billroth 2 reconstruction, and
placement of J-tube. He tolerated the procedure well and was
extubated and returned to the PACU. For full details of the
procedure, please refer to the separatelyl dictated Operative
Report. Following satisfactory recovery from anesthesia, he was
transferred to the Surgical Floor for further monitoring. On
___, patient self-removed his NG tube and his abdomen became
progressively distended and NGT was ultimately replaced on
___. On ___, patient was triggered for hypoxia ___ a
presumed aspiration event. He required intubation and was
transferred to the TSICU. A CT of the abdomen pelvis with
contrast via the NGT was concerning for a high grade small bowel
obstruction. Repeat CT the same day with contrast via the J-tube
was again concerning for small bowel obstruction. On ___,
patient continued to clinically decline with increasing need for
vasopressors. He was returned to the Operating Room where he
underwent exploratory laparotomy, enterotomy, removal of
inspissated tube feeds, and reduction of torsed mesentery. He
was closed primarily and returned to the ICU intubated. For full
details of the procedure, please refer to the separately
dictated Operative Report. Patient remained in atrial
fibrillation with persistent pressor requirement
post-operatively. On ___, patient was started on amiodarone
drip and underwent successful electrical cardioversion with
conversion to sinus rhythm. Also, on ___ a PICC was placed
and patient was started on TPN. On ___, patient was off of all
pressors and on minimal ventilatory settings. He was extubated
successfully on ___. On ___, patient self removed his NGT
again and it was replaced. On ___, trickle tube feeds were
started via the J-tube. On ___, patient began having multiple
loose bowel movements and C. diff resulted as positive. He was
started on PO vancomycin and Flexiseal was placed. NGT output
remained high, though TFs were successfully increased to goal
via the J-tube. On ___, patient had a new leukocytosis to 15.3
and some wound erythema. CT showed stranding in the subcutaneous
tissues in the midline incision. Several staples in the midline
incision were removed and wet-to-dry dressing applied. Flexiseal
and Foley were removed on ___. On ___, tube feeds were at
goal and patient expressed desire to eat. He was weaned to
half-TPN and speech and swallow eval was ordered. He was
transferred to the floor on ___.
Mr. ___ spiked a fever (102.7) on ___. Empiric antibiotic
treatment with Zosyn was added to the antibiotic regimen of PO
Vancomycin and IV Metronidazol. A CXR was reassuring for no
signs of pneumonia. Although a CT of abdomen and pelvis as well
as an ultrasound of the abdomen raised the concern for acute
cholecystitis the clinical concern for acute cholecystitis was
low in the absence of abdominal pain or tenderness. Mr. ___
was diagnosed with an E.coli urinary tract infection.
Antibiotic treatment was continued with cefazoline based on
sensitivities and switched to cephalexine on discharge. The last
day of treatment is ___.
As the consistency of the patients bowel movements improved a
Clostridium difficile PCR of ___ returned negative. Antibiotic
treatment for Clostridium difficile colitis was discontinued on
___.
Mr. ___ was discharged on therapeutic anticoagulation with
Lovenox instead of Warfarin as per the patients oncologists
recommendation (concern for interaction of oral chemotherapy
with warfarin).
The restart of Metoprolol and Diltiazem on the patients home
dose was complicated by bradycardia with heart rates in the ___.
Hence the dose of Metoprolol and Diltiazem was reduced to half
the patient's home dose, i.e. Metoprolol XL from 50 mg PO QD to
25 mg PO QD and Diltiazem from 240 mg PO QD to 120 mg PO QD. The
treatment with amiodaron was not resumed on discharge. This
requires reassessment by the primary care physician.
At the time of discharge on ___ Mr. ___ felt well and
was without pain. His diarrhea had resolved and he was
tolerating a regular diet. He was ambulating with a walker and
was cleard by our Physical Therapy service for discharge home
with home ___ and ___ services. | 513 | 793 |
17605195-DS-7 | 27,985,420 | ___ were admitted to the hospital with upper and and lower
abdominal pain. ___ underwent a cat scan of the abdomen and ___
were found to have a bowel obstruction most likely related to a
Crohn's flare. ___ were placed on bowel rest and started on
antibiotics. ___ were also seen by the GI service who provided
recommendations about the management of your care. Your
abdominal pain has since resolved and ___ have resumed a regular
diet. ___ are now preparing for discharge home and instructed
to follow-up with Dr. ___. ___ are being discharged with the
following instructions:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern ___.
Please complete the course of antibiotics as ordered | ___ year old gentleman admitted to the acute care service with
upper and lower abdominal pain. Upon admission, he was made
NPO, given intravenous fluids and underwent radiographic
imaging. Cat scan of the abdomen showed a high grade small bowel
obstuction. He was placed on serial abdominal examinations and
bowel rest. The GI service was consulted because of his history
of Crohn's disease and recommended medical management. He was
placed on intravenous ciprofloxacin and flagyl for a ___s his abominal pain resolved, he was placed on clear liquids
with advancement to a regular diet. His white blood cell count
and hematocrit remained normal. He is preparing for discharge
home on pentasa and budesonide. He will follow-up with Dr. ___
___ his primary care provider.
Of note: he was found to have a large amount of blood in his
u/a on ___. Pt reports "burning" noted after placment of foley
catheter. Catheter d/c, pt denies frequency, urgency, burning.
Voiding without difficulty. Will discharge on ciprofloxacin and
flagyl for GI coverage. | 239 | 183 |
19509298-DS-35 | 21,647,194 | Mr ___,
You were hospitalized at ___
for severe infections, including Proteus UTI and Staph epi
bacteremia and require Critical Care management. With
assistance of Intensivist and Infectious Disease specialists, we
were able to treat you infections successfully with IV
antibiotics.
Currently, you have finished antibiotics for UTI; however, will
need to continue IV Vancomycin for another week to finish
treatment for bactermia.
You will be discharge back to Golden Living with IV antibiotics
and special IV line flushing protocols to reduce risk for blood
infections.
Please follow up with your PCP/Dr. ___ 7 days of
discharge and urology/Dr. ___ as directed.
Sincerely,
Your ___ Team | This is an unfortunate ___ with secondary progressive MS with
resultant
quadriplegia requiring trach/PEG/SPT, AF on Warfarin, HTN, HL,
hypothyroidism, GERD/PUD, chronic constipation with prior
sigmoid
ulcer, healing decubitus ulcer, nephrolithiasis, and chronic
poor
IV access with tunneled line ___ situ, who presented with
hypotension and transient hypoxemia, found to have likely UTI,
sputum with Pseudomonas/GNRs thought to be colonization, and GPC
bacteremia.
# Severe sepsis with shock
# Proteus foley associated UTI, with 12mm right non-obstructing
nephrolithiasis
# Pseudomonas pneumonia/aspiration vs colonization, suspected
colonization
# Staph epi bacteremia, x2 initial blood cultures, suspected
source from ___ CVL. Has been treated with Gent ___,
vancomycin (___) and meropenem (___), which was
narrowed to vanc/cefepime (___). TTE showed no
evidence of endocarditis.
# s/p non-powered ___ ___ R. IJ tunneled line place by ___
___
- Per ID recommendations, con't Cefepime x 7 days, last dose
___
- Per ID, IV vanco through ___
- as d/w ID and IV specialist, will initiate Vanco/Heparin lock
for duration of IV antibiotics therapy, and 70% Ethanol lock as
long as ___ remain ___ place.
- monitor repeat BC's to ensure clearance of bacteremia, all
have remained negative since initial BC's.
- urology/Dr. ___, SPT changed ___.
- d/w urology re. treatment for the 12mm R. kidney stone,
especially considering Proteus. Patient is recommended for
outpatient follow up, risk vs. benefit is not clear at this
point
to proceed as it will unlikely significantly change his UTI risk
with high complication risk with intervention.
# Acute on chronic hypoxic respiratory failure, s/p trach.
Resolved.
# Pseudomonas airway colonization.
Patient had multiple episodes of desaturations to ___ while ___
ED
which improved with deep suctioning. Has chronic trach and
history of multiple aspirations and lung abscess. History of
pseudomonas and steno ___ sputum cx. He remained without
respiratory distress ___ FICU. Received VAP coverage with
vanc/cefepime due to treatment for GPC bacteremia and Proteus
UTI, though was thought unlikely to have true PNA given negative
CXR. These intermittent episodes are likely 2* secretions,
especially worse ___ AM after awakening.
- no specific antibiotics for airway Pseudomonas colonization
- con't trach care, including deep suctioning per RT PRN
- I will specifically request for deep suctioning ___ AM after
awakening as patient has consistently shown a pattern of
decompensation early ___ AM as secretions tend to accumulate
overnight while asleep.
- keep HOB > 30 degrees
# Chronic Fe-defic anemia: stable at baseline. No signs of
bleeding now. h/o acute anemia 2* duodenal ulcer bleeding.
- Continue PPI
- Continue to monitor
# AFib: On warfarin and metoprolol. INR 3.6 on arrival;
warfarin
was held until INR 1.6 and was restarted on ___. Metoprolol was
held during FICU admission ___ the setting of hypotension.
- Cautious resumption of fractionated beta blockers
- Con't Coumadin for INR 2.0-3.0
# End-stage MS: Quadriplegic, s/p trach, SP tube, and GJ tube.
- Continue home modafinil, baclofen, and scopolamine
# HTN - Holding home antihypertensives given soft BPs
# GERD - Home lansoprazole, substituted to omeprazole
# HLD - Continue home fenofibrate
# DM2 - Continue 8U glargine daily
# Decubitus ulcer present on admission: Reportedly stable
without signs of infection. Continue wound care, offloading | 104 | 531 |
10225619-DS-6 | 21,697,329 | It was a pleasure caring for you during your hospitalization for
palpitations. We kept you on the monitor and you had one 6 beat
run of ventricular tachycardia while you were sleeping.
Electrophysiology specialists saw you and recommended changing
your metoprolol to twice daily dosing to provide better
protection throughout the day. You will receive a cardiac
monitor within a week have follow-up with Dr. ___ as an
outpatient, see appointment below. | ASSESSMENT AND PLAN: ___ M with two episodes of perimyocarditis,
most recently in early ___ with VT/VF arrest and
respiratory failure requiring intubation and MICU stay, with
improvement in EF, ventricular ectopy since, presenting after
experiencing a fluttering heartbeat reminiscent of Vtach for 8
beats at home, 6 beat run of monomoprhic NSVT on tele ___.
# NSVT: Had 6 beat run of NSVT on ___ on tele, asymptomatic,
while sleeping. No palpitations, chest pain, dyspnea, while
ambulating around floor. No clinical evidence of
perimyocarditis (no chest pain, fevers, negative cardiac
enzymes, ___ echo showed normal LV function). He has been
uptitrated on metoprolol reduce incidence of ventricular ectopy.
Has discussed ICD placement but decided against it for now.
-Appreciate EP recs: increase metoprolol to 50mg bid
-Arrange for home cardiac monitor
-Outpatient exercise stress test
-Follow-up with Dr. ___.
# PUMP: Last Echo (___) showed normalisation of EF.
-continued lisinopril.
#CODE: Full | 74 | 163 |
12251149-DS-9 | 28,516,798 | Dear Ms. ___,
You were admitted to the hospital for evaluation and treatment
of your headache. You received imaging of your brain including
the vessels which showed no acute bleed or clot. We performed a
lumbar puncture to ensure you did not have an infection. Your
headache improved, however we did not have the full information
from your lumbar puncture except for the white blood cell count
which did not suggest infection. We recommended you stay for
further evaluation in the morning but you elected to leave AMA
(against medical advice). Please arrange outpatient Neurology
follow up by calling ___.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Care Team | Patient admitted for nonspecific headache. Neurologic
examination revealed bilateral endgaze monocular diplopia
without other cranial nerve pathology. MRI/MRV/MRA negative.
Because of an initial serum leukocytosis which appeared to
improve with fluid administration, lumbar puncture was performed
to rule out meningits; it showed WBC 1 with normal protein and
glucose results. OP could not be measured. Patient elected to
leave AMA prior to return of the CSF studies and consideration
of other diagnostic studies, reporting that her headache
improved after the LP and IVF. | 114 | 83 |
17632500-DS-17 | 23,100,115 | Dear Ms. ___,
***FOR YOUR MEDICATIONS:***
PLEASE CALL FINANCIAL COUNSELING OFFICE IN 2 WEEKS at
___ TO REQUEST CLEARANCE FORM TO CONTINUE RECEIVING
FREE CARE MEDICATIONS.
You were admitted to the ___
after falling and having a seizure at a shopping mall. You were
found to have had a stroke and likely due to that you fell and
had a fracture of your occipital bone of the skull, then had
some bleeding in the head (subdural and subarachnoid
hemorrhage), then had a seizure due to the bleeding. You were
evaluated for causes of stroke and no cause was found. There are
some labs still pending to evaluate for reasons to have had a
stroke. You will also wear a heart monitor after discharge to
evaluate for atrial fibrillation, a heart rhythm that can
pre-dispose you to having strokes.
You were also found to have chronic inflammation of your
gallbladder, for which you underwent laparoscopic removal of
your gallbladder. You tolerated this procedure well and are now
ready to return home to finish your recovery. Samples from your
gallbladder were sent to the pathology department for analysis;
you will receive the results of this analysis at your follow up
appointment. Please see the following instructions regarding
your recovery.
ACTIVITY:
- You should not drive until the cause of your seizure is
determined; you are at risk of hurting yourself and others if
you were to have a seizure while operating a vehicle. Also, do
not drive until you have stopped taking pain medicine and feel
you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
PAIN MANAGEMENT:
- You may take Tylenol as needed, not to exceed 3000mg in 24
hours. - Your pain should get better day by day. If you find the
pain is getting worse instead of better, please contact your
surgeon. If you experience any of the following, please contact
your surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
WOUND CARE:
- dressing removal: you may remove the outer, clear bandages
- You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off. Do
not take baths, soak, or swim for 6 weeks after surgery unless
told otherwise by your surgical team.
-Notify your surgeon if you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
- Your ___ care team | Ms. ___ is a ___ woman with history of anxiety on
fluoxetine and multiple skin recurrent abscesses, who was
admitted after an unwitnessed fall at a shopping mall followed
by a witnessed GTC, found on non-contrast head CT to have a left
frontal small subdural hematoma as well as subarachnoid
hemorrhage with right occipital fracture presumably due to
trauma. She was also found to have infarcts in the right
cerebellar hemisphere in the ___ distribution. CTV does not
suggest an acute sinus venous thrombosis. She remained
clinically stable with headache likely secondary to irritability
from hemorrhage and peripheral vertigo possibly secondary to
injury to the inner ear when she fell. Most likely stroke led
to fall which led to fracture and hemorrhage which led to
provoked seizure.
For seizure prevention she was started on Keppra 1000mg BID
which she will continue at least until next Neurology follow-up.
She had no breakthrough seizures while admitted.
For stroke work-up she had a TTE with no intracardiac source of
embolus identified; EF >55%, no rmal biventricular global
systolic function; no significant valvular disease. She had a
hypercoagulable work-up including beta2 glycoprotein, lupus
anticoagulant, cardiolipin Ab, SPEP, protein C/S, antithrombin
III that was negative. She had stroke labs including HbA1c
4.9%, TC 186, LDL 107, ___ 101, ESR 29. There was initial
concern for possible acute sinus venous thrombosis on imaging
that was ultimately thought to be a hypoplastic sinus rather
than an acute process. Therefore she was not started on
anticoagulation. She was started no ASA 81mg daily and
monitored on telemetry with no evidence of atrial fibrillation;
she will have an event monitor after discharge.
She had persistent nystagmus noted in bilateral directions with
likely multifactorial central vertigo in addition to peripheral
vertigo. She had a temporal bone CT with minimally displaced
longitudinal fracture through the right occipital bone extending
into the right mastoid air cells and the right jugular foramen.
Also a partial opacification of the right mastoid air cells; no
definite involvement of the right facial nerve; Trace soft
tissue density in Prussak's space adjacent to the scutum with
question of a tiny cholesteatoma. ENT was consulted and
recommend audiogram and outpatient ORL follow up; also
vestibular ___.
Her course was complicated by acute RUQ abdominal pain secondary
to acute cholecystitis now s/p lap cholecystectomy on ___,
recovering well with surgery follow-up scheduled. Ms. ___
was taken to the OR on ___ and underwent an uncomplicated
laparoscopic cholecystectomy. For details of the procedure,
please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. Post-operatively,
she did well without any major issues. She was able to tolerate
a regular diet, get out of bed and ambulate without assistance,
void without issues, and pain was controlled on oral medications
alone.
She was followed closely by ___ and OT, particularly vestibular
___ due to concern for severe vertigo.
She was discharged with plan for close Neurology, ENT, Surgery
and Cardiology (for event monitor) follow-up. | 710 | 523 |
15924309-DS-19 | 22,357,463 | Dear Mr ___,
___ were admitted to the hospital after a total Colectomy for
surgical management of your rectal cancer. ___ have recovered
from this procedure well and ___ are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. ___ will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact ___ regarding these
results they will contact ___ before this time. ___ have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. ___ may return home
to finish your recovery.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
___ monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
If ___ have any of the following symptoms please call the office
for advice ___:
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
Incisions:
___ have a long vertical surgical incisions on your abdomen
closed with staples. This is healing well however it is
important that ___ monitor these areas for signs and symptoms of
infection including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area.
___ may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips), these will fall off
over time, please do not remove them. Please no baths or
swimming until cleared by the surgical team.
Pain
It is expected that ___ will have pain after surgery and this
pain will gradually improved over the first week or so ___ are
home. ___ will especially have pain when changing positions and
with movement. ___ should continue to take 2 Extra Strength
Tylenol (___) for pain every 8 hours around the clock and ___
may also take Advil (Ibuprofen) 600mg every hours for 7 days.
Please do not take more than 3000mg of Tylenol in 24 hours or
any other medications that contain Tylenol such as cold
medication. Do not drink alcohol while or Tylenol. Please take
Advil with food. If these medications are not controlling your
pain to a point where ___ can ambulate and preform minor tasks,
___ should take a dose of the narcotic pain medication _____.
Please take this only if needed for pain. Do not take with any
other sedating medications or alcohol. Do not drive a car if
taking narcotic pain medications.
Activity
___ may feel weak or "washed out" for up to 6 weeks after
surgery. No heavy lifting greater than a gallon of milk for 3
weeks. ___ may climb stairs. ___ may go outside and walk, but
avoid traveling long distances until ___ speak with your
surgical team at your first follow-up visit. Your surgical team
will clear ___ for heavier exercise and activity as the observe
your progress at your follow-up appointment. ___ should only
drive a car on your own if ___ are off narcotic pain medications
and feel as if your reaction time is back to normal so ___ can
react appropriately while driving.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck! | ___ hx of obstructing rectosimgoid cancer s/p metallic stent
placement on ___ returned on ___ with large bowel obstruction
concerning for impending perforation . He was taken emergently
to the OR for exploratory laparotomy, total colectomy, ileostomy
w/mucus fistula. He tolerated the procedure well, discharged to
PACU. After a brief and uneventful stay in PACU, he was admitted
to the floor for further post-operative management.
On hospital dayHe was admitted to ICU for ut of concern for ST
elevation on EKG.
FICU ACTIVE ISSUES
===================
# Inferior ST Elevations
Patient taken to cath lab on ___ and found to have clean
coronary arteries. Initial trop and CK-MB negative, repeat trop
0.03. Repeat ECG following transfer to ICU showed resolution of
inferior ST elevations. Differential for patient's transient ST
elevations includes coronary vasospasm vs. stress
cardiomyopathy. Cardiology was consulted. The patient was
continued on his home ASA and statin.
# Fever
Patient spiked fever post-cardiac cath. Cultures and a CXR was
obtained which showed a RLL pneumonia. Patient was started on a
7-day course of levofloxacin to treat a presumptive HAP. Urine
and stool cultures were negative. Blood cultures were still
pending.
# Rectosigmoid cancer
Patient presented to ___ on POD #3 from total colectomy with
diverting ileostomy and mucus stoma. He had 400cc output from
his ileostomy on arrival. His post-operative pain was controlled
with IV Tylenol. He remained hemodynamically stable.
Neuro: Pain was well controlled
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge.
GU: Patient had a Foley catheter that was removed at time of
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever.
Heme: The patient had blood levels checked post operatively
during the hospital course to monitor for signs of bleeding. The
patient had vital signs, including heart rate and blood
pressure, monitored throughout the hospital stay.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge. | 897 | 375 |
12850009-DS-24 | 29,210,381 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were hospitalized because you have been
falling. We believe that you are having mechanical falls for a
combination of several different reasons. It is important that
you continue with physical therapy to improve your strength and
coordination.
During your stay we also performed a therapeutic, large-volume
paracentesis. We removed 6L of fluid from your abdomen. You were
also evaluated for esophageal varices by endoscopy and 2 were
banded during this exam.
We made the following changes to your medications:
Added:
Docusate Sodium 200 mg by mouth twice per day to prevent
constipation
Senna 2 TAB by mouth twice per day for constipation
Sucralfate x 14 days
Changes:
spironolactone 120mg by mouth daily
furosemide 40mg by mouth daily
Stopped:
diazepam
lisinopril | Patient is a ___ y/o woman with a h/o HTN,DM II, non-alcoholic
fatty liver and cirrhosis, who presents with recurrent
mechanical falls. | 129 | 22 |
12839177-DS-4 | 29,653,961 | 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:
- Touch down weight bearing
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: daily by RN | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left comminuted acetabular fracture and left native
dislocation and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for ORIF
left acetabulum, 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. Given the
pt's extensive cardiac history, hct threshold has carefully
monitored for values higher than 27. Patient's hct values were
23.8, 26.3 and 24.1 on POD ___ and 2 so the patient received 1
unit of PRBC daily to increase his hct which increased
appropriately and is now stable around 27.3. The patient also
complained of right wrist pain for which an xray was ordered
showing comminuted right triquetral fracture without significant
displacement. Hand surgery was consulted and recommended an
orthoplast volar resting splint x2 weeks and then can come out
of splint, can use platform walker or conventional walker with
splint on during these two weeks, whichever the patient is more
comfortable with patient can follow up with orthopaedic trauma
team at regularly scheduled visit and with either the hand
fellows clinic or Dr. ___ prn if issues. Hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearin with posterior hip precautions in the
right lower extremity, and will be discharged on Lovenox 40mg SC
daily 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. | 221 | 404 |
11374532-DS-26 | 26,046,721 | You were admitted with leg swelling and redness which were
consistent with venous stasis and cellulitis. The redness
improved with antibiotics. Please continue taking the
antibiotics by mouth until finished. You can also start using
compression stockings to decrease the fluid in your legs. We
also decreased your dose of lasix from 40mg to 20mg.
Your labs also showed a high uric acid level which is concerning
for gout. Please discuss with your primary care physician about
start medication to prevent gout flairs. | A ___ y/o male with baseline ___ edema and a past history of
cellulitis presented with 1.5 weeks of LLE swelling and warm.
1. Cellulitis/venous insufficinecy. His lower extremity
erythema and swelling improved with vanco and elevation. Blood
cultures were no growth to date on discharge. He was discharged
to complete a 5 day course of keflex and bactrim and compression
stockings . He will follow up with his pcp.
2. acute renal insufficiency: improved with hydration and
holding lasix. He will restart lasix at a decreased dose 20mg
daily. Please check renal function at follow appointment.
3. Anemia. His Hct was around his base line. We will follow his
Hct daily
4. Elevated uric acid: patient had no pain or swollen joint
consistent with gout flair. His PCP can consider starting
allopurinol to prevent gouty flairs in the future. | 87 | 145 |
13656933-DS-18 | 29,608,995 | Dear Ms. ___,
It was a pleasure to take care of you during this
hospitalization. You were admitted to ___
___ after you were found to be confused and with a
low blood sugar and blood pressure. During this
hospitalization, you were found to have a fever and low blood
pressure, for which you were started on antibiotics and
administered intravenous fluids. Because we did not find a
clear source of infection and you remained clinically stable
without fevers, antibiotics were stopped.
You also received hemodialysis during this hospitalization. You
are now safe to leave the hospital. Please follow-up with your
doctors as ___ and take your medications as prescribed. | ___ year-old woman with PVD s/p R AKA in ___, DM, HTN, CKD
stage 5 on HD (anurics) with a recent ___ admission who
presented on ___ for fever and hypotension.
# Fever: The patient developed fever prior to arriving at ___
and another overnight from ___ to T 101. Given concern for
infection, patient was started on Vancomycin and Zosyn. However,
she remained without any obvious source of infection. Blood
cultures remain without growth, chest xray was clear, she is
anuric, her recent left leg amputation was evaluated by vascular
surgery who did not think there was infection of the stump,
hemodialysis fistula looked well. As such, antibiotics were
discontinued on ___, and the patient remained afebrile for
over 72 hours at the time of discharge.
# Hypotension: She has baseline blood pressure with systolics
130-140s on four antihypertensive agents. She was recently
started on dialysis, and she went to dialysis the day of
presentation and had an unknown amount of fluid removed. She had
fever with concern for possible sepsis. She also has been
getting pain medications. All these may have contributed to her
hypotension. She quickly resolved in the ED with fluid
resuscitation. She needed no more IV fluids in the ICU or on the
medical floor. Her blood pressure medications were initially
held and restarted when her blood pressure increased.
# Altered mental status: Patient was found to have altered
mental status in the setting of a hypoglycemic episode at
dialysis. This slowly resolved and was at what was thought to be
her baseline in the ED prior to ICU arrival. The cause was
unknown whether hypoglycemia, sepsis, pain medications. She
remained at her baseline mental status during her time on the
medical floor.
# CKD stage 5: She was followed by renal and continued on her
TTS dialysis schedule.
# Bowel movements: She had worsening pain with bowel movements
for one day. This is likely related to constipation from
opiates. She was placed on an aggressive bowel regimen. While on
the floor, she passed 2 hard BM's with subsequent improvement in
her pain.
# PVD s/p bilateral AKA: Vascular assessed her L AKA leg and
determined no need for further surgical intervention. They
recommended that her staples remain in place until her next
appointment with Vascular surgery (Dr. ___. His office will
call to schedule the appointment in late ___ or early
___. Instructions for contacting his office are provided
below.
# Diabetes: She was reported to be hypoglycemic at OSH. She was
quickly back to normoglycemic with glucagon. She was ordered for
an insulin sliding scale, and her blood sugars remained
well-controlled during this admission.
# Hypertension: Patient presented with hypotension so all her
home hypertensive medications were initially held. As the
patient's blood pressure increased to sBP 170s, her home
atenolol and lisinopril were restarted prior to discharge.
Atenolol was increased from 50mg to 75mg daily in the morning.
Lisinopril was converted from 20mg BID to 40mg daily in the
morning. Her home nifedipine and valsartan were not restarted
given the concern for | 115 | 507 |
15190257-DS-15 | 23,276,886 | Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, yellowing of skin or
eyes, persistently elevated blood sugars or 200 or greater or
lower than 80, increased abdominal pain, incisional redness,
drainage or bleeding, JP drain output greater than 1 liter,
dizziness or weakness, decreased urine output or dark, cloudy
urine, swelling of abdomen or ankles, or any other concerning
symptoms.
Empty JP drain when half full. Record all output. Change
dressing daily and as needed.
You will have labwork drawn every ___ and ___ as
arranged by the transplant clinic, with results to the
transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT,
Alk Phos, T Bili, Trough Tacro level.
**On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. The
staples are removed approximately 3 weeks following your
transplant.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids (2 liters)to keep your urine light in color.
Your appetite will return with time. Eat small frequent meals,
and you may supplement with things like carnation instant
breakfast or Ensure.
Check your blood sugars and blood pressure at home. Report
consistently elevated values to the transplant clinic
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise | ___ y/o male with HTN, AMA-negative PBC and subsequent cirrhosis
p/w 1.5 weeks of abdominal distension and nausea, found to have
elevated Cr, Tbili, and ascites, concerning for hepatorenal
syndrome in the setting of decompensated cirrhosis.
Infectious work up was done with no source for decompensation.
Attempted to add on diuretics & nadolol, though this worsened
renal function (creat 3.0 from 1.6), so these were stopped.
Known untreated nephrolithiasis had caused non-functioning of
left kidney in past. US of right kidney demonstrated no
obstructing stones or hydronephrosis. Cr improved to 1.8 with
albumin, though increased to 2.6 with diuresis, after episode of
flash pulmonary edema. Cr decreased without intervention, but
remained in the 1.8 to 2.4 range, without oliguria.
Ascites was managed with therapeutic paracentesis prn. Ursodiol
was increased for symptomatic relief of pruritis.
On ___, he had hematemesis secondary to esophageal variceal
bleeding and was transferred to the MICU. EGD was done with
successful banding of varices. Moderate portal hypertensive
gastropathy was noted.
Initially spiked a temperature on ___, started on CTX for
presumed SBP (could not be tapped due to insufficient fluid)but
spiked again to 101.7 on ___ and was broadened to vanc/zosyn.
Blood and urine cultures negative. CXR showed pulmonary edema,
but could not rule out infection. CXR improved by ___.
Following GI bleed, he was on empiric CTX treatment (last day
___.
He was extubated shortly thereafter and was transferred out of
the MICU. He underwent expedited eval for liver transplantation,
for which he was approved and was listed for transplantation on
___. On ___, he received a liver offer that he accepted, and
underwent deceased donor liver transplant using piggyback
technique and temporary portacaval shunt. Surgeon was Dr. ___
___ assisted by Dr. ___. Please refer to operative
note for details and transfusion requirements.
Postop, he went to the SICU intubated. A neo drip was required.
Hct was 26.6 and he was given 1 unit pRBC x2. CVVHD was started.
LFTs increased as expected and liver duplex demonstrated patent
vasculature with hepatic artery indices of 7.7-7.8. He was
extubated on ___, and continued to have a transfusion
requirement for a couple days for low platelets and decreased
hct. This stabilized.
CVVHD was stopped as well as the neo drip. On ___, he was given
hydralazine for hypertension. Hydralazine was subsequently
changed to carvedilol 3.125 twice daily with decreased SBP. He
was de-lined and the foley was removed prior to transferring out
of the SICU on ___. Amlodipine was added for persistently
elevated SBP.
Diet was advanced very slowly. Intake was poor and supplements
were given. Glucoses were elevated to 300s and a Humalog sliding
scale was given. A ___ consult was obtained with NPH insulin
added. ___ MD made adjustments.
LFTs decreased daily. JP drain outputs were high. The medial JP
was removed on ___ and the lateral JP output continued to range
between 1600 down to 1000cc/day for which intermittent albumin
was given for several days. Serum WBC increased as previously
mentioned without clear source. JP fluid cell count was negative
for peritonitis.
Mental status was flat. Pan-culturing was done without any
source of elevated wbc and malaise. BUN was 92 with a creatinine
of 2.4 on ___. Hemodialysis was performed (via a right IJ HD
line)as his fatigue and flat affect were attributed to uremia.
He did feel better after this treatment (no further HD
treatments were done). Creatinine continued to range between 2.9
and 3.0. 24 hour u/o averaged 750-895ml per day.
Diet was slow to advance and appetite was poor. Supplements were
ordered and he tried to drink these. Weight was 62.4kg on the
day of discharge down from admission weight of 75.6kg. He and
his wife were instructed regarding dietary needs and
recommendations. A potential tube feeding was discussed.
A ___ consult was obtained and insulin adjusted to NPH and
Humalog sliding scale. AM glucoses were on the low side,
therefore, NPH was decreased to 18 units every am.
Immunosuppression consisted of cellcept 1 gram twice daily.
Dosing was spaced out to 500mg qid for gi complaints. Tacrolimus
was started on postop dAy 2. Dose was increased up to as high as
7mg twice daily for low levels then trough increased to 17.2on
___. Dose was held once then resumed at 2mg twice daily. Dose
was further decreased to 1.5mg twice daily for levels ranging
between 11.3 and 9.8. Trough was 10.4 on day of discharge with
dose set at 1.5mg twice daily. Steroids were tapered to 17.5mg
daily on ___.
___ worked with him and he was out of bed to the chair then
ambulating in the hall with a rolling walker. He felt ready for
d/c to home on ___ and was discharged after extensive
medication/transplant education and removal of the right IJ
temporary HD line. He was discharged to home with the JP
averaging 1100ml/d on ___. | 358 | 814 |
11126801-DS-13 | 24,226,601 | It was a pleasure participating in the care of Mr ___ during
this hospitalization. He was hospitalized with pneumonia and
required breathing support on a mechanical ventilator. His
hospitalization was complicated by other infections including
cholangitis and a ventilator associated infection, for which he
received antibiotics. Also, as a result of his critical illness,
he suffered set-backs in his mental status and swallowing
safety. He will go home with following medication changes:
1. antibiotics for VAP (Vancomycin) until ___
2. antibiotics for cholangitis (Zosyn) until ___
3. Daily furosemide 80mg with goal even weight. This is to be
increased to twice daily dosing if he gains greater than 2
pounds in one day or greater than 5 pounds in one week
4. Amiodarone 200mg PO daily for atrial fibrillation | Mr. ___ is a ___ year old male transfer from ___ with
refactory hypoxemia and septic shock.
# Refractory Hypoxemia. Due to multifocal pneumonia with a large
focus in the right upper lobe and associated shunting. Picture
initially concerning for ARDS given PaO2/FiO2 in the 60, though
never met criteria as patient did not develop bilateral
infiltrates. Patient was intubated at ___, initially started
on ARDSnet lower TV ventilation, but patient was not breathing
off the CO2 well and settings were liberated as patient did not
develop a full ARDS picture. Required prolonged intubation
given 40L positive fluid balance. Was able to switch to PSV on
___. On ___ continued to spike fevers and sputum culture grew
MRSA. He was started on a 14 day course of vancomycin for MRSA
VAP. Extubated on ___ and did well post extubation, transferred
to floor where he had another episode of respiratory distress
and hypoxemia, aspiration vs flash edema. Patient transferred
back to MICU, diuresed further, and monitored with improvement
in respiratory status. No signs of new consolidation. PICC
placed to secure access. Continued on VAP course of antibiotics.
Diuresed until bump in creatinine to 2.0, then kept even.
Discharged on daily dosing of oral lasix with goal body balance
even. Daily weights need to be followed with escalation of lasix
therapy to twice daily if weight gain or other signs of fluid
overload.
# Septic Shock ___ Multifocal Pneumonia and Bacteremia: RUL PNA
seen on CXR ___ and CT. There is also consolidation in the
RLL and LLL seen on CT. Vanc and Zosyn started at ___ on
___. Recieved one dose of Levoquin for possible Legionella and
discontinued with negative antigen. Switched to Cefepime for one
dose given initial decompensation, Cefepime was discontinued
when ___ blood cultures showed GPC and Zosyn restarted once
GNR grew in blood cultures. ___ blood culture speciated to H.
Influzena and coag negative Staph. He was then switched to
ceftriaxone. Bedside BAL was done when patient arrived at ___
with negative cultures. Initially required Norpeinephrine and
Vasopression, pressors weaned off on ___. Lactate peaked at
3.8. Discharged on final course of VAP treatment with Vancomycin
to be completed on ___ and Cholangitis treatment with
piperacillin-tazobactam.
# Cholangitis - Patient found to have elevated LFTs and
bilirubin. RUQ concerning for periampullary obstruction. He
underwent ERCP with stent placement and drainage of purulent
material. Obstruction thought to be secondary to compression
IPMN pancreatic lesion. He was intially on ceftriaxone and
flagyl, however, given continued fevers he was switched to
piperacillin-tazobactam to be completed on ___. He should
complete a 14 day course of zosyn for cholangitis. He will need
follow up with ERCP in ___ weeks for stent removal. Planned for
___ at 9AM.
# ___ vs CKD. Cr on admission 2.2 uncertain baseline. Trending
down to 1.6-1.8 and remained stable. Likely secondary to
hypovelmia in the setting of sepsis. Continued diuresis until
elevation in creatinine to 2.0. Goal is to keep the patient even
now. Will continue with daily oral Lasix with goal to follow
weights.
# Elevated Trop at OSH. Trop 0.06 at ___ with non-sepcific
EKG changes. Elevated Trop likely due to ___. Ruled out with
negative enzymes x 2.
# A. Fib. Admitted in sinus rhythm. CHADS of ___. Uncertain if
stroke is ischemic or hemorrhagic. Patient likely no
anticoagulated likely due to previous hemorrhagic stroke but
uncertain. Patient developed A. Fib with RVR on the evening of
___. Patient was loaded with Amiodarone with conversion to
sinus bradycardia. Given bradycardia and possible sick sinus
syndrome, Amiodarone was discontinued. However, given repeated
episode of Afib with RVR later in MICU course, he was restarted
on oral amiodarone.
# CVA. History of CVA uncertain if ischemic or hemorrhagic
complicated by cystic encephalomalacia through left MCA
terratory and flaccid hemiplegia and hemiparesis. In addition,
patient displaying recrudescence of previous speech and swallow
deficits. He was evaluated by ___ who reported that he would
likely benefit from intensive SLP therapy upon discharge to
address receptive/expressive language and dysphagia. Throughout
his hospitalization, he was continued on Phenytoin and Baclofen.
Baclofen dosing was reduced given prolonged period of AMS -- no
increase/worsening of stiffness or contractures noted on
decreased dose.
# DM. Maintained on insulin sliding scale. Was put on lantus
while on tube feeds to be continued upon discharge.
# Nutrition - Mr ___ had tube feeding via NG tube for entire
hospitalization due to concern for aspiration. He was evaluated
speech and swallow evaluation and was found to be at high risk,
and PEG was recommended by team for feeding until more thorough
swallow therapy could be completed. The family agreed and a G-J
tube with a single distal port was placed on ___ under
flouroscopy. He was discharged with continued plan for speech
and swallow therapy.
# Goals of care: Had family meeting after re-admission to ICU.
Explain that another aspiration event or pneumonia could be
catastropic. Family agrees but reports that patient made it
clear to them, "not to let him go" during this hospitalization.
They would like to continue with FULL CODE and re-evaluate on
case-by-case basis. | 125 | 850 |
12494390-DS-18 | 20,105,803 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for nausea, vomiting, and
abdominal pain
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You got an EKG to measure your heart, since a few of your
medications can make people's hearts beat abnormally
- You continued to receive your home medications
- You started to feel better after we gave you medications for
nausea
- You were found to have elevation of your pancreas enzymes, and
inflammation in your stomach
- You were started on a medication to protect your stomach
- You felt like you were ready to leave at the end of the day
after you were able to keep food down and did not vomit
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Marijuana is associated with nausea in some people, so try
taking a break from it to see if your nausea improves
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | ___ is a ___ year old man with PMH hypertension,
ESRD on ___ dialysis, who presented from HD with nausea and
vomiting and abdominal pain. Patient notes that he has had
chronic nausea and difficulty keeping food down for months. His
symptoms improved without specific intervention and were felt to
be multifactorial (diabetic gastroparesis and cannabinoid
hyperemesis syndrome.)
TRANSITIONAL ISSUES
===================
[] Will need CBC, CMP, and LFTs checked as outpt
[] Pt noted to have asymptomatic bacteruria, will benefit from
repeat UA if symptomatic
# Abdominal pain
# Nausea, vomiting
Patient underwent lab testing notable for elevated lipase to
170s and CT imaging with antral gastral inflammation. Notably
patient s/p cholecystectomy and RUQ ultrasound without
significant findings of biliary sludge. Patient reporting
worsening of symptoms with increased marijuana use recently. We
offered ongoing inpatient management including gastrogram to
evaluate for gastroparesis. As the patient is feeling better,
his labs are reassuring and he is eating without nausea or
vomiting or pain, patient elects to continue work up as an
outpatient. He notes his symptoms have improved without
marijuana in the past 48 hours.
# Pyuria
# Cystitis
Patient with UA with WBC, leuk esterase. CT with bladder wall
inflammation. Patient denying symptoms. He received dose of
ceftriaxone in the emergency department. Given lack of symptoms,
treatment was not continued.
# Hypertension
Allowed permissive HTN given history of HD and missed dialysis.
Continued home regimen: carvedilol, nifedipine.
# ESRD on HD
This is ___ uncontrolled HTN. He receives MWF HD. Received a CT
w/ contrast which resulted in Cr bump O/N. Also received dose of
IV morphine in ED, which resulted in Cr bump.
# Anemia
Most likely i.s.o. ESRD and chronic disease.
# Chronic diastolic heart failure
EF > 55% in ___. TTE last admission unchanged from prior,
with
estimated LVEF 70%. No significant concern for acute
exacerbation
at this time.
# History of IV drug use, in remission
Patient takes methadone 30mg twice daily and receives a month
long supply at a time. Qtc 499. Continued methadone 30mg BID.
# CAD
Held home atorvastatin 40mg as LFTs seemed to uptrend.
# Glaucoma
Left eye blindness as a multifocal result of glaucoma and
hypertension per patient. Continued home dorzolamide eye drops
QD.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 189 | 412 |
18942983-DS-14 | 27,826,898 | You are being discharged on warfarin (coumadin) and will need to
be very closely monitored at ___
clinic. The nurse is expecting you to call there and make an
appointment. Warfarin is very sensitive to diet changes,
particularly around green leafy vegetables. It is important that
you keep a small consistent amount of vegetables in your diet
and neither eliminate them nor eat to many.
You will also be seein Dr. ___ on ___ for workup of why you
had the clots in the first place. | 1. Acute Pulmonary Emboli, Vaginal Bleeding
- Continue lovenox to warfarin bridge. Lovenox bridge completes
this morning
- Unclear if this is provoked, given recent surgery versus
occult
malignancy versus inherited coagulopathy. Confirmed with
gyn-surgeon that her pathology was benign fibroids.
- Given daughter's history factor-5 leiden unlikely (per
daughter) and daughter notes each PE was when pregnant but she
is
on lifelong anticoagulation which is unusual. I have arranged
follow up in ___ benign hematology with Dr. ___ on
___
- INR goal ___
- anticoagulation monitoring confirmed at ___
clinic
- Only gave short course of warfarin so that the ___ clinic can
write for warfarin in correct dosing. Will go out on 3mg
- GYN consult appreciated, initial heavy menorhagia was fixed at
suture line with silver nitrate, will reassess her new bleeding,
which was felt to not need further coagulation. hematocrit has
been steady.
2. Nephrolithiasis
- Likely cause of flank pain
- urine cultures negative to date, but on ciprofloxacin (not
caution with warfarin)
3. Benign Hypertension
- Aspirin, Losartan and Amlodipine continued
4. Gout
- Continue colchicine
Full Code
Systemic Anticoagulation | 85 | 166 |
16462507-DS-22 | 26,960,729 | Dear Mr. ___,
You were admitted to the hospital with sigmoid diverticulitis
complicated by a 2cm abscess. You were treated with a course of
antibiotics and instructed to ___ in the clinic after
completion of the antibiotic course. You represented to the
hospital with abdominal pain and diarrhea. A c.diff infection
was ruled out but cat scan showed colitis and a small fluid
collection not amenable to drainage. Because there was no
improvement in your symptoms, you were taken to the operating
room to have a segment of your large bowel removed and a
ileostomy. During your hospital course, you developed a blood
clot in your leg and treated with intravenous heparin. You have
been transitioned to an oral anticoagulant which you will need
to continue for...... Your vital signs have been stable and you
are preparing for discharge home with the following
instructions;
*please continue with the oral anticoagulant, apixaban as
instructed.
*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 ___ with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | ___ year old male with a history of chronic abdominal pain
and axial back pain on chronic opioid. He ___ had
an
admission here at ___ with sigmoid diverticulitis complicated
by a 2cm abscess. He received conservative treatment with
antibiotics and left AMA, but had f/u at clinic with completed
antibiotic course.
He was admitted on ___ with new onset of abdominal pain and
worsening diarrhea, C.diff was ruled out. Cat scan imaging
showed pan-colitis and a small fluid collection not amenable to
drainage. His prior abscess was resolved. Upon admission, the
patient was made NPO, and given intravenous fluids. The Chronic
Pain Service was consulted to assist in pain management.
Because the patient failed to improved with intravenous
antibiotics and bowel rest. he was taken to the operating room
where he underwent a sigmoid resection, colorectal anastomosis,
takedown of splenic flexure, and loop ileostomy. The operative
course was stable with minimal blood loss. The patient was
extubated after the procedure and monitored in the recovery
room. The Chronic Pain service continued to follow the patient
for pain management during the post-operative course. The foley
catheter was removed and the patient voided without difficulty.
On POD #5, the patient was reported to have a left popliteal and
posterior tibial DVT. A heparin drip was started with daily
monitoring of the PTT. The patient's bowel function was slow to
return. To rule out obstruction, the patient underwent a cat
scan of the abdomen which showed a rim-enhancing fluid
collection near the anastomosis. The patient was taken to ___
where the pelvic collection was aspirated and sent for culture.
The patient was placed on ciprofloxacin and flagyl. The
patient's heparin drip was discontinued and apixiban was
started. The ciprofloxacin was discontinued and the patient was
discharged on a course of flagyl.
The patient was discharged home on POD #8. His vital signs were
stable and he was afebrile. He was tolerating a regular diet
and voiding without difficulty. Hie pain was controlled with
oral analgesia. The patient was instructed to schedule an
appointment in the Acute care clinic with Dr. ___ and to
___ with his primary care provider. Discharge
instructions were reviewed and questions answered.
S | 360 | 390 |
16359518-DS-12 | 28,728,511 | Dear Ms. ___,
You were admitted to ___ for
evaluation following a fall where you sustained a left wrist
fracture and laceration by your right eye. You are recovering
well and are now ready for discharge. Please follow the
instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | P - Presents following mechanical fall at home
A - noted to have L radius fx which was evaluated by orthopedics
and splinted, non-operative, and R median canthus laceration
repaired by plastic surgery. Also, small subdural hematoma; does
not require intervention or follow up by neurosurgery.
C - pt on eliquis, held on admission and given sc heparin,
restarted HD2. Instructed to hold eliquis for 1 week and then
restart (given small subdural hematoma).
T - Plan for follow up with orthopedics and plastic surgery in 1
week. | 261 | 87 |
19513255-DS-13 | 27,463,197 | Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for one week. This is to prevent bleeding from
your wrist.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (wrist).
Soreness in your arms from the intravenous lines.
The medications given during the procedure may make you bleed
or bruise easily.
Fatigue is very normal.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
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 | ___ female who initially presented to the ___ ED on
___ for left facial pain and numbness. At that time, she
had a CTA head/neck that was initially read as negative for
acute abnormality, but on second read was questioned for a left
ICA aneurysm. She was called back to the ___ ED late on ___
and admitted to the Neurosurgery floor. She was made NPO in
anticipation of cerebral angiogram, which she went for on ___.
The case was uneventful, and was negative for any aneurysm or
other concerning vascular abnormality. Her right radial artery
was used for access. After being observed for a couple of hours
during which she remained neurologically stable and intact, she
was discharged home without any further work-up or intervention.
No neurosurgical follow-up is indicated. | 294 | 131 |
12089662-DS-5 | 21,181,021 | Dear Mr. ___,
You were hospitalized at ___ for hyponatremia (low sodium)
and a prolonged seizure. You were initially in the Intensive
Care Unit, but subsequently did very well.
The cause of your breakthrough seizure was likely due to a
combination of your known epilepsy (pre-disposition to have a
seizure) and hyponatremia secondary to excessive desmopressin.
You were monitored on EEG and started on a new anti-seizure
medication (Vimpat). You were also seen by endocrinology, who
monitored your sodium and desmopressin, and recommended changing
your regimen to 1 spray in each nostril twice per day.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- START Vimpat (lacosamide) 150mg TWICE PER DAY.
- START Desmopressin 1 SPRAY in EACH NOSTRIL TWICE PER DAY.
Follow-up with your neurologist and Dr. ___ as previously
planned.
It was a pleasure taking care of you,
Your ___ Neurology Team | Mr. ___ is a ___ year old man with hx of craniopharyngioma
s/p resection in ___ and resulting panhypopituitarism,seizure
(last documented sz ___ who was transferred here
following intubation for status epilepticus in setting of extra
doses of desmopressin.
#Seizures:
Started on cvEEG which showed slowing, but no seizures. Was
started on keppra, in addition to his home meds Lamotrigine
325mg BID and Zonisamide 350mg QHS. However, per his neurologist
patient was tried on keppra in the past and this resulted in
mood swings. Thus keppra was stopped and Vimpat initiated. He
underwent CTA which did not show any acute intracranial
abnormality. MRI showed empty sella, no residual pituitary
tissue, and no acute intra cranial abnormality.
#UTI:
Patient found to have UA c/w possible UTI on admission and was
started on CTX. However, urine cx came back negative and CTX was
discontinued.
#Craniopharyngioma s/p resection:
Endocrine consulted on admission. Patient's sodium and urine
output were monitored. Desmopressin restarted at home dose
(later modified, see attached endocrine note below). He was
maintained on his home Levothyroxine, and hydrocortisone. Per
endocrine he does not need Norditropin and testosterone during
hospital stay. | 158 | 191 |
17001497-DS-4 | 21,063,398 | Dear Ms. ___,
Thank you for choosing ___ for your medical care. You were
admitted to the neurology service after your family noticed you
were not moving your right side and you were not talking. You
had a CT scan to look for evidence of a stroke. Your CT scan did
not identify a stroke, however your symptoms are highly
suggestive of a stroke. A confirmatory study, called an MRI, was
not able to be performed (you were not able to be laid flat).
Your symptoms are very typical for stroke. This stroke was most
likely caused by a blood clot that originated in your heart.
You have been diagnosed with 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.
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 ___
- 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 ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- 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 you with care during this
hospitalization. | Ms. ___ was admitted to the ___ Neurology Stroke service
after presenting with global aphasia and right sided weakness as
above. Her presentation was clinically consistent with an acute
infarct of her left MCA. There was no hemorrhage identified on
initial CT scan. Her hospital course, by active system, is as
follows:
1) Neuro: Presented as above. Diangosed with acute ischemic
infarct of L MCA given clinical exam and lack of hemorrhage on
initial CT of head. Patient was unable to tolerate MRI
(desaturated upon laying flat, though CXR was unrevealing).
Given the patient's advanced age, it was decided to defer more
aggressive pursuit of MR imaging. Repeat CT head failed to
demonstrate obvious abnormality. Of importance, patient
presented with new finding of atrial fibrillation, suggesting
thromboembolic origin of stroke. She was started on 325mg daily
aspirin. She was effectively rate controlled without additional
beta-blockade. After discussion with family members, the
decision was made to defer more aggressive anticoagulation (such
as wafarin), given the patient's risk of falls and elderly
status. She passed a speech and swallow evaluation on HD1, and
was easily tolerating a regular diet before discharge. She
remained non-ambulatory, and was largely globally aphasic
(occasional short responses such as "hi" or "okay").
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 97) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
2) Atrial fibrillation: Presented with new diagnosis of atrial
fibrillation as above. Rate well controlled without beta
blockade. Started on aspirin 325mg on HD1. Deferred more
aggressive anticoagulation given risk of falls and family's
desire to avoid polypharmacy in this ___ year old patient.
3) HTN: Permitted hypertension in the setting of acute infarct.
Systolic pressure >180 treated with hydralazine. | 338 | 453 |
18341342-DS-14 | 26,142,711 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You
were admitted to the hospital for evaluation of a large,
Right-sided pleural effusion. The interventional pulmonologists
conducted a thoracentesis to drain off the fluid and also
collect a sample for analysis. We also had imaging including a
pelvic ultrasound, MRI of your abdomen, and CT Scan of your
chest. The imaging did not demonstrate any evidence which would
be concerning for cancer, and your renal angiomyolipomas have
not changed significantly since ___. Your chest CT scan showed
that there is still fluid around your Right lung. There is no
evidence that you have an active infection or need antibiotics.
Your PPD skin test was negative, indicating that you have not
been exposed to tuberculosis.
You will be discharged on pain medications. You will need to
follow-up with your primary care doctor and the interventional
pulmonologists. There are several results which are still
pending. | ___ year old female with history of renal angiomyolipomas, recent
influenza-like illness, found to have large exudative right
sided pleural effusion.
#pleuritic chest pain - Due to Large Right pleural effusion.
This patient was evaluated for the following causes of pleural
effusion: infectious causes, malignancy, rheumatologic.
Initial results of pleural fluid analysis from ___
thoracentesis indicated an exudative effusion (high LDH, high
protein) with atypical cell clusters, raising the concern for
malignancy, however prelim imaging reports did not demonstrate
any evidence for malignancy. There was an addendum to the ___
CTA which stated "The radiolucent lesions in the lungs are
actually thin-walled cysts, given this patient's history of
bilateral renal angiomyolipomas, this finding is compatible with
mild lymphangioleiomyomatosis." She did not have infectious
symptoms which made infection seem less likely; her PPD was
negative. She did have elevated inflammatory markers (CRP 132,
ESR 124). Both interventional pulmonology and pulmonology were
consulted for the evaluation and management of this patient.
She will need outpatient follow-up to receive the results of her
pending studies (cytology, RF, ___ titers) and for management of
the pleural effusion. Given on going pain she was discharged on
prn pain medications (ibuprofen, oxycodone-acetaminophen) in the
meantime. She maintained oxygen saturation during the entire
hospitalization and never required supplemental oxygen. | 165 | 223 |
19995012-DS-14 | 27,305,089 | Dear Ms. ___,
You were admitted to the ___ on
___ with abdominal pain. You were evaluated by the Acute
Care Surgery Service and after a CT scan was done, we found a
piece of your bowel was entrapped in your stomach lining. We
took you to the operating room and repaired this. You tolerated
the procedure well and are now being discharged home to continue
your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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.
It was a pleasure being part of your care! | Ms. ___ is a ___ year old female who presented to the
Emergency Department on ___ with abdominal pain. The
patient was evaluated by the Acute Care Surgery Service and a CT
scan of abdomen and pelvis was obtained. These images revealed
an incarcerated hernia. Given these findings, the patient was
taken to the operating room for repair. There were no adverse
events in the operating room; please see the operative note for
details. She was extubated, taken to the PACU until stable, then
transferred to the surgical floor for observation.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV Tylenol and Dilaudid and then
transitioned to oral Tylenol and Tramadol once tolerating a
diet.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored.
She remained stable from a pulmonary standpoint; vital signs
were routinely monitored. Good pulmonary toileting, early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
The patient was initially kept NPO. On POD1 diet was advanced to
clears with good tolerability. On POD2 the patient tolerated a
regular diet. Patient's intake and output were closely monitored
She has a midline incision to her abdomen with staples that are
clean, dry and intact (will be removed at follow up appointment
with Dr. ___. Her bowel function returned and began to
pass gas and have bowel movements.
The patient's fever curves were closely watched for signs of
infection, of which there were none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible.
The patient was seen and evaluated by physical therapy who
recommended discharge to home with continued home physical
therapy.
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. | 355 | 347 |
13253519-DS-17 | 23,435,416 | Please call Dr ___ office at ___ if you develop
worsening abdominal pain, feel dizzy or weak, have a fevre or
chills, nausea, vomiting, diarrhea, bloody bowel movements or
dark/tarry appearing stool, you vomit blood, pain is not
controlled by your prescribed pain medication or have any other
concerning symptoms.
You may walk around but do not lift anything heavier than 10
pounds
Resume your normal diet, try to avoid sodium/salty foods
No driving if taking narcotic pain medication
DO NOT take aspirin, advil (ibuprofen) or any herbal medications
as they can increase the risk of bleeding | ___ y/o male admitted from an outside hospital following PEA
arrest presumably from NTG given for his presenting symptom of
chest pain and right sided abdominal pain. Prior to
transferring, CTA of chest to r/o PE and a CT Abdomen was done
which showed 2 large exophytic liver masses with moderate
hemoperitoneum and he was
transferred to ___.
Hct on admission was 29.8, serial hematocrits were performed,
and about 8 ours after admission, the hematocrit was noted to
have fallen about 4%, and he received one units of pRBCs. He had
an appropriate increase, and has been stable around 30% since
the transfusion. The patient was kept on bedrest for 48 hours.
He then underwent an MRI to further delineate the hepatic
masses. Findings include two large hepatic lesions, with the
lesion off of segment V measuring up to 3.9 cm. The lesion off
the caudate lobe measures up to 4.2 cm in the transverse
direction and extends inferiorly approximately 6.8 cm. The
features of the lesions appear to be most consistent with HCC.
Cirrhosis with mild splenomegaly. Hematoma in the mid-left
abdomen, anterior to the pancreas in the lesser sac, measuring
up to 7.2 cm.
Additionally CA ___: 51, AFP: 170.5, CEA 4.6
Hepatitis serologies and antibody testing were pending at time
of discharge.
The patient's imaging and history were reviewed on ___ at
hepatobiliary tumor conference and the consensus was that the
patient was an adequate candidate for TACE. He will follow up
with Dr. ___ radiology and oncology as an
outpatient.
The patient underwent an EGD on ___ which revealed no
evidence of esophageal varices. A medium size polyp was noted at
the GE junction, which was biopsied. Normal mucosa in the
duodenum, and otherwise normal EGD to third part of the
duodenum.
At the time of discharge, the patient was ambulatory, tolerating
a regular diet, had stable labs, pain well controlled and had no
active complaints. | 93 | 317 |
16096601-DS-16 | 24,209,028 | Dear Ms. ___,
You were admitted to ___ after
your traumatic injury and underwent open reduction and internal
fixation of your right tibia fracture. You are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
Your right leg was fractured in the accident and was repaired by
the orthopedic surgeons. You should not bear weight on that leg
until the orthopedic surgeons clear you to do so. You also have
a fracture of your right humerus which is non operative. You
should not lift anything with that arm until the orthopedic
surgeons clear you to do so. Please wear your sling for comfort.
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.
DO NOT DRIVE while taking narcotic pain medication.
You should follow up with the oral surgeons for repair of your
fractured mandible and teeth as an outpatient. | Ms. ___ is a ___ F Pedestrian struck on ___ @30mph
with positive loss of consciousness, concussed on arrival with
comminuted maxillary fracture, avulsion of teeth 7,8,9 and right
tibial plateau fracture, fibular head fracture, left humeral
head fracture. She was admitted to the trauma surgery service
with consults to orthopedics and OMFS.
She had a lip laceration and chin laceration which was repaired
by ___, she will follow up as an outpatient for her maxilla
fracture and avulsed teeth. She was taken to the operating room
with orthopedic surgery for her right tibial plateau fracture
which was repaired with ORIF on ___. Please see operative
report for details. She was placed in a sling and non weight
bearing for her left humeral head fracture.
Her diet was advanced as tolerated to a mechanical soft diet and
pain control was transitioned to oral pain medication. She
worked with physical and occupational therapy who recommended
discharge to an acute rehab facility. The patient was accepted
for an acute rehab bed at ___.
Prior to discharge the patient was able transfer and work with
physical therapy to aid in her recovery. She was tolerating a
soft diet without issue. She was voiding and having bowel
movements spontaneously. Her pain was controlled on oral pain
medications. She was also followed by social work for family
coping following her trauma and should continue to be seen by
social work and physical therapy after discharge to continue
with her recovery and coping. She will follow up as an
outpatient with OMFS and orthopedic surgery. She was discharged
to rehab in stable condition. | 314 | 268 |
19823084-DS-9 | 28,711,627 | You were admitted to the stroke service after you had sudden
onset of weakness on your left side. Although most of your
symptoms resolved within hours of your presentation there was
evidence of an ischemic stroke on your MRI. An ischemic stroke
is a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
We did not see evidence of atrial fibrillation on your telemetry
or on ECGs. We discussed this with your cardiologist, Dr.
___ asked that you be seen in his clinic next week for
possible longer-term monitoring. You were taking only Plavix on
admission and there was some concern that you were not
responding to this medication. We opted to switch you to aspirin
at 325 mg daily. Although we discussed coumadin therapy, there
was no clear evidence of atrial fibrillation and you were
reluctant to start this medication given the complexity of
monitoring. The risks were explained to you that you may be at
risk for another stroke without coumadin, but you declined.
You will need to stop your Plavix (clopidegrel)
You will need to take aspirin (325 mg every day)
You will follow up with both Dr. ___ in cardiology and Dr.
___ in neurology.
All these discussion were had with the ___ interpreter over
the phone and you told us that you understood. | ___ ___ woman who presented with left-sided
weakness and sensory disturbances similar to prior symptoms of a
reported stroke in ___. Her symptoms of stroke in ___ included
a left hemiparesis and sensory loss from which she recovered
over five months; she has a residual left hemiparesis, reported
previously. She has diabetes, hypertension, and obstructive
sleep apnea. Her symptoms suddenly worsened 1 day PTA at 11 AM
in the absence of any apparent trigger. Her symptoms have
persisted without any improvement.
Her examination was notable for left nasolabial fold flattening,
left-handed pronation, left arm and left leg mild hemiparesis,
and minimal diminishment of light touch sensation in the left
arm and left leg (poorly localizing) with normal pin and
proprioception, left hand dysmetria, and left extensor plantar
response. These findings have now resolved.
Her noncontrast ___ CT is similar to a scan one year prior,
except perhaps a small hypodensity in the right pons and
midbrain which may be an artifact.
This clinical history was suspicious for reexpression of
symptoms from a prior neurologic injury (namely her prior
reported stroke) or a possible new injury from ischemic stroke
or another cause elsewhere along the
corticospinal-sensory-coordination pathways. Pt was therefore
admitted to the neurology service for a stroke workup.
She reports a prior clinical diagnosis of atrial fibrillation
without any documented evidence, including a negative ___ of
Heart outpatient monitoring recently. Her cardiologist is
unaware of any evidence that she has ever had atrial
fibrillation.
MRI of the brain did show a new right-sided subcortical infarct. | 261 | 253 |
17296323-DS-15 | 29,828,517 | Dear,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for compression of your spinal cord.
What was done for me while I was in the hospital?
- The orthopedic surgeons operated on your spine to save your
spinal cord and relieve pressure.
- A biopsy was performed of the tissue compressing your spinal
cord which showed was concerning for myeloma cells
- You had a bone marrow biopsy
- We increased your pain medications to improve your nerve pain
- You were seen by physical therapy who recommended you go to
rehab
What should I do when I leave the hospital?
- Continue taking your medications and keep all of your
appointments
- Continue to work with the physical therapists at your rehab to
get stronger
- Make sure to go to your appointments with ___ will
determine your treatment plan as an outpatient
Sincerely,
Your ___ Care Team
NEW MEDICATIONS
Tramadol
Senna
Miralax
Bisacodyl
MEDICATIONS WE CHANGED
Increased your Gabapentin to 600/600/800mg | SUMMARY STATEMENT
====================
___ with a history of CAD s/p stenting on aspirin and
ticagrelor, hypertension, DLBCL s/p chemo and radiation, lambda
chain MGUS, and spinal stenosis, transferred to ___ for
evaluation of neurologic symptoms concerning for cauda equina
syndrome & an abnormal enhancing lesion of his lumbar spine. He
underwent a laminectomy by ortho spine to decompress the cauda
equina. He had an L3 biopsy by ___ which showed clonal plasma
cells. He was subsequently transferred to ___ service for
further workup of possible multiple myeloma.
TRANSITIONAL ISSUES
=====================
[] Should f/u with his ___ urologist ___, MD for
now-foley-dependent urinary retention as well as filling bladder
defects seen on MRI
[] Pt found to have left heel ulcer, can be followed by PCP, but
may need referral to podiatry if does not resolve
[] Ticagrelor was held this admission in the setting of
hypovolemic shock following laminectomy, was not restarted given
unclear indication now that greater than ___ year post PCI
placement
[] HCTZ originally held for hypotension, and was not resumed as
patient continue to be normotensive
[] Will need staples removed in ___ weeks, ___
should be calling to set this up. Please call them if to make
sure this happens if it has not been set up by ___ -
___
#Multiple Myeloma
#Anemia
Pt now meets criteria for multiple myeloma given anemia w/ hgb
<10 ___ ), free lambda chains at 557 and free kappa/lambda
ratio of 0.05, and now w/ pathology suggestive of plasmacytoma
vs bone marrow involvement of multiple myeloma given light chain
restriction noted on pathology of L3 vertebrate. There was no
soft tissue mass or epidural mass noted on MRI. Biopsy of the
bone in this area was mainly composed of bone marrow and showed
plasma cells. We suspect that the initial MRI abnormalities and
progressive compression as below are all related to his multiple
myeloma, however, it is also possible that his spinal/MRI
abnormality was all secondary to severe spinal stenosis and
degeneration. He underwent bone marrow biopsy ___, results
still pending at discharge. He also had a PET CT as well as bone
survey as part of staging which were negative for further lytic
lesions. He did have UPEP w. monoclonal free light chains and
___ proteinuria, putting him at risk for cast formation
but his renal function remained normal as did his calcium. Per
conversation w/ spine surgeon (___) he would be
comfortable w/ the patient starting treatment three weeks after
surgery (___) to allow for adequate wound healing.
Additionally, he was seen by radiation oncology while here to
evaluate for the role of possible adjunct or palliative
radiation following his laminectomy, they felt as though the
patient would benefit from further rehab and possible initiation
of treatment for his multiple myeloma first. He can than be
referred to radiation oncology for palliative radiation should
he continue to have focal spinal pain at this time.
#Cauda Equina syndrome
#Cord Compression
#L3/L4 erosion with abnormal enhancement
The patient has had back pain for years, but experienced
significant worsening approximately one month ago. The patient
was admitted to ___ ___ for low back pain with radiculopathy to
the left leg. The month prior he had been hospitalized at
___ and had an MRI which identified the severe
stenosis. It was recommended that he have surgery but he
declined, and was discharged to a rehab facility. He had come to
the ED the end of ___ complaining of worsening pain and
limited mobility. He was seen at ___, while there he was noted
to have urinary retention. He had an MRI that showed interval
progression at L3-L4 with destructive bone changes and
enhancement of surrounding paravertebral soft tissues with fluid
in the intervertebral discconcerning for disco-vertebral
osteomyelitis. He was taken to the OR by orthopedic surgery and
a L2-L5 laminectomy/decompression was performed and complicated
by hemorrhagic shock. Tissue was unable to be collected during
this procedure because of the significant blood loss. Following
L2-L5 fusion/laminectomy he was transferred to medicine. ___
guided biopsy of the L3 vertebral body was performed and showed
no evidence of infection but did demonstrate a minor population
of lambda restricted plasma cells, which implicated either a
plasmacytoma or simply contamination of the biopsy with bone
marrow as above. He did continue to experience sigfnciant pain,
more consistent w/bilateral neuropathic pain than true incision
pain from surgery. His gabapentin was titrated to 600mg/600/800.
He additionally required 50-100mg tramadol daily for
breakthrough pain. However, his pain was improving w/ steroids
and he was able to stand w/ his TLSO brace and help of nursing
staff / physical therapy. He was discharged to rehab w/ hope for
continued improvement. Of note patient did not have any fecal
incontinence or focal ___ weakness at discharge. Prior to
discharge he was found to have some minor drainage at his
surgical site, ortho-spine recommended a 2 week course of
Keflex. His staples will be removed ___ weeks following
discharge.
#Urinary Retention
The patient has a history of BPH. He had urinary retention at
the OSH; unclear how much of this was related to cauda equina
compression vs. chronic worsening of BPH. Failed more than one
voiding trial during this admission, so ___ was left in with
planned urology followup. Rectal exam was notable for normal
sphincter tone. His home finasteride and tamsulosin were
continued.
#L-heel pressure ulcer
#Peripheral Vascular disease
Noted to have a L-heel ulcer on admisison. Podiatry was
consulted and felt that the ulcer was most consistent with a
pressure ulcer with perhaps a slight contribution of peripheral
vascular disease. LENIS were reassuring. The wound was dressed
and topical Santyl was applied daily. He was give a multipodus
boot. ___ follow with podiatry as needed as an outpatient.
#Asymptomatic bacteriuria
UCx grew pansenstive Pseudomonas, UA was negative, and the
patient was not symptomatic. This was in the context of having
had a foley in place. ID was consulted, and per their
recommendations, no abx were administered (thought to be
colonization without infection).
Chronic Issues
================
#Coronary Artery Disease s/p stent
On asa and ticagrelor, both of which were held prior to and
immediately after surgery. ASA was later resumed but we decided
to keep holding ticagrelor given the patient's severe anemia &
recent procedures (may be restarted as an outpatient at the
discretion of PCP or cardiology). Home metoprolol and Entresto
were continued.
#HTN
Home HCTZ was held given soft BPs. It was not resumed given that
the patient was not hypertensive without it. Entresto was
continued and metoprolol was decreased to 12.5 mg daily.
#CODE: Full confirmed
#CONTACT:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.is still
indicated. | 181 | 1,157 |
17890530-DS-55 | 28,050,611 | Dear Ms. ___,
You were admitted for shortness of breath and weight gain due to
a heart failure exacerbation. You were given IV lasix to help
clear the fluid from your body. You will need to take several
new medications as outlined below and follow up with your
cardiologist in the next two weeks. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
It was a pleasure to care for you!
Your ___ Team | ___ yo female with history of HFpEF with frequent admissions for
decompensated heart failure (most recently ___, atrial
fibrillation on amiodarone and warfarin, COPD/pulmonary
hypertension on 3L home O2, DM, CKD III-IV, OSA, HTN, HLD, who
presented with a heart failure exacerbation (20 lbs above dry
weight), diffuse abdominal anasarca and a lack of bowel
movements associated with nasuea/vomiting.
# Heart failure
Patient's last echo EF 50-55 %. She was diuresed with lasix gtt
and metolazone to an approximate dry weight of 124.4 kg.
Diuresis was held on ___ for ___ likely secondary to aggressive
diuresis. On ___ oral torsemide was restarted but on ___ it was
held again for ___. Torsemide was started day prior to
discharge at half home dose (80 mg). She was continued on home
labetalol. Spironolactone was increased to 50 BID during
aggressive diuresis and decreased to home dose of 25 mg two days
prior to discharge.
#Abdominal Pain
Abdominal pain thought likely secondary to right heart failure
(cor pulmonale physiology ___ COPD). Ct Abd/pelvis on admission
showed no acute findings. Her abdominal pain improved with
diuresis. Pantoprazole as initiated for GERD. Nausea
controlled with zofran and ativan.
# ___ on CKD STAGE III (baseline ~2)
Patient had rising creatinine in the setting of aggressive
diuresis with lasix gtt. FeNa<1% which was consistent with pre
renal disease. Her Ct improved to 2.7 with holding of diuretics
and was stable upon initiating torsemide prior to discharge.
# Acute weakness
Patient had one episode of acute left sided weakness (upper and
lower extremity) which was evaluated by neurology. CT ___ w/o
contrast showed no intracranial hemorrhage. MRI showed chronic
changes and no acute process or ischemic stroke. MRA was unable
to be obtained secondary to ___. Patient was monitored, INR was
kept therapeutic, and patient improved and had no further
episodes.
# Atrial fibrillation with history of PE and central retinal
occlusion:
CHADS2= 3. Amiodarone was held due to her severe pulmonary
disease. She was continued on warfarin in house which was
adjusted for INR ___. She was discharged on home dose 22 mg
with INR to be followed up on ___ following discharge.
# Hypertension
Patient was continued on amlodipine and isordil was initiated
and transitioned to Imdur on discharge.
# Urinary tract infection
On admission, patient had 25 WBC in urine with symptomatic
abdominal pain. She was treated with three day course of IV
ceftriaxone.
# Diabetes mellitus type 2
Patient admitted on 60 units glargine with agresive ISS.
Glargine was decreased to 45 units due to morning symptomatic
hypoglycemia.
# Obstructive sleep apnea
Patient continued on CPAP
# COPD, pulmonary HTN
Patient was continued on home 3L O2.
Transitional Issues
# New medications: aspirin 81 mg, hydralazine mg TID, Glargine
45 units bedtime with sliding scale, Imdur 90 mg daily,
pantoprazole 40
# Warfarin dosing: patient on 22 mg of warfarin at home,
decreased to 19 mg in house for supra therapeutic INR, increased
on discharge for downtrending to home dose 22 mg. INR on
discharge 2.0. She should have her INR drawn on ___.
# Follow up with Dr. ___ as scheduled above. Patient's
diuretics on discharge are half home dose as patient normally
takes torsemide 80 mg BID. Please follow up volume status and
alter regimen as necessary. | 79 | 559 |
17140226-DS-12 | 20,652,530 | Dear ___,
___ was a pleasure caring for you while you were admitted to the
___ neurology service. You were admitted for
symptoms which were due to a stroke in a part of your brain
called the thalamus. We investigated as to the cause of your
stroke but did not find any major reversible cause. We did start
aspirin and a drug called atorvastatin (to lower your
cholesterol) to minimize your risk of future stroke.
You will undergo a work-up for causes of excess clotting after
leaving the hospital. Your heart rhythm was normal while you
were in hospital, but on occasion stroke can be caused by an
occasional heart rhythm abnormality called atrial fibrillation.
This monitor will increase our chances of finding this
abnormality if it exists.
We also found that you have several nodules in your thyroid and
borderline hypothyroidism. For this, you need to have repeat
thyroid function tests and a thyroid ultrasound in 6 months.
This was not related to your stroke.
Please call ___ or your physician if you experience any of the
"warning signs" below.
If you have any questions, please feel free to email me at
___
Your medication list has changed:
START
1. Aspirin 325mg (1 pill) daily
2. Atorvastatin 40mg daily | ___ with suspicion for thrombus traveling from the right
posterior circulation terminating in the thalamus.
.
ACTIVE ISSUES
# Stroke: The patient was found to have multiple foci of acute
infarct within the right cerebellum and subacute left thalamic
infarct. It was suspected that an embolus (or emboli) had
traveled up the right vertebral into the PCA before finally
lodging in the left thalamus. TTE revealed PFO. D-dimer and
fibrinogen normal. No evidence of venous clot on lower extremity
dopplers. No large vessel abnormalities in the head or neck. No
evidence of arrhythmia. No obvious source of hypercoagulability
noted. Started on aspirin and atorvastatin.
.
# Pulmonary nodules: small, noted on CT torso to work up
potential neoplastic causes of hypercoagulability.
.
# Thyroid nodule: Noted on CT torso to work up potential
neoplastic causes of hypercoagulability. TSH was normal at 2.2,
FT4 very mildly low at 0.89.
.
# Left neck lymph node/cystic space: Asymptomatic, noted on
thyroid ultrasound.
.
# HTN: Managed in house on home regimen.
.
INACTIVE ISSUES: None
.
TRANSITIONAL ISSUES
# Stroke: follow LDL on atorvastatin. To follow with ___
___.
.
# Two new pulmonary nodules identified measuring up to 4 mm. A
six-month followup is recommended to assess for stability.
.
# Multiple thyroid nodules. A six-month followup ultrasound is
recommended to reassess these nodules. Please repeat TFTs in
several months.
.
# Small oval lymph node in the left neck which contains a small
cystic space. This lymph node can be reassessed on the
recommended six-month followup ultrasound. | 205 | 244 |
10572581-DS-16 | 23,707,889 | It was a pleasure taking care of you during your recent
admission.
You were admitted because of fatigue and dark stools concerning
for a gastrointestinal bleed.
You had an endoscopy, looking at the upper portion of your GI
tract, which did not show any source of a bleed.
You were given blood transfusions, and your blood levels
remained stable prior to discharge.
We did a capsule endoscopy which was pending at the time of your
discharge.
The following changes were made to your medication regimen:
- STOP cilostazol, discuss restarting this medication with your
primary care doctor
- STOP rivaroxaban
- CHANGE Aspirin to 81mg daily asa dosing | ___ yom with CAD, s/p NSTEMI with DES placed ___, recent
diagnosis of a. fib, discharged on ___ on
aspirin/plavix/rivaroxaban now presenting with significant Hct
drop in setting of GI bleed, initially admitted to MICU.
# GI bleed with Hct drop: Hct 19.7 on admission. Given dark
stools without signs of bright red blood, most likely represents
an upper GI bleed in setting of starting aspirin, plavix,
rivaroxaban. He was maintained on protonix ggt and changed to
PO PPI once EGD showed no active bleed. It did however show
barrets esophagus which will need outpt followup. He remained
hemodynamically stable in the MICU s/p 3 U PRBC with Hct
stabilizing in the low ___. His aspirin/plavix were continued
(though changed to lower dose aspirin) givne recent DES.
Rivaroxaban was held given low daily stroke risk with afib and
discharge plan for this was to continue to hold it. Lisinopril
was held given bleed and was restarted at discharge. Metoprolol
was restarted at a low dose and was restarted on discharge.
# SOB: Pt developed acute SOB on morning of ___. CXR showed
concern for volume overload vs. TRALI in setting of blood
transfusion. Received lasix 40mg x1, with significant
improvement in respiratory status .
# Recent NSTEMI: S/p DES in OM1 graft, discharged on
aspirin/plavix. Both were continued given the high risk of
in-stent thrombosis, though aspirin was initially changed to
81mg in-house and changed to 81 mg on discharge. Metoprolol was
continued at lower dose given GI bleed and was changed back to
home dose on discharge. Lisinopril was initially held and
changed back to home dose on discharge. He was continued on
home atorvastatin
# Atrial fibrillation: New onset during recent admission for
NSTEMI. CHADS of 2. No cardioversion performed. He was
maintained on rate control with metoprolol and started
rivaroxaban on that admission. On this admission, he remained
NSR on EKG and tele. Overall has very low daily risk of CVA off
of anticoagulation (~5% yearly risk) so held rivaroxaban with
plan for continued holding on d/c and follow up with PCP/
cardiologist. We also lowered aspirin to 81mg daily per
consultation with cardiology. We continued lower dose
metoprolol given GIB in the MICU and was changed back to home
dose at discharge.
# Thrombocytosis: Pt with Plt of 628 on admission, have been
trending down. Likely represents inflammatory state in setting
of bleed.
# PVD: On cilostazol as outpt for PVD for symptomatic treatment.
This was held while in the MICU and while on the floor. We
continued to hold this at discharge, with consideration of
restarting as an outpatient.
# GERD: Maintained on protonix ggt and then changed to BID PPI
# Transitional Issues
-Pt is full code
-Needs outpt follow up for ___ esophagus
-Restarting cilostazole per PCP.
-Follow up capsule report per GI | 102 | 490 |
11906222-DS-24 | 23,103,832 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted after a fainting episode. We
monitored your heart rate while you were here and there were no
abnormalities seen. You also had an ultrasound of your heart
which showed that all of your heart valves are normal. We were
unable to identify a cause of your fainting episode. You will
follow up here on ___ for a holter monitor test to see if it
records any abnormal heart rhythms. \
We have made no changes to your medications. | ___ year old female s/p cereberal hemmorthage and VP shunt
presenting with episode likely of vasovagal syncope, no events
on tele since she's been here and she is asymptomatic. | 94 | 29 |
10577647-DS-19 | 24,646,166 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for abdominal pain, which is
due to a recurrent gastroparesis flare. We treated you with IV
fluids, and pain and anti-nausea medications. We also increased
your blood pressure medication nifedipine since your pressure
was very high.
You underwent an upper endoscopy scope (EGD) by our GI doctors
which did not show ulcers or other causes of abdominal pain. We
advanced your diet when you felt ready. It is important your
diabetes remains under control, as this can cause worsening of
your gastroparesis.
We are glad you are feeling better and we wish you the best.
Your ___ team | ___ with history of IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), and obesity
presented with acute-on-chronic abdominal pain, clinically
consistent with a gastroparesis flare. | 111 | 28 |
17873103-DS-9 | 27,750,553 | Surgery
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet when out of bed at ___ times.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Call your neurosurgeons office and speak to the Nurse
Practitioner if you experience:
- Any neurological issues, such as change in vision, speech or
movement
- Swelling, drainage, or redness of your incision
- Any problems with medications, such as nausea vomiting or
lethargy
- Fever greater than 101.5 degrees Fahrenheit
- Headaches not relieved with prescribed medications
Activity:
- Start to resume ___ activities as you tolerate but start
slowly and increase at your own pace.
- Do not operate any motorized vehicle for at least 10 days
after your surgery your Nurse Practitioner can give you more
detail at the time of your suture removal.
Incision Care:
- Keep your wound clean and dry.
- When you are allowed to shampoo your hair, let the shampoo run
off the incision line. Gently pat the incision with a towel to
dry.
- Do not rub, scrub, scratch, or pick at any scabs on the
incision line.
Post-Operative Experiences: Physical
- Jaw pain on the same side as your surgery; this goes away
after about a month
- You may experience constipation. Constipation can be
prevented by:
o Drinking plenty of fluids
o Increasing fiber in your diet by eating vegetables, prunes,
fiber rich breads and cereals, or fiber supplements
o Exercising
o Using over-the-counter bowel stimulants or laxatives as
needed, stopping usage if you experience loose bowel movements
or diarrhea
- Fatigue which will slowly resolve over time
- Numbness or tingling in the area of the incision; this can
take weeks or months to fully resolve
- Muffled hearing in the ear near the incision area
- Low back pain or shooting pain down the leg which can resolve
with increased activity
Post-Operative Experiences: Emotional
- You may experience depression. Symptoms of depression can
include
o Feeling down or sad
o Irritability, frustration, and confusion
o Distractibility
o Lower Self-Esteem/Relationship Challenges
o Insomnia
o Loneliness
- If you experience these symptoms, you can contact your Primary
Care Provider who can make a referral to a Psychologist or
Psychiatrist
- You can also seek out a local Brain Aneurysm Support Group in
your area through the Brain Aneurysm Foundation
o More information can be found at ___ | ___ with history of IVDU, endocarditis, RLE arterial occlusions
on Xarelto and IV Toradol PRN found with altered mental status
and R forehead lac at rehab. NCHCT concerning for aneurysmal
SAH. CTA head revealed large L MCA aneurysm. Patient was
admitted to the ICU.
___
Transferred from ___ with ___ concerning for aneurysm
rupture. On Xarelto, Received Kcentra at OSH. CTA H&N shows new
large L MCA aneurysm. FFP for uptrending INR. Repeat NCHCT
showed worsening bleed in L frontal. EVD placement initially
deferred given anticoagulation. 7am ___- left pupil blown, few
minutes later Right pupil nonreactive but small. Given Mannitol
50gm and rushed to OR for clipping and evacuation. Intraop
course complicated by rerupture, extensive blood loss, Carotid
artery was temporary clamped intraop for 30 min, L MCA aneurysm
clipped, insertion of subdural drain to JP, bone flap kept off.
Patient went to angiogram immediately after OR which showed
aneurysm well clipped, branch of L MCA not filling but good
collaterals, right groin angiosealed. After OR bilateral pupils
equal and small.
CT after angio revealed worsened midline shift and cerebral
edema. He was started on 3% for treatment of cerebral edema. On
___, the subdural drain was removed. Cervical collar was cleared
on ___. Subdural drain was removed on ___. Nimodipine was
restarted on ___ and discontinued due to hypotension. On ___,
the patient underwent a repeat non-contrast head CT which showed
complete L MCA territory infarct with edema. A CTA done ___
revealed possible left MCA, ACA A1 segment, and left
supraclinoid ICA vasospasm. Exam remained stable. On ___, he was
transferred to the ___. He remained neurologically stable, and
transferred to the floor in stable condition.
#Pneumonia
The patient was found to have right lower lobe pneumonia. He was
started on a seven day course of Meropenem, completed ___.
#Endocarditis
Throughout his hospitalization, the patient was treated with
Vancomycin and Gentamicin for treatment of endocarditis.
Gentamicin was discontinued after two weeks course. Vancomycin
is projected to continue through ___. Vancomycin trough on ___
was supratherapeutic and dose was decreased. Repeat Vancomycin
trough on ___ was therapeutic. He will continue to follow as
an outpatient with the Infectious Disease Clinic.
#Anemia
On ___ the patient was noted to have a low H&H and was
transfused 1 unit of pRBCs. On ___, the patient received a
second unit of pRBCs.
#Fevers
The patient continued to spike fevers and ID was consulted. Per
ID, the fevers are thought to be central in origin due to the
fact that they are persistent. He spiked to 102.9 on ___ and was
placed on cooling blanket. Pancultures were sent and remained
negative. Despite WBC trending up on ___ he remained afebrile.
On ___, ID was called to make aware of trending WBC, and
recommended further work up with Lenis, blood cultures and urine
cultures, which were ___ negative.
#Hyponatremia
The patient was started on a 3% HTS gtt with a goal serum Na of
140-150. The gtt rate was titrated to achieve this sodium goal.
The hypertonic saline gtt was stopped on ___. He was started
on salt tabs 1g TID and weaned as tolerated.
#Dysphagia
The patient was evaluated by speech and swallow and recommended
keeping the patient NPO. A DHT was placed and tube feeding was
initiated. ACS was consulted for PEG placement. On ___, the
patient underwent PEG placement. | 428 | 553 |
11923920-DS-18 | 25,722,908 | You were admitted to the hospital with acute abdominal pain.
Initially, it was not clear if you had appendicitis, however
your pain resolved without any intervention and your white blood
cell count normalized. We advanced your diet to a regular diet
and you tolerated it without any nausea or vomiting. We
recommend that you follow up with your primary care provider.
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. | This is a ___ year-old male that presented to his PCP with
intermittent upper abdominal painover the past 2 days associated
with vomiting and diarrhea.
Patient states this is somewhat consistent with prior episodes
of addisonian crisis. He was admitted to the Acute Care Surgery
service for suspicion of having early appendiicits. At the time
of admission, his white blood cell count was 12. The patient was
admitted for observation; he was not given any antibiotics or
pain medication, was kept NPO and underwent serial abdominal
exams. His pain improved without any intervention and his white
blood cell count normalized. The patient was started on a
regular diet which he tolerated. He reported no return of his
abdominal pain, and was not-tender on his examination. He never
developed leukocytosis, or a fever. For this reason he was
discharged. He was ambulatory, tolerating a regular diet, and
voiding without assistance. He was given instructions to see his
primary care provider, and instructions on how to follow up with
the ___ clinic. The patient endorsed understanding of his
discharge instructions. | 183 | 177 |
12662557-DS-21 | 23,210,358 | You were admitted to the hospital after being stabbed. You were
taken to the operating room and underwent a laparoscopy to look
for any injuries to to control some arterial bleeding in your
muscle. You are no longer exhibiting any signs of bleeding and
no major injuries were found. You were also found to have a
fracture in your left big toe. You are now being discharged home
with the following instructions:
Wear the hard soled postop shoe given to you when walking at all
times. Follow up in the ___ clinic as instructed below.
You have staples in your wound sites. You need to follow up at
the appointment scheduled for you below to have these staples
removed. Keep your wound sites covered with a dry gauze and
change the gauze if it becomes saturated or dirty. You may
shower but do not soak/submerge the incision in water by taking
a tub bath or swimming. You should check your wound sites daily
for signs of infection. Signs of infection include increased
redness or pain at the site, pus-like drainage from the wound,
foul smelling drainage, fever, or chills. A small amount of
bloody drainage is normal.
You are being given a prescription for pain medication. Take the
medication as prescribed. Do not take it more frequently than
prescribed. Do not take it more often than prescribed.
*Do not drink alcohol or drive/operate heavy machinery while
taking narcotic pain medication, as it can cause sedation.
*Narcotic pain medication can cause constipation so take an over
the counter stool softener such as colace (ducosate sodium) or
milk of magnesia if needed. Continue to drink plenty of fluids
and increase your fiber intake. | Mr. ___ was admitted on ___ under the acute care surgery
service for management of his injuries. He was taken to the
operating room for a diagnostic exploratory laparoscopy and
control of muscular arterial bleed. (see operative report for
details of this procedure). Postoperatively he was extubated and
taken to the PACU, where he was monitored and remained
hemodynamically stable. From the PACU he was admitted to the
surgical floor.
He remained alert and oriented throughout his hospitalization.
His pain level was routinely assessed and he was given
analgesics as needed. His vital signs were monitored routinely
and he remained afebrile and hemodynamically stable without any
signs of bleeding. He denied any chest pain or shortness of
breath. He tolerated a regular diet without nausea/vomiting
postoperatively. He voided adequate amounts of urine.
Of note, the patient complained of left great toe pain, and his
toe was noted to be swollen. An xray was obtained which showed a
fracture of the distal phalynx and orthopedics was consulted.
Orthopedics recommended a postop shoe for the injury with
weightbearing as tolerated. Follow up was scheduled in 2 weeks
in the ___ clinic. Prior to discharge he was encouraged
to mobilize out of bed and ambulate as tolerated, which he was
able to do with a steady gait.
The patient was also seen by social work during his admission
for his history of drug use as well has housing/resources after
discharge. The patient had reportedly been homeless and been
staying with friends at times since the age of ___. Social work
discussed the need for a drug rehabilitation program with the
patient, who refused. Please see social work notes for details
of this. | 278 | 279 |
14399272-DS-7 | 26,546,382 | Ms. ___,
You presented to ___ with
chills and shortness of breath. Your pleurX catheter draining
the fluid in your left lung was found not to be working
appropriately. A new pleurX catheter was placed, and your
breathing improved. In addition, you have chronic pain at the
site of your mastectomy. An ultrasound and CT scan were
performed to ensure that there was not a dangerous event
occurring either in your lungs or abdomen that could explain the
pain. It was found that this was likely pain related to your
mastectomy. Your pain medications were modified so that you can
have relief from this discomfort.
You discussed your wishes with the palliative care team, and
have decided to go to an ___ facility.
It was a pleasure caring for you here at ___, and we wish you
all the best.
Kind regards,
Your ___ Team | ___ year old woman with a history of metastatic breast cancer who
presents with worsening dyspnea in the setting of a
dysfunctional pleurX catheter.
# Right sided pain:
Patient with severe right sided radicular pain that has been
chronic since her mastectomy earlier ___, but with new
exacerbation. Continuing to titrate pain medications to provide
relief to patient for pain. Have since obtained RUQ ultrasound
and CTA chest which show that there is no acute intra-abdominal
or pulmonary etiology such as PE. Rather, the CT scan does show
progression of patient's malignancy and the metastatic disease
may be causing some of her pain symptoms on the right side. Dr
___ met with the patient and had a long discussion of goals of
care. She also met with the hospice and decided to go to a
facility with hospice services available.
# Dyspnea: Secondary to worsening pleural effusion in the
setting of dysfunctional pleurX catheter. Possible contribution
as well from anemia. Superimposed pneumonia possible but no
signs or symptoms of infection. S/p TPA, and no drainage from
tube. IP was consulted on ___, placed a new chest tube
and pleurX drain to vacuum suction. Continued supplemental O2,
guaifenesin, albuterol/ipratropium/prn morphine to reduce
dyspnea. After discharge, the pleurX drains should remain
capped. Every 3 days please attach the pleurX to vacuum bottle
and drain. If no drainage then please contact interventional
pulmonology at ___ for recommendations. PHONE: ___.
# Pancytopenia: Likely anemia of inflammation in the setting of
cancer and marrow suppression from chemo. No signs/symptoms of
blood loss. Patient received 2 units pRBCs on ___.
# Metastatic breast cancer: PO cyclophosphamid discontinued. No
further treatment indicated.
# GERD:
Omeprazole.
# Epilepsy
Continue keppra/zonisamide | 142 | 289 |
19156328-DS-12 | 29,727,311 | Dear Ms. ___,
You were admitted to the hospital after awakening with double
vision and dizziness. We found that you have something called an
internuclear ophthalmoplegia (INO) affecting your right eye
which means that you have trouble looking toward the left with
your right eye. This was most likely caused by a small ischemic
stroke. An ACUTE ISCHEMIC STROKE is a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- smoking
We are changing your medications as follows:
- start aspirin 81mg daily
- start atorvastatin (Lipitor) 40mg daily
- we also prescribed nicotine gum to help you stop smoking
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as well.
We expect your symptoms to improve over time. For comfort, you
can wear an eye patch over one eye or the other. If your double
vision is still present after a couple months, please discuss
this with your eye doctor because they may be able to fit you
with special glasses.
We are starting you on an aspirin to reduce your risk of future
strokes. It is also very important that you stop smoking to
prevent future strokes as well. You had most of your stroke
workup done in patient but you still need to have an
echocardiogram (with bubble) done of your heart to complete your
stroke workup so please discuss this with your primary care
doctor ___ cardiologist or neurologist) to get this done as soon
as possible.
We wish you the best,
your ___ neurology team | Ms. ___ is a ___ woman who presented after awakening with
double vision and dizziness. | 341 | 16 |
19860678-DS-8 | 29,059,642 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for chest pressure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did two EKGs (test of electrical activity in the heart)
which were not significantly changed from your prior EKG and
suggested a possible old and resolved heart attack
- We checked blood tests for heart injury which were normal (x3)
- A chest X-ray of your lungs was normal
- We did a CT scan of your chest with contrast that did not show
any evidence of pulmonary embolism (clot in the lungs)
- We found that your kidney function was slightly worse and we
gave you some IV albumin. Your kidney function then improved.
- We gave you Tylenol and your chest pain improved
- In normal circumstances, we would have kept you in the
hospital to do a stress test with imaging to evaluate for
reversible blockages in your heart. However, after a candid
discussion with both you, your health care proxy, your
outpatient oncologist Dr. ___ our inpatient team, we
decided that you would pursue this test as an outpatient. The
reason is that you had an important second opinion oncology
appointment at ___ that you wanted to prioritize over
obtaining cardiac imaging.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. We have held your metformin in the setting of
having a CT scan, please re-start this medication on ___.
- You will need to do a cardaic stress echo as an outpatient. We
have ordered this and you should hear from them. Please call
___ to arrange if you do not hear from them in the
coming days.
- It is okay to take Tylenol ___ three times a day for mild to
moderate pain
- Please make an appointment with your primary care doctor to
follow-up on discharge and on the cardiac stress test.
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES:
[ ] will need an outpatient pharmacologic stress test to assess
for ischemia (ordered, will need follow-up), and primary care
follow-up for the same
[ ] will need QTc monitoring given history of prolongation and
risk of prolongation upon starting lenvantinib. Last QTc 486 on
___.
[ ] will need follow-up oncology appointments with DFCI and with
Dr. ___ at ___ (already scheduled)
[ ] we are holding metformin for 48 hours in the setting of
contrast, will resume ___
[ ] patient had elevated Cr to 1.3 after receiving contrast,
which down-trended to 1.2 on discharge after IV albumin | 353 | 99 |
10657092-DS-19 | 26,587,944 | Dear Mr ___,
You were admitted for a dizziness and difficulty with walking.
With the history of a vertebral dissection, there was initial
concern that this may have been related to either a stroke or
transient ischemic attack, however you had a normal MRI of your
brain and normal vessels and your symptoms appear more
consistant with a peripheral vestibulopathy. You should follow
up with physical therapy and make appointments with w Drs.
___ in ___ clinic.
Your stroke risk factors were checked. You should not smoke.
Your cholesterol was normal at (LDL at 101, and Triglycerides at
54). You need to continue your blood pressure control. You
should continue to eat a low fat healthy diet.
It was a pleasure taking care of you. | Mr ___ is a ___ yo. left-handed ___ w/PMH of recent vertebral
dissection in ___, multiple TBIs, NASH, palpitations, who
presented for several days of headache, lightheadedness and
amnesia that was appreciable on exam.
Initial concern in the setting of his PMH of vertebral
dissection, his new sudden-onset occipital/neck pain was
concerning for re-occurrence of dissection. His amnesia was
concerning for impairment of the memory pathways, which may
include the hippocampi uni- or bilaterally as well as the
thalami. However this has been a long standing problem and was
thought to be likely related to his previous TBI. He and his
wife expressed interest in more extensive neuropsychiatric
testing and therefore he was referred to the cognitive neurology
clinic ___ clinic).
As for the concern for recurrence of dissection of his vertebral
arteries, he was very briefly started on heparin but had an MRI
which did not demonstrate any recurrence or ischemic disease.
He was continued on his Aspirin 81 mg daily for prophylaxis and
should follow up with Vascular neurology for his vascular risk
factors.
*of note at time of discharge final read of MRI was not posted
and therefore he should follow up with his Neurologists/PCP on
the final report.*
On further exam he did have a positive ___ to the left.
His symptoms were worse with head movements and therefore made
a peripheral vertigo the likely etiology with BPPV the most
likely etiology. He was referred for vestibular therapy to be
done as an outpatient.
Of note his stroke risk factors were checked. His cholesterol
was normal at (LDL at 101, and Triglycerides at 54). | 130 | 271 |
15553601-DS-10 | 24,471,596 | Dear Ms. ___,
You were transferred from ___ to the ___ for
evaluation of a partial obstruction of your small intestine. In
addition to the symptoms of this partial small bowel
obstruction, you were also found to have kidney dysfunction,
blood in your urine, decreased nutritional status, and
depression. You were evaluated by colorectal surgery, oncology,
nephrology, urology, nutrition and psychiatry.
The colorectal surgeons felt that surgery was not appropriate
given your overall health status. They also felt that since your
cancer has unfortunately spread to your abdomen, it was probable
that the bowel obstruction would happen again, even if they did
perform surgery this time. Your partial small bowel obstruction
was thus managed non-surgically with bowel rest and IV fluids.
Please do not hesitate to call with any questions or concerns.
It was a pleasure caring for you and we wish you the best.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning
signslisted below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team | Mrs. ___ is a ___ female with Crohn's disease
complicated by ___ fistula status-post ileocecectomy,
sigmoid resection, takedown of enterovesical fistula with repair
of the bladder, & diverting loop ileostomy (___), found to
have metastatic adenocarcinoma of the small bowel on pathology
currently on weekly ___, who presented to ___
with 1 day of nausea/vomiting, and was found to have a partial
small bowel obstruction on CT abd/pelvis, then was transferred
to the ___ ED for colorectal surgery evaluation.
# Partial small bowel obstruction: This was felt to be related
to peritoneal carcinomatosis seen on ___ CTAP. There was no note
of malignancy directly on the colon at the transition point.
Colorectal surgery evaluated patient on admission and
recommended conservative management with bowel rest, IV fluids.
NG tube was offered for symptom relief but Ms. ___ declined
this intervention as she felt minimally symptomatic. Ondansetron
and promethazine were given as needed for nausea (QTc 467).
During her hospitalization, her abdomen was not significantly
distended and non-tender. On ___, she had a small amount of
stool and gas output into her ostomy bag, then a large amount of
stool and gas on ___. Nevertheless, she continued to have
intermittent nausea and small amounts of emesis. Surgery placed
a red rubber tube to help aid in distal decompression A
small-bowel follow-through study showed some transit of contrast
through the small bowel, but with significant gastric
distention. On ___, in consultation with the colorectal
service, the care team and oncology consultant reviewed the
management plan with Ms. ___ and ___ family. We explained that
the obstruction was likely related to her malignancy (i.e.,
peritoneal carcinomatosis; no evidence of a mass at the
obstruction site although we could not rule-out the possibility
of an intra-luminal process); that there were no chemotherapy
options that could relieve her bowel obstruction, because of the
nature of her cancer and because of her frailty and reduced
kidney function that chemotherapy was not an option for her
(this had been discussed with her ___ oncologist Dr ___.
Surgery was discussed with the patient, but felt to have high
risk of complication. Patient declined surgical options after
discussion with colorectal surgery. CRS recommended venting
Gtube given continued gastric distention. Patient was considered
for venting gtube placement for paliation prior to transfer, but
___ team wanted patient to trial NGT prior to tube placement,
which she did not want to do. Thus, this was deferred.
She was subsequently transferred back to ___ in line with the
wishes of the patient, family, and her oncologist to continue
the treatment of other medical issues and explore palliative
options.
# Metastatic adenocarcinoma: Ms. ___ is followed by Dr. ___
___ at ___. Patient has been receiving palliative weekly ___
(often held for poor renal function). Unfortunately her ___
CT from ___ shows new peritoneal carcinomatosis, concerning for
disease progression on current therapy. Additionally, most
recent cystoscopy in urology office was concerning for bladder
recurrence. After discussing with outpatient oncologist Dr.
___ oncology consult service concluded there was no
role for inpatient chemotherapy. Venting Gtube was subsequently
placed to alleviate symptoms in the absence of surgery. Dr
___ originally requested for placement of PICC and
initiation of TPN, however this was held in the setting of GPC
bacteremia (although this was likely a contaminant). She was
transferred to ___ to explore further palliative options with Dr
___.
# Hematuria and acute blood loss: She previously had gross
hematuria leading to cytoscopy/TURBT in ___ with pathology
consistent with small bowel invasion of bladder. Most recent
cystoscopy on ___ was notable for 5x5mm area of irritation
concerning for disease recurrence. Urine cultures were negative
here and at ___ and antibiotics withheld. IUC was placed at ___,
but this was removed on ___ admission and she tolerated a
voiding trial - however she continued to have small volume
hematuria. Urology was consulted but recommended no intervention
in the absence of obstructive urinary symptoms. H/H remained
stable and serial bladder scans were without urinary retention.
Vitamin K was given to reduce malnutrition-related elevated INR
in an attempt to slow bleeding. She was transfused 1u PRBC for
Hb 6.8 during this admission.
# Acute renal failure: History, exam, and labs were suggestive
of hypovolemic, prerenal etiology. On admission to ___, her Cr
was 4.6. Felt to be related to hypovolemia, prerenal etiologies
and treated with IVF. Nephrology consulted. Creatinine improved
to 2.1 by time of discharge. with supportive treatment and she
did not require RRT. ___ creatinine is unclear as she has
had variable renal function from ___ prior to admission ranging
from 1.1 to 2.0.
# Likely Contaminant
# GPC bacteremia: 1 set of blood cultures grew coagulase
negative staph on HD#2. Notably, blood cultures taken from ___
prior to ___ course, adn subsequent surveillance blood
cultures taken prior to abx administration were no growth. She
was treated with vancomycin while awaiting blood culture
results, but this was stopped prior to transfer back to ___.
# Major depressive disorder: Ms. ___ endorsed passive
___ on admission. It was determined that there was no
need for 1:1 or ___ per admission evaluation. Per psych
consult, she does seem depressed in context of cancer, though
they also noted fatigue and low energy as contributors. Psych
recommended Ritalin but this was not started this admission
pending GOC and palliative options at ___. Would recommend
persistent psych involvement at ___, and consideration of
Ritalin initiation.
# Leukocytosis: Her leukocytosis had resolved, then had a mild
bump to 12.4 on ___. It is likely reactive in the setting of
the small bowel obstruction and/or malignancy. We followed the
microbiology results and treated possible bacteremia with
vancomycin.
# Severe protein calorie malnutrition: She is very cachectic.
Nutrition was recommending TPN, however PICC placement and TPN
initiation was held because of initial concerns for bacteremia
# Insomnia: Her home lorazepam and rameleon were continued.
# Crohn's colitis: Previously complicated by colovesicular
fistula s/p bowel resection/fistula repair with ileostomy. She
has never been on medical therapy for Crohn's which was only
diagnosed last year.
# Hypertriglyceridemia: Continued home fenofibrate
# Code status: When discussing code status on admission, Ms.
___ stated that she did not want to be resuscitated in the
event of cardiopulmonary arrest. However, she did not want to
change her code status until she could discuss with her family.
Her code status was kept as full code.
TRANSITIONAL ISSUES
- Would recommend involvement of oncology service (specifically
patient's primary oncologist Dr ___
- Patient still has red rubber tube in ostomy (placed by
colorectal surgery at ___. This should be removed with
resolution of partial SBO or with next ostomy change.
- Venting G-tube was planned for placed for palliation of
obstructive symptoms, but ultimately deferred while at ___.
Please consider
- Dr ___ originally requested for placement of PICC and
initiation of TPN, however this was held in the setting of GPC
bacteremia (although this was likely a contaminant).
- Continue to address code status and GOC with patient and
primary oncologist.
- Hematuria ongoing at time of transfer, with absence of
obstruction. Suspect adenocarcinoma recurrence in the bladder
- Depression: psych recommended ritalin initiation, but not
started here
Time spent coordinating discharge > 30 minutes. | 202 | 1,189 |
12764570-DS-22 | 21,791,078 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for treatment of an infection in your left
upper gum that had spread to your left cheek.
What was done for me while I was in the hospital?
- You had a CT scan of your head and neck that showed signs of
a soft tissue infection in your gum and cheek. There was no sign
of an abscess that would require drainage.
- You were started on an antibiotic called clindamycin to
control the infection.
What should I do when I leave the hospital?
- Please go to your oral surgery appointment today for further
evaluation and treatment.
- Please make an appointment with your primary care doctor to
follow up on the nodule that was found incidentally in your
thyroid gland on the CT scan.
- Please continue to take all of your medications as
prescribed.
Sincerely,
Your ___ Care Team | ___ with history of depression, aspergilloma s/p VATS in ___,
HTN, and hx of dental abscess presenting with 2 day history of
left-sided facial swelling following URI.
ACUTE ISSUES
============
#Left facial swelling
#Leukocytosis
Clinical presentation consistent with swelling and potential
cellulitis from odontogenic infection. Low suspicion for spread
into deeper fascial spaces, as patient has no trismus. No
evidence
of parotitis on CT head or on exam. No signs of orbital
cellulitis and no pain with EOM. Does have a history of
aspergilloma, but clinical presentation and status not
consistent
with mucormycosis or other serious fungal infection. Per ___ need IV antibiotics and outpatient follow-up. Has a history
of anaphylaxis to penicillin. Discharged on PO clindamycin 450mg
QID for total of 7 days (D1: ___ with instructions to follow
up with ___.
#Elevated lactate
3->3.5 on day admission, down to 2.1 after 1L LR. Unclear cause
at this point. Patient states she has been taking min normal
amount of PO fluids and food. Does not appear septic. Is on
metformin at home, though only taking 500mg once daily with no
evidence of renal dysfunction. No signs of abdominal pathology,
making ischemia less likely. BPs normal to elevated, so low
perfusion state unlikely. Held metformin while inpatient.
#Cough
#Rhinorrhea
Symptoms consistent with URI. Low concern for bacterial
etiology.
CHRONIC ISSUES
==============
#HTN: Continued home amlodipine and spironolactone
#Hx of anxiety/depression: Continued buspirone 5mg daily
(prescribed 3 times daily, though not taking it like this at
home), PRN clonazepam, and duloxetine
TRANSITIONAL ISSUES
===================
# L thyroid nodule:
6 mm left thyroid nodule observed on neck CT. Patient endorses
no symptoms of hyper/hypothyroidism. Will need follow-up imaging
for this as outpatient.
#Medication adherence
Patient is prescribed medications multiple times a day,
including
metformin and buspirone, though only takes them daily.
COMMUNICATION
=============
Emergency contact: ___
Relationship: Sister
Phone number: ___
Code: Full, but would not want prolonged life support | 186 | 295 |
16889230-DS-16 | 21,836,892 | Please keep your right leg elevated over the next ___ hours to
continue to allow for draining of the hematoma. You may bear
weight on the right leg. Please return to the ED with any change
in sensation or ability to move the right leg or pain that is
not controlled by the pain medications.
******WEIGHT-BEARING*******
weight bearing as tolerated bilateral lower extremities
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___. | The patient was admitted to the orthopaedic surgery service on
___ with RLE hematoma. Pt was admitted to rule out
compartment syndrome. He was checked every ___ hours. His pain
was controlled with PO pain meds and his compartments became
increasingly compressible during his stay. He had no ___
deficits. He worked with ___, WBAT RLE prior to discharge.
Neuro: post-operatively, patient's pain was controlled oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
At the time of discharge on HD#2 the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. All questions were answered prior to discharge
and the patient expressed readiness for discharge. The patient
will follow up with Orthopaedic Surgeons in ___ per
his father (a doctor himself). | 134 | 227 |
19302720-DS-17 | 26,415,233 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to the hospital for
food impacted in your esophagus. An upper gastrointestinal
endoscopy was performed and the impacted food was removed. A
benign esophageal stricture was found and it was successfully
dilated.
We have the following recommendations below:
- Please eat only soft foods for the next 3 days. You may slowly
advance your diet afterwards.
- Dr. ___ would like to re-dilate your
esophagus in 2 weeks. Please call ___ to set up this
appointment.
Please call your surgeon or return to the emergency department
if you experience any of the following symptoms:
- Difficulty swallowing
- Inability to tolerate oral intake
- Fever greater than 100.4 F
- Increasing pain
- Any other symptoms that become concerning to you | Mr. ___ presented to the ___ ED with food impaction in his
upper esophagus after a large dinner the night prior to arrival.
He was evaluated by the gastroenterology service, who decided to
perform an EGD, where they found food in the upper third of the
esophagus and a benign intrinsic appearing 6 mm stricture that
appeared at 20-22 cm from the incisors was seen at the level of
the anastomosis. This stricture was successfully dilated to 12
mm. He was observed overnight and appeared well the next
morning. He was able to tolerate a soft diet. | 129 | 98 |
13580435-DS-21 | 21,929,073 | Dear Ms. ___,
You presented to the ___ on
___ after you were struck by a train. You were admitted to
the Trauma/ Acute Care Surgery team for further medical
management. You sustained an injury to your left thigh and had
it washed out and a drain was placed. Your images were negative
for any acute fractures.
Please monitor and record the output from your abdominal drain.
You have worked with the Occupational Therapist and there is no
concern for cognitive issues. You are now medically cleared to
be discharged to home to continue your recovery. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Ms. ___ is a ___ year-old female who presented to ___ on
___ after being struck by a commuter rail. She had imaging
which was negative for any acute bony injury. The only injury
was a large laceration across her left buttock/thigh. She was
admitted to the Trauma/Acute Care Surgery team for further
medical management.
Given that the patient's left buttock/thigh injury was 10cm with
a blush on CT, on HD1, the patient was taken to the operating
room for washout and debridement. There were no adverse events
in the operating room; please see the operative note for
details. The patient was extubated, taken to the PACU until
stable, then transferred to the ward for observation.
The rest of the ___ hospital course is detailed by systems
below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with IV pain medication and
she was transitioned to oral pain medication once tolerating a
diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. On POD1, after
administering the patient's home blood pressure medications, the
patient's blood pressure was found to be 88/54 with a stable
heart rate. The patient was asymptomatic and she stated that
was a "normal blood pressure" for her. No intervention was
necessary.
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's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible. During surgery, the
patient had a JP drain placed in her left upper thigh to assist
with drainage. ___ services were offered, but the patient's
daughter and husband declined and said they would manage the
drain at home. Teaching was provided on how to record the
drainage output, how to empty the drain and what concerning
findings to be aware of.
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. Follow-up appointments were
made with the Acute Care Surgery team and with her PCP.
Interpreter services were used to assist with providing
discharge instructions. | 508 | 460 |
12816392-DS-7 | 25,737,367 | Ms. ___,
You were admitted to ___ with vomiting and diarrhea. This has
most likely been from a condition called "gastroenteritis"
caused by a virus or bacteria making the gut angry. We did not
see signs of problems with your bile duct stent or other
problems in your gut using ultrasound and a CT scan to take
pictures. Your symptoms may take a few more days to completely
resolve. Stick to bland foods for now to avoid making the
diarrhea worse.
Please work with your PCP to set up an ERCP for stent removal in
4 weeks close to home. Otherwise, out team here would be happy
to perform the procedure if you call ___. | ___ male with a history of CAD and MI ___ s/p 3x stents,
DM, and recent choledocholithiasis s/p stent placement in ___
in ___ who presents with nausea and vomiting. | 113 | 30 |
18038562-DS-10 | 24,528,734 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Touch-down weight-bearing left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
Physical Therapy:
TDWB LLE
Treatments Frequency:
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
-Elevate left lower extremity when resting | Ms. ___ was admitted to the Orthopaedic Surgery service for
operative repair of left periprosthetic femur fracture. She was
taken to the Operating Room on ___ to undergo this
procedure. Please see Operative Report for further details.
The patient tolerated the procedure well. Post-operatively, she
was taken to the recovery room before being transferred to the
floor in the usual fashion. She was given prophylactic
antibiotics as well as Lovenox for DVT prophylaxis.
The patient worked with Physical Therapy and made steady
progress with range of motion exercises as well as mobility. It
was determined that her needs would be best served by a
rehabilitation facility. On POD#2, her Foley catheter was
discontinued and her pain medication was transitioned from a PCA
to oral medications. She was discharged to rehab in stable
condition with detailed precautionary instructions as well as
instructions for discharge. | 239 | 155 |
10035844-DS-12 | 27,129,365 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital because you had a seizure due
to low blood sugars.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-While you are in the hospital you received a number of imaging
diagnostic test to evaluate for causes of your seizure. These
tests all came back normal. Additionally, you also met with the
diabetes doctors as ___ as diabetes educator to work on a more
stable insulin regimen.
WHAT SHOULD I DO WHEN I GO HOME?
-Take your medications as prescribed and attend your follow up
appointments as scheduled.
-Please call ___ on ___ and request a "hospital
transition
appointment" within ___s a Dietician appointment on
the same day.
Thank you for letting us be a part of your care!
Your ___ Care Team | ___ is a ___ female with a history of
hypertension, diabetes on insulin who presented as a transfer
from ___ with hypoglycemia secondary to overinsulinization
found to have post-hypoglycemic tonic-clonic seizure complicated
by ___ paralysis with normal neurologic imaging and mental
status returning back to baseline. Her insulin regimen was
adjusted by the ___ diabetes team with education provided by
the diabetes educator. | 158 | 63 |
14149304-DS-13 | 26,328,297 | You have undergone the following operation: Thoracic
Decompression With Fusion
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs for 2
weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate. Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
Brace: You may have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
-Weight bearing as tolerated
-No lifting >10 lbs
-No significant bending/twisting
Treatments Frequency:
Remove the dressing in 2 days. If the incision is draining cover
it with a new sterile dressing. If it is dry then you can leave
the incision open to the air. Once the incision is completely
dry (usually ___ days after the operation) you may take a
shower. Do not soak the incision in a bath or pool. If the
incision starts draining at anytime after surgery, do not get
the incision wet. Cover it with a sterile dressing. Call the
office. Staples will be removed at your follow up appointment | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with oral pain medications. Foley was
removed on POD#2. Physical therapy and Occupational Therapy was
consulted for mobilization OOB to ambulate and ADL's. OMED
service followed Mr ___ during his ___ course and
recommended inpatient/outpatient radiation therapy with Dr.
___. The patient declined inpatient/outpatient treatment with
Dr. ___ follow up with Dr. ___
in ___ at ___ in ___
days for follow up care and receive treatment as discussed. If
he changes his mind regarding radiation therapy, please contact
Dr. ___ at ___ or ___ to schedule therapy.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. | 527 | 183 |
10312715-DS-72 | 25,743,352 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ for worsening abdominal pain and
diarrhea. You underwent a work-up that fortunately didn't
identify any new infections. Your pain was most likely caused by
your underlying Crohn's disease after reducing your prednisone
dose and pain medications. You were given IV fluids and pain
medications, and your condition improved.
You are now safe to be discharged home. Please be sure to
follow-up with Dr. ___ Dr. ___ as scheduled. Please
be sure to keep up with your fluid intake and take your
medications as prescribed.
We hope you enjoy the rest of the holidays!
Your ___ care team | ___ yo M w/ longstanding hx of Crohn's disease s/p total
colectomy w/ ileorectal anastamosis; and multiple failed medical
regimens presenting with worsening of diarrhea.
ACTIVE ISSUES:
# Abdominal pain and diarrhea: Improved after IV fluids and pain
medications. Etiology was concerning for Crohn's flare given his
known chronic severe Crohn's, temporal association with
down-tapering of prednisone, and identical symptoms as prior
flares. His inflammatory markers were not very high, though
notably they have not been elevated in prior flares either.
C-diff was negative. Relative opiate withdrawal was also
considered since he just recently ran out of his home oxycodone,
though he did deny other symptoms of this including rhinorrhea,
yawning, etc and his symptoms began prior to his running out.
Given his complicated Crohn's history, GI was consulted, and his
prednisone was restarted back at 10mg daily. His symptoms
significantly improved with this treatment. He had a mild ___ as
well which remained stable with IV fluids. He was counseled on
maintaining adequate po intake, and he should have labs checked
at his next outpatient appointment.
# Acute kidney injury: Improved with IV fluids though not back
to his baseline. He understood the importance of maintaining
adequate salt and fluid intake and following up with his
outpatient doctors for further ___.
# Crohn's disease and pain management: He recently
re-established care w/ GI (Dr. ___ with a plan was for slow
taper of prednisone with continuation of azathioprine 100mg
daily. His GI providers have been reluctant to provide ongoing
prescriptions for opiate pain management and referred him to
pain management clinic, where he has not yet been able to
establish care due to transportation issues. Given that he has
been unable to do so and given his high risk of recurrent GI
symptom and pain flare, he was provided with an additional
prescription for oxycodone as a bridge to his upcoming GI and
PCP ___. He will need to establish care with the pain
management clinic for further management.
CHRONIC ISSUES:
# Vitamin B12 deficiency: IM replacement as outpatient prn.
# Depression: No home medications.
# Degenerative Disc Disease: Not active.
# Nephrolithiais: No recent flare, no dysuria/hematuria.
# Atypical chest pain with neg stress ___: Not active.
# Latent TB treated with INH in ___: No pulm symptoms.
# GERD: Continue home famotidine.
# Code: full confirmed
# Emergency Contact: Aunt ___ HCP ___,
___. Per pt, do not call after 9PM. | 111 | 418 |
19671332-DS-7 | 25,644,091 | Dear Ms. ___,
You were hospitalized because of fevers. We believe this
occurred because of an infection in your blood that started in
the temporary line you were using for dialysis. The line was
removed and you were treated with antibiotics. Your fevers then
improved.
You were also evaluated by our physical therapists, who
recommended that you were safe to be discharged home with
physical therapy as an outpatient.
We are glad that you are feeling better.
All the best,
Your ___ team | ___ with NIDDM, CAD, severe aortic stenosis (Area <1.0), HFrEF
(EF35%), ESRD on HD (MWF), hx MSSA bacteremia ___ AVF infection
s/p AVF revision ___ getting HD thru temporary tunneled line,
now presenting with fevers, purulent drainage from tunneled
line, and MSSA bacteremia.
#MSSA Bacteremia: History of MSSA bacteremia from LUE AVF
infection requiring AVF revision last month. Now with purulent
drainage expressed from temporary tunneled line site and blood
culture x2 with pan-sensitive MSSA. Likely central line
infection, now s/p line removal ___. Per outpatient HD, pt was
able to complete cefazolin course for prior history of MSSA
bacteremia. However, pt's son reports the pt developed a severe
allergy to cefazolin near end of the prior course, with a
superficial desquamating rash that covered the pt's back, chest,
arms, and face. This allergy was reportedly confirmed by a
dermatologist. TTE with no evidence of valvular vegetation;
however, despite adequate windows, sensitivity for detecting
vegetation is questionable in light of the pt's pan-valvular
disease (evidence of mitral annular calcification, MR/MS, AR/AS,
TR). These same limitations would also make it difficult to rule
out vegetation on TEE as well.
# CKD stage V: Initiated ___, secondary to long standing
diabetes, on HD MWF. Has LUE fistula, revised in ___.
Presented with infected tunneled line s/p line removal ___. HD
was continued while inpatient via LUE AVF. Nephrocaps started.
#Diarrhea: ___ be due to meds such as zosyn, less likely
infectious. Cdiff negative.
CHRONIC ISSUES
===============
# Anemia. Hemoglobin was stable. Likely ACD given ESRD. She is
on Aranesp q 2 weeks.
# Systolic heart failure: Diagnosed ___ with LVEF ___
consistent with LAD ischemia. Cath showed 3 vessel CAD.
Continued aspirin, atorvastatin. Was previously on lisinopril
and metoprolol but was held after admission for sepsis in
___.
# Non-insulin dependent Diabetes Mellitus: Complicated by
retinopathy and CKD. It does not appear that she is on any
medications for glycemic control. Pt's son reports DM is diet
controlled. A1c 4.7%
# Severe AS: Patient with severe AS on TTE with valve area <1.0.
Per OMR notes she is undergoing evaluation for CABG/AVR.
# Skin sensitivity: Prefers paper tape. | 81 | 352 |
18902344-DS-75 | 22,734,181 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | # Pancreatitis: By the time the pt was admitted to the floor,
his ___ pain had nearly resolved, and he was requesting PO
diet. He ate crackers and clears overnight, and then advanced to
full reg diet on the morning of ___, w/o any problems. He
then requested to leave immediately.
# Hyperglycemia: The pt's glycemic control was suboptimal during
admission, likely ___ not being on his very aggressive home
regimen of lantus / humalog. He was restarted on his home
regimen on ___ at time of advancing diet, w/ good effect, and
was discharged on same regimen.
# SOB: Pt received diuresis for likely volume-related SOB, w/
good effect. At time of d/c, pt was not using any O2 and was
able to ambulate independently w/o difficulty.
# Dispo: Per pt request, pt was discharged home. PCP appt was
set up for ___. | 14 | 144 |
15255975-DS-10 | 20,666,897 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
You were here because you had a fall at home and broke you leg.
You had a surgery with the orthopedic team and you were put on a
blood thinner for a month to prevent clots.
While you were here, we noticed you had trouble with swallowing.
He had the GI (stomach) doctors and the ___ team see you
to see if we could figure out why. While we still are not sure,
the speech and swallow team worked with you to find a diet that
would decrease your risk of aspiration (food going down the
wrong pipe). We will continue to address this issue at rehab and
as an outpatient.
When you leave, it is important to take your medications as
prescribed. It is also important to attend your appointments as
listed below.
If you have any fevers, chills, chest pain, or shortness of
breath, let your rehab know.
We wish you the best of luck!
Your ___ Care Team
=========================
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.
=============================================================
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:
- Touch down weight bearing in right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
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 | ___ female with a past medical history COPD, CAD s/p 2
PCI, severe AS s/p AVR hypertension, hyperlipidemia presented
s/p fall with right distal periprosthetic femur fracture s/p
ORIF on ___. Course complicated by worsening leukocytosis,
aspiration event, transient delirium, and fevers, so was
transferred to medicine for further work-up. She was placed on a
modified diet of pureed and nectar thick liquids and was
discharge to rehab in stable condition. Needs ongoing outpatient
evaluation for dysphagia (GI), stenotic bioprosthetic aortic
valve, and ortho follow-up.
#s/p mechanical fall
#Frequent falls at home
Patient endorses falling asleep in her chair and waking up with
her feet asleep and then tried to ambulate, subsequently
falling. Does endorse some falls recently with lightheadedness
at home. She was monitored on telemetry without cardiac events,
TTE was with high gradient in AVR but stable and otherwise
remained without dizziness or lightheadedness.
#Acute Hypoxemic respiratory failure
#Hx of COPD
Patient with ongoing O2 requirement, likely ___ to atelectasis
and restrictive defect with elevated hemidiaphragm, along with
baseline COPD. Her hypoxemia improved and she did not require
oxygen on discharge, though could be considered for it in the
future based on her respiratory status.
#Aspiration
#Dysphagia
Per family and patient, ongoing issue for several years. Had a
suspected unwitnessed aspiration event leading to fevers and
leukocytosis. Was seen by SLP with aspiration on bedside
evaluation. FEES study with severe oropharyngeal dysphagia and
issues with esophageal dysmotility. Neurology and GI were
consulted for work up. Neurology recommended myasthenia graves
work-up and GI recommended barium swallow, which showed mild
esophageal dysmotility. MG workup negative except pending anti-
MUSK Ab at discharge. GI recommended esophageal manometry as
outpatient for further work-up. After a discussion regarding the
risk and benefits of eating with her aspiration risk, she was
placed on a modified diet of pureed solids and thickened
liquids. She was continued on SLP training while in house.
Notably, she is likely to continue to aspirate small amounts but
continuing to eat is consistent with her goals of care;this
should be an ongoing conversation.
#Hx of AS s/p AVR
Noted to have high gradients on TTE while in house concerning
for early valve failure vs clot. She was seen by cardiology who
recommended ongoing outpatient monitoring of her gradient. Based
on their evaluation most likely some level of patient prosthesis
mismatch. Severity is moderate.
#right distal periprosthetic femur fracture s/p ORIF (___). She
had operation on ___ and was started on lovenox with plan to
continue for 28 days to end ___. Recs per ortho:
Activity: touch down weight bearing to RLE. For pain, continue
Tylenol scheduled and oxycodone prn. Lovenox to continue through
___.
#Leukocytosis
Patient noted to 22 post-operatively, along with fever. She was
treated with 3 days of ceftriaxone for suspected UTI, with
downtrending in her leukocytosis, though persistently elevated
on ___ with eosinophilia without constitutional symptoms. She
should follow-up as an outpatient for ongoing work-up, but this
appointment has not been scheduled and we defer to PCP.
#Fevers
Noted on ___ after suspected aspiration event. Likely
aspiration pneumonitis vs UTI vs post-operative. Received 3 days
of ceftriaxone with improvement in her fever curve. Afebrile
thereafter.
#Delirium
Did have episodes of somnolence and agitation while in house.
This resolved after recovery from surgery. Her dose of Seroquel
was decreased from 50 (home) to 25 mg qhs.
#CAD w/hx of PCI
#HTN
#HLP
Continued on aspirin, metoprolol BID, rousvastatin 20mg QHS, and
amlopidine 2.5mg
#Elevated right hemidiaphragm
Noted on CXR and persistent since ___.
TRANSITIONAL ISSUES
--------------------
[] Will continue lovenox for total of 28 days (to end ___
[] Should follow-up with cardiology for increase AVR gradient
and ongoing TTE monitoring
[] follow up with GI for dysphagia
[] Would consider heme/onc evaluation for ongoing leukocytosis
and eosinophilia (we defer to PCP)
[] F/U myasthenia ___ work-up MUSK ANTIBODY, remainder of MG
workup negative
[] Filled out MOLST this admission - for now, full code
[] Patient likely high aspiration risk but has indicated she is
willing to take the risks to continue po intake; continue this
goals of care discussion as outpatient
[] Dose of Seroquel decreased from 50 mg qhs to 25 mg qhs; would
consider trying to d/c as outpatient given antipsychotics and
mortality in elderly
SPEECH/SWALLOW RECS | 747 | 678 |
14473881-DS-10 | 26,149,470 | Dear Ms. ___,
You were seen at ___ due to a
fall. You were found to have a broken foot. You were seen by
podiatry (foot doctor) for the fracture, and they recommended
surgery. However, given your concern with surgery, we did
casting instead. You have a cast on your foot, and you should
follow up with podiatry in the clinic at the appointment below.
In addition, while you were here you had a seizure. You had a
study called an EEG which monitors any seizure activity. This
did show some evidence of seizure potential. We wanted to do an
MRI for further evaluation, but you did not want to do an MRI at
this time. Please consider getting an MRI in the future. In the
meantime, you were seen by neurology, who started you on an
anti-seizure medication called zonisamide. **Please take 1 pill
of this every day until ___. On ___, please
start taking 2 pills of this every day.** Please follow up with
your neurologist in the clinic at the appointment we have
arranged.
Please take all medications as prescribed and please follow up
with the appointments we have arranged.
It was a pleasure taking care of you at ___.
Sincerely,
Your ___ care team | ___ yo female with history of opioid and heroin abuse, on chronic
methadone, etOH withdrawal seizure who presents after fall,
found to have R foot fx and generalized tonic-clonic seizure in
the ED.
#Fall: Patient presents after witnessed fall, during which she
sustained foot fracture. Does not recall events prior to fall,
raising concern for seizure (see below). Patient was monitored
on telemetry and no arrhythmia was noted. She had EKG that
showed NSR, normal QTc (430s), normal intervals. She had TTE
that was negative for valvular disease or any structural
abnormality. She had negative infectious work up, negative CT
head. She was seen by ___ this admission.
#Seizure: Patient had a generalized tonic-clonic seizure while
in the ___ ED. She had postictal agitation and was given 6 mg
of Ativan. During prior ___ course, pt did have etOH
withdrawal seizure requiring phenobarbital in the ICU. At the
time, had transminitis more consistent with alcoholic hepatitis
and was intoxicated on admission. The witnessed seizure in the
ED was initially concerning for etOH withdrawal or substance
use. However, given that patient had negative toxicology screen,
not scoring on CIWA, no significant transaminitis (vs prior
admission), and denied etOH, it was felt that this presentation
may represent primary seizure disorder. Given this, neurology
was consulted. Patient had EEG that showed intermittent mild to
moderate focal slowing in the left temporal region, concerning
for cerebral dysfunction, possibly structural in origin. Pt had
CT head that was negative for intracranial pathology. She
refused MRI brain. She was started on zonisamide 100 mg daily x7
days and will increase to 200 mg daily starting ___. She will
follow up with neurology for an outpatient.
# R foot fracture: Patient fell while walking for the T. She has
no memory of the fall but was suspected to be due to possible
seizure as above. She had XR of the foot, which showed fracture
___ metatarsal comminuted and angulated fracture. She was
recommended for R ORIF, but patient refused procedure. She
therefore had a cast placed by ortho tech and will follow up
with podiatry in the outpatient setting.
#H/o opioid/heroin abuse, on methadone: Patient was going to
___ clinic before her fall. Per discussion with ___
___ Clinic, patient has been dispensed 140 mg daily of
methadone. Patient was adamant that she takes 110 mg methadone.
She was given 120 mg methadone daily when admitted due to our
pharmacy options (had to receive 3 40 mg tablets given no other
convenient way to dispense 110 mg). Her last dose was on ___
with methadone 120 mg at 0800. She is being discharged on
methadone 120 mg daily as stable on this regimen during hospital
course.
#h/o Alcohol abuse: Last drink one year ago per patient. She
does have a history of etOH withdrawal seizures, which may have
increased her likelihood of developing a seizure disorder. She
was placed on CIWA but did not require valium. She was placed on
thiamine, folate, and multivitamins during hospital course.
#COPD: continued home Spiriva, advair, albuterol PRN
#H/o homelessness: patient currently resides in a group home but
appears her living situation is unstable, unable to name her own
address for example. Patient was seen by social work. She will
go to ___ house on discharge. Ongoing compliance
with medications and outpatient visits should be emphasized. | 203 | 553 |
14215764-DS-10 | 27,269,376 | ___ were admitted to the hospital after a revision of your
ileostomy. ___ have tolerated a regular diet, passing gas and
stool from the stoma and your pain is controlled with pain
medications by mouth. ___ may return home to finish your
recovery.
Please monitor your bowel function closely. If ___ 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.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
___ have a long vertical incision on your abdomen that is closed
with staples. ___ have a pervena vac over the incision which is
a purple sponge dressing attached to the incision line. This
will be removed on ___ by your wound/ostomy nurse.
Please call ___, NP at ___ to give me her contact
information so i can give her instruction regaurding the pervena
vac. This can not stay on for longer than 7 days. Please monitor
the incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. Please call
if the pervena vac is alarming or is not on suction. It is an
infection risk for the sponge to be on without suction.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___ may
gradually increase your activity as tolerated but clear heavy
exercise with your surgical team.
___ will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck! | ___ was admitted from home for redo of her stoma for
obstructive sytmpoms. On ___ the stoma was revised by Dr.
___. She did well post-operatively. Voided after foley
removal and all laboratory calues were stable. Her diet was
advanced to clear liquids and when the ostomy had output, on
___ she tolerated toast. On ___ she tolerated a regular
diet. She was assisted in caring for the new stoma by the
nursing staff and she was stable and ready for discharge home. | 750 | 84 |
19796209-DS-5 | 22,308,595 | Please continue to receive care from the trauma and spine
services until you are ready to be discharged.
You should follow up with a spine surgeon and an orthopedic
surgeon after you leave the hospital. | The patient was admitted to the TSICU initially.
Neuro: The patient was awake and alert, and had no neurological
impairment. His pain was controlled with PO medications.
CV: The patient remained hemodynamically stable during his
stay in the trauma SICU.
Resp: The patient had adequate oxygen saturations during his
stay in the TSICU and received only nasal canula oxygen
initially. His pain was well controlled and his tidal volumes,
as assessed by IS were more than adequate. On HD 2, a chest
tube was placed in the right side for increasing o2 requirement
and concern for R hemothorax. The tube returned 700cc of
serosanguenous fluid with output tailing off after this. There
was no pneumothorax post-placement.
Abd/GI: The patient was appropriately advanced to a regular diet
on hospital day 1.
Renal/GU: The patient's urine output was monitored.
Endo: The patient's blood sugars were monitored and he was on
an insulin sliding scale.
Heme: His plavix was held on admission and SQH was held
starting HD 1 for conern for ongoing bleeding. His aspirin was
continued. There was an initial concern that the patient may
have a small ___ hematoma and vascular surgery was
consulted. They recommended avoidence of systemic
anti-coagulation and a repeat CT scan prior to discharge. The
patient also had a hematocrit drop from 37.8 on admission to
27.7 on HD 1. A right sided chest tube was placed and a
significant amount of blood returned though this tailed off as
the day went on. On HD 3, the patient's Hct dropped to 21.1
and he was transfused 1U PRBC. A repeat CTA was also obtained
which did not show any evidence of bleeding in the chest or
abdomen as well as a stable appearance of the ___
hematoma. On HD 4, he was transfused 2U PRBC for HCT of 22 with
a plan to go to the OR with spine for surgical fixation of his
t10-11 chance fracture.
ID: The patient's temperature curve was monitored as was his
white blood cell count.
MSK: A fracture of an anterior osteophyte between T10 and T11
was noticed on initial imaging. Spine was consulted who
requested standing plain films of the T-spine when the patient
was able. The patient was also noted to have a R knee
hemearthrosis and Ortho Trauma was consulted. They recommended
___ brace soft tissue injury and he may follow up with
them as an outpatient. On HD 2, the CT c-spine was over-read as
a t10-11 chance fracture. The patient was kept bed-rest until
TLSO fitted and on HD 3, spine decided to perform operative
intervention. On HD 4, the patient refused operative
intervention and requested a second opinion.
The patient was transferred to the floor on ___. Per his
request, he was transferred in stable condition to an outside
hospital for a second opinion and ongoing treatment of his
injuries. | 34 | 501 |
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