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10082163-DS-21 | 26,875,625 | Dear Ms. ___,
It was a pleasure to care for you during your hospital stay,
You were admitted to the hospital because:
- You were having redness and pain in your right groin, and the
emergency department saw another abscess
What happened to you while you were in the hospital:
- You were started on antibiotics for the abscess
- You had your abscess drained by our radiologists
- You were seen by our colorectal surgeons
What should you do when you leave the hospital:
- Continue taking all of your antibiotics as listed
- Please follow up with your gastroenterologist to decide on
future treatments for your Crohn's disease
- Please follow up with your primary care doctor
___ wish you the best,
Your ___ Care Team | This is a ___ year old female with past medical history of
hypertension, seizure disorder, Crohn's disease recently
complicated by enterocutaneous fistula and R groin abscess
requiring drainage and prolonged course of antibiotics, admitted
with recurrent abscess, unable to be drained due to insufficient
fluid, improving on antibiotics, seen by GI and planned for
outpatient imaging and follow-up, able to be discharged home.
# Crohn's Disease complicated by R groin Enterocutaneous Fistula
and R groin abscess
Patient with recent history of infected enterocutaneous fistula
requiring prolonged antibiotic course who presented with pain
and erythema at right hip. CT scan showed a fluid collection
present within the right groin compatible with abscess, with
associated cellulitis. Colorectal surgery was consulted who
recommended drainage of abscesss by ___. She had a repeat
ultrasound performed by ___ which showed fluid collection
decreased in size, so much so that it was not amenable to
drainage. Per discussion with consulting services, plan was ton
continue antibiotic therapy, until her GI follow-up. Of note,
given recent metronidazole course and new peripheral neuropathy
symptoms, patient was transitioned from flagyl to clindamycin
this admission. Patient aware of warning signs that should
prompt her to seek additional care (relating to worsening of
skin findings / pain or failure to improve). Per GI consult,
the patient will follow-up in ___ clinic on ___ for
consideration of humira pending resolution of her abdominal
abscess. Patient will have a CT abdominal scan to determine
resolution of the abscess in ___ weeks.
# HTN: BP well controlled on this admission, on lisinopril,
amlodipine and metoprolol. | 115 | 267 |
11035109-DS-16 | 24,501,754 | Dear Mr. ___,
What brought you to the hospital?
================================
You came to the hospital because of abdominal pain and nausea
and because you felt fast heart rates.
What happened while you were in this hospital?
=============================================
-You receiving an ultrasound of your liver, which did not find
any abnormalities that would explain your symptoms. A thorough
work up at ___ before you were transferred here
did not show anything concerning to cause your symptoms
including no heart attack, bowel obstruction, infection.
-You received medications to help with your abdominal pain -
pantoprazole (acid suppressant) and carafate (coats your
stomach).
-You likely have something called "dyspepsia" or pain from
impaired digestion.
-We monitored your heart rates and did not notice any fast or
concerning rhythm.
-Your symptoms improved and you felt better.
What should you do when you leave the hospital?
==============================================
-You should continue to take pantoprazole 40mg daily and
sucralfate as needed.
-Take the pantoprazole daily before you eat breakfast. It works
best on an empty stomach.
-Remember to eat small portions, more frequently and slowly.
Avoid spicy or fatty foods.
-Please follow up with your primary care doctor (___) as
scheduled below.
-You should see a Gastroenterologist after discharge. The
office at ___ is working on this and will call you with
details.
-You should discuss with the doctors whether ___
(camera study) would be useful to evaluate your
esophagus/stomach.
-You mentioned that you have already set up a Cardiology
appointment on ___, please go to this appointment to
discuss your intermittent fast heart rates.
Please seek care if you develop severe abdominal pain, severe
vomiting, develop fevers, have chest pain or fast heart rate.
We wish you the best,
Your ___ Care Team | ___ with PMHx notable for anxiety, gastric bypass ___,
appendectomy, CCY, hernia repair right groin, liver resection of
the ciliated cyst ___ who was a transfer from ___ for
epigastric abdominal pain and nausea, also with episode of
tachycardia outpatient.
ACUTE ISSUES:
=============
#Abdominal pain
Patient had acute onset abdominal discomfort in epigastrium, LUQ
and RUQ which has persisted associated with burping and nausea.
Patient reports this episode is not typical for him, although
intermittent will note fullness in upper abdomen if eats too
quickly or too large bites, given history of RnYGB. Initially
presented to ___, where work up included negative cardiac eval,
rule out for dissection, ACS, PE and negative evaluation for
acute abdominal/pelvic etiology with largely benign CT abdomen
w/ contrast. No obstruction, hernia, biliary ductal dilation. CT
was notable for small (2 mm) non-obstructing left renal
calculus. No fevers, chills, melena, diarrhea, hematochezia,
dysphagia, regurgitation and abdominal exam was benign. On
review of outpatient records, has seen GI here last ___ for
chronic abdominal pain largely characterized by bloating and
bowel irregularity. ___ endoscopy and bacterial overgrowth
breath test were negative. At that point, seemed like from a GI
standpoint that his symptoms were likely functional in etiology.
This admission, patients symptoms largely improved with
pantoprazole and carafate. He was tolerating PO and was having
bowel movements. Differential included gastritis, GERD,
esophagitis, dyspepsia, constipation, also compounded by
anxiety. Inpatient EGD was deferred as it was unlikely to change
management. The patient would benefit from outpatient GI follow
up and will be set up with GI follow up at ___. He was
discharged on pantoprazole and sucralfate.
#Transaminitis
Unclear etiology. AST/ALT initially at ___, and trended up
to 150/162, before downtrending to normal. ___ CT reassuring
against any acute hepatobiliary pathology. RUQ U/S here notable
for fatty liver. Hep serologies notable for hep A immune;
cleared Hep B infection, not active; Hep C negative. CCY was ___
years ago, do not suspect choledocolithiasis and CBD was not
dilated. Per patient, he has history of intermittent
transaminitis.
#Reported tachycardia
Prehospital, patient reported episode of fluttering in chest and
fast heart rate, concerning for possible tachycarrythmia.
Occured in context of feeling abdominal fullness. Unclear if
related to anxiety, vagal stimulus or represents isolated
arrhythmia. Telemetry on ___ showed NSR.
#Anxiety
Continued home lorazepam.
TRANSITIONAL ISSUES:
=========================
[] For dyspepsia, started protonix and carafate for symptoms. Rx
for 14 days. Please reevaluate symptoms at next ___ office
visit.
[] Patient wants to reestablish care with ___
gastroenterology. ___ appointment scheduled for ___.
Would benefit from EGD as outpatient if symptoms recur.
[] Patient will have PCP follow up on ___
at 3:00 pm.
[] Noted to have low ferritin in previous admission; Iron
studies notable for likely Fe deficiency, Vit D 20, elevated PTH
suspect compensatory due to decreased absorption. B12, folate,
B1 replete. Iron supplementation and vitamin D/calcium
supplementation should be addressed.
[] Given reported intermittent tachycardia, would consider
outpatient cardiac event monitoring. Patient reported he has
outpatient cardiology appointment to establish care on ___.
[] Patient is interested in outpatient neurology referral given
self-reported chronic intermittent headaches.
Time spent coordinating discharge > 30 minutes | 277 | 529 |
15731508-DS-10 | 24,861,300 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were losing your balance and falling frequently at ___
___
What did you receive in the hospital?
- You were treated for a urinary tract infection.
- You were seen by physical therapy, who recommended rehab
- You were seen by neurology, who recommended treating your
urinary tract infection and then following up with them in
clinic.
What should you do once you leave the hospital?
- Continue to work with physical therapy to improve your
mobility
- Take all of your medications as prescribed
- Follow up with Neurology for further titration of your
medications
- Follow up with Urology regarding your urinary retention.
Please note that if you continue to retain urine like you have
been and do not straight cath, urine will back up and can cause
significant kidney injury. This is why it is important to try to
catheterize to decrease the backup of urine.
We wish you all the best!
- Your ___ Care Team | Mr. ___ is a ___ yo man with PMH of bipolar disorder,
drug-induced Parkinsonism complicated by gait instability and
neurogenic bladder, normal pressure hydrocephalus s/p VP shunt
placement ___ without symptom improvement presents with
weakness and recurrent falls over the last few weeks likely due
to recurrent UTI. | 172 | 48 |
13331721-DS-21 | 22,582,300 | 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** | Mr. ___ was admitted on ___ and underwent a pre-operative
work-up. On ___ he underwent a coronary artery bypass grafting
x 4 performed by Dr. ___. Please see the operative note for
details. He tolerated this procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. He extubated later that same day. He transferred to the
step down unit. His chest tubes and wires were removed per
protocol. He was seen in consultation by the physical therapy
service and the ___ diabetes service. His home Plavix was
restarted for his stroke history. He will follow up with ___
as an outpatient. He is discharged home with ___ and follow-up
instructions. | 109 | 117 |
16180069-DS-17 | 21,579,859 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-You will be discharged with supplies and instruction on caring
for your thigh wound. Schedule follow up appointment in wound
clinic in one week. ___ call MD if redness spreads or s/s of
infection.
For questions or concerns please call outpatient wound
clinic at ___. You will also get antibiotics.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | Ms. ___ was admitted to Dr. ___ for
nephrolithiasis management with flank pain, concern for fever.
She is status post right ureteroscopy, laser lithotripsy on
___ for 1.2 cm stone who was admitted from the ED with with
flank pain, fever, UTI following stent removal and imaging
showing large grouping of stone in the right distal ureter. She
was given intravenous fluids, pain medication, intravenous
antibiotics and prepped for operative intervention/stenting. She
was taken to the OR and underwent cystoscopy, right ureteral
stent placement. She tolerated the procedure well and recovered
in the PACU before transfer to the general surgical floor. See
the dictated operative note for full details. She was monitored
overnight and on POD1 a consult with wound care specialist
obtained for an eschar on the right thigh of unclear etiology.
Overnight, the patient was hydrated with intravenous fluids and
received appropriate perioperative prophylactic antibiotics.
Intravenous fluids, Toradol and Flomax were given along with
intravenous antibiotics. At discharge on POD1, Ms. ___ pain
was controlled with oral pain medications, tolerating regular
diet, ambulating without assistance, and voiding without
difficulty. She was discharged with wound care plan and a
course of antibiotics and she was explicitly advised to follow
up as directed as the indwelling ureteral stent must be removed
and or exchanged. | 397 | 216 |
18448279-DS-3 | 21,682,426 | Dear Dr. ___,
___ was a pleasure to participate in your care here at ___
___! You were admitted with malaise
and fevers, and were found to have infection in your blood from
E. coli. We assume that this came from a urinary source, as your
urinalysis showed evidence of infection as well. You were
treated initially with intravenous cefepime, then transitioned
to oral ciprofloxacin.
While you were here, your thyroid stimulating hormone (TSH) was
noted to be high at 6.4. This ___ have just been elevated from
acute illness. Please have your TSH checked in ___ weeks.
Please note, the following changes were made to your
medications:
- START ciprofloxacin 750 mg by mouth every twelve hours
- HOLD your lisinopril and losartan until ___
Please see below for your follow-up appointments.
Wishing you all the best! | Dr. ___ is a ___ year old lady with PMH CKD Stage III, HTN, who
was admitted with fever and malaise, and was found to have E.
coli bacteremia and sepsis, with course complicated by acute on
chronic kidney disease and hyponatremia.
.
.
ACTIVE ISSUES
# E.coli septicemia: Patient presented with evidence of UTI on
positive UA (but only mixed growth on culture), but growth of
gram negative bacteermia within 12 hours of BCx being drawn;
also with leukocytosis to 14.2 with 81% PMNs on admission. She
was febrile, with initial tachycardia and hypotension. She met
SIRS criteria, with infectious source in blood. Because of acute
on chronic kidney disease, her sepsis was classified as severe
due to evidence of end-organ dysfunction. While she was febrile
for the first three days of her hospital course, tachycardia and
hypotension resolved swiftly after 5L of NS boluses, followed by
continuous fluids. At the time of admission, she was treated
with cefepime for broad coverage of gram negative bacteria while
speciation and sensitivities were pending. Cultures eventually
revealed pan-sensitive E. coli. The day prior to discharge,
antibiotic coverage was changed to ciprofloxacin PO, to which
her E. coli was sensitive with MIC < 0.25. She remained afebrile
on ciprofloxacin, which she will continue to complete a 14 day
course of treatment.
.
# Acute on chronic kidney disease: Patient has stage III CKD,
with Cr baseline 1.2-1.5. Admitted with Cr 2.0, which trended
down gradually after aggressive IVF as above. This worsening of
renal function was most likely due to low right-sided filling
pressures in the setting of sepsis, with ultimate kidney
hypoperfusion. In this context, the patient's ACEi and ___ were
held. She was instructed to continue holding these medications
until 3 days after discharge. At the time of discharge,
creatinine was 1.3.
.
# Hyponatremia: On HD#4, patient developed mild, asymptomatic
hyponatremia. It was suspected that she ___ not have been
keeping up with her PO intake, thus causing a hypovolmeic
hyponatremia. There was no evidence of volume overload that
would suggest hypervolemic hyponatremia. No cirrhosis/CHF. Also
on DDx for hyponatremia was SIADH (but patient without signs/sxs
PNA nor any known malignancy), iatrogenesis (no diuretics),
hyperglycemia (though currently well-controlled), hypothyroidism
(no PMH of this; TSH checked during this admission was high, but
___ have been evidence of sick euthyroid). Serum sodium
corrected to 137 by the time of discharge.
.
. | 131 | 391 |
10215416-DS-19 | 27,534,252 | You were admitted with vomiting and diarrhea consistent with a
viral gastroenteritis. You have improved greatly with fluids.
Please continue to follow a bland diet at home, and avoid dairy
for the next few days. Thus far, we have not found bacteria in
your urine, so we are stopping antibiotics for a urinary tract
infection. Also, your blood pressures were slightly elevated in
the hospital - please discuss this with Dr ___. You also had
very slight elevation in liver function tests which you can also
discuss with her. | ___ with suspected acute gastroenteritis causing electrolyte
disturbance and acidosis as well as tachycardia.
#Gastroenteritis: Symptoms resolved in hospital, norovirus
negative.
#Tachycardia: resolved with hydration
#Alcohol use: She did not score on CIWA
# Abnormal LFTs: Advised her to f/u with PCP | 94 | 43 |
17716210-DS-80 | 28,986,204 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why you were here?
You came to the hospital because you were having worsening pain
in your leg.
What we did while you were here?
-We did CT scans of your leg to monitor the large bleed in your
leg.
-The interventional radiologists tried to find where you were
bleeding. They were unable to locate the location of the bleed.
-We had the hematology team see you to help us with a plan for
your anticoagulation. We gave you Lovenox 40mg daily, which is a
lower dose than you came in on.
-We monitored your blood counts and gave you a unit of blood
when your blood counts dropped.
What you should do when you go home?
-Please follow up with the hematology team to discuss when you
can restart the higher dose of your lovenox.
-Please make sure we monitor your blood counts as an outpatient.
-Please take your medications as prescribed. We discharged you
with a five day supply of oral morphine. Please follow up with
your PCP for further pain management.
Your ___ Team | Patient is a ___ female with recent admission for L
thigh intramuscular hematoma (___), chronic SBOs and
sclerosing mesenteritis since ___ s/p multiple surgeries
including decompressive G-tube, recurrent DVTs on Lovenox (last
___, and prior stroke who presents with worsening left upper
thigh pain after restarting anticoagulation, found to have
interval increase in left thigh hematoma. She underwent
arteriogram with ___, unable to locate source of bleeding. Her
therapeutic anticoagulation was reduced to Lovenox 40mg daily.
Patient remains hemodynamically stable with stable H/H.
# Acute blood loss anemia:
# Recurrent Left thigh hematoma
Patient with hematoma in adductor musculature with size of 9.6 x
7.8 x 11.5 cm, which is slightly larger than on last admission
on ___ (was 10.9cm). Her initial hematoma was thought to
provoked from chronic tunneled L femoral line (removed during
prior admission) and lovenox use for recurrent DVTs. On CTA on
___ there was active extravasation visualized, however on
arteriogram with ___ the bleeding was not able to be localized.
She received 1 unit pRBCs on ___. Does have L femoral DVT that
appears to be new since ___, may have occurred in setting of
held anticoagulation. Hematology was consulted given history of
recurrent DVTs and plan for lifelong anticoagulation with
inability to safely restart lovenox. Had extensive discussion
with heme/onc and ___- need to hold anticoagulation given active
bleeding/nonresolving hematoma. She is not a candidate for an
IVC filter given her challenging vasculature with inability to
remove filter safely as patient has no IJ access with the
exception of where her port was currently located. Per
discussion with heme/onc plan to discharge on Lovenox 40mg daily
(for DVT ppx) with plan to follow up as an outpatient with
heme/onc to determine when therapeutic lovenox can be restarted.
Appointment with heme/onc is scheduled for ___. Discharge Hb
8.7.
For her pain from her L thigh hematoma, patient was given
Morphine oral solution 8mg every 4 hours as needed. She feels
she is unable to absorb oral tablets given her GI dysfunction.
She was discharged with a 5 day supply of the medication and
plans to follow up with her PCP for repeat assessment of her
pain.
# L femoral DVT:
Patient with L femoral DVT on ultrasound from ___, new from
___. Likely formed in setting of held anticoagulation for
thigh hematoma. Per ___, her left external iliac vein is
chronically occluded and it would be difficult for blood clots
to travel to the lung. Has had multiple DVTs in the past with
plan for lifelong AC in the past. As discussed above not a
candidate for IVC filter. Cannot restart therapeutic
anticoagulation given large hematoma. Of note, last Lovenox dose
was 80mg Q12hrs as she was subtherapeutic on 70mg Q12 (per Xa
levels). Discharged on Lovenox 40mg daily for DVT ppx.
# Sclerosing mesenteritis:
# Chronic pain and nausea:
Chronic abdominal pain/nausea exacerbated by thigh pain, but not
significantly above baseline. Reports she manages her pain with
marijuana at home. She was given IV Dilaudid 0.25-0.5mg Q8hrs
prn for her abdominal pain during this hospitalization with plan
to transition to her marijuana on discharge. Her nausea was
treated initially with IV promethazine then transitioned to home
PR promethazine.
# Dysphagia:
Speech and swallow eval per pt request. Pt will tolerate regular
solids and thin liquids with use
of a liquid wash after each bite of solids w/o overt s/sx
aspiration and without sensation for pharyngeal residue. | 178 | 563 |
19548058-DS-20 | 28,536,966 | ===========================================
DISCHARGE INSTRUCTION BLURBS
===========================================
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had chest pain and shortness of
breath.
What happened while I was in the hospital?
- You had a stress test and cardiac angiogram which showed
narrowing in the blood vessels of your heart. They were not
narrow enough to warrant intervention at that time. The best
treatment will be to continue the medication prescribed during
the hospital stay.
- You were also incidentally found to have a high white blood
cell count highly suspicious for chronic lymphocytic leukemia.
What should I do after leaving the hospital?
- Please continue to take the medications listed in the
discharge summary because they will help prevent further
narrowing of your heart blood vessels. Please follow up at the
appointments listed below with your primary care doctor,
hematology/oncology, and cardiology.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | Mr. ___ is a ___ year old man with hypothyroidism,
anxiety/depression, GERD, BPH who presented with atypical
anginal symptoms and was admitted for cor angio.
ACTIVE ISSUES:
# Coronary Artery Disease: Patient presented with abnormal
sensation in his chest described as "like Christmas lights going
on and off" for several days prior to presentation concurrent
with exertional dyspnea. His ECG had no ST changes and negative
troponins x2. Stress testing showed resting mild hypokinesis of
inferior, posterior, and lateral walls with baseline LVEF of
45%. With exercise these same regions became severely
hypokinetic. These findings were concerning for CAD and he was
admitted for cardiac cath, which showed diffuse non-occlusive
coronary artery disease but no lesion upon which to intervene.
He was continued on medical management of CAD including aspirin,
metoprolol succinate 25mg po qd and atorvastatin 80 mg qd.
#Lymphocytosis: Patient was incidentally found to have
leukocytosis to 19. He did not have any localizing symptoms and
remained afebrile throughout his hospital stay. Differential and
peripheral blood smear had lymphocytosis and atypical
lymphocytes including smudge cells. He did not demonstrate
symptoms of CLL. After discussion with hematology/oncology, he
is being discharged with hemo/onc follow up for further
outpatient management.
# HTN: On arrival patient had markedly elevated BP to 189/122.
He has unclear baseline blood pressure as he has not seen PCP
for ___ long time. His home medication did not include any
anti-hypertensive agents. His pressures downtrended with
addition of metoprolol succinate and amlodipine. Upon discharge
BP was 132/75.
Chronic
--------
# Anxiety: Received home meds (bupropion, celexa)
# Hypothrydoism. tsh 1.4, free t4 0.7 t3 120. He received home
liothyronine
# BPH - Continued home meds (finasteride, terazosin)
Transitional Issues
====================
[]Coronary Artery disease- Cardiac angiogram showed diffuse
non-occlusive coronary artery disease and did not receive any
intervention. He was discharge on medical management. Please
ensure he continues to take aspirin, metoprolol, and
atorvastatin.
[]Lymphocytosis - Incidentally found on CBC and diff. Highly
suspicious for CLL. Will have scheduled hematology/oncology
follow up. Please ensure patient has appropriate followup.
Please follow up on pending EBV and CMV labs.
[]HTN: Hypertensive to 180s systolic on admission. Please
titrate metoprolol and amlodipine as appropriate at outpatient
followup. | 188 | 362 |
17767802-DS-7 | 24,044,032 | Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with weakness and fatigue. We
did many different blood tests all of which were normal. We also
tested for carbon monoxide in your blood which was negative. You
are likely weak from deconditioning and you should continue your
home exercises.
.
Regarding your left shoulder, it is likely that you have frozen
shoulder. You should work with the physical therapist on this. | ___ year old woman with DM, HTN, HLD, and h/o SVT, who presents
with generalized weakness and fatigue.
.
# Fatigue/weakness: Patient has been symptomatic for the past
several months, likely due to deconditioning. Though TSH was
elevated, T3/T4 were normal. LFTs wnl. No significant anemia or
metabolic abnormalities. Patient was concerned about carbon
monoxide exposure, so carboxyhemoglobin was checked which was
wnl. ESR mildly elevated though likely in the setting of her
age. No infectious focus.
.
# Left shoulder pain: X-ray showed some degenerative disease and
rotator cuff arthropathy. Rheumatology was consulted and felt
that this was likely frozen shoulder. Patient was discharged
with home ___.
.
# H/o SVT: Continued metoprolol succinate 25mg daily. Patient
was monitored on telemetry with no events.
.
# DM: BS well controlled. Continued metformin.
.
# HTN: BP well controlled. Continued amlodipine and lisinopril.
.
# Hyperlipidemia: Continued pravastatin. | 75 | 150 |
19467161-DS-14 | 26,469,856 | ___ were admitted to the inpatient colorectal surgery service.
___ were treated for an abscess under the skin near the
ileostomy. This was drained at the bedside. ___ should return
home on Augmentin and antibiotic for 7 more days. Please call if
___ develop fevers, chills, or weakness. Call for increased
abdominal pain.
___ will no longer need to take Coumadin but ___ will need to
take Lovenox at home to prevent blood clots after surgery.
___ will be discharged home on Lovenox injections to prevent
blood clots after surgery. ___ will take this until ___. ___ do not need anticoagulation after that. ___ have these
syringes at home, only take until ___. This will be
given once daily. Please follow all nursing teaching instruction
given by the nursing staff. Please monitor for any signs of
bleeding: fast heart rate, bloody bowel movements, abdominal
pain, bruising, feeling faint or weak. If ___ have any of these
symptoms please call our office for advice or seek medical
attention if there is an emergency. Avoid any contact activity
while taking Lovenox. Please take extra caution to avoid
falling.
Please monitor your bowel function closely.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
___ 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.
Incisions:
___ have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures. These are 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
Oxycodone. 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. | Mrs. ___ was admitted to the inpatient colorectal surgery
service with an ileus and abdominal pain requiring placement of
a nasogastric tube. She was hydrated intravenously. She was
treated for a fluid collection adjacent to the ileostomy with
intravenous Cipro and Flagyl. The ileus resolved with antibiotic
treatment of this collection and drainage of the abscess at the
bedside. On ___ the skin at ___ oclock around the stoma was
cellulitis and an abscess was drained from the junctional area
with a Qtip. The patient dramatically improved after this
drainage and the nasogastric tube was discontinued and she was
able to tolerate a regular diet. She was discharged home to
complete a course of Augmentin. | 978 | 116 |
18401162-DS-18 | 27,558,335 | Mrs. ___,
___ were admitted to the hospital with an obstruction of your
small intestine. ___ were treated with bowel rest, IV fluids,
and IV abx. The GI team and the surgery team were involved in
your care. ___ improved with these conservative measures, your
diet was advanced and ___ continued to do well. The GI doctors
are planning to see ___ in clinic and want ___ to have an MR
enterography in a couple of weeks to further evaluate for active
Crohn's disease.
When ___ return home ___ should continue to advance your diet as
recommended by Dr. ___. If ___ develop recurrent fevers,
chills, vomiting, or severe abdominal pain or distention, please
seek medical attention.
It was a pleasure caring for ___ while ___ were hospitalized and
we wish ___ a fully and speedy recovery.
Sincerely,
The ___ Medicine Team | ___ y/o F w/ Crohn's disease, HTN, & GERD who presents with
abdominal pain, nausea and vomiting concerning for recurrent
SBO. She improved with conservative therapy including bowel
rest, IVF, and IV cipro/flagyl. Now tolerating soft solids. GI
and Colorectal surgery teams evaluated her. She will follow up
with GI (Dr. ___ in clinic on ___ and have outpatient MRE,
which the patient will call to schedule, prior to that
appointment. The patient will further advance her diet at home
to soft foods per Dr. ___. She is being
discharged on oral cipro/flagyl to complete a total of 7 days
(___) of abx per the GI team's recommendations. | 142 | 108 |
12288913-DS-14 | 23,163,789 | You were admitted for fever, a rash in the left lower extremity
along with pain in that same leg. You were started on IV
antibiotics for the redness and inflammation. Out of concern for
your history of vasculitis, dermatology was consulted. They felt
that you had a skin infection called cellulitis and recommended
continuing a full course of antibiotics. You had a skin biopsy
which DID NOT show any evidence of vasculitis.
You should be off from work for 3 days, but may take up to 1
week total if still with pain in your leg that affects your job | ___ yo male with history of IgA vasculitis (___), vitiligo, hx
of
alcohol use, presenting with subjective fevers swelling/pain in
left leg found to have cellulitis. Patient initially treated
with Cefazolin, switched to Vanc/Ceftriaxone given minimal
improvement in LLE cellulitis. Had biopsy performed on LLE by
dermatology which demonstrated ______. Patient was discharged on
Bactrim to complete a 7 day course of antibiotics to complete on
___.
# Left leg rash:
# Fevers:
# Leukocytosis:
# While leukocytosis and fever have resolved on IV antibiotics,
initial demarcated boundaries or erythematous/blotchy area on
LLE
have not improved. As per admission, rash is characterized by
numerable discrete macular lesions that happen to coalesce in
multiple areas, instead of a uniform distribution of
erythematous
skin as one would expect with simple cellulitis.
-Small vessel vasculitis was on differential given his history
of
self reported vasculitis with a long term (? 6 months) taper of
prednisone. His CRP is also markedly elevated at 191.6.
Complement levels normal. Has family history of scleroderma with
renal impairment in his mother. His f/u ANCA negative, ___
___ 1:40 (borderline), ESR 14. LLE ultrasound negative for
DVT
- Given recent ___ reports with history of leukocytoclastic
vasculitis treated with steroids, discussed with dermatology
regarding biopsy, biopsy completed on ___, dermatopath results
demonstrated NO EVIDENCE OF VASCULITIS per my discussion with
Dermatology
-He reports during the week when he was working at
___, he was laying down floor and
may have hit the plastic sheeting to his legs and caused
scratches to his legs.
-No evidence of proteinuria on UA, as such, self described
"foamy
urine" not likely to be representative of any
glomerulonephritis,
especially in context of normal renal function, now his reports
his urine is wnl
- Initially started on IV Ancef, but due to lack of clinical
improvement was
changed on ___ to Vanc/Ceftriaxone and erythema noted on left
thigh, continue
antibiotics for 7 day course. Start Bactrim on ___ and continue
for total 7 day course (to complete on ___
- Will need BMP in 5 days while on Bactrim to check renal fxn
- Discharged with PO Oxycodone for pain #20/No Refills. No
further Hydrocodone/APAP d/t hepatitis C Hx. ___ take Tylenol at
discharge for mild pain, up to 2 g per day
#History of anterior fibular non-aggressive cortical lucency on | 100 | 359 |
19385130-DS-19 | 29,917,833 | 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 continue to take Coumadin as prescribed by your ___
___ surgeon
ACTIVITY AND WEIGHT BEARING:
- WBAT with immobilizer ___ locked in extension
- Abduction pillow in bed
- Strict posterior hip precautions
Physical Therapy:
WBAT RLE with immobilizer ___ locked in extension
Abduction pillow in bed
Strict Posterior Hip precautions
Treatments Frequency:
No incisions were made during this admission.
Continue pre admission care per Dr. ___. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right THA dislocation and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for closed reduction of right THA dislocation, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patients home medications were continued throughout this
hospitalization. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT with strict posterior hip
precautions with the knee locked ine extension in ___ in
the right lower extremity, and will be discharged back to rehab
with plan for continuation of DVT prophylaxis on Coumadin per
Dr. ___. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 125 | 237 |
14720722-DS-16 | 22,103,279 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___! You were admitted for symptomatic control of
your nausea, lightheadedness, and dizziness. You underwent
multiple studies which did not show a clear cause for your
symptoms, but very reassuringly did not reveal any dangerous
findings either.
Since you continued to have palpitations you were discharged
with at ___ monitor to use when you have episodes of
a fast heart rate.
While you were here, no changes were made to your medications.
It is important that you keep yourself well hydrated and well
nourished. | >> BRIEF HOSPITAL COURSE
Ms. ___ is a pleasant ___ year old lady with history of
anxiety/depression, presenting with pre-syncopal symptoms,
nausea, vomiting, light-headedness, palpitations. She was
monitored on telemetry (without acute events) and orthostatics
were negative. Electrolytes were WNL as well. She was discharged
with ___ of Hearts monitor as she felt palpitations that we
were not able to correlate on telemetry during hospital course.
Overall, her symptoms were likely secondary to a recent viral
syndrome. She was discharged with instructions to continue good
PO hydration and to follow-up with her primary care doctor. She
also has a history of anorexia and was encouraged to maintain
intake of increased calories while she is feeling unwell, and
her lack of motiviation to do this may be playing a role in her
presentation.
.
>> ACTIVE ISSUES
# Nausea/vomiting: She received 5L of NS in the ED, and was
started on continuous ___ until she was able to tolerate
POs. She was also treated symptomatically with ondansetron.
.
# Headache: Likely from dehydration and viral syndrome. Could
also be consistent with migraine headache given mild
photophobia. Not concerning for meningismal headache as she had
no meningismal signs and did not appear toxic.
- Treated symptomatically with acetaminophen, ibuprofen, and
low-dose oxycodone.
.
# Presyncopal symptoms with feelings of palpitations: Both could
be ___ dehydration, viral syndrome. Elevated lymphocytes on diff
supports viral cause of recent symptoms as well. Telemetry was
unrevealing during hospitalization save for bradycardia that
occurred during sleep (asymptomatic). Orthostatics have been
negative.
.
>> INACTIVE ISSUES
# Anxiety, depression: Stable on this admission. Continued home
clonazepam, bupropion (though with BID dosing as home bupropion
is non-formulary), and aripiprazole.
.
>> TRANSITIONAL ISSUES
- Code status: Full code.
- Emergency contact: ___ ___
- TSH was 5.0. Please consider further investigation into
thyroid disease.
- Noted to have TSH of 5.0 on this admission. Please consider
evaluating this further. | 99 | 303 |
18060844-DS-11 | 22,466,353 | You had a cerebral angiogram to assess the blood vessels in
your neck and brain. You may experience some mild tenderness and
bruising at the puncture site (groin).
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon. You may
continue taking aspirin as ordered.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs. | Mr. ___ was transferred from OSH for WHOL with CT/CTA
showing hemorrhage near the brainstem and concern for left
vertebral artery dissection. He was given keppra and nimodipine.
He was started on nicardipine for blood pressure control.
On ___ He underwent an MRI/MRA which did not show evidence of
true vertebral artery dissection or aneurysm. He remained in
the ICU for close monitoring. His diet was advanced.
On ___ Patient remained neurologically stable. He remained in
the ICU for close monitoring and blood pressure control.
Neurology consult was placed to evaluate for other etiology of
hemorrhage. TCDs were negative for vasospasm.
On ___ the patient remained neurologically stable. His foley was
replaced for urinary retention.
On ___ the foley was kept in place ___ urinary retention and
the patient was started on Flomax.
On ___ the patient remained neurologically stable. Physical
therapy worked with im and they are recommending rehab.
On ___, the patient remained neurologically stable. He had some
mild agitation overnight. His BUN is trending up and will
continue to be monitored.
On ___, the patient remained neurologically stable. He is
ordered for a CTA Head and is waiting for test to be performed.
On ___ review of his CTA head/neck showed a left vertebral
artery dissection and he was planned for pipeline embolization
procedure on ___. He was loaded with plavix and ASA. He was
pre-op'd and made NPO.
On ___ he was neurologically stable and underwent a diagnostic
angiogram which revealed stenosis of the Left vertebral artery
at the origin and no sign of traumatic dissection or aneurysm.
He continued on aspirin.
On ___ and ___, the patient remained neurologically and
hemodynamically stable. Re-evaluation by physical therapy
determined patient needs rehab placement at discharge.
On ___, the patient remained neurologically and hemodynamically
stable. He was started on a 7 day course of Bactrim for UTI.
On ___, the patient remained neurologically and hemodynamically
stable. He remained inpatient pending rehab placement.
On ___, the patient remained neurologically and hemodynamically
stable. Aspirin dose was changed to 81mg per recommendations
from stroke neurology and he was referred for follow up in the
Stroke and Cerebrovascular Disease Clinic. He was approved for
rehab placement and discharged in stable condition. | 336 | 370 |
13043390-DS-10 | 26,712,707 | Dear Ms ___,
You were recently hospitalized at the ___
___ for abnormal findings on your electrocardiogram,
or test that looks at the electrical signaling of your heart, at
your outpatient provider's office. We performed an
echocardiogram, or an imaging test that looks at the structure
and function of the heart. This showed you had a heart attack in
the past and now have a blood clot within the heart cavities.
For treatment, we started a blood thinning medication known as
heparin, which breaks down the blood clot. We then switched to
a medication known as warfarin. This medication will need to be
closely monitored by your outpatient providers. You also had a
special stress test that looked to see how your heart pumps.
This confirmed that the heart attack was not new.
Physical therapy evaluated you and recommends rehabilitation.
Please weigh yourself every morning and call MD if weight goes
up more than 3 lbs. Please follow-up with the appointments
listed below and take your medications as instructed below.
It was a pleasure taking care of you.
-Your ___ team
Your ___ cardiology team | This is an ___ y/o F with a significant PMH DM with ophthalmic
complications and osteoarthritis who was found to have
ST-elevations in V4-V5, II, III, avF, found to have elevated
cardiac enzymes and moderate-large sized left ventricular apical
thrombus.
# ST Elevation: present on ECG without significant chest pain.
Initial trop at 0.5 with CK elevated to 620, MB20, amd MBI3.2.
She was started on heparin infusion. It was unclear if this
distribution was consistent with the location of apical
thrombus, so cardiac enzymes were trended with trop:
0.50->0.36->0.38->0.39->0.32->0.25. CKMB was initially elevated
to 20 was downtrended with troponin to 6. She was chest pain
free. It was suspected that the thrombus was ___ prior
myocardial infarction and regional wall motion abnormality as a
result. Heparin infusion was discontinued in favor of lovenox
injections as bridge to warfarin. She was continued on ASA 81mg
and atorvastatin 80mg QHS. Catheterization was deferred for
post-acute hospitalization. However, MIBI was performed to
assess for any reversible ischemic and performed on ___
which demonstrated moderate fixed apical defect and akinetic
apex.
-titrate ACE-I/BB as BP tolerated
# LV apical thrombus: as demonstrated on echo. Unclear the
source, though most likely due to old infarct of unknown time.
Could explain ST-elevations, though distribution of
inferolateral is not consistent with thrombus location. Has
started on heparin gtt, then bridged to warfarin with Lovenox
-Continue with warfarin 3 mg daily; f/u INR
# Recurrent falls: Unclear source of recurrent falls. Difficult
to obtain history but she reported walking in her home without
her usual support ___ or walker and falling. She as down
for 18 hours, unable to get up. She denies any chest pain
during this period of time. She denied any loss of
consciousness, loss of bowel or bladder continence. Suspect that
this was a mechanical fall. She was evaluated by ___ who
determined that she needed rehab.
# pyuria: Patient had uptrending WBC with U/A grossly positive
for UTI, however contaminated with 9 epis. Patient denies any
dysuria/increased frequency.
-continue to monitor
# Diabetes Mellitus hx: She is not currently treated with any
medications. As per atrius records, she has reached HbA1c goals
<6.5%. She was monitored with daily BG levels and did not
require intervention. | 181 | 380 |
13293446-DS-10 | 27,394,932 | Dear Mr. ___,
You were admitted to the hospital because you were anemic. You
were found to have two bleeding ulcers in the beginning part of
your intestines and several smaller ulcers in your stomach. The
2 large ulcers were clipped and your blood counts returned to
normal with transfusions of blood.
Your ulcers seem to have been caused by the aspirin that you
were taking and the warfarin which thins your blood. You should
only take "enteric coated" aspirin which will be dissolved more
slowly and you should have very very close monitoring of your
blood thinning effect of warfarin.
It was a pleasure taking care of you in the hospital! | ___ year old male with history of DVT/PE, multiple sclerosis
complicated by wheelchair bound and neurogenic bladder, who was
admitted with upper GI bleed in context of supratherapeutic INR.
# GIB: Symptomatic with weakness. He underwent EGD which showed
2 duodenal ulcers with visible vessel and ulceration/friability
of the antrum of the stomach and remaining duodenum. The large
ulcers were both clipped and he was treated with continuous PPI
drip for 48 hours. This likely occured in setting of
supratherapeutic INR likely as a result of concurrent
antibiotics for patient's UTI (Cipro/Amox). Accounting for OSH
ED, he received 5U pRBCs with appropriate bump, 1U FFP, 10mg IV
vit K. His hematocrit on admission was 15 and increased to 25
on discharge. He was transitioned to pantoprazole 40 mg PO BID
and should continue on this regimen for 8 weeks. He can then
change to daily pantoprazole but should never discontinue PPIs
indefinitely. His aspirin has been changed to enteric coated.
He should avoid all NSAIDs for his lifetime and should have very
close INR monitoring.
# Diabetes mellitus type 2: He had an episode of hypoglycemia
in the morning of ___, with sugar as low as 18. This is
because he was given lantus 20 units overnight on ___ but he
did not eat as much sugar as the normal diet that he has at
home. His lantus was discontinued and he was kept on only his
metformin and a sliding scale of insulin. He should have
fingersticks checked QID and lantus added back as tolerated to
keep sugars less than 200.
# HX DVT: Patient does not know if this was one DVT event or
multiple, but does report it occured last ___ yrs ago. He was
told that he should remain on warfarin lifelong to prevent DVT
since he is chronically bedbound. As above, his INR was
reversed due to GIB and is currently subtherapeutic. After his
bleed was stabilized, he was restarted on warfarin, without
bridge since no active clot. His INR should be checked biweekly
starting ___ to avoid supratherapeutic INR. | 116 | 362 |
18090215-DS-12 | 24,711,547 | Dear Mr. ___,
You were admitted for etoh and opiate withdrawal. You were noted
to have a seizure during your stay here. You were given
benzodiazepines for symptom control. You chose to leave against
medical advice with the understanding that you are at high risk
for recurrent seizures and death. We provided you with ___
___ to help you with transport and information to get to
___ House/shelter. We also gave you information regarding
detox faciliteis in ___. We wish you the best and
recommend that you stop drinking alcohol and using drugs as you
are at high risk for death. Please go the detox facilities that
we recommended.
Sincerely,
Your ___ team | Mr. ___ is a ___ year old gentleman with history of
polysubstance abuse, complicated ETOH withdrawal history
including DTs and seizures, childhood seizure disorder,
Hepatitis C, presenting with intoxication and admitted for
seizure associated with ETOH withdrawal.
# Seizure, likely from ETOH withdrawal. Withdrawal-associated
seizures are GTCs, usually ___ hours. Phenytoin is ineffective
in the treatment of alcohol withdrawal seizures and shouldn't be
used. Responded to IV ativan. Most likely ETOH-related seizure
given normal serum glucose, no intracranial abnormality, history
of withdrawal seizures, lack of FNS, fever, meningeal signs, or
severely altered electrolytes. ETOH withdrawal seizures are
usually self-limited and don't requre long term AEDs. Glucose
remained wnl throughout. Patient declined phenobarbitol
protocol as he reported he 'doesn't do well' with it.
# ETOH abuse with complicated ETOH withdrawal with history of
DTs with visual hallucinations, seizures (>10), multiple
admissions for detox. Initially planned to transition to
phenobarbital protocol, however patient reports that he has had
this protocol multiple times and it does not improve his DTs,
tremors, etc. Patient was put on benzodiazepine CIWA protocol
for eoth withdrawal. He chose to leave AMA stating that he
wanted to go back to ___, ___ to a ___ facility.
Patient stated understanding that he is at risk for death and
recurrent seizures. We provided him with money for
transportation (___) and directions to ___,
a local ___, in addition to information on detox facilties
in ___. Patient subsequently left hospital against medical
advice
# Depression. Has had dual diagnosis treatment before. Not on
meds at home. He had left ___ before psych RN or social work
could see him
# Heroin abuse/withdrawal. Placed on prn robaxin 750mg Q6H PRN:
muscle pain/cramps, bentyl 20mg PRN GI cramps, vistaril prn
itching, acetaminophen and ibuprofen, and clonidine 0.1m TID:PRN
with holding parameters. Pt refused repeat HIV testing.
# Hepatitis C. Hep C Ab pending at discharge. Reports he had
been previously diagnosed but never seen a liver specialist.
# Tobacco abuse. Placed on Nicotine patch 21mcg
# Bradycardia. Patient reports bradycardia and low blood
pressures at baseline, reports history of this in the past, and
reports exercise/weight lifting.
# QT prolongation. Unclear if genetic (prolonged QT syndrome?).
Patient has not received haloperidol in MICU and is not aware of
this issue. No prior EKGs here. Qtc in 480s. | 110 | 383 |
15712171-DS-13 | 23,307,363 | Dear Ms. ___,
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 found to
have a blood clot in your right atrium.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were given anticoagulation to prevent
further progression of your blood clot. You had an
echocardiogram which confirmed that you had a blood clot in your
right atrium, but showed an otherwise normal heart.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- If adjusting the timing of your doses, only move up the AM
dose by 1 hour per day until you reach the desired time.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
___ F with recent diagnosis of Hodgkin lymphoma who presented
after incidental finding of right atrial mass on TTE, found on
cardiac MRI to be right atrial thrombus. MASCOT team was
consulted to discuss anticoagulation vs thrombolytics,
ultimately decided on anticoagulation. Patient initiated on
heparin drip and transitioned to lovenox on which she was
discharged home. | 138 | 57 |
15763629-DS-9 | 25,927,506 | Dear Ms. ___,
You were admitted to ___ for an abnormal heart rhythm called
atrial fibrillation (a fib). You did not have a heart attack.
Your heart rate was controlled with a new medication called
metoprolol. To treat the swelling in your legs, we switched your
amlodipine to hydrochlorothiazide to help get rid of this excess
fluid. We also started the blood thinner warfarin (Coumadin) to
prevent a stroke caused by your a fib. You will have to have
your Coumadin levels checked regularly.
***You should have your labs checked 2 days after discharge
(___) and your primary care doctor ___ follow these
results. | ___ w/ h/o HTN, DM, CKD, HLD, and spinal stenosis presented with
new A-fib.
# Atrial fibrillation: Unclear chronicity of this arrhytmia.
There was no clear instigating event. Only new symptom was
worsening lower extremity edema. ACS ruled out w/ trop. negative
x2. TSH wnl. CHADS-VASC = 5, placing her at moderate risk of
thromboembolic event, so she was initiated on warfarin 2.5mg
daily w/ goal INR ___. HR was in the ___ w/ 25mg PO metoprolol,
so this was increased to metoprolol tartrate 50mg BID at time of
discharge.
# Lower extremity edema: DDx includes worsening venous
insufficiency vs. subacute presentation of decompensated heart
failure with new onet of worsening ___ edema over the last few
days with evidence of pulmonary on CXR and BNP of 5,000. She did
not have any cardiopulmonary symptoms related to this. She does
not have a previous diagnosis of CHF. She did not appear to be
excessively volume overloaded. She was given 1 dose of PO
furosemide 40mg. Amlodipine was switched to HCTZ 25mg to
diminish fluid retaining effect of CCB and also achieve mild
diuresis w/ thiazide.
# Pyuria: patient is asymptomatic so we did not treat w/
antibiotics.
# Spinal Stenosis: Patient with severe pain ___ spinal stenosis
with no evidence of cord compression. Continued home pain
medications.
# DM:
- continued home Lantus
# HTN: BP has been stable since discovery of onset of AF
- switched amlodipine to HCTZ as above
- increase metoprolol as above
# HLD: continued home simvastatin | 103 | 260 |
13411047-DS-11 | 24,169,559 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were found to have a rare type of cancer
called Fibrolamellar hepatocellular carcinoma that was blocking
the ability of your liver to drain properly. You underwent
placement of a drain to help your liver drain and will go out
with this capped. In a few weeks, you will see the
Interventional Radiologist to see if they can fully remove the
external portion of this drain. You will discharged with some
pain medications to take as needed but we expect this pain will
continue to subside.
In regards your new diagnosis, our Oncology team is working very
hard to devise the best treatment available for you but this
will take a little bit of planning. In the mean time, it is safe
for you to be at home and our doctors ___ be in close contact
with you to devise the next steps in your care. You had a port
placed during your hospitalization so that you can receive
treatment as an outpatient.
Lastly, because your pulmonary embolism may have been related to
your cancer, you will need to go back on a blood thinner. You
will be using a shot medication for now but may be able to
resume an oral medication by mouth in the future.
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with history of PE who was
found to have obstructive jaundice secondary to newly diagnosed
Fibrolamellar Hepatocellular Carcinoma.
# Hepatic Mass:
# Fibrolamellar Hepatocellular Carcinoma:
Found to have large intraabdominal mass, suspicious for neoplasm
with metastatic disease that was found incidentally with CTA
obtained to rule out recurrent PE. The mass appears to arise in
segment VII with extension into the porta hepatis and resultant
compression of vasculature and bile ducts causing obstructive
jaundice. Now s/p PTBD and liver biopsy with ___ on ___.
Pathology finalized as fibrolamellar hepatocellular carcinoma.
The patient was evaluated by oncology and by transplant surgery.
She is not an operative candidate at this time and tentative
plan is for chemotherapy pending ongoing improvement in
obstructive jaundice. She will follow up with oncology as an
outpatient with consideration of referral to other specialty
centers, including ___. With regards to her
PTBD drain, the patient initially did not tolerate a capping
trial as evidenced by rising bilirubin. Her drain was then
re-positioned and upsized. She subsequently tolerated a capping
trial well and will be discharged with her PTBD drain capped.
The interventional radiology team will arrange outpatient
followup in ___ weeks to assess whether her drain can be fully
internalized. Bilirubin on discharge is 1.9. She was provided a
prescription for oxycodone on discharge and counseled in risks
including constipation, sedation, respiratory depression and
addiction.
# Prior PE:
Diagnosed ___ and treated with 3 months of Eliquis. Thought to
be secondary to OCP use but in setting of new suspect cancer
diagnosis, will need to go back on anticoagulation. Per
discussion with Med Onc team, preference would be for Lovenox at
this time and she was started on 70mg BID for now. If LFTs
continue to improve, then her oncologist will revisit whether it
is safe to resume DOAC.
TRANSITIONAL ISSUES:
===================
[] patient to follow up with oncology- appointment on ___- She
will be contacted with time
[] discharged with PTBD capped at this time; ensure follow up
with ___ to discuss ability to fully internalize drain. Patient
will need anesthesia for drain manipulation
[] discharged on Lovenox due to presumed malignancy-associated
PE in ___. Ability to transition back to DOAC will depend on
ongoing improvement of LFTs and will be at the discretion of the
outpatient oncology team.
[] Foundation 1 testing pending on discharge; pending results,
family members may also need genetic testing.
[] Prior to initiation of chemo, please discuss with patient
feasibility of fertility preservation
Code: Full
NOK: Sister- ___
Partner: ___ ___
Ms. ___ was seen and examined on the day of discharge. She is
stable for discharge home today. >30 minutes on discharge
activities. | 227 | 443 |
17088495-DS-8 | 21,156,530 | Dear Ms. ___,
You were hospitalized due to symptoms of language difficutly
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.
Your stroke was discovered early and you received a clot busting
medication (tpa) to help dissolve this clot. Afterwards, you
were monitored closely in the ICU and then on the stroke
neurology service.
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:
alcohol consumption
high cholesterol
We have started you on a number of medications which are listed
on the next page. Please take your other medications as
prescribed.
Please call your primary care doctor to obtain a referral for a
Neurology ___ appointment.
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 | ___ with a PMH of alcoholism presented as a transfer from ___
___ after sudden onset of aphasia at 12:50 ___ s/p tPA
and then transferred to ___.
NEUROLOGY:
She was admitted to ___ Neuro ICU where post-tPA CT head
revealed acute infarct of the left inferior division MCA
distribution. There were also small areas of hemorrhage within
the left insula and left corona radiata. CTA revealed no
significant stenosis or occlusion. Due to low fibrinogen, she
was transfused with cryoprecipitate. Further repeat NCHCTs
confirmed stability of the hemorrhage. Clinical examination was
stable as well and she was transferred to the stroke floor
within 2 days.
Etiology of her stroke was felt to be embolic to the left
inferior division LMCA with post-tpa hemorrhagic conversion.
Stroke risk factors were evaluated and include: hyperlipidemia
and alcohol use. She was started on aspirin for stroke
prevention and atorvastatin for hyperlipidemia. There was no
evidence of afib on telemetry after 5 days of recording on
telemetry. Echo was negative for PFO or atrial enlargement or
clot. CT torso was also obtained given the possibility of
occult malignancy leading stroke. CT torso showed some bony
lesions that were concerning for myeloma however SPEP, UPEP and
immunoglobulins were negative.
BONY LESIONS ON CT TORSO: Screening CT torso revealed bony
lesions at multiple sites. UPEP and SPEP were negative.
Recommend further work-up for these bony lesions with MRI on an
outpatient basis.
ALCOHOL USE:
She has a history of alcohol use and was monitored on CIWA but
did not go through withdrawal. She was started on MVI and
thiamine supplements. | 329 | 274 |
12712435-DS-21 | 24,906,845 | Dear Ms. ___,
You were admitted to ___ due to
concern for a left lingular pneumonia ___ the setting of
persistent cough, runny nose, and post-nasal drip. We did not
think a pneumonia was likely on reviewing your labs, vital
signs, x-ray and CT scan. However, because you had worsening
shortness of breath, we performed a CT scan on your lungs and
sinuses, which found evidence of acute bronchitis ___ the lungs
and apparent polyps throughout your sinuses. We believe the
polyps are leading to poor mucous clearing, contributing to your
prior pneumonia and bronchitis.
We treated your breathing with oxygen, ___ addition to an
inhaler, nebulizer, decongestant, cough suppressant. We started
you on a prednisone (steroid) taper and clindamycin as a
prophylactic measure for your sinus polyps.
You continued to need oxygen, so we sent you home on home O2
pending your ENT consult and probable surgery to remove the
polyps.
It was a pleasure taking care of you!
- Your care team at ___ | ___ female with 6 months of rhinorrhea, cough, dyspnea,
not improving w/ nasal spray, inhalers, antibiotics, steroids,
found on ___ RLL pneumonia status post 7d levofloxacin with
progressive cough, dyspnea, and fatigue, referred for possible
lingular pneumonia, found to have acute bronchitis with
signficant mucous plugging leading to hypoxia and new oxygen
requirement, as well as significant sinonasal polyposis which
may be contributing to recurrent infections and chronic cough.
ACTIVE HOSPITALIZATION ISSUES
=============================
# COUGH: Given severe polyposis, suspect element of post-nasal
drip causing chronicity of cough. Likely exacerbated by acute
bronchitis recently. Initially refractory to symptomatic
control, but improved with guaifenesin-dextromethorphan, codeine
HS, ipratropium nebulizers, and treatment of bronchitis (below).
Overall, allergies still possibly playing into symptoms.
Immunoglobulin panel normal. ANCA and strep pneumo negative.
# ACUTE BRONCHITIS: Symptoms of bronchitis suggested clinically
and on presentation CXR, confirmed with CT chest. Most likely
viral, though viral panel negative. Significant mucous plugging
contributed to hypoxia below. Managed symptomatically with
supplemental oxygen, N-acetylcysteine nebulizers q6h,
guaifenesin for mucous plugging, and use of positive expiratory
pressure device.
# HYPOXIA: New on hospitalization and persistent throughout
stay, typically 90-91% on shovel mask or 4L nasal cannula.
Likely worsened by polyposis affecting nasal breathing. Lung
exam initially with minimal air movement ___ left lower lung
field, likely from mucus plugging as identified on CT imaging,
improved towards discharge. ABG consistent with partially
compensated respiratory alkalosis. Patient endorsed intermittent
dyspnea, somewhat improved with bronchitis treatment above.
Exercise tolerance was minimal and patient regularly desaturated
to 89% on ambulation even with supplemental O2. Repeat CXR on
___ not revealing of new process. By discharge, oxygen
saturation had improved to 93-94% on 4L during ambulation and
similar saturation on 3L at rest. Discharged on home oxygen with
close ENT, allergy, and PCP appointments, and pending
pulmonology appoitment (now schedued).
# NASAL POLYPOSIS: Identified on CT. Patient will require
polypectomy, though not urgently. On ___ started a prednisone
taper (20 mg BID x5 days, 10 mg BID x5 days, 10 mg QD x5 days),
as well as 10 day course of clindamycin (given ampicillin
allergy) for sinonasal polyposis vs. acute sinusitis (less
likely on clinical exam and family history). ENT follow up
scheduled for ___
CHRONIC ISSUES ON HOSPITALIZATION
=================================
# IRRITABLE BOWEL SYNDROME: patient had some diarrhea ___,
C.diff negative. Managed on low-fructose, low-lactose diet for
sensitivities.
# CONTACT: ___ [___] ___ [___] ___
# CODE: Full | 162 | 393 |
17094218-DS-4 | 27,908,761 | * You were transferred from ___ for further evaluation
of your esophagus, stomach and small bowel. You also had a
recent fall and have some discomfort from that as well. You
were taken to the Operating Room for placement of a feeding tube
as you are malnourished and need to increase your calories
before you undergo surgery. Due to your illness, deconditioned
state and weight loss you will need to spend some time in rehab
prior to returning home.
* Continue your J tube feedings even after discharge from rehab
to increase your calories.
* Work hard with Physical Therapy to increase your strength and
mobility
* If you develop any increased abdominal pain, vomit blood or
have any new symptoms that concern you, call Dr. ___ at
___.
* You will need to follow up with Dr. ___ in a few weeks to
discuss future plans for surgery. | Ms ___ is a ___ with history ___ transfered from OSH
with abdominal pain and imaging revealing dilated stomach and
esophagus. She was admitted to the medical service, made NPO
and hydrated with IV fluids. Her dilated stomach /esophagus was
concerning for SBO vs mechanical obsturction vs gastric outlet
obstruction. She was evaluated by thoracic surgery and ACS and
no acute surgical intervention was warranted. Gastric
decompression was warranted and the GI service performed an EGD
on ___ and found a 2 cm crated ulcer with possible
perforation in the lower third of the esophagus. She then had a
barium swallow which showed no leak. She remained NPO and was
eventually treated with PPN prior to agreeing to J tube
placement. Her hematocrit dropped to 20 on ___ and she was
transfused with 2 units of PRBC's. She was on a Protonix
infusion for a few days and then changed to 40 mg IV BID. Her
hematocrit has beeb stable in the high 20's since ___. She
underwent a repeat EGD ___ which was essentially the same.
The ulcers were visible but there was no evidence of bleeding.
She was changed to Prevacid ODT 30 mg BID
She had severe malnutrition by her blood work and physical exam
and needed to have a jejunostomy tube placed for tube feedings
so that she will be in good nutritional shape to undergo surgery
in the future. Both she and her family were agreeable to this
and she was taken to the Operating Room on ___ for
laparoscopic jejunostomy feeding tube placement. She tolerated
the procedure well and returned to the PACU in stable condition.
Her abdominal exam remained tympanic and slightly distended
therefore tube feedings were started very slowly and she
received laxatives to promote bowel movements which were
effective. Her distension decreased and her tube feedings were
gradually increased to goal. She underwent a repeat EGD
___ which was essentially the same. The ulcers were
visible but there was no evidence of bleeding. Manometry was
also done but results are currently pending. She was changed to
Prevacid Solutab 30 mg BID following that EGD. She is also
taking clear liquids without difficulty but Prevacid Solutabs
were ordered for better absorption.
Due to her malnourished and deconditioned state, a short term
rehab was recommended prior to returning home especially in
light abdominal surgery being planned for the near future.
Of note, she had some brief atrial fibrillation during her
initial admission which has resolved but for that reason she was
placed on Metoprolol. She remains in NSR in the 70 range.
After a long hospital stay she was discharged to ___ on
___ and will return to see Dr. ___ in a few weeks. | 148 | 465 |
13275939-DS-18 | 24,364,350 | Dear ___,
___ was a pleasure taking care of you during your hospital stay
at ___. You were admitted for
symptoms of burning with urination and chills. Upon admission, a
urine specimen showed evidence of infection that was later
revealed to be E. coli, a bacterium. You were initially treated
with two antibiotics: zosyn and vancomycin. You had a poor
reaction to vancomycin, which resolved with Benadryl and
stopping of the vancomycin. After discovering that your
infection was caused by E. coli sensitive to ciprofloxacin, your
zosyn was discontinued and you were started on ciprofloxacin,
another antibiotic. Please take this antibiotic for the next ___
days (total 14 days) and follow up with your primary outpatient
nephrologist, Dr. ___. Thank you for allowing us to be a
part of your care team.
Sincerely,
Your ___ Team | ___ with history of renal transplant ___ ESRD ___
glomerulonephritis), who presented with lower abdominal pain and
pain with urination concerning for urinary tract infection.
#Urinary Tract infection/Pyelonephritis:
Mrs. ___ initially reported symptoms of dysuria, hematuria,
increased frequency and suprapubic tenderness. WBC was 13.4 and
UA showed evidence of infection and was consistent with UTI with
potential pyelonephritis. Treatment was initiated with zosyn and
vancomycin. Mrs. ___ had "___ syndrome" reaction to
vancomycin with first dose, developing a red rash on her skin.
The vancomycin was discontinued and her rash resolved with
dosing of IV Benadryl. Urine culture returned and showed E. coli
infection susceptible to ciprofloxacin and leukocytosis resolved
(WBC <6,000). Mrs. ___ antibiotic coverage was subsequently
switched to PO ciprofloxacin with instructions to finish the
last 10 days as outpatient (total of 14 days).
#Hydronephrosis on U/S scan:
Mrs. ___ initial renal ultrasound showed evidence of mild
hydronephrosis. She had previous shown some hydronephrosis on
transplant ultrasound. Nephrology recommended testing of urine
for BK PCR along with TID post void residual bladder scans. Post
void scans did not show evidence of above normal residual
volumes.
# s/p Renal transplant: Mrs. ___ home immunosuppressant
medications were continued during her stay: AZA 50mg daily and
cyclosporine 75mg BID. Her trough level of cyclosporine on ___
was 84, slightly above target of 50. Creatinine was 1.6 on
admission and ranged between 1.6 and 1.8 during her stay. These
values were within her baseline creatinine ranges were
reassuring against current allograft compromise.
# HTN: Mrs. ___ history of hypertension was well controlled
with low sodium diet during her stay. | 135 | 267 |
11717234-DS-21 | 24,762,249 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with difficulty breathing and a fall. We have adjusted
your medications to help you be as comfortable as possible. You
will go home with hospice services to help you and your family
transition to being back home again. | ___ h/o critical aortic stenosis (mean gradient 66mmHg, ___
0.6cm2), aortic regurgitation, CAD s/p CABG ___ and RCA stent
___, Afib (on coumadin), dual chamber pacemaker for
bradycardia, presents with shortness of breath and fall x 1 day. | 56 | 39 |
18283749-DS-18 | 23,008,725 | Dear Ms ___,
It was a pleasure taking care of you during your admission. You
presented to the hospital with abdominal pain and were found to
have worsening of your idiopathic chronic pancreatitis. You had
an MRI and it was normal. We managed your pain and nausea and
slowly advanced your diet as your symptoms improved. Please
follow up with your outpatient doctor at the appointments below. | ___ y/o female with a past medical history of chronic idiopathic
pancreatitis who presents with severe epigastric pain refractory
to home narcotics.
# Abdominal pain: Most likely etiology is patient's chronic
idopathic pancreatitis. Lipids were checked in ___ and she
had normal triglycerides. Calcium was wnl. IgG4 and CFTR ___
mutation checked in the past and were normal. MRCP during
admission was normal. Patient's pain and nausea was controlled
with IV medications then slowly transitioned to oral as her diet
advanced.
# Isolated hyperbilirubinemia: Patient presented with a
bilirubin of 1.7. It was of unclear etiology and trended back
down to 1.2 on discharge. | 66 | 103 |
16946310-DS-26 | 29,430,740 | Dear ___ was a pleasure participating in your care at ___. You were
admitted to the hospital for a stroke and were also found to
have several blood clots in your legs and lung. You are being
discharged to a rehab facility to assist in your recovery. You
were started on a blood thinning medication called warfarin
which you should continue unless instructed to stop by your
doctors. After you leave rehab your PCP ___ check
you INR every week either in the office or with a machine you
can take home.
-Your Care Team | ___ with recent admission for HCAP and rehab course complicated
by C. Diff presenting with sudden onset lethary and slurred
speech found to have R MCA and ___ ischemic stroke, pulmonary
emboli and extensive ___ DVT's and persistent left sided pleural
effusion.
# R MCA and ___ Ischemic Stoke: Patient presented after
sudden onset lethargy and slurred speech. Intial work up at OSH
with postive CTA and deferred tPA. Subsequent tranfer to ___
where CTA revealed R MCA infarct. Hemorrhagic conversion was
ruled out by repeat CTA (___). MRI with R insular cortex
and R cerebellar infarct indicating a likely embolic origin,
however Echo with Bubble (___) ruled out PFO. HbA1c was
elevated at 6.8. LDL was elevated at 152, home atorvastatin
increased from 10mg to 80mg. Physical and occupational therapy
assessed and worked with the patient. Diet was advanced from NPO
to pureed ___ thickened liquids with NGT
supplementation per speech and swallow recommendations.
Neurology recommended HOB 30 degrees, SBP autoregulation to 200,
and fingersticks for normoglycemia.
#Submassive Pulmonary Emboli/ Provoked Deep Vein Thrombosis:
Incidentally found to have right pulmonary artery emboli on CTA.
Vital signs on presentation were signficant for fever to 101 and
tachycardia. ___ revealed ___ extensive DVTs. Echo
___ out R heart strain. She was initially treated
with heparin gtt on admission, then transitioned to warfarin
with enoxaparin bridge ___. Discharged to rehab on
warfarin 5mg (INR 1.7) with plan to continue lovenox until INR
at goal (___). Planned ___nticoagulation, but could
consider indefinite warfarin given stroke. Arranged for
___ clinic follow up via PCP ___. An
appointment should be scheduled 1 week following d/c from rehab.
#Dysphagia: Video swallow performed ___ was mild
aspiration of secretions and minimal aspiration with honey
thickened liquids that subsequently cleared. Supplemental
nutrtion with and NGT was recommended and placed on
___ to dysphagia diet with thickened liquids
(___) We contiued aspiration precautions. Pt eventually
met caloric needs with PO intake and NGT was removed ___. PO
supplementation with Ensure pudding should be continued along
with nectar-thickened liquids. She will need assistance with
meals at rehab.
#GERD: Patient has a PMH of GERD. Increased home lansoprazole
from 15mg to 30mg given initiation of anticoagulation.
# HLD: Elevated LDL at 152. Increased to Atorvastatin 80mg PO as
above.
#Goals of Care: Extensive conversations were had with patient's
3 children regarding the patient's poor prognosis. A family
meeting with the presence of the medical team, primary neurology
resident, social work, nursing was held on ___ during
which the patient's prognosis and treatment plan were discussed
extensively. A second meeting was held on ___ and after an
extensive discussion the patient's primary HCP ___ made the
decision to make the patient DNR/DNI; despite disagreement from
the secondary HCP ___, the rest of the family members were
supportive of the decision.
#Anemia: The patient has a known low baseline Hct of 33-35. The
patient's Hct was downtrending following admission (32.1, 30.7,
28.1) but stablilized and pt remained hemodynamically stable
with no evidence of bleeding. HCT 32.2 on ___.
#C. Diff Colitis: Rehabilitation course starting on ___ was
significant for mild C. Diff Colitis. The patient remained
afebrile without leukocytosis, asymptomatic and has maintained a
benign abdominal exam. The patient completed a 7 day course of
Flagyl 500mg Q8hr anitbiotics on ___.
#Persistent Left Sided Pleural Effusion: Despite the patient's
recent admission (___) for complicated HCAP (LLL
consolidation and pleural effusion), we have a low suspicion for
persistent pneumonia. The patient's fever upon presentation was
most likely a result of her PE and broadened infectious work up
(Bcx and UCx) was negative. IV vancomycin and cefepime we
discontinued on ___. The patient has remained afebrile
without leukocytosis, asymtpomatic and has had a stable oxygen
saturation on RA. A malignant etiology of the patient's
persistent left sided pleural effusion should be considered and
discussed as an outpatient.
#Chronic Pain: Patient had well controlled pain throughout her
hospital course. We switched gabapentin 300 QHS to 100 TID per
pharmacy recommendations
#Osteoporosis: Chronic and stable. Patient previously on
raloxifene but patient's secondary HCP ___ did not want to
continue due to risk of adverse effects. The patient should
continue Vitamin D as an outpatient.
#Bladder Incontinence: We discontinued home Tolterodine since
the patient's secondary HCP ___ did not want the patient on
the drug due to potential adverse effects.
#TRANSITIONAL ISSUES
- Emergency Contact: ___ Primary HCP (___)
and ___ (___)
-Warfarin started this admission planned course of at least 3
months for new DVT/PE, but could consider longer/indefinite
course given ischemic stroke. Arranged for anticoagulation
follow up through PCP ___. An appointment should
be scheduled 1 week following d/c from rehab.
-ASA discontinued this admission while on warfarin
-HGB A1C 6.8%, will a follow up HbA1c in 3 months,consider
starting metformin as outpatient
-DNR/DNI determined by healthcare proxy after patient's stroke,
but would reassess patient's capacity to make own health
decisions as functional and mental status improve. For now.
DNR/DNI with son ___ as primary HCP.
-A malignant etiology of the patient's persistent left sided
pleural effusion should be considered and discussed as an
outpatient. | 95 | 839 |
18513809-DS-32 | 25,420,227 | Dear Ms ___,
It was a pleasure caring for you during your recent admission to
___. You were admitted with back pain and found to have a
compression fracture of your thoracic spine. You were seen by
the spine doctors who recommended ___ wear a brace and to follow
up with them as an outpatient. Additionally, you have a mass in
your pancreas, which was evalutated by MRI. This was not
concerning but should be followed with repeat MRIs over time. | Mrs. ___ is a ___ female with Hx of chronic GVH, now
three and a half years after allogeneic stem cell
transplantation, who presents to the ER with low back pain.
.
ACUTE
# Low back pain - Pain is acute on chronic. Pt reports new
onset of worsened pain 2 wks ago after getting up from a seated
position. MRI T and L spine c/w old L5 compression fracture and
new T11 compression fracture. No neurological compromise. This
likely explains new pain. Ortho spine consulted. Brace was
provided. Pt started on MS ___ 30 BID with continued use of
oxycodone, flexeril, and lidoderm patches. F/U was obtained
with orthospine for possible vertebroplasty down the line if she
fails conservative management.
# Abd pain: LFTs stable and lipase negative. MRCP was performed
which demonstrated numerous likely side-branch IPMNs (largest
was located in head and 1.8cm in size) for which repeat MRCP in
6mo should be performed.
.
# Chronic GVH manifesting as joint aches increased liver
transaminases and ocular GVH, now three and a half years after
allogeneic stem cell transplantation from CML. Pt was continued
on serolimus and prednisone, as well as bactrim and fluconazole
ppx.
.
CHRONIC
# Recurrent DVTs/PEs on lovenox c/b GI bleed. On Lovenox daily.
Pt has a history of GI bleed but no evidence of such event
during this admission. HCT was stable on lovenox was continued
throughout admission.
.
# DM2 - c/b chronic prednisone use. Continued home basal-bolus
insulin.
.
TRANSITIONAL
# f/u MRCP in 6 mo
# arrange spine f/u for vertebroplasty
# titrate pain meds as necessary
# continue management of metabolic bone disease (Bisphosphinate,
ca, vit d, calcitonin, etc...) | 84 | 291 |
19745809-DS-3 | 24,242,993 | Dear Mr. ___,
You were admitted to ___ from ___.
WHY WERE YOU ADMITTED?
========================
- You were admitted because you were seeing things that others
weren't.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
==============================================
- We started medications to remove toxins from your body (that
are caused by your liver disease).
- We stopped some medications.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
=================================================
- Take all of your medications as prescribed.
- Follow up with your doctors as listed below.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | ___ year old man with afib (on warfarin), aortic stenosis, HTN,
spinal stenosis and liver cirrhosis decompensated by portal
hypertension in the form of ascites/pleural effusion and
multifocal HCC now s/p recent thermal ablation who presents with
visual/tactile hallucinations c/f possible HE vs. medication
side effects. | 82 | 46 |
12035989-DS-20 | 23,591,794 | Dear Ms. ___,
You were admitted to the ___
after being transferred from the ___ after
experiencing shortness of breath. You were found to have fluid
on your lungs because of a worsening of your heart failure. We
performed some tests and found that your heart's ability to pump
blood had decreased from your last test in ___. We gave you
medicines to help pull the fluid off of your body and changed
some of your blood pressure medicines.
It is important that you follow up with your cardiologist Dr.
___ ___ that we can perform additional tests to help diagnose
the cause of your heart worsening. We would also like you to
follow up with your primary care doctor Dr. ___ the next
week. We have scheduled these appointments for you.
If you experience any symptoms of chest pain, leg swelling,
weight gain, or shortness of breath, please return to the
emergency department immediately. Weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
We wish you the best,
Your ___ Care Team | BRIEF SUMMARY
=============
Ms. ___ is a pleasant ___ year old female with past
medical history of HTN, HLD, T2DM, OSA on CPAP, AICA stroke, and
recent diagnosis of diastolic CHF in ___.
She presented to ___ from ___ after
experiencing sudden shortness of breath the morning of
admission. She was found to be hypertensive and in a heart
failure exacerbation and was diuresed and given blood pressure
medications.
She underwent a CTA chest to rule out pulmonary embolism, and
was found to have chest lymph nodes with changes consistent with
sarcoidosis. An echocardiogram and nuclear stress test revealed
new global biventricular dysfunction consistent with
non-ischemic cardiomyopathy. Given these findings, it is
possible that her cardiomyopathy is secondary to sarcoidosis. A
cardiac MRI was ordered to be performed as an outpatient after
discharge.
She was discharged with medication changes as below with
instructions to follow up with her cardiologist and primary care
physician.
ACUTE ISSUES
============
#non-ischemic cardiomyopathy
#acute CHF exacerbation: The patient presented with acute SOB
the morning of admission, with CXR at ___
showing pulmonary edema. Her BNP was elevated to 3690, and her
SOB was rapidly relieved with diuresis. In ___, the patient
had an episode of flash pulmonary edema in the setting of a
hypertensive emergency, resulting in her initial diagnosis of
dCHF. Her BP in the ED was 145/80, however it was increased to
160s/70s on the floor. This was controlled with changes in her
BP meds as below. She did have intermittent chest pain but had
negative trops and no EKG changes. CTA PE negative on ___, but
did show lymph node enlargement c/w sarcoid or granulomatous
inflammation. A TTE was performed and showed new Bi-V global
dysfunction with EF 35-40%, c/w toxic or metabolic cause; given
her CT findings she may have cardiac sarcoidosis. She was
diuresed to euvolemia, was transitioned from labetalol to
carvedilol 25 mg BID, and started on Lasix 40 mg PO daily prior
to discharge. Given that her new ventricular dysfunction may be
related to sarcoidosis, she was discharged with an order for an
outpatient cardiac MRI and follow up with her cardiologist, Dr.
___.
Her discharge weight was 92.9 kg.
Diuresis used: 20 mg IV Lasix
# Iron deficiency anemia: The patient was noted to have a
downtrending H/H, and hrion studies revealed a ferritin of 28,
iron of 46, and TIBC of 429. She was given a dose of IV iron and
will need a f/u ferritin as an outpatient.
CHRONIC ISSUES
#Hypocalcemia: The patient was noted to have hypocalcemia (range
6.8-7.8), potentially secondary to thyroid resection. The
patient takes calcitriol daily, but was given additional calcium
supplementation during her course. She will need a repeat
calcium level as an outpatient with possible dose adjustments of
her calcitriol. Her vitamin D level was within normal limits.
# Hypertension: Continued amlodipine, and lisinopril,
transitioned labetalol to carvedilol as above
# Hyperlipidemia: Continued rosuvastatin
# T2DM: Held metformin, continued insulin NPH and sliding scale
# GERD: Continued pantoprazole
# Hypothyroidism: s/p resection for multinodular goiter,
continued levothyroxine 125 mg po daily
# OSA on CPAP: continue CPAP at night
TRANSITIONAL ISSUES
===================
-The patient has a new diagnosis of non-ischemic cardiomyopathy
with a reduced EF of ___. Possibly secondary to sarcoidosis
(given CTA findings above), although etiology is unknown at this
time
-The ___ home dose of Lasix was increased to 40 mg daily
up from 20 mg daily; she was euvolemic on this dose the day of
discharge.
-The patient was started in carvedilol 25 mg twice daily, to
replace her home labetalol for newly depressed EF as above
-The patient will need to follow up for cardiac MRI as an
outpatient. She is scheduled to see her Cardiologist, Dr. ___ ferritin was noted to be low, so she was given a
dose of IV iron. She will need a repeat ferritin level in ___
weeks as an outpatient to ensure repletion (ferritin 28 in
house)
-Her calcium was consistently low during her admission
(6.8-7.8). She is on home calcitriol; she will need a repeat
calcium level with possible dose adjustment. Vitamin D was 70 in
house.
-weight on d/c (92.9 kg; identical to prior d/c weight),
creatinine on d/c: 1.2 | 175 | 678 |
19912537-DS-10 | 29,825,378 | Dear Ms. ___,
___ were admitted to ___ for vomiting blood. Upon admission,
___ were bleeding significantly and were intubated to prevent
___ from aspirating blood. At CT scan of your chest and abdomen
did not show where the bleeding was coming from but was
concerning for a pneumonia, so ___ were treated with
antibiotics. Our GI doctors tried multiple ___ to find and
stop the source of the bleeding using a scope, or EGD.
Ultimately, no site of bleeding was seen in your GI tract,
however it was noticed that ___ had a mass on the base of your
tongue which may have been the source of your bleeding. Our Ear,
Nose, and Throat (ENT) doctors examined the ___ and decided
that they should biopsy it while ___ were in the hospital. The
results of the biopsy are still pending. ___ can call the number
below to schedule a follow up appointment with the ENT doctor
who did the biopsy (Dr. ___.
___ were started on an antacid because of your bleeding and ___
can continue to take that at home. Otherwise no changes were
made to your home medications. ___ will be discharged to a
rehabilitation facility.
___ should have a repeat EGD in 8 weeks because the GI doctors
saw ___ of your small intestine that they feel should be
biopsied. ___ will also need a repeat CT scan of your chest in
several weeks to evaluate a vascular lesion that was
incidentally seen here.
It was a pleasure taking care of ___,
Sincerely,
Your ___ Care Team | Patient is a ___ with a history of CAD s/p DES ___,
hypertension, and reflux who presented with hematemesis. The
patient was urgently intubated for airway protection and
transferred to the ICU. She initially underwent two EGDs without
a clear source of bleeding identified, though visualization was
limited due to frank blood in the stomach. Epinephrine was
injected into the fundus of the stomach out of concern for a
possible Dieulafoy lesion. It was also noted that she had a
lesion or laceration on the base of her tongue, originally
thought to be from traumatic intubation/extubation or scoping.
Her bleeding stabilized spontaneously and she was extubated and
transferred to the general medicine floor. She had a third EGD
once on the floor which showed no signs of a bleeding source in
the esophagus, stomach, or duodenum. However, a lesion/adherent
clot was noted on the base of the tongue. ENT evaluated the
lesion and requested a CT scan of the neck, which confirmed a
mass but no local destruction/invasion and no lymphadenopathy.
ENT then biopsied the lesion and the pathology results are
pending. It is notable that the patient has a 40+ pack-year
smoking history.
After transfer to the floor the patient showed no other overt
signs of bleeding, had a rising HCT, and did not have melena.
She was continued on a PPI due to concern for an unseen GI
source for bleeding, and given her history of reflux. | 255 | 238 |
17602562-DS-13 | 28,168,377 | You were admitted to the hospital with abdominal pain. You
underwent a CAT scan which showed acute diverticulitis, an
infection in the small out-pouches of your colon. You were
placed on bowel rest and started on an intravenous antibiotic.
You pain improved but you continued to have right upper quadrant
pain. Your CAT scan and ultra sound showed gallstones in your
gallbladder and therefore you underwent HIDA (hepatobiliary
iminodiacetic acid scan) that showed your gallbladder was
infected. You then underwent laparoscopic surgery and had your
gallbladder removed. You tolerated the procedure well and your
abdominal pain improved after surgery. You are now doing better,
tolerating a regular diet, and ready to be discharged home to
continue your recovery from surgery. You should continue to take
antibiotics as prescribed to complete your course for
diverticulitis.
Please note the following discharge instructions.
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. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain in the
right upper quadrant. Imaging revealed likely diverticulitis,
for which he was admitted to the ACS service and started on IV
antibiotics. His pain in the right upper quadrant persisted and
ultrasound revealed cholelithiasis. Given his complex clinical
picture, a HIDA scan was done revealed an obstructed gallbladder
on ___. On ___ the patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor on
IV fluids and with pain control. The patient was
hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. His
antibiotics were then transitions from IV to oral. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 815 | 240 |
12517435-DS-38 | 23,412,441 | Dear Mr. ___,
You were admitted to the hospital with hyperkalemia (high blood
potassium) in the setting of a clotted fistula. You were
admitted to the ICU for management of your hyperkalemia and you
had a temporary HD line placed for urgent HD. You underwent
successful AV fistulogram on ___ and were able to tolerate HD
through your fistula on ___.
No changes were made to your medications during this admission.
Please continue to take all medications as prescribed and
follow-up with your physicians as scheduled.
It was a pleasure taking care of you,
Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ is a ___ year old male with PMH of CAD s/p CABG, IgA
nephropathy, CKD s/p LRRT c/b rejection who was recently started
on dialysis in early ___, now presenting with renal
failure, hyperkalemia in setting of missed dialysis. s/p
temporary R. HD line placement for emergent dialysis.
#ESRD s/p LRRT c/b rejection
#Allograft nephropathy
#HD initiation
Previously had RUE AV graft placed in ___ and has been
maintained on a TTS hemodialysis schedule since starting
dialysis in ___. Last received dialysis on ___. A Right
HD line was placed on ___ with initiation of urgent dialysis.
His electrolytes, specifically potassium, improved. ___ took him
for RUE fistulogram on ___ with successful clot removal. He
underwent HD on ___ successfully through his AVF and his
temporary HD line was removed on ___ prior to discharge. He
will resume his outpatient HD schedule after discharge.
# Leukocytosis: WBC 13.9 increased from 6.3 on prior admission.
Could be related to steroid use, downtrended to 6.3. Infectious
workup was unremarkable. | 109 | 167 |
12379465-DS-21 | 27,895,187 | Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your anterior abdominal wall fluid collection (seroma) which was
evaluated by Vascular Surgery and they opted to conservatively
manage this problem without drainage. You will ___ with
them in clinic. You also were worked-up given your new-onset
bilateral leg swelling. Your kidney and cardiac function
appeared stable. You had a liver evaluation with a reassuring
right upper quadrant ultrasound. Your primary care physician
___ the remainder of your laboratory studies. Your
platelet count was noted to be elevated at the time of your
discharge, and should be followed up by your primary care
physician. You were feeling well prior to discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. | ___ with a PMH significant for asthma, spinal stenosis and
scoliosis with lumbar spondylosis and disc herniation who
underwent L3-4 osteotomy, partial L4-5 vertebrectomy and
anterior spinal fusion L3-S1 with anterior approach and
allograft use (on ___ and also L2-3, L1-2 osteotomy with
anterolateral spinal fusion of T12-L3 with allograft use and
total laminectomy L2-5 with fusion of T10-S1 (on ___ with
Orthopedic surgery who was discharged in stable condition who
now presents with 2-days of lower extremity swelling and
continued back pain, found to have an anterior abdominal fluid
collection.
.
# ANTERIOR ABDOMINAL WALL SEROMA - The patietnt presented with
some anterior abdominal wall discomfort and a palpable fluid
collection with CT imaging that showed a focal fluid collection
in the anterior abdominal wall (right paramedian-midline)
measuring 7.5 x 4.6-cm in max transverse diameter with ___
suggestive of simple fluid, that likely was not infected. The
patient remained afebrile and normotensive with a mild
leukocytosis on admission. Her incision appeared to be healing
well without dehiscense and she had no evidence of purulence or
drainage from her incisions. Ortho-Spine reveiwed her imaging
and felt there were no issues. Vascular Surgery also saw the
patient and felt that the anterior wall seroma was not infected
and would not benefit from instrumentation and drainage.
Therefore, they opted for serial abdominal exams and to see her
as an outpatient in clinic. Her WBC was stable and she remained
afebrile this admission - she did not require antibiotics.
.
# BILATERAL LOWER EXTREMITY SWELLING - The patient presented
with 2-days of bilateral lower extremity edema following a
recent spine surgery - with no historical evidence of orthopnea,
PND or cardiac history (prior 2D-Echo was normal per the
patient, not in our system). No baseline evidence of impaired
liver function or renal disease (baseline creatinine 0.5). She
presented with normal oxygen saturations on room air without
exertional dyspnea. Possible etiologies considered: pulmonary
emboli or DVT (negative bilateral lower extremity U/S in our
system from outside hospital) vs. cardiac disease and CHF with
volume overload (unlikely, reassuring BNP, no cardiac history,
Troponin 0.02 - EKG showing NSR @ 89, NA/NI, no ST-changes, no
poor R wave progression) vs. nephropathy (creatinine 0.5, U/A
with trace protein and spot protein/creatinine ratio < 0.4) vs.
nutritional or hypoalbuminemia (albumin 2.7) vs.
medication-effect (unlikely, no CCB or thiazolidinedione or
NSAID use) vs. venous insufficiency and post-op fluid
immobilization or lymphedema (most likely etiology). We provided
___ compression stockings and encouraged ambulation with
elevation of her lower extremities while resting. A CXR did show
some evidence of bilateral, small pleural effusions, although
her oxygen saturations remained normal on room air. We also
evaluated her synthetic liver synthetic function (LFTs - AST 34,
ALT 46, Alk Phos 164, INR 1.3, Albumin 2.7, platelets 696) and
there was some mild concern for possible liver disease with
post-surgical decompensation as a source. She had no evidence of
chronic liver disease sequelae on exam. Possible explanations
would include alcohol vs. medications vs. steatohepatitis vs.
viral hepatitides. Her hepatitis serologies and iron studies
were pending at the time of discharge. A RUQ ultrasound was
performed to evaluate for any suspicious liver pathology, and
was reassuring on preliminary read.
.
# S/P ANTERIOR APPROACH TO LUMBAR SPINAL SURGERY, BACK PAIN -
She has a significant history of mobility-limiting back pain
with lumbar spinal stenosis, spondylosis and scoliosis who is
now s/p L3-4 osteotomy, partial L4-5 vertebrectomy and anterior
spinal fusion L3-S1 with anterior approach and allograft use
(___) and s/p L2-3, L1-2 osteotomy with anterolateral
spinal fusion of T12-L3 with allograft use and total laminectomy
L2-5 with fusion of T10-S1 (___) via a combined
Vascular-Orthopedic surgery approach and repair. Ortho-Spine
consulted and noted a stable exam without hardware or
post-surgical issues on CT imaging. We continued her back pain
regimen that she was admitted on: Diazepam 5 mg 1 tab ___ Q6H PRN
muscle spasm, Morphine sulfate ER 30 mg ___ Q12H for baseline
control, and Oxycodone 5 mg ___ tabs) Q3H PRN breakthrough
pain. Her serial neurologic exams were reassuring.
.
# SEVERE ASTHMA - She has a history of severe asthma since
childhood, with prior intubations and hospitalizations with ICU
stays (last hospitalization was ___ years prior). This
admission, she had no evidence of URI symptoms or acute
exacerbation. No PFTs were available in our system. In talking
to the patient, symptoms seem controlled and she is using her
rescue inhaler only sparringly. We continued Albuterol and
Ipratropium nebs Q4-6H PRN wheezing, dyspnea along with Ventalin
90 mcg ___ puffs Q4-6H PRN wheezing, dyspnea. We also continued
her baseline regimen of Advair 250/50 mcg 1 puff INH BID. We
monitored her oxygen saturations via pulse oximetry, encouraged
incentive spirometry and ensured Influenza vaccination this
admission.
.
# GERD, REFLUX ESOPHAGITIS - controlled on PPI therapy; prior
EGD (not in our records) with some abnormality, per the patient;
no symptoms of reflux, dysphagia or odynophagia. We continued
Omeprazole 20 mg ___ daily, without issue.
. | 301 | 820 |
18001923-DS-50 | 23,438,938 | Dear Mr. ___,
You left against medical advice. We discussed that you have
severe anemia and that you could possibly die. You understood
this but chose to leave anyways. As we discussed your blood
counts are worse than your previous admissions. We strongly
advise you to seek medical attention. If you again start to feel
dizzy or lightheaded, or have fevers go no an emergency room.
Please continue all your medications when you leave the
hospital. Please ___ with your primary care provider as
discussed.
Lastly, given the severity of your disease, if you continue to
drink and use drugs, you will die. Please reach out to us or
your PCP to help find resources in quitting.
Wishing you the best of health,
Your ___ team | Mr. ___ is a ___ hx HCV/EtOH cirrhosis (MELD 19 on
admission, c/b ascites, HE, parastomal variceal bleed s/p TIPS
___, and ongoing alcohol use), mild AS, bladder/prostate
cancer s/p cystectomy w/ileal conduit and L nephrostomy tube, hx
MDR klebsiella and VRE UTI, recently E coli UTI, presented w/
reported melena, hematochezia and hematemesis. Stayed 1 hospital
day, found to have worsened but stable anemia. Left AMA on
morning of hospital day 2, explained and perceptibly understood
risk of death in leaving. Advised patient to seek medical
attention with PCP and to seek resources to help quit substance
abuse.
# Hematochezia/melena/hematemesis: Patient presented with
reported BRBPR, melena and hematemesis which was never witnessed
during hospitalization. On presentation, patient had Hb of 8.2
(near his baseline of ___, which trended down to 7.5 on
hospital day 2. Patient w/ hx HCV/EtOH cirrhosis c/b parastomal
variceal bleed s/p TIPS in ___ however recent EGD on ___ w/
no varices. Anemia has been a long standing issue that
unfortunately has not been fully worked up as he continues to
leave AMA. On Day 2 of hospitalization patient left AMA again
after he was assessed for and found to have capacity. This was
the second time in one week the patient presented for
melena/hematemsis/BRBPR and left AMA, and the ___ time the
patient has left AMA in the last 3 months.
#Hx of UTI/Chronic colonization: Patient w/ hx of positive U/As
and UCx felt to represent chronic colonization of L perc
nephrostomy, R urostomy. No complaints of flank pain or CVA
tenderness were found on this admission. No antibiotics were
given during recent admission despite positive urine cultures,
as a decision was made to limit antibiotics in this patient with
frequent non-adherence as a harm reduction measure; he has
numerous partial courses of abx in the past that place him at
high risk of developing resistant organisms that could later
endanger him.
# EtOH intoxication/withdrawal: Patient hx of intoxication, no
signs of active withdrawal on this admission. We encouraged
abstinence.
# Cirrhosis: HCV/ETOH related cirrhosis MELD 19 on admission,
c/b ascites, HE, parastomal variceal bleed s/p TIPS ___, and
ongoing alcohol use. Continued home lactulose, rifaximin. | 124 | 362 |
14319319-DS-17 | 22,017,631 | It was a pleasure to care for you during your admission. As you
know, you were admitted for abdominal pain and nausea. We did
not find any new causes of your abdominal pain or nausea. We
also noted that your mood and concentration were not stable on
admission, and we stopped the wellbutrin that you had started
taking recently.
Medication changes:
We found that you responded well to ondansetron (zofran) before
meals, and will provide you with a short supply of this
medication until you can arrange to see your primary care
physician to see if this is something that you will need for a
longer time or not.
We suggest that you NOT take the wellbutrin and tizanadine that
were started after your last admission. | The patient is a ___ year old man with known colitis, on
prednisone taper after recent admission, known hepatitis C,
bipolar disorder with concern for active depression on recent
admission, here with with ___ days of intractable nausea and
vomiting with his recent abdominal pain. He reports that these
symptoms are similar to those prompting his recent admission. He
reports feeling well at the time of his PCP visit the day prior
to the development of these symptoms. He denies taking his
medications including his opiates at higher doses than
prescribed, and confirms he has been taking the medications as
prescribed including the tizanadine.
DDX of nausea and abdominal pain in this patient is complicated
by his medical history. He has known colitis, and is on a
prednisone taper, which could explain the increased symptoms. He
also has known hepatitis C, although his symptoms do not appear
as what one would suspect for chronic hepatitis. He has been
taking regular opiates and benzodiazepines, so is at risk for
constipation, although he denies this. He also is at risk for
withdrawal from opiates or benzodiazepines if he were taking his
medication differently than prescribed. It is also possible that
his depression and anxiety were playing a role, particularly in
terms of anticipatory symptoms, and we discussed this ___
with the psychiatric inpatient liaison who evaluated him in
consultation.
# Abdominal pain, unclear if colitis or other etiology:
He was continued on his home medications, including the
prednisone taper, with the addition of an antiemetic IV 30
minutes before. The ondansetron proved quite helpful to the
patient's nausea, and he reported being able to tolerate regular
oral intake during the admission. We suggested a short course of
oral ondansetron with close PCP ___ to determine if this
medication would be beneficial going forward as his outpatient
GI work-up continues.
# Colitis, with recent prednisone taper:
We continued his prednisone at 30mg for now, as patient is
reportedly now off mesalamine following last admission. He was
intructed to continue with the taper as previously reported.
Neither the patient nor the medical team felt that he had active
colitis symptoms, and his CT evaluation and recent extensive
work-up supported that a colitis flare was less likely.
# Influenza suspicion by ED:
We proceeded to rule out of influenza at this time, although low
clinical suspicion given no fevers, no muscle aches, and nausea
and vomiting appear linked to abdominal pain. His swab was
ultimately negative for evidence of influenza.
# Bipolar depression:
A partial program was recommended at discharge in consultation
with the inpatient psychiatric liaison team. We spoke with his
referring provider's coverage to ensure close ___ and
awareness of the plan. We discontinued wellbutrin due to concern
that this was exacerbating his anxiety and depression, and may
have contributed to his increased agitation reported on
admission. We suggest a different agent should be chosen in the
future. | 123 | 477 |
10011938-DS-19 | 24,772,774 | Dear Ms. ___,
You were admitted to ___ due to
new episodes of tongue heaviness and difficulty speaking.
You were monitored on EEG, which showed that these episodes are
seizures. In addition, you had dozens of subclinical seizures
each day, which you do not notice.
We think you are having more seizures due to infections. You
were found to have a urinary tract infection which has been
treated with antibiotics.
You also had ulcers on your left heel and your right buttock. An
abscess was found in your right groin which needed to be lanced
and drained by the surgery team.
You were treated for 7 days with antibiotics called Keflex and
Doxycycline.
Take your medications as prescribed.
You were started on an additional anti-seizure medication:
Fycompa (perampanel) 6 mg at bedtime. On ___, increase to 8
mg at bedtime.
You are being treated on antibiotics through ___.
Keep taking cephalexin 500 mg four times a day. Stop after ___.
Keep taking doxycycline 100 mg twice a day. Stop after ___.
Your Lisinopril 10 mg daily was held temporarily while in the
hospital. Please see your PCP about whether you should restart
it for your blood pressure.
Continue all your other medications as prescribed.
Follow up with your PCP ___ ___ weeks of discharge.
You had a couple episodes of painless blood in your urine. This
may be completely benign but there is a possibility that
sometimes it is an early sign of bladder or kidney cancer. You
should see your PCP or ___ urologist within the next month to
follow up on blood in your urine.
Follow up with your orthopedic surgeon (Dr. ___ in 2 weeks.
He suggests calling his office to make an appointment.
Follow up with your neurologist within 2 months.
Thank you for the opportunity to care for you.
Sincerely,
The ___ Neurology Team | Ms. ___ is a ___ woman with a history of epilepsy,
was well controlled on levetiracetam/lamotrigine/phenobarbital
who presented with new onset of episodes of tongue
numbness/swelling sensation, as well as aphasia. EEG shows
multiple left frontal brief seizures ___ long. Patient may be
having breakthrough seizures due to UTI and soft tissue
infections. She also has a L heel ulcer and a R groin abscess
s/p I&D by ACS.
#Epilepsy
-cvEEG monitoring showed numerous of electrographic seizures
daily (>80-90). Did not improve on addition of Ativan bridge,
vimpat, klonopin. However, there was decrease in clinical
seizures on fycompa 6mg such that there were no further clinical
events x24 hours prior to discharge.
- Continued home AEDs (LEV 1000mg BID, PHB 97.2mg BID, LTG 200mg
TID)
- vimpat 250mg BID (started ___ - ineffective - weaned off.
- trialed ativan bridge which was not improving EEG, so it was
stopped after 2 days
- stopped klonopin on ___ after short, ineffective trial
- prednisone 60 mg on ___, 40 mg on ___, 20 mg ___. Back to
home dose of 5 mg daily on ___. per outpatient epileptologist,
Dr. ___
- started Fycompa at 2 mg QHS and uptitrated to 6 mg QHS. Plan
to increase to 8mg QHS in 1 week as outpatient.
#R groin abscess- with purulent drainage
- consulted ACS; s/p I+D
- doxycycline and Keflex on ___ to complete 10 day course
- BID wet to dry dressing changes per ACS
#Heel ulcer, R buttock ulcer
- wound care consulted
- podiatry consulted
- please see wound recs
#multiple L tibia/fibula fractures, subacute in ___
- x-ray shows multiple subacute healing fractures
- spoke with patient's outpatient ortho, Dr. ___
- weight bearing as tolerated if CAM boot in place with walker
per OP ortho
- ___ consulted; recommended rehab
#UTI
- urine culture grew E. coli resistent to cipro and ampicillin.
sensitive to cephalosporins
- s/p ceftriaxone x1 in ED
- macrobid stopped; covered by Keflex and doxy for ulcers
- repeat UA negative
#Gross hematuria - painless, 2 episodes
- UA negative for blood, 1 RBC
- recommended outpatient follow-up with Urology
Chronic Issues:
#HTN
- Lisinopril 10 mg held. BPs mostly 120s-140s. Please restart as
appropriate.
=========================================== | 304 | 347 |
14154307-DS-17 | 27,946,390 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were referred to the emergency room from your outpatient
podiatrist's office due to an infected ulcer on the bottom of
your R foot
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were admitted to the hospital and received IV antibiotics.
On ___, you went to the OR with podiatry to have your
ulcer debrided and cleaned out. During this operation, podiatry
saw exposed bone, so you underwent an MRI to determine whether
you had osteomyelitis (an infection of your bone). The MRI
showed that you did have osteomyelitis, and needed to be treated
with a long course of antibiotics. The podiatry team discussed
possible amputation options with you, which would mean a short
course of treatment, but you opted against amputation for now
and to get a resection, which occurred on ___. You have
scheduled podiatry follow-up, and will also need a prolonged
course of antibiotics to treat your bone infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
- You were set up with home infusion services and a ___ line to
get your IV antibiotics at home. You should follow-up with the
ID doctors, as well as podiatry.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history significant
for HTN, HLD, CAD s/p DES, gastric bypass, gout, DM2 c/b
diabetic
neuropathy, retinopathy, and chronic foot ulcerations c/b
osteomyelitis, multiple debridements, R ___ metatarsal resection
(___), and a recent ___ admission for MRSA cellulitis, who
presented from his outpt podiatrist for R plantar ulcer and
antibiotic therapy, now s/p I&D for R plantar abscess with
subsequent imaging concerning for osteomyelitis. He returned
to the OR for resection, with plans for an outpatient course of
IV antibiotics for osteomyelitis and podiatry follow-up for
possible amputation.
Transition issues
=================
[ ] Ongoing follow-up with podiatry, consideration of
transmetatarsal amputation in coming weeks for definitive
treatment of chronic foot ulcer and osteomyelitis
[ ] ___ team followed you inpatient to manage your insulin
regimen, and made some adjustments. You are discharged on a new
regimen of NPH and Humalog, as detailed below. ___ will call
you to establish outpatient follow-up, if you wish to start
following in your clinic.
[ ] Infectious Disease team will arrange outpatient follow-up,
to determine final course of antibiotics based on whether
patient ultimately undergoes amputation or repeat debridement
with podiatry.
[ ] Outpatient antibiotic plan: | 249 | 188 |
10161801-DS-21 | 23,990,616 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery for your right
humerus fracture. 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:
- Nonweight-bearing right upper extremity
- minimal range of motion at shoulder, elbow, and wrist.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- 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 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right midshaft humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, 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 home with services 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
nonweightbearing in the right upper extremity extremity, and
will be discharged on aspirin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 283 | 257 |
17565285-DS-2 | 23,634,987 | Dear Mr. ___,
You came to us with a skin infection of your left lower foot
called cellulitis. We gave you IV antibiotics while conducting a
workup, which shows a localized infection without spread to the
bone or into your blood. Given this, it is safe to treat you
with oral antibiotics with close follow up with your PCP for
evaluation. You should see improvement in your foot within 48
hours of taking antibiotics. If you do not or if your foot
worsens (more red or swollen), please go to the ER for IV
antibiotics and further workup. Maintain good foot care and
treat athletes foot at the first sign of infection with over the
counter cream.
For wound care: apply over the counter antibiotic ointment to
any open wounds. While you have open wounds or blisters, keep a
dressing in place with vaseline gauze and dry gauze over that.
After all open wounds are closed and blistered areas are healed,
you can leave exposed to air. Your PCP can help guide you in
wound care if needed.
It was a pleasure taking care of you!
Sincerely,
Your ___ Team. | This is a ___ gentleman with a history of hypothyroism who was
referred by his PCP for evaluation and management of cellulitis
with associated with total body rash.
Infection: Painful unilateral erythema at site of likely tine
pedis allowing for bacterial infection consistent with
cellulitis. Pt was continued on IV unasyn overnight w/
re-ssessment in the AM. One dose of IV Vanc and CTX given on the
floor. Xray was negative for osteomyelitis and the patient did
not exhibit any signs of systemic infection. He has no MRSA
risk factors and he remained Afebrile w/out leukocytosis. Pt
was discharged on Bactrim DS and Keflex for 10 days with close
follow up with his PCP.
Pruritic Macular Rash: Ddx includes viral vs allergic rxn vs
tinea. Although it appears like a classic morbilliform drug
reaction and presentation occured after onset of foot findings,
patient denies taking any new medications other than benadryl to
treat these findings. He further denies system features of
fevers or chills. The rash greatly improved after initiating
Abx. HIV testing negative.
Hypothyroid:
- We continued home levothyroxine | 189 | 190 |
12925451-DS-3 | 20,850,129 | Dear Mr. ___,
You were admitted to the hospital with a flare of your
autoimmune bowel disease. You improved with infliximab and a
higher dose of steroids. When you leave the hospital please
follow-up with your GI doctor as planned in 2.5 weeks.
It was a pleasure taking care of you,
___, MD | Patient is a ___ year-old with HTN and autoimmune entheropathy
(recently started on infliximab), who presents with watery
diarrhea x ___ days, in setting of tapering of steroids.
# Autoimmune enteropathy: He was diagnosed ___ after an
admission at ___. He was started on infliximab s/p 2 loading
doses (received second loading dose on ___ and was due for
third dose on ___, with recent downtaper of prednisone
(20-->10mg), and then developed profuse watery diarrhea x4 days.
On admissino, MRE showed active inflammation of terminal and
distal ileum. He was started on solumedrol 20mg IV TID, and
received ___ loading dose of infliximab ___. His sxs improved
somewhat to ___ watery BMs daily on ___ (hospital day 2) Would
transition to PO prednisone 40 daily and discharge with a plan
for steroid taper over 2 months. His CRP was 4.1 on discharge.
-Prednisone 40mg daily for 2 weeks
-Prednisone 30mg until you see Dr. ___
# GPR positive blood culture: Likely contaminant as patient
afebrile with no s/s infection, no leukocytosis. Follow up final
report. Growing GPR that I suspect is a contaminant.
-F/u Blood culture will call patient if any concerning results | 50 | 194 |
14171423-DS-11 | 28,566,826 | Dear Mr. ___,
It was a pleasure to once again be part of your care team at
___. You were admitted because
you had a fast heart rate, and then we found that you have some
fluid in your lungs. We were not sure if you also had an
infection, so we started you on antibiotics. We drained some of
the fluid out, and you started to feel better. The fluid from
your lungs did not look like it was infected, so we stopped the
antibiotics. We then restarted your coumadin (warfarin), and had
to wait a few days for it to work well enough for you to go back
to rehab.
We also had the urology team come to see you, and they
recommended a biopsy of the tissue in your groin. We have set up
an appointment for you with Dr. ___, who is in ___.
For your medications, we want you to keep taking digoxin and
metoprolol for your heart. We also adjusted your pain
medications, which seemed to help. Finally, we increased your
coumadin (warfarin) dose to 7.5mg. Please see below for a
complete list of your medications.
It was very nice to see you feeling better, and we all wish you
the best!
Sincerely,
Your ___ Care Team | ___ COPD, IDDM, ESRD on HD, s/p R AKA, afib, multiple with
recent hospitalization from ___ presenting to ___ for afib with RVR, transferred for concerns of lung abscess.
#Abscess/PNA-
The patient was initially transfered to ___ due to possible
pulmonary abscess seen on CT. It also showed enlarging,
moderate, bilateral, nonhemorrhagic partially loculated pleural
effusions with associated compressive atelectasis. He was
evaluated by thoracic surgery in the ED, who felt that the
finding was unlikely to represent and abscess and recommended
the patient be admitted for possible interventional pulmonology
percutaneous drainage of his pleural effusion. The patient was
started on zosyn in the ED and vanc the following day, as the
patient had recently been hospitalized and was at risk for HCAP.
However, the patient was also found to be afebrile with no
leukocytosis. Interventional pulmonology was consulted to
evaluate his pleural effusions. The patient's warfarin was
reversed and he was kept on a heparin gtt. On ___, he underwent
a R-sided thoracentesis with chest tube placement. This was
complicated by a small hematoma which developed overnight. The
following morning the tube was pulled. The patient subjectively
felt much better following the procedure, and he was able to
weaned down to his home O2 of 2L. The fluid studies came back as
transudative, and no organisms were seen on gram stain. However,
given that there remained some question of pneumonia, the
antibiotics were continued. Pulmonology was consulted for
recommendations on antibiotic management, and they felt that the
imaging was more consistent with rounded atelectasis and there
were no signs of active infection, and recommended stopping the
antibiotics, which was done on ___. The patient remained at his
baseline respiratory status, continued to have no fevers or
leukocytosis, and clinically did not have cough or shortness of
breath. He will need follow up imaging in about 2 months to be
sure the atelectasis improves and his right middle lobe nodule
is stable.
# Afib RVR:
The patient intially presented to ___ with afib with RVR
to the 140s. He receieved IV 20 diltiazem, 30 PO dilt and full
dose aspirin. Trop I found to be 0.08. He began to
symptomatically feel better, and was transfered to ___ for
possible pulmonary abscess (see above). He was continued on his
home metoprolol 50mg Q6H. It was unclear from his rehab records
if he had been recently been receiving digoxin 0.0625 mg every
other day. The patient did not know of any reason why it would
have been stopped, and reported no allergic reaction. It was
started at ___ the day after admission, with no difficulty.
The heart rate improved to the ___, where it remained for the
majority of the hospitalization.
The patient was also noted to be somewhat subtherapeutic on home
warfarin, with an INR of 1.8. A heparin drip was started, and
the warfarin was reversed for his thoracentesis, as above. After
the procedure, warfarin was restarted. After having been
therapeutic for 48 hours, the heparin gtt was stopped.
During HD on ___, the patient was noted to have abnormal beats
on tele. He was having occassional paced beats, as well as rare
___ beat runs of what appeared to be a right bundle block. EP
was consulted, and felt that the rhythm represented a functional
right bundle branch block, and did not recommend further
intervention. They also interrogated the patient's pacemaker,
and found 5% pacing, no recorded episodes of sustained VT. No
changes were made. He was discharged on metoprolol 50mg Q6H and
digoxin 0.0625 mg every other day.
# Pulmonary embolism:
The patient was recently hospitalized from ___ and was
found to have RLL segmental and subsegmental PE with adjacent
consolidation concerning for infarction on CT. TTE on ___
showed moderate pulmonary HTN (also supported by enlarged PA
seen on CT), an EF <20%, and mild AS and MR. ___ on warfarin
4mg. Most recent INR ___ 1.74. As above,
it was reversed for his thoracentesis, and then was bridged back
on a heparin gtt, until found to be therpeutic for 48 hours.
#Penile lesion:
During previous admission, pt was discovered to have fibrous
tissue coming from meatus. During this admission, the lesion
appeared unchanged, but had a purulent odor. A urine cytology
was negative. Urology was consulted, who recommended a biopsy be
done on an outpatient basis. The patient stated that he would
prefer to have this done at ___. He was schedule for an
appointment on ___.
#Ecchymotic plaques:
The patient was noted to have large ecchymotic patches with
fragile-appearing skin, espcially on his arms. Dermatology was
consulted, who felt it was most consistent with traumatic
purpura due to his chornic prednisone for RA and
anticoagulation. Also of note, the patient's skin was found to
tear very easily with non-paper tape. On ___, non-paper tape was
used despite objections from the patient, and on removal created
a 1.5x2.5 skin tear with bleeding and tracking of blood down his
forearm.
#Dysuria:
Patient reported dysuria on ___. Urinalysis was not convincing
for a UTI, so he was not treated for this. Urine culture was
pending at time of discharge.
#R Renal Cyst:
Found on CT one month ago. Urology recommended that, as this was
found to be <1cm, it should be reevaluated in 6 months.
# C. diff:
The patient tested positive for C diff on ___ at his rehab
facility. He was started on PO vanc, which was continued through
his ___ admission, with a planned stop date on ___ (two weeks
after he completed a course of antibiotics.) The patient was
continued on PO vanc during this hospitalization, and given that
he was given antibiotics that were stopped on ___, he will
complete his course on ___. Also of note, the patient reported
that his diarrhea was much improved from his ___ admission.
#ESRD: Received HD ___. Medications were adjusted for HD.
#History of CAD with multiple stents placed in ___ and ___,
s/p NSTEMI with DES ___ on Plavix:
The patient's plavix was continued throughout the
hospitalization, and was not held for the thoracentesis. He was
continued on aspirin 81mg daily.
#HTN: continued metoprolol 50mg Q6H
#HLD: Continue home atorvastatin 80mg daily, Aspirin 81 mg
#RA: Continued on prednisone 10 mg daily
#DM: Covered on sliding scale insulin
#pain control: During his ___ admission and during his stay at
rehab, the patient was covered on mixed therapies of dilaudid
and oxycodone. During this admission his pain control was
simplified to dilaudid ___ mg PO/NG Q4H prn pain. He was also
started on gabapentin, which was dosed at 200mg daily for HD.
#GERD:
The patient had a recent GI bleed in ___. He was continued on
pantoprazole BID.
#s/p R AKA with ulcer:
He was previously seen by wound care, and also had multiple
other eschars and ulcers. Wound care was again consulted. Of
note, patient reported that many of his wounds were improving.
#Multiple myeloma:
Thought to be in remission, followed by Dr. ___ at ___
===========================
TRANSITIONAL ISSUES
===========================
- The patient's warfarin was initially discontinued for a
thoracentesis with chest tube placement. He was bridged back
with a heparin drip, and is being discharged on 7.5mg warfarin.
He should have his next INR checked on ___.
- The patient should be continued on Metoprolol Tartrate 50 mg
PO Q6H and Digoxin 0.0625 mg PO every other day. His last dose
of digoxin was given on ___, and so his next dose should be on
___.
- The patient is on PO vanc for C. diff. He was given
antibiotics for possible pneumonia, and so the PO vanc should be
stopped two weeks after these were stopped. His last dose of PO
vanc will be on ___.
- He will need a repeat CT chest in about 2 months to be sure
the atelectasis improves and his right middle lobe nodule is
stable.
- HD ___
- The patient was again noted to have a penile lesion, and is
recommended to have a biopsy on an outpatient basis. The patient
would prefer for this to be in ___, and he has an
appointment with Dr. ___ for ___.
- Only paper tape should be used on this patient due to easy
skin tearing.
- Findings on CT include:
-- hyperdense exophytic 1 cm lesion arising from the right
kidney. Recommend to follow with serial imaging. Repeat with
renal ultrasound or CT in ___ months.
-- additional nodular opacities in the right middle lobe and
left lung apex and subcarinal node which will require followup
in 3 months with repeat imaging given history of prior
malignancy.
# CODE STATUS: FULL (confirmed)
# CONTACT: ___ (wife) ___ | 208 | 1,440 |
15564819-DS-10 | 20,831,921 | Dear Ms ___, you were admitted to the hospital after you were
involved in a motor vehicle crash resulting in left sided rib
fractures ___, a bruise on your lung, and a small collapse of
the left lung. You did not require a chest tube or any surgical
intervention. During your hospitalization, you required oxygen
to maintain a normal oxygen level. You were weaned of the
oxygen prior to discharge. You were evaluated by physical
therapy and cleared for discharge home with the following
instructions:
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Additional 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. | ___ year old female who was admitted to the hospital after a
motor vehicle crash in which she was a restrained driver. Upon
admission, the patient was made NPO, given intravenous fluids
and underwent imaging. On review, of imaging, she was reported
to have left sided rib fractures, ___ and a left lateral
pulmonary contusion. A small left pneumothorax was identified,
no chest tube was placed. Her c-spine and head cat scan were
normal.
The patient's rib pain was controlled with oral analgesia.
During her hospitalization, she did experience decrease oxygen
saturation requiring supplemental oxygen via nasal cannula. A
pulmonary consult was ordered. Nebulizer treatments were
ordered and the patient was instructed in the use of the
incentive spirometer. They recommended a referral to a
pulmonologist. The patient was evaluated by physical therapy
and was provided instruction in deep breathing.
The patient was weaned off her supplemental oxygen at the time
of discharge. She was tolerating a regular diet and voiding
without difficulty. She was ambulatory and her rib pain was
controlled with oral analgesia. Discharge instructions were
reviewed and the patient was encouraged to follow-up with her
primary care provider ___ 1 week with a repeat x-ray and a
referral to a pulmonologist. She was also given the telephone
number of the Acute care clinic and encouraged to call with
questions or concerns. | 271 | 236 |
15557492-DS-10 | 23,280,319 | You were admitted to the hospital for abdominal pain. You were
found to have stones in your gallbladder which is likely
contributing to your abdominal pain. The surgeons evaluated you
and recommend that you follow up with them outpatient to discuss
having an elective surgery in the future to remove the
gallbladder.
It is important to have a LOW FAT diet. This will help prevent
your abdominal pain.
It is also possible that you still have ulcers in your stomach
(you had these ulcers in ___. Thus, we have increased your
omeprazole from 20->40mg once a day. This will lower the acid
level in your stomach.
You were found to have elevated liver enzymes. This is not new,
you have had this in the past as far back as ___. You were seen
by Dr. ___ in liver clinic in the past for these liver
findings. It is very important to follow up with him. You might
have a chronic liver inflammation process called Autoimmune
Hepatitis. The liver doctors are experts in managing this.
Medication changes:
STOP:
atorvastatin- you may consider resuming this medication in the
future if the Liver doctor thinks it is appropriate.
INCREASE:
Omeprazole 20mg daily->40mg daily- this will protect your
stomach and lower the acid
DIET: LOW FAT diet | ___ h/o GERD and peptic ulcer disease admitted for and episode
of nausea/vomiting/RUQ abdominal pain after eating a fatty meal.
# Abdominal pain and nausea: most likely biliary colic. RUQ US
showed no signs of cholecystitis but found gallstones. Other
consideration include her PUD, especially in setting of NSAID
use. Surgery evaluated patient and recommended outpatient
elective cholecystectomy. She was instructed to fatty foods.
Omeprazole was increased from 20mg->40mg. Abdominal pain
resolved and she was able to take good PO at discharge.
# Transaminitis: Transaminases were elevated in the 200s. This
was most likely due to her autoimmune hepatitis diagnosed in
___ by liver biopsy/elevated IgG/pos ___/ Smooth Muscle. She
was found to be non-immune to HBV (HBV surface antibody
negative) and should receive HBV vaccination as an out-patient.
She was strongly encouraged to follow up with hepatologist
outpatient.
# Hypothyroidism: continued home synthroid at 88 mcg daily.
# DM2: Metformin held during hospitalization. She was placed on
insulin sliding scale and then told to resume metformin
outpatient.
# HLD: Patient's statin was stopped given concern for worsening
transaminitis. | 207 | 177 |
18743637-DS-23 | 22,703,871 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you steroids and antibiotics to help you breathe.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary care provider.
We wish you the best!
Sincerely,
Your ___ Team | ADMISSION
=========
___ male with history of COPD who presents with 1 day of
increasing dyspnea. Patient normally uses 2 L supplemental
oxygen at home. He has been using his home inhalers. He normally
has a mild cough, which has become slightly more productive. He
says that the sputum is white. He denies fevers. Denies chest
pain or lower extremity edema. Denies orthopnea. Denies
abdominal pain, vomiting, diarrhea. Patient states this feels
similar to his COPD exacerbations in the past. His most recent
COPD exacerbation was about 2 months ago, at which time he was
admitted to the hospital for 2 days. | 100 | 101 |
14666729-DS-19 | 25,694,568 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You came in after you
fell and hit your head at home. Our neurosurgeons evaluated you,
and determined that you had a small bleed in your head, but that
you were stable. We believe you may have fallen in the setting
of a urinary tract infection, which we are treating with
antibiotics. Our physical therapists evaluated you and
recommended a brief course of ___ rehabilitation. It is
now safe for you to be discharged.
Please be sure to take all of your medications as prescribed and
keep your ___ appointments.
Sincerely,
Your ___ Medicine Team | ___ y/o female with past medical history significant for CAD
(CABG in ___, PCI to ___ in ___, and sick sinus sindrome
(dual chamber PPM, most recent implant ___. She presents to
___ after a mechanical fall at home.
# Fall: History is very consistent with a mechanical fall and
not syncope. However, the fall was unwitnessed, and exact
details are unable to be recounted by the patient. Given lack of
post-ictal confusion and lack of incontinence, seizure is not
likely. She has a strong cardiac history, and did fall forward,
thus it is prudent to rule out an obvious cardiac etiology.
Finally, given the fall timing after standing,
orthostasis/presyncope is a possibility, with potential
contribution from UTI. She was monitored on telemetry overnight
with no acute events, troponins were negative, (no ischemic
changes on EKG). Pacemaker interrogation while in house was
unremarkable. ___ consult recommended a short course of acute
___ rehab. Plastic Surgery was consulted in ED for facial
lacerations; ___ recommendations can be found in the
"transitional issues" section of this summary.
# Subarachnoid hemorrhage: noted on CT head, in right sylvian
fissure. Evaluated by Neurosurgery in the ED. Given her intact
and stable neurologic exam, there was no further need for
imaging. Neuro checks q8h were unremarkable. Goal SBP was
maintained at <160 per Neurosurgery recommendation. Held heparin
ppx and home ASA with plan to restart ASA seven days after her
bleed (___), this was determined with guidance from
neurosurgery.
# Uncomplicated cystitis: s/p mechanical fall at home,
leukocytosis of 15k on admission, and urinalysis suggestive of
infection. Denies dysuria, though has had nausea for several
days. Per daughter had been started on Bactrim the day prior to
presentation by PCP for presumed UTI. Continued ceftriaxone and
transitioned to PO cipro at time of discharge, to complete a
seven day course. Urine cultures were negative to date.
# Goals of care: Discussed code status with the patient and her
daughter. Patient is currently FULL CODE, but has recently begun
discussions with her family regarding DNR status. PCP should
consider exploring code status further with patient and her
family (of note HCP is son ___.
# CAD: CABG in ___, PCI to LCx in ___. She also survived a VF
arrest in ___ (while vacationing in ___, for which she
is now on amiodorone. Continued home carvedilol 3.125mg BID,
held ASA 81mg daily as above given SAH, continued atorvastatin
20mg daily and amiodorone 400mg daily
# Diabetes: held home metformin (1000mg qAM and 500mg qPM) and
glipizide (7.5mg daily).HISS while in-house.
# Depression: continued setraline 75mg daily.
# FEN: No IVF, replete electrolytes PRN, regular diet
# PPX: TEDs (holding heparin for now given SAH)
# ACCESS: peripherals
# CODE STATUS: Full code (confirmed with patient and daughter)
# CONTACT: ___ (son, HCP) ___ ___ (daughter)
___
# DISPO: Medicine pending above
***TRANSITIONAL ISSUES***
- Calcium slightly elevated, PCP should ___ with a PTH.
- Bacitracin ointment to suture line and lip abrasion once to
twice daily. HOB elevation and iceing to right eye to reduce
swelling. ___ discontinue ___.
- 5 day course of Cipro, start date ___ last day ___
- Patient should have brow sutures removed on ___. She may
follow up in plastic surgery clinic, however, she and her
daughter state that patient's son is an ENT surgeon, and will
likely remove them himself on that day, in which case, she may
follow up on an as needed basis.
- if any change in neurologic exam (here, she is AOx3 without
any deficits), she should be re-evaluated for expansion of
subdural hematoma
- aspirin should be restarted 1 week after discharge (eg on
___ | 110 | 623 |
15201393-DS-16 | 26,368,402 | You presented to the hospital at the urging of your primary care
physician for low blood pressure and new onset atrial
fibrillaiton.You required a large infusion of IV fluids and
blood pressure support with necessary ICU care. After
stabilization of your blood pressure, your care was trasnfered
to the general medicine floor.
You were also evaluated and managed in the hospital for an
ongoing infection with C. dificile. After transfer to the
medical floor, you were monitored for stool output with an
eventual reduction in the amount of stool made and maintained an
appropriate blood pressure. You were treated with Vancomycin
antibiotcs for your C. Dificile infection. It will be important
for you to continue your antibiotic regimen for the full
prescribed duration.
Should you experience a recurrence or worsening of your
symptoms, it would be important for you to seek immediate
medical attention as soon as possible. | ___ yo M w/ h/o epilepsy, pseudoseizures, cognitive deficits, C.
difficile, and PTSD presenting ___/ hypotension in setting of new
AF.
#) C. difficile infection: Pt has a history of chronic diarrhea
for nearly one year. He was recently diagnosed with C. diff
during admission in ___. Has failed to complete his
original antibiotic regimen of Flagyl or vancomycin. Would meet
criteria for severe C. diff given elevated creatinine (>1.5x
normal) and ICU admission. Abdomen has been distended and
focally tender in LLQ on exam. He was treated for severe C.
difficile with vancomycin 125 mg q6hr with plans for a 14 day
course, which he has tolerated well. He had a Flexiseal
apparatus in place which was removed on ___ and reduction of
bowel movements. On the day of discharge he was down to
approximately ___ loose non-bloody stools per day.
--> Continue oral vancomycin till ___
#) Seizure Activity: Pt with history of tonic clonic
epileptiform seizures as well as non-epileptiform (pseudo)
seizures attributed to conversion disorder. He is followed by
Dr. ___ these issues and has been maintained on
Clobazam 30mg though has had some issues with compliance in the
past. Per neurology clinic note, has been having more frequent
pseudoseizures and ? seizures which could be attributed to
numerous stressors including upcoming birthday of sister who was
murdered. Dr ___ Dr ___ emailed regarding
his hospitalization. Flagyl does low the seizure threshold and
was thus avoided. During the hospital course, he had one episode
of seizure activity with falling during ambulation. He was
evaluated via head CT for intracranial bleeding which was
negative. After discussion with Dr. ___ changes
were made to his medications.
--> Continue Clobazam 20 mg qam and 10 mg pqpm
#) Hypotension: He originally presented to the hospital because
of low blood pressure. Likely due to hypovolemia in setting of
dehydration from chronic diarrhea related to C. diff and poor
oral intake. Distributive shock is also possible contributing
factor given known source of C. diff prior to presentation, and
incomplete therapy for infection per PCP ___. In the
hospital he was afebrile and with a presenting lactate of 2.0 on
admission. Cardiogenic shock was unlikely given a negative
history of heart disease and warm extremities w/o evidence of
elevated JVP or edema. The patient was started on empiric
Vancomycin, cefepime, and Flagyl in the ED with eventual use of
Vancomycin only for C difficile infection. He received
approximately 10 L of IV fluids during a stay in the MICU with
appropriate blood pressure response. After transfer to the
floor, his blood pressures consistently ranged from ___
systolic over ___ diastolic. He had a cortisol stimulation
test which showed an appropriate response.
#) ___: Patient experienced an elevation of BUN (48)and
Creatinine (3.0) on admission from baseline creatinine of 0.8.
This was likely due to hypovolemia and potential ATN given
hypotension. His creatinine and BUN normalized with IV fluid
therapy and oral rehydration.
#) Atrial fibrillation: New onset A fib, likely due to severe
dehydration with resolution with fluid rehydration in ED.
Unclear duration of arrhythmia as patient was asymptomatic.
Troponin negative in ED. CHADS2 score was 0. TTE without
structural heart disease. TSH WNL. He was in sinus rhythm on
admission to the ICU.
#) Depression/PTSD: Pt with significant psychiatric history
which appears to have decompensated in the setting of the
stressor of his deceased sister's upcoming birthday. Would
benefit from additional support and psychiatric treatment. Pt
currently endorsing passive SI. Discussed case with his
outpatient case manager, ___. Social work was
consulted. He was maintained on Citalopram as an inpatient.
#Care Coordination/Physical Decompensation: The patient became
increasingly deconditioned as he was bed bound during his
hospitalization. As a result, there were several attempts made
to have him agree to transfer to a rehabilitation facility to
improve his functional status, especially given his history of
seizure disorder and risks of falling. HE was adamantly against
the idea of rehab transfer and insisted on a home discharge with
services. After careful consideration and care team coordination
meeting with his assisted living facility, it was decided that
he could be safely discharged to home with ___ and physical
therapy services arranged via the assisted living staff. He was
also agreeable to the assisted living facility administrating
his daily medications and providing increased home custodial
care services.
#) Communication: Patient, ___ (private case
manager): cell ___, h) ___, brother
___ is HCP: ___ | 146 | 733 |
15003038-DS-21 | 25,248,100 | Dear Ms. ___,
It was a pleasure taking care of you while you were a patient at
___. You came to us with
slightly decreased kidney function and low sodium. We treated
you with IV fluids. Your kidney function and low sodium are
stable today but because you are not having symptoms you can go
home. Be sure to drink plenty of fluids at home.
Please take all of your medications as listed below. We have
decreased your diuretics to Lasix 40 mg daily and spironolactone
100 mg daily going forward. Please keep all of your ___
appointments. | ___ yo F with alcoholic cirrhosis with ascites, esophageal
varices, and hepatic encephalopathy who was called into the
hospital after labs showed an elevated Cr to 1.4 and Na of 131
in the setting of aggressive diuresis.
ACTIVE ISSUES
# Acute kidney injury: Cr on admission 1.4. Baseline was 1 after
last admission. Likely due to volume depletion in setting of
aggressive diuresis with Lasix and spironolactone. Urine lytes
were remarkable for FeNa of 0.56% and high osmolality on
admission suggesting a ___ etiology. Patient was treated
with albumin on night of admission. Home diuretics were held.
Her Cr remained slightly elevated at 1.3 the next day. PO fluids
were encouraged. Urine output good while in hospital. Her
diuretics were subsequently restarted a lower dose. As she was
asymptomatic patient was discharged home with outpatient
___.
# Hyponatremia: Na of 131 down from a normal baseline. Patient
was asymptomatic. Likely hypovolemic hyponatremia given clinical
picture. As above, home diuretics were held on admission and
___ on day of discharge. She remained hyponatremic but
was discharged given absence of symptoms.
CHRONIC ISSUES
# Alcoholic cirrhosis: Patient has history of ascites,
esophageal varices, and hepatic encephalopathy. No history of
SBP. MELD 31. Urine and serum toxicology screens negative on
admission. Her home lactulose and rifaximin were continued.
Nadolol was held last admission given diuresis. It was held on
admission given ___. Workup for transplant was continued while
inpatient. A PPD was placed in left arm on evening of ___.
Patient received HAV and HBV vaccines. An MRI was obtained
immediately prior to discharge.
# RLE Swelling: Patient has bilateral lower extremity edema more
tense on the right. This is most likely related to vascular
injury sustained during knee trauma several years ago. RLE US on
admission negative for DVT.
# Substance abuse: Patient has not had alcohol since ___ as
above.
TRANSITIONAL ISSUES
- Will need PPD read on ___ or ___. Will be read by ___.
- Will need to have labs drawn on ___ with PCP. Fax to Dr.
___.
- Now on Lasix 40 mg daily and spironolactone 100 mg daily
- Consider restarting nadolol for grade II varices
- Consider slit lamp exam as outpatient
- Consider sleep study as an outpatient given disordered sleep
and snoring
- ___ with PCP scheduled
- ___ with Liver Clinic scheduled | 96 | 374 |
15044961-DS-23 | 26,048,725 | Dear Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with abdominal pain that was caused by
obstruction to your bile duct. In addition, you had obstruction
in your ureter, the tube that drains your kidney. You improved
with a drain placed in your bile duct and in your kidney. It is
important that you appear for your appointment with your
oncologist that is detailed below. | ___ M with rectal adenocarcinoma (mets to liver and lung) s/p
rectal sigmoid resection ___ and last chemo on ___ (C2D1 of
___ presents with worsening abdominal pain and
recent MRCP suggesting worsening intrahepatic disease with
peripheral biliary obstuction
# Abdominal Pain/Transaminitis
Patient admitted after MRCP showing biliary obstruction. Lipase
at admission was >4000, but abdominal exam was trended and
decreased tenderness was subsequent. EGD with ERCP was performed
and showed no obstruction at the site on the MRCP. Peak T bili
was 7.5. Percutaneous biliary drainage with I/E drain was
performed to decompress the biliary system. The drain was
externally drained until the ___ to last day of admission, at
which time it was capped. T bili continued to trend down after
capping to 4.3. Patient was discharged with follow up in ___
months with ___.
# Hydronephrosis: patient was found to have ___ and
hydronephrosis on MR abdomen. Urology was consulted and
recommended perc nephrostomy with anterograde nephrostogram to
evaluate grade of obstruction. No contrast passed and the perc
nephrostomy was draining appropriately. The patient's ___
resolved after perc neph and will be followed by urology in ___
weeks at ___.
# Rectal Adenocarcinoma: patient recently completed chemotherapy
with ___ on ___ and despite therapy had progression
of disease. This will be followed by the patient's oncologist
and further therapies will be determined as an outpatient.
# Orthostasis: patient was found to be profoundly orthostatic
into the ___ systolic prior to discharge. Patient received
aggressive fluid repletion throughout his hospital stay and ___
was consulted. With fluids, his orthostasis improved and he was
asymptomatic at the time of discharge, though continued with
orthostasis. He was cleared by ___ to discharge with ___
walker.
Transitional Issues
- f/u biliary drain with Atrius
- urology follow up for perc nephrostomy and consideration of
internal stent
- recheck LFT's at onc followup to confirm biliary drainage | 72 | 316 |
16973998-DS-20 | 28,441,629 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had been feeling unwell, with productive cough, when
you had a sudden onset right upper back pain with swelling. At
___ you were found to have a fracture of the right 7th rib.
This is likely a pathologic fracture, which occurs when a bone
breaks due to a likely malignancy (possible cancer). Other
imaging on CT scans showed that there is a mass in your sigmoid
colon, as well as likely lesions in your liver, areas in your
femur bones and pelvis, and some of your ribs.
You were found to have a moderate pericardial effusion (liquid
in the heart sac that surrounds your hear), cardiology evaluated
you with an ultrasound, and they recommend a repeat ultrasound
(ECHO) in 10 days. If you develop shortness of breath, chest
pain, feeling like you are going to pass out, pass out, or have
a very fast heart rate, please seek emergent medical help and
call ___. This would be concerning for tamponade, which is when
the sac surrounding the heart becomes completely filled with
fluid. The cardiology department will contact you about
scheduling an appointment early next week.
You were also seen by the orthopedic team who felt that you
should have repeat imaging of your hips in the future to ensure
no progression of the presumed tumor involvement there.
Please follow up with your PCP/Oncology for results and
treatment options. We encourage you to bring your daughter to
these appointments.
We wish you the best and thank you for participating in your
care,
Your ___ team | ___ with a history of HTN, 30+pack-year history of ___ use,
aortic aneurysm not requiring surgery, HLD, who presents with
right upper back pain that resulted after coughing, found to
have likely pathologic fracture of right 7th rib with recent CT
abdomen showing likely primary sigmoid colon cancer with
metastases to the femurs, pelvis, liver, and ribs, now s/p
supraclavicular node biopsy (pathology pending). | 268 | 64 |
18548611-DS-10 | 28,990,427 | Dear Mr ___,
You were admitted to the Stroke Service at ___
___ after presenting with visual abnormalities and
left upper extremity weakness and numbness. You had a CT of
your brain and the blood vessels in your head and neck that was
notable for plaque build up in your arteries. MRI of your brain
showed evidence of multiple small strokes on the right side of
your brain. You had an echocardiogram of your heart that was
without evidence of a clot or hole in your heart. Your
hemoglobin A1c was noted to be high at 9.4, suggesting that your
diabetes is not under good control. You should continue to
follow with your PCP or ___ for adjustment of your
insulin regimen. Your cholesterol was noted to be high
(cholesterol 215, LDL 159) so your statin dose was increased
from 20mg to 40mg per day. Your aspirin dose was also increased
from 162mg to 325mg per day. | Mr ___ was admitted to the Stroke Service at ___
___ after presenting with visual
abnormalities and left upper extremity weakness and numbness. He
had a CT & CTA of the head and neck that showed a non-occlusive
filling defect at the M1 branch of the left MCA with appropriate
flow seen in the left MCA territory. CTA was also notable for a
diminutive left vertebral artery with non-visualization of the
origin but normal flow in the posterior circulation. MR brain
showed multiple subacute and chronic deep watershed infarcts in
the right cerebral hemisphere. Echo was without evidence of
thrombus or PFO. Mr ___ hemoglobin A1c was noted to be
high at 9.4. He will continue to follow with his PCP or
___ for adjustment of his insulin regimen. His
cholesterol & LDL were also noted to be high (cholesterol 215,
LDL 159) so his statin dose was increased from 20mg to 40mg per
day. His aspirin dose was also increased from 162mg to 325mg per
day. | 162 | 167 |
18626972-DS-15 | 20,584,995 | Dear Mr. ___,
You were hospitalized due to symptoms of right-sided arm & leg
weakness and bilateral tunnel vision 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:
Hypertension (HTN)
Hyperlipidemia (HLD)
Smoking
We are changing your medications as follows:
- Please add the following medications.
1. Clopidogrel 75 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY RX
3. Nicotine Patch 21 mg TD DAILY RX
- Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ man with history of HTN, HLD, smoking,
TIA's, carotid artery disease s/p bilateral endarterectomy
(___) who presented to ___ following a history of
right-sided arm & leg weakness 9 days before admission and
transient bilateral tunnel vision 3 days before admission with
MRI & CT results concerning for subacute infarct and bilateral
carotid stenosis.
His brain MRI from OSH is notable for a LEFT hemispheric 9 mm
periventricular infarct adjacent to the posterior body of LEFT
lateral ventricle as well as a possible RIGHT hemispheric 2 mm
infarct in the RIGHT parasaggital parietal lobe, although the
right-sided infarct may be artifact. In addition, his imaging is
notable for its vascular anatomy: both his RIGHT ACA and LEFT
MCA arise from the LEFT anterior circulation. CTA head and neck
from OSH was remarkable for >90% stenosis of Rt proximal ICA
about 1cm distal to carotid bulb, and 50% stenosis Lt proximal
ICA 1cm from bifurcation.
Carotid Doppler Ultrasound at ___ shows severe RIGHT internal
carotid artery stenosis yielding a 80-99% degree stenosis and
moderate degree of homogeneous irregular calcified plaque in the
LEFT internal carotid arteries yielding a 60-69% degree
stenosis. The patient's predominantly RIGHT-SIDED arm &
leg-weakness indicates that his LEFT circulation is symptomatic.
Vascular surgery was consulted. Vascular surgery recommended
consideration of carotid stent placement in an internal carotid
artery as an outpatient but Vascular Surgery has not yet made a
final determination regarding which carotid artery should be
stented. Medical management with aspirin, Plavix, and a statin
will be pursued on discharge; the patient was amenable to
management with aspirin and Plavix, but resistant to statin use
due to past adverse reaction to statins (muscle cramping). He is
already on ezetimibe and has had discussions about evolocumab
(PCSK9 inhibitor) with his PCP, this may be beneficial to him as
cholesterol control is very important in this instance (current
LDL 146).
His laboratory results at ___ showed elevated TSH 5.3 (nl
range 0.27-4.2), elevated CRP 16.9 (nl range ___, and high
normal %HbA1c 5.8 (nl range 4.0-6.0). His echocardiogram showed
a normal left atrium and LVEF >55%. No thrombus/mass in the body
of the left atrium and no atrial septal defect or patent foramen
ovale. The echocardiogram was notable for mildly thickened
aortic & mitral valve leaflets and mild aortic & mitral
regurgitation (1+).
Managing stroke risk factors was discussed with Mr. ___,
including lowering his blood pressure, lowering his cholesterol,
and smoking cessation. Mr. ___ was discharged on his admission
medications plus Plavix, Losartan, and nicotine patches. He was
advised to discuss further cholesterol management with his PCP.
He will follow-up with vascular surgery as an outpatient for
management of his carotid disease.
DISCHARGE ISSUES
1. Discuss evolocumab (PCSK9 inhibitor) to lower cholesterol
2. Smoking cessation counseling
3. Blood pressure management | 260 | 464 |
14240998-DS-17 | 25,232,168 | You came to the hospital on ___ complaining of worsening
abdominal pain over three days. It was determined that you have
a small bowel obstruction. You were transferred to the floor for
monitoring on NPO, IV fluids and NG tube for decompression. You
progressively got better during your hospitalization, however,
after a week of being managed conservatively, you began to feel
worse again and we replaced the NGT. This management was
pursued for several days, however, it was determined that you
were not improving as we had hoped and you were taken to the
operating room (OR) for an exploratory laparotomy with lysis of
adhesions. You recovered well from this procedure and your NGT
was removed, the pain medications you took were transitioned
from IV to oral, your Foley catheter was removed and you voided;
you were also started on a regular diet, which you tolerated.
The day of discharge you are walking, tolerating a regular diet,
voiding, your pain was controlled and you were passing flatus,
or gas from below.
You are now ready to be discharged. Please adhere to the
following instructions.
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 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
-You may start some light exercise when you feel comfortable.
-You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
-Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
-You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
-You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
-You may have a sore throat because of a tube that was in your
throat during surgery.
-You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
-You could have a poor appetite for a while. Food may seem
unappealing.
-All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
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.
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
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
It has been a pleasure taking care of you! | The patient presented to Emergency Department on ___.
Patient was evaluated by upon arrival to ED to have a small
bowel obstruction. Given findings, the patient was taken to the
floor to monitored on an NPO diet, with IV fluids and an NG
tube.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___ the
NGT was removed, therefore, the diet was advanced sequentially
to a full liquid diet, which was not well tolerated. Patient's
intake and output were closely monitored and she was made NPO
and an NGT was placed again on ___.
On ___, the patient was then taken to the operating room for
an exploratory laparotomy with lysis of adhesions and the
patient tolerated this well. She returned to the PACU where
recovery was uneventful and she was subsequently transferred to
the floor. Her nasogastric tube was retained overnight and on
the next day was removed after she tolerated a clamping trial of
approximately 5 hours. The next morning she was advanced to a
clear liquid diet, which she tolerated and in the afternoon she
was advanced to a regular diet.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 871 | 339 |
14810396-DS-17 | 27,124,616 | It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
with an infected wound of your left foot. You were treated
with IV antibiotics. We did an ultrasound that showed the
bypass graft we did in 4 month ago was clotted. We did not do
an angiogram to try to open the bypass again as further
angiographic intervention would likely have minimal benefit
given the complexity and extent of your vascular disease.
Because of the graft is clotted, you no long need to take
coumadin.
We do not think the wound on your foot will heal as the blood
flow is very poor. We have arranged a follow up appointment
with Dr. ___ in one week to discuss your options. | ___ PVD with patent femoral-femoral BPG and history of L
profunda-popliteal BPG (PTFE) ___ with subsequent occlusion
requiring thrombectomy ___ returns to the ER from his
nursing home with ~1 week worsening L hallux ulcer with
malodorous discharge, persistent dependant rubor and 2cm
pretibial eschar.
He was started on broad spectrum antibitoics. He remained
afebrile with a normal wbc and pain free. We will discharge him
on a course of oral antibiotics (Augmentin for 10 days). He
worked with ___ who cleared him to return to his nursing home.
His blood sugars were very labile from ___ to 300s although his
A1C was 7.8. ___ team was consulted and adjusted his insulin
regiment. Please continue to monitor his blood sugar closely
and adjust accordingly.
Further workup including ultrasound duplex of the graft shows
that it is occluded. Further angiographic intervention would
likely have minimal benefit given complexity and extent of
disease. We have discontinued his coumadin. He will follow up
with Dr. ___ in one week in clinic to discuss further
treatment recommendations. | 135 | 181 |
10912090-DS-25 | 28,072,342 | Ms. ___,
You came to the hospital due to feeling weak and having fevers.
We did a spinal tap, drew blood, and cultured your stool to
attempt to understand what was going on. Your blood tests did
not show us any particular cause, but indicated that your HIV is
very active. We treated you with medications to control your
HIV. You improved quickly for unclear reasons.
It is very important that you take your anti-retroviral therapy
and antibiotics. Please follow up with your PCP and your
infectious disease doctor. It was a pleasure taking care of you!
-Your ___ Team | ___ year old woman with recent CD4 17,VL 1,050,000 on ___
presented with fatigue and fever for the two days prior to
admission. Recently drained abscess was treated with Keflex due
to concern for a possible source. Multiple stool and CSF labs
pending. Patient has been afebrile since ___ with improving
fatigue. Underwent flexible sigmoidoscopy with biopsy, no active
colitis visualized, CMV viral load negative.
# Fevers, Weakness: Unclear etiology. Had staph lug___ skin
abscess which has been resolving, but still had some minimal
discharge. Other possible source was CMV Colitis, biopsy was
pending at the time of discharge but visualization by GI was not
concerning. She had only a few episodes of diarrhea during her
hospitalization. Other work-up including stool cultures and EBV,
CMV were all negative.
# Leukopenia: Initially downtrending with nadir of 1.9 (ANC 780)
on ___ and 3.1 (diff pending) on ___. DDx includes infection
vs. medication side effect (valgancyclovir). She was improving
at the time of discharge with no neutropenia.
# Recent abdominal abscess: Left abdominal cutaneous abscess,
culture only growing coagulase-negative Staph, but most
consistent with a Staph aureus or community MRSA type abscess.
Treated initially with Bactrim 5 day course (started ___.
Currently appearing well healed with no drainage or fluctuance.
She was continued on a 7 day course of Keflex to ensure adequate
treatment.
# CMV: Biopsy proven CMV in the mid-esophagus ___ with
negative biopsy of the colon at that time. Stool cultures were
negative and CMV viral load also negative. A colonoscopy was
done and the biopsy was pending at the time of discharge.
# HIV: CD4 31 on ___. Viral load 1,050,000 on ___.
Persistent viremia and low CD4 concerning for medicaiton
non-adherence. Has been getting progressively leukopenic. She
was continued on lamivudine, dolutegravir, darunavir-cobicistat
with atovaquone and azithromycin as prophylaxis.
Transitional Issues:
[ ] Medication adherence vs. genotyping: pt endorses taking her
medications and denying any barriers (although is not
knowledgeable about the medications), will likely need some
further intervention to ensure adherence as an outpatient.
CODE STATUS: FULL
CONTACT: ___ (sister) - ___ (Only sister knows her
HIV status!!) | 105 | 352 |
14596198-DS-10 | 28,066,594 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having chest pain, and you were found to be having a
heart attack.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You underwent a procedure called cardiac cath, where a stent
was placed in one of your heart arteries to open up a blockage
- You were started on new medications to treat heart disease
- You had imaging studies of your heart, which showed preserved
pump function of your heart, which is good.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention 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.
=========================== | Mr. ___ is a ___ yo man with previous smoking history and
current alcohol use disorder who presented with substernal chest
pain. He was found to have an inferior STEMI and underwent ___
___ to the RCA. He was started on appropriate medical
management and was discharged home with instructions to follow
up with PCP and cardiology.
# Inferior STEMI
# Two-vessel CAD
Patient presented with acute onset chest pain. No history of
angina or dyspnea; patient is very active cyclist and tennis
player. Risk factors include history of smoking (quit ___ years
ago) and active alcohol use (3 drinks daily). He was not
previously on any medications. He was found to have ST
elevations in leads II, III, and aVF consistent with inferior
territory ischemia. Patient received aspirin and was loaded with
ticagrelor, and subsequently underwent cardiac cath on ___
which found 100% occlusion to the RCA and 95% stenosis of OMB1.
The RCA was stented. He was then transferred to the CCU for
further monitoring. ECHO post-cath showed a preserved ejection
fraction of 50% and LV hypokinesis in the RCA territory. His
medications at discharge include aspirin, ticagrelor,
atorvastatin, and lisinopril. Metoprolol was not started due to
resting heart rates in the ___. The patient should get lipids
and ECHO in 3 months. He should continue DAPT for ___ year. He may
benefit from stress ECHO in 6 months to determine if he would
benefit from metoprolol.
# Hyperlipidemia
Post-STEMI workup identified total cholesterol of 216 and
triglycerides 252. The patient was started atorvastatin 80. He
should get repeat lipid panel in 3 months with goal LDL <70.
# Bradycardia
Unknown baseline heart rate. Presented with heart rate in the
low 50's, which persisted after revascularization. Patient
remained asymptomatic. He likely has resting bradycardia due to
his exercise regimen. Metoprolol was not started for this
reason.
# Hypertension
Patient was not on anti-hypertensives prior to presentation. He
was started on lisinopril and discharged on 5 mg daily.
# Alcohol use disorder
Patient endorses to having ___ drinks per day. He did not
exhibit signs of withdrawal on this admission. He was counseled
on alcohol cessation and limiting to maximum 2 drinks daily.
===================
TRANSITIONAL ISSUES
===================
[ ] Patient does not have medicare coverage for prescriptions
and needs to apply for this as early as possible. He was
provided with a one month supply
[ ] After obtaining prescription coverage for medications, he
will need a prior authorization started for ticagrelor.
[ ] Consider increasing lisinopril if persistently hypertensive.
[ ] Should have lipids and TTE in 3 months
[ ] Needs DAPT for one year
#CONTACT/HCP: ___
#CODE: full (confirmed) | 215 | 430 |
15575292-DS-21 | 26,456,634 | Dear ___
___ were you admitted to the hospital?
-You were feeling short of breath and noted significant weight
gain over the past week (~10 lbs)
What happened while you were here?
-You were given IV lasix to remove excess fluid and improve your
breathing
-You were also seen by ophthalmology to follow up after your eye
surgery. They prescribed you a number of drops to use on your R
eye.
What should you do when you go home?
-You should continue to take Lasix 20mg daily and should follow
up with your primary care doctor
-___ should weigh yourself every morning, and call your doctor
if your weight goes up more than 3 lbs
It was a pleasure taking care of you,
Your ___ Care Team | Ms. ___ is a ___ w/ HFrEF (LVEF 40%), RCC s/p nephrectomy c/b
CKD, HTN, T2DM, PVD s/p R transmetatarsal amputation, and
neovascular glaucoma now s/p vitrectomy (___) who was admitted
with acute dyspnea. Patient was diuresed for an acute heart
failure exacerbation with improvement in shortness of breath.
ACUTE ISSUES
============
#Dyspnea:
#Acute on chronic systolic CHF with LVEF 40%:
Patient typically takes 20mg furosemide daily, however diuretic
was held on ___ due to worsening renal function. Patient's
acute dyspnea was attributed to ___ exacerbation. On admission
probnp was 4746 and patient's weight was up ~8lbs since ___.
Less likely, but also on the differential was PNA. Patient was
initially started on azithro/ctx, however abx were discontinued
as patient remained afebrile with no leukocytosis, a
nonproductive cough and an unremarkable CXR. Patient was
diuresed with 60mg IV Lasix and reported improved breathing. Her
weight downtrended 2.5kg since admission. She was discharged
home on 20mg po Lasix.
#Neovascular glaucoma s/p vitrectomy ___: Patient was seen by
ophthalmology inpatient who started her on right PredForte 1%,
Atropine 1%, Cosopt (timolol/dorzolamide), and Alphagan
(brimonidine) drops as well as Polysporin ointment. Patient only
requires her hard shield for R eye at night.
CHRONIC ISSUES
==============
#HTN: Stable. continued on Metoprolol Succinate XL 50
#T2DM: Stable. Patient was continued on 14units NPH BID and
insulin sliding scale with appropriate FSBG. Patient reports a
follow up appointment with ___ Diabetes scheduled ___.
#PAD s/p R transmetatarsal amputation: Stable. Continued on
aspirin, plavix.
TRANSITIONAL ISSUES
===================
[]Patient was discharged on lasix dose of 20mg. Creatinine was
downtrending from 1.8 to 1.6. Please adjust Lasix dose as
necessary.
[]Patient should continue to take prescribed eye drops per
ophthalmology and has scheduled follow up with them on ___. | 120 | 298 |
13905910-DS-14 | 25,042,015 | You were admitted to ___ with abdominal pain and were found to
have a bowel obstruction. You were taken to the operating room
and underwent an exploratory laparotomy and lysis of adhesions.
You tolerated this procedure well. You are now tolerating a
regular diet and your pain is under control with oral
medications; you are ready to be 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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed a closed loop bowel
obstruction. The patient underwent exploratory laparotomy and
lysis of adhesions, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
nothing by mouth with a nasogastric tube, on IV fluids, and an
epidural for pain control. The patient was hemodynamically
stable. On POD1, the nasogastric tube was discontinued and the
patient was given sips. She was endorsing return of bowel
function. On POD2, the patient was started on clears and the
epidural and Foley catheter was removed.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She had follow-up scheduled in the ___
clinic. | 362 | 256 |
18347490-DS-10 | 29,189,491 | Dear Ms. ___,
We admitted you to help manage your low sodium level which
occurred in the setting of a severe migraine. You were given IV
fluids until your oral intake improved. You are now doing much
better and are safe to go home.
We wish you the best with your health.
___ Medicine | # Hyponatremia: Pt received NS repletion and Na was monitored
frequently, w/IVF being titrated to goal rates of correction. At
time of d/c, pt's Na is 129. PO intake was much improved,
migraine resolved, so expected that she would continue to
normalize with time. She was amenable to discharge today,
feeling back to normal.
# Migraine: Pt received standard migraine therapy w/ IVF,
antiemetics, ketorolac, and symptoms improved throughout
admission. Imitrex nasal spray prescribed at discharge in case
of need for abortive therapy.
# Dispo: Pt will be d/c'd to home to f/u w/ PCP. I asked her to
schedule an appointment within 7 days. I wrote her a
prescription for lab work (sodium level) for early next week.
>30 minutes spent coordinating discharge home | 52 | 123 |
15974873-DS-9 | 24,904,503 | Dear Mr. ___,
You were admitted to ___ for an infection by a bacteria called
fusobacterium. You had the infection in your bloodstream, liver,
and around your right lung. You were treated with antibiotics
and drainage of your liver abscess and the infected fluid around
your lung. Your fevers/chills, nausea, and chest pain improved.
It is unclear what the source of this infection was. You will
require 4 weeks of the IV antibiotic called ertapenem to
completely get rid of this bacterial infection. You will
follow-up with the lung doctors that placed and removed your
chest tubes, as well as with the infectious disease doctors.
Your cholesterol medication was held out of concern for damage
to your liver with the abscess. You should discuss restarting
this medication with your PCP.
It was a pleasure taking part in your care at ___ and we wish
you a speedy recovery! | ___ y/o M PMH hyperlipidemia with recent history of liver abscess
s/p ___ drainage and fusobacterium bacteremia, now
re-presenting with recurrent fevers/pleuritic chest pain and new
CT findings of fluid collection in right pleural space. | 147 | 35 |
12259649-DS-15 | 20,776,204 | You were admitted to the hospital due to meningitis, which was
caused by a type of enterovirus. Your condition improved after
about a week. You can follow-up with your primary care doctor,
as well as the infectious disease and neurology doctors as noted
below. | ___ with hx of "syncope with seizures" (extensive workup at
___ reportedly unrevealing), migraine headaches
transferred from ___ for further evaluation for
meningitis, ultimately found to have aseptic meningitis due to
an enterovirus.
# Aseptic meningitis due to enterovirus
Patient presented with neurologic symptoms as described above,
headache, photophobia, fever, and neck stiffness. Her LP at
___ was consistent with aseptic meningitis, although she
was noted to be at risk for bacterial meningitis due to lack of
prior vaccine administration. She was transferred to ___ due
to lack of ID consultation at ___. She had initially been
started on broad antimicrobial coverage, although antibiotics
were later stopped due to low concern for bacterial cause and
lack of evidence from tap. However while admitted her course
worsened and she underwent a second LP, which showed a rising
pleiocytosis, although with a greater % of lymphocytes (see
above), and so she was restarted on antibiotics on ___ given
the diagnostic uncertainty. Ultimately her symptoms improved and
given continued lack of growth on cultures her antibiotics were
stopped. Toward the end of her course her enterovirus assay from
___ returned positive, confirming the diagnosis of viral
aseptic meningitis.
#Nausea/vomiting
Patient ate minimal food during her meningitis course, and once
her symptoms were improving and she tried eating again she had
___ days of nausea and vomiting. However this improved somewhat
and she was tolerating fluids and bland food prior to discharge.
This was likely due to her prolonged poor intake, the virus, and
antibitoics.
#Rash
The patient developed an erythematous pruritic rash with
pinpoint vesicles vs pustules toward the end of the admission.
It was only on her back, buttocks, and back of neck, and was
suspected to be heat/sweat rash. Improved with use of cotton
clothing and reduced time in bed. Also possible the rash was due
to the virus.
======================================== | 44 | 304 |
18362524-DS-27 | 22,073,657 | Dear ___,
___ came to the hospital with lower extremity swelling in the
setting of ___ weeks of sore throat and productive cough. We
think that ___ are having a flare of your bronchiectasis with a
likely bacterial infection in your lungs. We gave ___ IV
antibiotics to treat this infection, and ___ slowly regained
your ability to breathe comfortably on room air and your cough
seemed to improve. ___ are transitioning to a rehab facility to
continue your care until ___ are strong enough to return home.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | Ms. ___ is an ___ year old female with mild bronchiectasis
and past hx of pulmonary TB, MAC infection s/p treatment who
presented with one day of increased bilateral leg swelling in
the setting of 7 days of productive cough and 2 weeks of sore
throat, found to have likely bronchiectasis flare. | 101 | 52 |
15647805-DS-6 | 23,185,184 | Dear ___,
___ was our pleasure to take care of you here at ___
___. You were admitted to the hospital
after a seizure in which you lost consciousness for 10 minutes
and were found to have low blood pressure and loss of bladder
control. The reason for your seizure was not entirely clear, but
may be due to several factors, including not taking your seizure
medication in the past few days prior to admission and a recent
increase in depression and anxiety symptoms.
In the hospital, you developed high fevers and you were treated
for a post-obstructive pneumonia. You did have a seizure during
your hospital stay, resulting in lethargy and low blood
pressure, and you were transferred to the intensive care unit
for 1 day for stabilization.
You had a mass in the left upper lobe of your lung. You
initially underwent a transbronchial (through the lung) biopsy
of this mass, which showed inflammation. You then had an
interventional radiology-guided biopsy of this mass. The
pathology of this mass revealed small cell lung cancer. You were
not able to make medical decisions for yourself because of
confusion from a condition called delirium, which often occurs
in patients who were as sick as you.
You were transferred to the oncology service where it was
decided with your family that you would not receive radiation or
chemotherapy and you are being discharged to hospice care. You
continued to be very sleepy but intermittently more awake. | ___ with hx of renal cancer s/p nephrectomy ___, hx of
cavernoma s/p brain radiation ___, hx of seizure disorder on
oxcarbazepine, CVA ___ on lifelong clopidogrel, recent LUL
pneumonia ___, admitted ___ after 1 episode of
generalized complex seizure and hypotension, with left
mediastinal mass found to be localized small cell carcinoma. Her
course was complicated by hypoactive delirium requiring
activation of her daughter's health care proxy, and the decision
was made in consideration of the patient's prior stated wishes
to forego treatment and transition to hospice care.
# Left upper lobe mass with post-obstructive pneumonia. Left
suprahilar mass was concerning for malignancy. Patient spiked
daily fevers despite being initially on vancomycin and cefepime
and then on vancomycin and Augmentin. She was switched to
vancomycin and Zosyn on ___. She continued to spike fevers up
to Tmax 103 every ___hest scans showed left
upper lobe mass with worsening bronchial invasion consistent
with post-obstructive pneumonia. Given the high likelihood of
malignancy and with her goals of care, Palliative Care was
consulted on ___. She underwent a transbronchial ultrasound
of her mass on ___. Pathology showed acute organizing
pneumonia and acute on chronic inflammation. Due to her
continual fevers, nondiagnostic EBUS result, and the high
suspicion for malignancy, she underwent a CT-guided biopsy of
her left lung mass on ___. Patient was treated with
vancomycin, clindamycin (___), aztreonam, where were
stopped on ___ per ID recommendations. She was also on
azithromycin for several days for atypical coverage which was
stopped on ___.
Cytology showed small cell lung carcinoma. Heme/Onc and Rad Onc
were consulted on ___. Rad Onc was not comfortable giving the
patient radiation given the location and size of the mass, and
her poor performance status. They recommended chemotherapy
first. The patient was transferred to the oncology service her
course was complicated by hypoactive delirium requiring
activation of her daughter's health care proxy - she was
determined to be unable to consent for chemotherapy. The
decision was made, despite the chemo-sensitive nature of
localized small-cell, in consideration of the patient's prior
stated wishes to forego chemotherapy in the event that the mass
was cancer (her mother had previously said "I am sick and tired
of being sick tired"), as well as the likelihood that given her
deconditioned state she would be unlikely to tolerate
chemotherapy, to transition her to hospice care. She then
emerged from her delirium, saying she wanted "not to die"...
# AMS: Patient's course was complicated by progressive
hypoactive delirium characterized by absence of verbal responses
and refusing of most POs. She was seen by psychiatry who felt
that this was most likely ___ multifactorial causes including
seizures, sepsis, progressive malignancy. Small cell carcinoma
is not typically associated with paraneoplastic encephalopathy.
This was likely all exacerbated in the setting of underlying
cerebrovascular disease. Psychiatry recommended methylphenidate
for stimulating effects, as well as treatment of whatever
component of her presentation was related to depression, but she
continued to refuse POs. She was given D5-NS as maintanence for
euvolemia. Her daughter's healthcare proxy was activated for
healthcare decisions as the patient was determined to not have
capacity. Amitriptyline and mirtazpine were held due to her
altered mental status. This improved...
# Seizure. On day of admission, patient had a 10-minute episode
of generalized complex seizure with loss of conscioussness and
urinary incontinence. She states normal seizures for her are
loss of consciousness with tonic-clonic movements and post-ictal
confusion. Never urinary incontinence of tongue biting. Patient
reported nausea hours before episode. After discussion with her
daughter, the patient had missed several doses of her Trileptal
prior to day of admission for unclear reasons. She states she
forgot. Denied any side effects from the Trileptal. Etiology of
her seizure was most likely due to Trileptal noncompliance and
increased depression and aggravation recently (historical
trigger for her). ECG with 60 NSR, normal intervals, axis, no
ischemia, T-wave flattening V1-V2. Tox screen negative.
Noncontrast head CT normal.
On ___, patient was noted to be more lethargic than usual.
A 24-hour EEG was obtained which showed mild encephalopathy, no
seizures. On ___, pt was found to be unresponsive on
routine visit, and a code stroke was called, where a STAT CT
head was unchanged from prior. She was given 4mg IV Ativan, with
subsequent improvement in mental status, but ultimately required
another 3mg IV Ativan. Neurology team recommended loading her
with Fosphenytoin 1.5g IV empirically and starting standing dose
of 100mg IV q8hrs. She became hypotensive to SBP ___ and was
transferred to the MICU for closer monitoring. Mental status
slowly improved in the ICU and Fosphenytoin dosing was adjusted
per levels. EEG showed no seizure but diffuse slowing of
background waves. Patient was taken off oxcarbazepine while she
was on fosphenytoin to avoid further lethargy and altered mental
status. She was briefly on fosphenytoin for several days. This
was discontinued on ___ as the patient was mentating at her
baseline. She was restarted on her home oxcarbazepine 600mg PO
BID per Neurology recommendations but because of delirium the
patient was refusing POs. She was put back on IV fosphenytoin
for seizure prevention with palliative intent because she was
refusing PO meds. She was discharged on PR phenytoin for
prophylaxis.
# Hypotension. She was transferred to the MICU on ___ for
hypotension due to Ativan and Fosphenytoin loading dose. Blood
and urine cultures were negative. CXR with unchanged left upper
lobe mass. No other localizing signs of infection. She was
quickly weaned off Levophed on arrival to the ICU.
# Stroke prevention. Patient was on clopidogrel 75mg daily for
history of stroke. We spoke with her neurologist Dr. ___ on
___. She is on clopidogrel for chronic small vessel
ischemic strokes. She was previously on aspirin but failed
therapy as she continued to have ischemic changes, so she was
switched to clopidogrel. For her procedure on ___, she needed
to be off anticoagulation for 5 days. Her clopidogrel was
stopped after her ___ AM dose. We discussed the risks and
benefits of stopping her anticoaguation given her risk for small
vessel ischemic disease during this ___ period.
Patient and her daughter (healthcare proxy) agreed to stop
clopidogrel in advance of the procedure. In anticipation for her
CT guided biopsy, clopidogrel was held again. It was restarted
on ___ but the patient began to refuse POs in the setting
of hypoactive delirium. It was not continued in the setting of
transition to hospice care.
# Anemia. Prior hematocrits ___ range, last ___ was 35.
Previously normal MCV, ___ was 81. Patient stated she had
normal colonoscopy ___ years ago. No recent melena or
hematochezia. Guiac negative in ED. Patient had hematocrit nadir
of 20.8. She received 1 unit pRBC on ___ and her hematocrit
responded to 23.6. Etiology of her anemia was most likely anemia
of chronic disease, bone marrow suppression from multiple
antibiotics and antiepileptics, and/or progressive malignancy.
She also received 2u pRBC after a mechanical fall with
appropriate rise in hematocrit. See below.
# Mechanical fall. Patient had a mechanical fall on ___ AM
while getting up to use the bathroom. It was unwitnessed, but
there was a head strike on chair and then on floor, with blood
pooled on the floor. She had a 1-inch laceration on her right
parietal-temporal area. She was evaluated by ACS where they
applied 9 staples with good hemostasis. CT head with no acute
changes. CXR with no hemothorax. She complained of some right
hip pain. Bilateral hip xrays were negative for fracture. She
was started on oxycodone 5mg PO Q6H PRN pain. She did have a
hematocrit down from 25.3 to 21.9, and she received 2u pRBC with
rise up to 26.0 the next morning. She did not have evidence of
rebleeding at discharge.
# Leukopenia. Her WBC downtrended during her hospitalization.
This was believed to be medication-induced, especially given her
cefepime use, fosphenytoin, and multiple other antibiotics. Her
leukopenia improved.
# Transaminitis. Patient's AST, ALT, and alk phos were elevated
during this admission, with normal TBili. Etiology believed to
be medication induced, especially due to fosphenytoin, given the
time course of her transaminitis after fosphenytoin was started
on ___. Her LFTs downtrended. She did have a RUQ ultrasound on
___ which did not show any liver or gallbladder pathology.
Her LFTs improved without intervention.
CHRONIC ISSUES
# Hypertension: Held triamterene-Hydrochlorothiazide given nml
BPs.
# Hyperlipidemia: Discontinued pravastatin at discharge given
transition to hospice
# GERD: Continued ranitidine in case patient starts to take POs,
for comfort.
# Depression: Amitriptyline and mirtazapine were held due to
altered mental status.
### TRANSITIONAL ISSUES ###
- PO vs PR fosphenytoin with palliative intent to prevent
seizures.
- Scalp staples should be removed before ___ if
laceration has closed
- if she continues to be very somnolent please consider checking
phenytoin level and correct for albumin as high levels could
make her somnolent. You could also go down on her gabapentin. | 243 | 1,478 |
16715999-DS-36 | 24,167,627 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for severe back pain.
What was done for me while I was in the hospital?
- You were treated with pain medication which helped get your
pain under control.
What should I do when I leave the hospital?
- Please continue all your medications as prescribed.
- Please attend all your appointments as scheduled.
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES:
=====================
[ ] Completed 7-day course of Augmentin for bacterial bronchitis
which was started as outpatient prior to admission. Please
follow-up resolution of respiratory symptoms. | 92 | 25 |
10017393-DS-6 | 21,985,481 | Dear Dr. ___,
___ was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
for the onset of petechiae, purpura, lower leg swelling, and
ankle tenderness, predominantly on your right lower leg, in the
setting of 7 days of Augmentin usage. Upon admission, you were
found to have signs of mild injury to your liver and kidney. You
were found to have a leukocytoclastic vasculitis and your
symptoms managed with cessation of Augmentin and initiation of
prednisone, to which you responded well.
On discharge, it is important for you to continue applying
vaseline to your biopsy site with a change in the bandaid daily.
Continue to wrap the leg and elevate it to facilitate resolution
of the edema. If the rash worsens or becomes more bothersome,
please page dermatology at ___ during business hours or call
___ and request pager ___ after hours.
Please continue to take your home medications as prescribed. In
particular, you should take 20 mg of prednisone daily for 1 week
from discharge, after which you should take 15 mg of prednisone
daily until you have your follow-up rheumatology appointment.
For management of your pain, ibuprofen or tylenol are acceptable
but do not exceed 2 g tylenol daily given your recent
transaminitis.
Take Care,
Your ___ Team. | Dr. ___ is a ___ year old woman w/ h/o spontaneous retinal tear
admitted w/ palpable purpura in bilateral lower extremities and
right ankle swelling in the setting of Augmentin (which she
started for suspected sialolithiasis and submandibular gland
infection), found to have leukocytoclastic vasculitis and
improved with cessation of Augmentin and initiation of
prednisone. | 213 | 55 |
14535212-DS-15 | 28,950,260 | Ms. ___,
It was a pleasure to care for you at ___. You were admitted to
the General Medicine service with the chief complaint of tremor
and difficulty walking. We think that your symptoms were caused
by withdrawal from alcohol. You did not have any other symptoms
of withdrawal during your hospital stay. An ultrasound of your
liver showed no new changes to your chronic liver disease. You
were found to have an infection of your urinary tract, which we
treated with antibiotics while you were in the hospital.
Please continue your current home medications. You do not need
to take pentoxifylline. We talked this over with Dr. ___.
We prescribed a multivitamin, thiamine, and folic acid, which
you should take once daily.
Please follow up with your primary care provider, Dr. ___,
___ 7 days of discharge. | In summary, Ms. ___ is a ___ year old woman with history of ETOH
cirrhosis w/varices (MELD 19), and multiple recent
hospitalizations for acute hepatitis, who presents with
tremulousness and difficulty with motor skills at home, found to
have elevated LFTs compared to 3 weeks prior, but within
baseline range. | 136 | 50 |
17688794-DS-16 | 27,109,110 | Dear ___,
___ was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having a lot of difficulty breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- A CAT scan of your lungs showed that you had a lung infection,
called a pneumonia.
- You were given antibiotics through an IV to treat your lung
infection.
- An ultrasound of your heart (called an echocardiogram) showed
that your heart was not pumping properly.
- You did not have a heart attack, and we expect your heart
function will improve with time.
- You were feeling much better and were ready to leave the
hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Outpatient Providers: ASSESSMENT/PLAN
=================
Ms. ___ is a ___ y.o. female with a past medical history
significant for ulcerative colitis status post total colectomy
with end ileostomy, osteoporosis, history of lung adenocarcinoma
S/P resection ___, peripheral neuropathy, and chronic abdominal
pain, spinal stenosis s/p spinal surgery at ___
on ___ and discharged to rehab facility on ___, who presented
with nausea and vomiting, and later developed acute hypoxemic
respiratory failure, likely secondary to pulmonary edema in the
setting of global cardiac systolic dysfunction from stress
cardiomyopathy. She was also treated for a pneumonia.
TRANSITIONAL ISSUES:
======================
[ ] She will continue 1 more day of antibiotics (doxycycline) to
complete a 5 day course for pneumonia, which will be completed
on ___.
[ ] Her blood pressures are chronically low, without symptoms;
her blood pressure goal should be to maintain MAP >60.
[ ] She should follow up with Dr. ___ at
___, for consideration of hiatal hernia repair.
[ ] Her cardiologist should obtain a repeat TTE in ___ to
assess for recovery of systolic function.
[ ] Her cardiologist should consider starting her on ___
and beta blocker once her BPs can tolerate these medications, as
they may help recovery of her cardiomyopathy.
[ ] Her cardiologist should coordinate with her spinal ___
as to when to initiate systemic anticoagulation (cardiology
recommended apixaban 2.5mg BID given CM).
#CONTACT: ___
___: ___
ACUTE ISSUES
=======================
#Hypotension
#Newly reduced EF
#Stress cardiomyopathy
Patient presented with hypotension and shortness of breath. An
echocardiagram showed EF of ___, with akinesis of mid, distal
and apical segments suggestive of stress cardiomyopathy; no
evidence of active ischemia on EKG or biomarkers. Her BP
remained low throughout hospitalization, which appears to be her
baseline, as she was asymptomatic and without any evidence of
end organ damage. For her cardiomyopathy, cardiology recommended
initiation of beta blocker and ace inhibitor when appropriate
from a blood pressure standpoint, as well as follow-up TTE at
___ weeks for surveillance of cardiac function. Additionally, it
was recommended that she start on systemic anticoagulation given
the high risk of thrombus; however, in discussing this with her
spinal ___ (Dr. ___ at ___), there is a
very high risk of bleeding post spinal surgery. A decision about
when to initiate anticoagulation will need to be made by her
cardiologist, in conjunction with her spinal ___.
# Acute Hypoxemic Resp Failure
# Acute Pulmonary Edema
# Pneumonia
Initial CXR showing pulmonary congestion concerning for volume
overload, also with evidence of possible pneumonia. Her
pulmonary edema responded well to IV diuretics. She was started
on IV Vancomycin and ceftazadine, with improvement in clinical
status. She was discharged with one more day of oral antibiotics
(Doxycycline) to complete a ___HRONIC/RESOLVED ISSUES
=========================
# Spinal Stenosis
S/p spinal fusion. Continued baclofen and dilaudid.
# Chronic Depression
Continued lexapro, prestiq, temazepam
#Urinary Retention
Patient presented with foley catheter, which was placed post
spinal surgery for retention. Plan per ___ discharge
summary is to leave for 2 weeks, and see urology as outpatient
before removal. Successful voiding trial ___, and ___ was
dc'd.
# Chronic Abdominal Pain
# Inability to tolerate PO
The patient reports that she has had chronic abdominal pain
since
___. S/p work up w/ GI w/ elimination diets, MRI/MRA which
demonstrated questionable celiac artery stenosis. Patient
requires prn compazine. Also has hiatal hernia on imaging and
may benefit from a surgical referral. | 150 | 541 |
10672112-DS-10 | 29,497,850 | Dear ___,
___ were admitted to the ___ on ___ with couging up green
sputum and fevers. ___ were evaluated and treated here for a
pneumonia with intravenous antibiotics. ___ improved on these
medications and will go home with oral antibiotics and have
follow up in Dr. ___.
Please continue taking:
alendronate - 70 mg Tablet once weekly on ___
fluticasone - 50 mcg Spray two puffs in each nostril once daily
lisinopril - 20 mg Tablet once daily
aspirin - 81 mg Tablet once daily
calcium carbonate-vitamin D3 [Calcium 500 + D] once daily
Please START the following mediciations at home:
Cefpodoxine 200mg one tablet twice per day for three days until
___
Azithromycin 500mg one tablet for one day until ___
It was a pleasure looking after ___ at the ___ | PNEUMONIA: Patient with undertreated CAP pneumonia for assorted
reasons. The etiology of her recurrent RLL Pna's is not
abundantly clear, though Dr. ___ has raised the possibility
of bronchiectasis and she admits to coughing while eating. She
has not had a decent trial of traditional CAP treatment with her
having an allergic reaction to levaquin, diarrhea with
augmentin, getting a mystery antibiotic at ___ then getting
discharged without pneumococcus coverage. Patient also had
diarrhoea, likely a drug response from augmentin, has been
on-going and could also have contributed to malabsorption of her
antibiotics. She was treated in-house with IV Ceftriaxone 1g
Q24H (intended 7 day course, start date ___ and PO Augmentin
500mg Q24H (intended 5 day course, start date ___. She did
very well on these and was switched over to oral therapy on
___. Her oral therapy consisted of Cefpodoxine 200mg BID
and Azithromycin 500mg q24H. She was discharged on ___ and
will be followed up by her PCP and Dr. ___. | 124 | 168 |
17078621-DS-20 | 27,236,009 | Dear Ms. ___,
You were admitted to the hospital for a severe UTI which
involved your kidney (pyelonephritis). You were given IV
antibiotics and IV fluids and you improved.
Please take your antibiotics for 10 more days.
Sincerely,
Your ___ Team | ___ y/o ___ F with no
significant PMHx who was transferred here from OSH ED with
urosepsis/pyelonephritis.
# UROSEPSIS:
# PYELONEPHRITIS:
Pt with fever, tachycardia, and hypotension at OSH requiring
pressors transiently. UCx grew E coli pansensitive from
___. No
symptoms of PNA. Flu
negative. She was treated with vancomycin, CTX, flagyl, and
cefepime at OSH. Improved and was off pressors in ___ ED so
was sent to ___ floors where she was transitioned to
ciprofloxacin for discharge for 10 day total course.
# TRANSAMINITIS
#HBV: Mild AST and ALT elevated that improved to normal during
admission. Tested for hepatitis and found HBcAb positive and
HBsAg positive consistent with chronic HBV. No evidence of
cirrhosis on OSH CT scan. Patient did not know she had HBV and
we discussed the diagnosis during admission. Discussed that she
will need follow up for this condition.
# Hypophosphatemia: Mild and improved with repletion.
# Hypocalcemia: Mild. Corrects to 7.9.
# Hypoalbuminemia:
- nutrition c/s recommended Ensures and MVI w/ minerals | 37 | 152 |
11644797-DS-21 | 29,483,434 | Dear Ms. ___,
You came to the hospital after falling. You had a scan of your
head that did not show evidence of bleeding. While you were in
the hospital your heart rate was noted to be rapid because of a
condition you have called atrial fibrillation. We started you on
a medication called metoprolol to help control your heart rate.
We recommended that you stay in the hospital for further
monitoring and work up of your low sodium levels but you elected
to leave the hospital. You were able to voice the risk of
leaving including bleeding in the head and more falls.
Please monitor yourself very closely for headache, seizure,
vision changes, or chest pain. These are all reasons to
immediately seek care in the emergency room.
Please continue to follow up with your primary care physician.
An appointment has been scheduled for you. Please see discharge
instructions.
Your ___ Team | ___ with afib presents s/p mechanical fall, found to be in afib
w/ RVR:
# Afib: Hx of afib on pradaxa and nadolol. Presented with
asymptomatic, HDS Afib w/ RVR w/ rates to 140s. Exacerbating
factor could have been recent fall. There might also be an
element of hypovolemia given poor PO intake. No signs of
infection (no leukocytosis, afebrile, no symptoms). Nadolol 20
mg was stopped and fractionated metoprolol was started for
titration to rate control. Patient was continued on pradaxa with
monitoring for ___ iso head trauma (CT neg). Patient continued
to have afib w/ RVR, but was asymptomatic, HDS and requested to
be discharged despite medical advice to remain hospitalized for
monitoring on telemetry. She expressed understanding of risks of
fall which could lead to injuries, hemorrhage, and death. She
was discharged on metoprolol XL 100 mg.
# s/p mechanical fall: The patient endorsed a mechanical fall
without associated symptoms or loss of consciousness, though
there was some concern for possible underlying cardiac etiology
given severity of patient's fall. Patient did endorse head
strike. Patient had ecchymosis/abrasions of right eye. Right
knee w/ ecchymosis w/ intact ROM. CT head negative for acute
hemorrhage or orbital fracture. Patient was ambulating
independently prior to discharge. Patient felt well prior to
discharge w/ no focal neuro deficits.
# At-Risk EtOH Use: Patient reports anywhere from 2 bottles of
wine per WEEK to ___ bottle wine per NIGHT. There is some c/f
EtOH use disorder. Patient initiated on multivitamin and
thiamine prior to discharge.
---------------
CHRONIC ISSUES:
---------------
# HTN: Continued home enalapril with good BP control.
# HypoNa: Ongoing issue (126 as outpatient) and unknown
etiology; thought to be contributing to her cognitive deficits
(memory loss). Was being followed as outpatient w/ CXR w/ no
mass. We recommended patient stay in the hospital for further
___, but she expressed capacity and wanted to
leave so she could be home for ___. Of note, patient Na
went from 125 > 128 after fluids, which argues against SIADH.
# ?Mild Cognitive Decline/Memory issues: Unknown etiology but
could could be due to hyponatremia vs. EtOH use disorder.
Previous MRI head w/ mild atrophy. Ongoing f/u as outpatient w/
Dr. ___.
--------------------
TRANSITIONAL ISSUES:
--------------------
#STOPPED MEDICATIONS: Nadolol 20 mg
#NEW MEDICATIONS: Metoprolol XL 100 mg for rate control, Daily
multivitamin, Daily Thiamine
[] Please follow-up heart rate as outpatient and consider
uptitration of metoprolol as needed.
[] Ongoing monitoring of mental status in setting of head strike
and anticoagulation
[] TSH and B12 pending at time of discharge as part of
hyponatremia w/u
[] Consider checking morning cortisol in setting of hyponatremia
[] Please consider ongoing monitoring/education for at-risk EtOH
use/EtOH use disorder | 149 | 441 |
14138155-DS-19 | 25,578,697 | It was a pleasure taking care of you at ___. You were
admitted to the hospital with mental status changes. You were
initially treated for a meningitis but your cultures were
negative. You completed a course of antibiotics (ceftriaxone)
for a urinary tract infection. You were seen by the psychiatry
service and the dose of your clozapine was adjusted (decreased).
You continued to be very withdrawn and minimally interactive
and will need to follow up with a neurologist and psychiatrist
after discharge. | ___ yoM with schizophrenia vs dementia and anemia who presented
with acute encephalopathy and fevers.
# Acute encephalopathy: He presented to the hospital confused.
This was felt initially to be due to infection given concurrent
fevers. His infections were treated but he remained very
withdrawn. His initial confusion subsided but he remained
minimally interactive and would only answer some questions. He
was followed by the ID and psychiatry consult teams. TSH, B12,
RPR were normal.
# Fever: Source of initial fever was unclear. CXR was not
consistent with pneumonia. Blood cultures were positive in ___
bottles for coag-negative staph which was felt to be a
contaminant as he remained afebrile and subsequent cultures were
negative. LP results were not consistent with bacterial
meningitis but he was treated for this empirically
(vanco/CTX/ampicillin) until CSF culture returned negative. His
antibiotics were changed to ceftriaxone only to treat
complicated UTI as his UA was positive on admission, although
culture was negative. Given his LP did have ___ WBC, it was
though he could have had an aseptic meningitis but enterovirus
PCR from the CSF was unremarkable. He completed a 7 day course
of ceftriaxone during admission.
# Schizophrenia vs Atypical dementia: He has a very severe case
of schizophrenia vs other psychotic disorder. He was followed
closely by the psychiatry team. Clozapine was continued but
dose was decreased due to high trough levels. He remained very
withdrawn with strong negative symptoms, although did not appear
to have active psychosis. Please see the psychiatry team's
recommendations below:
***--continue reduced dose of clozeril for 150 mg po BID, goal
level: 350-500
--Please check clozepine trough before AM or ___ dose on ___
--Avoid polypharmacy and avoid anti-cholinergics,benzodiazepines
and opioids as much as possible as these medications can
contribute to delirium
--OK to hold gabapentin given sedation risk and deliriogenic
***--Continue to identify and treat underlying medical
conditions
as you are (treated for possible infection)
***--Given history of stiffness with haldol and calcified basal
ganglia would avoid antipsychotics other than clozaril. please
re-consult psychiatry in case of agitation to discuss
possibility
of using ativan OR olanzapine.
***--If clinical picture does not improve, consider Neurology
consult for EEG (no signs of seizure) and head MRI (pt could not
cooperate) when to rule out seizures andevaluate basal ganglia
findings in this man with concurrent
atypical psychosis and cognitive decline
--Frequent reorientation regarding time and location, increase
stimulation during the day (TV, lights on, encourage family
visits, decrease sleep), and decrease stimulation at night for
regulation of sleep/wake cycle.
.
1. Pt will need a clozaril level/trough drawn ___ am. Goal
trough is 350-500. ___ d/w psychiatry if level is not
appropriate as dose was recently decreased.
2.Pt will need to follow with a psychiatrist closely after
discharge
3.Pt will need to be set up for a cognitive neurology evaluation
after discharge.
"In small controlled RCT studies, memantidine (20 mg per day)
and
modafenil (300 mg/day) have been identified as potentially
beneficial augmentation agents to clozeril. Although
memantidine
is a D2 agnoist and may worsen psychosis, there is evidence that
this agent improves baseline cognition (increase of 6.12 points
in MMSE). The evidence for modafenil (300 mg per day) is more
equivocal but is generally well-tolerated and not known to have
a
dopaminergic impact. However, the patient exhibits poor PO
intake
(though this has improved recently) and modafenil is a known
appetite suppressant. These medications warrant consideration
in
an outpatient setting after his Clozeril levels normalize."
# Hypernatremia, Hypokalemia, Hypomagnesemia: He had poor po
intake and required intermittent free water repletion. This
improved. Nutrition evaluated the patient and recommended
Scandishake 3 per day.
# Mood disorder: Stopped sertraline per psych recs. Trazodone
was also discontinued.
# Iron deficiency: Continued ferrous sulfate
# Hyperlipidemia: Continued home statin
.
Transitional issues.
1.Please follow up ___ am clozaril level, as level was high and
dose decreased during admission. Goal trough 350-500.
2.please set pt up with regular psychiatry f/u
3.please set up pt with a cognitive neurology follow up. | 87 | 643 |
10275325-DS-3 | 29,093,969 | 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-weightbearing left upper extremity. Okay for coffee-cup
but NO more weight than that.
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 aspirin 325mg once daily for 4 weeks. This is to
prevent blood clots. You will not need to take this medication
forever.
WOUND CARE:
- You may shower after 3 days. 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.
- You may take down the ACE wrap after 3 days. After this,
incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
Please call his office to confirm this appointment at the time
of your discharge. His office number is ___. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of his L distal humerus
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The ___ 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
nonweightbearing in the left upper extremity, and will be
discharged on ASA 325mg 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. | 630 | 250 |
15035323-DS-3 | 24,986,279 | Dear Mr. ___,
You were admitted to ___ because you were withdrawing from
alcohol. You also had abnormal liver function tests which
suggests you have inflammation of your liver due to alcohol.
You were admitted to the ICU for management of withdrawal and
then transferred to the floor. You were started on nutritional
supplements and your liver function recovered well.
Please note the following changes to your medications:
-START thiamine, folate, calcium, vitamin D, multivitamin
It is also very important that you refrain from drinking
alcohol.
Please see below for your currently scheduled appointments at
___.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery. | Pt is a ___ y/o male who presented with alcohol withdrawal,
transferred to the ICU for management of withdrawal and
alcoholic hepatitis
Active Problems:
# Alcohol withdrawal: Last drink on the afternoon of ___
and he had been drinking up to 1.5L wine per day for an extended
period of time. Pt was requiring increasingly frequent dosing of
ativan and was therefore tranferred to the MICU. In the MICU
psychiatry was consulted and recommended loading him with
diazepam. He required approximately 100-120 mg of diazepam
before scoring less than 10 on the CIWA scale. His tachycardia,
diaphoresis and tremors improved and was subsequently
transferred back to the medical floor. On the floor he
continued a very slow valium taper and required intermittent
valium dosing for anxiety, tremulousness and tachycardia for
about a week. He was also started on thiamine, folate and
multivitamin, which was continued throughout his
hospitalization. He continued to be anxious at the time of
discharge, and close follow-up was arranged.
# Alcholic Hepatitis: Pt presented with classic AST:ALT ratio
of 2:1, as well as an elevated INR and rising T bili. He was
started on pentoxyphylline before being transitioned to
prednisone on ___ after his acute alcohol withdrawal had
improved. A dobhoff was also placed on HD #2 for increased
nutrition. Although a 28 day course of steroids was planned, he
was very anxious and tremulousness despite successfully being
weaned off benzodiazepines and it was felt that steroids may be
contributing and they were stopped. His LFTs continued to trend
down throughout hospitalization. He was advised that he should
not drink alcohol again.
# Thrombocytopenia: He had thrombocytopenia on admission felt to
be related to acute alcoholic hepatitis. His platelets improved
to normal by the time of discharge.
# Deconditioning: After being transferred to the floor from the
MICU, he initially had difficulty participating with physical
therapy. He stayed in the hospital a few extra days as he lives
on the third floor at home and was having difficulty navigating
stairs. He was felt to be safe for discharge home by the time
he left the hospital. | 111 | 363 |
16123839-DS-38 | 26,593,688 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were having nausea,
vomiting and chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were worked up for your chest pain and nausea. Your
symptoms were not due to a cardiac etiology but likely due to a
flare of your gastroparesis.
- You were given fluids, pain and nausea medications.
- Your gastroenterology doctors did ___
___ and botox injections.
- We gave your a diet and you tolerated it very well.
- We continued to give your tacrolimus, mycophenolate sodium,
and prednisone for your kidney and pancreas transplant.
- We increased your blood pressure medication given you had high
blood pressures in the 180-190's/90's.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Patient Summary
===============
___ with PMH of kidney and pancreas transplant on mycophenylate
and tacro, HTN, DM2, gastroparesis, who presented with chest
pain, nausea, vomiting, c/f gastroparesis flare. He received an
EGD with botox injection to pylorus on ___. His pain was
controlled with Tylenol, viscous lidocaine, and tramadol. He
received Ativan and Zofran for nausea with good effect. At time
of discharge, he was tolerating a diet. | 173 | 67 |
16346753-DS-19 | 24,778,787 | Dear Ms. ___,
You were admitted to ___ because you were having trouble
breathing. We were concerned that this was related to your
tracheal stenosis. You underwent successful tracheostomy. It is
very important that you protect against self-deccanulation.
Please follow up with the interventional pulmonologist after
discharge.
No changes were made to your medications. Please continue taking
all of your medications as previously prescribed. It was a
pleasure taking care of you.
You will be provided with a passy muir valve and a portex
thermovent at your rehabilitation facility. | PRIMARY REASON FOR HOSPITALIZATION: Patient is a ___ female s/p
post intubation for hypoxic respiratory failure with subsequent
tracheal stenosis, s/p multiple IP procedures, who presents with
an episode of stridor and difficulty breathing. The episode
self-resolved but given patient's tenuous airway with stenosis
and increased sputum, she was admitted for observation and
potential IP management. | 88 | 56 |
14580631-DS-3 | 29,733,104 | You will have multiple follow up appointments listed below that
are very important to attend. If you have any concerns about
your health, questions about medications, or issues attending
any of these appointments, do not hesitate to call someone to
discuss your treatment.
Wear your back brace as directed at all times when out of bed
until your follow up with Neurosurgery in 4 weeks. This is
extremely important in order to protect your spine.
Do not lift anything greater than 10 pounds until cleared by a
physician.
Wound care: Do not disturb or probe the area with any objects.
The sutures placed in your mouth are usually the type that self
dissolve. If you have any sutures on the skin of your face or
neck, your surgeon will remove them on the day of your first
follow up appointment. SMOKING is detrimental to healing and
will cause complications.
Healing: After the first week, you should be more comfortable.
The remainder of your course should be gradual, steady
improvement. If you do not see continued improvement, please
call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks. Do not lift any
heavy loads and avoid physical sports unless you obtain
permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: You may apply warm compresses to the skin over
the areas of swelling (hot water bottle wrapped in a towel,
etc), for 20 minutes on and 20 min off to help soothe tender
areas and help to decrease swelling and stiffness. Please use
caution when applying ice or heat to your face as certain areas
may feel numb and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb. To avoid injury to the gums during
brushing, use a child size toothbrush and brush in front of a
mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean is essential. Use 1
teaspoon of salt dissolved in an 8 ounce glass of warm water and
gently rinse with portions of the solution, taking 5 min to use
the entire glassful. Repeat as often as you like, but you should
do this at least 4 times each day. If your surgeon has
prescribed a specific rinse, use as directed.
Showering: You may shower
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most jaw injuries are accompanied by some degree of
discomfort. You will usually have a prescription for pain
medication. Some patients find that stronger pain medications
cause nausea, but if you precede each pain pill with a small
amount of food, chances of nausea will be reduced. The effects
of pain medications vary widely among individuals. If you do not
achieve adequate pain relief at first you may supplement each
pain pill with an analgesic such as Tylenol or Motrin. If you
find that you are taking large amounts of pain medications at
frequent intervals, please call our office.
Diet: You can have a full liquid diet. Avoid extreme hot and
cold. If your jaws are not wired shut, then after one week, you
may be able to gradually progress to a soft diet, but ONLY if
your surgeon instructs you to do so. It is important not to skip
any meals. If you take nourishment regularly you will feel
better, gain strength, have less discomfort and heal faster.
Over the counter meal supplements are helpful to support
nutritional needs in the first few days after surgery. A
nutrition guidebook will be given to you before you are
discharged from the hospital. Remember to rinse your mouth after
any food intake, failure to do this may cause infections and gum
disease and possible loss of teeth.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal sprays
and pain medications. Use them as directed. A daily multivitamin
pill for ___ weeks after surgery is recommended but not
essential. If you have any questions about your progress, please
call the page operator at ___ and have
them page the on call Oral & Maxillofacial Surgery resident or
Acute Care Surgical Resident.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Return to either the ED or your regular doctor to have your
sutures taken out in ___ days | ___ year old male who was struck by a car at a high rate of speed
(approx 45 mph) when he was riding his bicycle. He rolled on top
to the car and suddenly rolled off the car. He was found briefly
unconscious and was confused on ED arrival. Complains of jaw
pain. Was not helmeted, +ETOH. Denies back or other painful
areas.
In the ED his neurological exam was completely intact, and
imaging demonstrated as follows:
CT Head
Subdural hematoma along the superior right cranial convexity
with
no significant mass effect. Small focus of subarachnoid blood in
the anterior right frontal lobe.
CT Mandible
1. Non-displaced comminuted fracture of the right mandible
anteriorly extending to the alveolar aspect of the mandible.
2. Mildly angulated fracture of the proximal left mandible with
medial subluxation of the left mandibular head. | 1,000 | 136 |
12155939-DS-7 | 27,429,244 | You were admitted following a suicide attempt with tylenol and
baclofen ingestion. You were treated for the tylenol overdose
and monitored in the intensive care unit. You were briefly
intubated to protect your airway as you were sedated from the
baclofen overdose. You were evaluated by obstetricians, and
found to have a live pregnancy at 6 weeks and 6 days on
ultrasound.
You are being discharged to for a psychiatric facility for
admission. You should be seen by obstetrics once you are
discharged.
We wish you the best,
Your ___ Care Team | ___ w/ hx of depression, ~2 mo pregnant, not on any home
medications that was intubated by medflight for AMS ___
acetaminophen overdose and admitted to the MICU.
# acetaminophen overdose - Ms. ___ ingested between 15 to
16 grams in the setting of an intentional tylenol overdose. She
was given a bolus of N-acetylcysteine while at ___
___ (initial 150 mg/kilogram bolus). She was continued on
IV NAC at 50 mg/kg over four hours (12.5 mg/kg per hour)
followed by 100 mg/kg per hour over the next ___ hours (6.25
mg/kg per hour). LFTs and INR were monitored. At the completion
of 21 hour NAC course, her LFTs were normalized and her
synthetic function mostly intact (INR 1.2) and her NAC course
was considered completed.
# baclofen overdose - Baclofen is a GABA agonist. In overdose,
it causes CNS and respiratory depression and in some cases can
also cause hypotension and bradycardia. Seizure-like activity is
also seen. Effects can last for 48 hours or more. She was
managed with supportive care.
# Pregnancy - at ~ 2 months, acetaminophen, baclofen, and NAC
all cross the placenta. It is unknown what effect this will have
on the developing fetus and ob/gyn evaluated the patient with US
and patient found to have viable IUP at 6 weeks 6 days on ___.
# Suicide attempt - Has a history of depression for which she
has never been treated. Psychiatry was consulted and recommended
a 1:1 sitter at all times. Patient being discharged to psych
admission to deac 4. | 97 | 258 |
10901772-DS-48 | 20,432,575 | Dear ___,
You were admitted to the hospital because of pain in your right
leg and cough. An ultrasound of your leg showed that there were
no issues with your blood vessels. Vascular surgery saw you and
did not feel that the leg was infected. They felt that the leg
was healing nicely from the surgery last month.
You improved and were allowed to leave with close follow up with
vascular surgery and your primary care doctor.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
-Weigh yourself daily and tell your doctor if you gain more than
3 lbs
-Take all of your medications as prescribed (listed below)
-Follow up with your doctors as listed below
-___ medical attention if you have new or concerning symptoms
or you develop fever, chills, worsened fatigue, drainage from
surgical wounds.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team | ___ F with PMHx CAD s/p CABG ___ (and multiple other
procedures), ischemic CM (EF ___ s/p AICD, PAD s/p
right femoral-popliteal bypass ___, DM2, COPD and history of
polysubstance abuse on methadone admitted with Rt leg pain and
erythema and URI symptoms. Vascular surgery was consulted and
felt that these were reasonable post-surgical changes that are
healing appropriately. They recommended against antibiotics. She
had no fever or elevated WBC, and therefore antibiotics were
deferred. She had RLE arterial and venous US, which showed
patent vessels. In terms of her URI symptoms, CXR was clear. She
was given guaifenesin and felt improved from admisison. She was
sent home with PCP follow up scheduled for ___ and vascular
surgery follow up on ___. | 152 | 122 |
14879847-DS-23 | 24,978,393 | Dear ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted to the hospital because you had fevers. This
was felt to be due to a pneumonia.
WHAT HAPPENED IN THE HOSPITAL?
-You were treated with a course of antibiotics and improved.
-For your ongoing cough, we felt it would be appropriate to
prescribe you a low dose steroid.
-Your blood pressures were low. All lab studies were normal. We
felt this was due to you not drinking enough fluids. We held
your blood pressure medications. As a result your heart rates
were slightly increased, but we monitored you closely and it was
determined to be stable and safe. We
-We also had a very important conversation regarding your goals
for your quality of life with you, your family, and Drs.
___, you decided that in the event of a
medical emergency you would prefer to not receive CPR or be
placed on a mechanical ventilator (a machine that breaths for
you). We value and respect your wishes.
WHAT SHOULD YOU DO AT HOME:
-You should continue to eat and drink as much as you would like
and the foods you would like!
-Continue to walk and move as much as physically able. Sometimes
it is difficult to do when you are tired, but the more you move
the better.
-If you are uncomfortable, ask your nurse for medication to help
with pain, nausea, anxiety or feeling short of breath.
Thank you for allowing us be involved in your care.
Your ___ Oncology ___ | Mr. ___ is an ___ male with history of
metastatic urothelial cancer on pembrolizumab with T10 vertebral
mass s/p surgical decompression/fusion and cyberknife with
adrenal, lymph node, and lung metastases presenting with fever
and cough after recent admission for CAP likely w/recent
inadequate treatment course vs HAP.
# HOSPITAL-ACQUIRED PNEUMONIA
# FEVER
# COUGH
Presented less than one week after discharge from admission for
community acquired pneumonia after completion of therapy with
levofloxacin with fever, cough, and leukocytosis. Viral
etiologies ruled out. No significant changes on interval
imaging. He was treated initially for hospital acquired PNA with
vancomycin, aztreonam, and levofloxacin. He continued to have a
low grade temp with persistent leukocytosis since ___. This was
felt to be due to underlying malignancy. He was continued on
levofloxacin for ___. Additionally he was
started on low dose prednisone for possible pembrolizumab
induced pneumonitis.
# Metastatic Urothelial Carcinoma:
Patient has metastatic upper tract urothelial carcinoma to lymph
nodes, T10 vertebrae s/p surgical decompression/fusion and
cyberknife, adrenal and lung.
Overall he has been declining functionally over the last 2
months with very poor PO intake. CT C/A/P last admission showing
progression of disease. Outpatient Oncology team followed
admission. After family meeting with his oncologist it was
decided not to pursue additional treatments and decision to
discharge home on hospice.
#Goals of Care
#New DNR/DNI Status
Given his overall frailty, cytotoxic chemotherapy was felt to be
unhelpful at this time in prolonging his quality or quantity of
life. Primary oncologist discussed that the response rates to
third line chemotherapy are not high and that the agents that
are
available could be associated with substantial side effects,
including worsening of his fatigue and anemia. Ultimately,
patient decided to be DNR/DNI. Conversation regarding
rehospitalization is still ongoing, but at this time if acute
needs for comfort are needed it would be within his goals to be
readmitted. MOLST was signed and is in the chart. He was
discharged home on hospice.
# Hypotension
# Sinus tachycardia w/frequent ectopy
Due to hypovolemia from poor PO intake. "Food doesn't taste the
same and less appetite." Responsive to significant fluid boluses
and on mIVF.
-home atenolol and antihypertensives discontinued, remained
normotensive for remainder of admission
# Anemia:
No evidence of active bleed. Iron studies with evidence of mixed
anemia d/t iron deficiency and inflammatory block from
underlying malignancy. He required one transfusion during
hospitalization. Felt that given elevated ferritin he would not
be iron responsive therefor was not given iron repletion.
# Stage II CKD: Renal function stable.
# Malnutrition: Patient with poor PO intake and weight loss. He
was continued on mirtazapine and supplements.
# Hyperlipidemia
- Continued home atorvastatin and aspirin
# GERD
- Continued home omeprazole
# OSA
- Continued CPAP
Transitional Issues
=====================
[ ]Evaluate benefit to ongoing dexamethasone use
[ ]Consider appetite stimulant, Palliative diet w/favorite foods
ad lib
[ ]Discharged to home hospice
CODE: DNI/DNR, okay to rehospitalize
EMERGENCY CONTACT HCP: ___ (daughter) ___ | 255 | 466 |
12806479-DS-22 | 27,646,635 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted with blood in your stool and
nose bleeds. You were found to have low platelets which can lead
to bleeding. You were also found to have low white blood cells
which can place you at risk of infection. This is likely from
your recent chemotherapy. You were given a medication called
neupogen to stimulate the production of white blood cells and
your counts started coming up.
Because your platelets are still low which can lead to easy
bleeding, your Coumadin was stopped. Your counts will be
monitored in clinic and your physician ___ let you know when to
start taking your Coumadin again.
Your Lasix was stopped as you did not have swelling while in the
hospital. Please weigh yourself everyday and call your physician
if your weight increases by 3lb over 2 days as you may need to
restart Lasix. Your electrolytes were low so you were discharged
on potassium and magnesium supplements.
Please call your physician or proceed to the emergency room if
you have any signs of significant bleeding such as nose bleeds,
blood in your stool or blood in your urine or if you have any
fever >100.4.
We wish you the best!
- Your ___ medical team | Ms. ___ is a ___ with right breast invasive ductal carcinoma
(ER+/PR-/Her 2 amplified s/p mastectomy with axillary node
dissection, s/p 6 cycles TCH and Herceptin) now metastatic to
bone s/p 2 cycles of TDM-1, most recently on Palbociclib (on
hold as of ___, RA on chronic prednisone, hx of DVT/PE on
Coumadin who presents with bright red blood per rectum and
epistaxis in the setting of thrombocytopenia.
#GI bleeding/Epistaxis: ___ p/w BRPBR iso plt 26 and INR 2.3. Her
H/H was low and she received 1U pRBC, 2 bags of plts, FFP, and
vitamin K. She responded well o these treatments. Had one
episode of epistaxis early in course but had no episodes of
bleeding since. Given that HDS, and lack of BRBPR over past
several days, unlikely to be brisk upper GI bleed. Most likely
lower source, w/ddx for hemmorhoids (has hx), diverticulosis
(typically bleed at faster rate), angiodysplasia, polyp. GI was
c/s ___, but given neutropenia, will hold off on scoping for
now. Goal is plt>50 if bleeding, plt>10 if not bleeding. Plts 50
on discharge. Continue high dose PPI BID.
#Pancytopenia: Pt admitted w/ neutropenia to 420, H/H drop ___
-> ___, and plt drop to 26 on admission as above. ANC 260 on
___ and 340 on ___ and 300 ___ and 500 on ___. H&H and plt
stable as above, H/H 9.___.7 and plt 41 on ___. This is likely
iso Palbociclib, known to cause leukopenia and thrombocytopenia
and has been on hold with last dose ___. Initial ddx included
MAHA such as TTP, but w/ nml Cr, no neurologic findings, and no
fever, this is unlikely. Unlikely to be hemolysis, given LDH and
haptoglobin wnl, or DIC given nml fibrinogen. Worked up for
possible source of infection, CXR neg, UA wnl, blood cx pending.
Per outpatient oncologist covered with Vanc/cefepime as pt also
on chronic prednisone and may not mount fever. Given improvement
in WBC 500, and lack of infectious source, d/c'ed Abx on ___.
Received 3 shots of neupogen and neutropenia and WBC improved
subsequently.
#Coagulopathy: INR 2.3 in setting of Coumadin use. PTT recorded
initially as 96 but likely contaminated with heparin as it was
drawn from port, and repeat from PIV 25.7. INR back to 1.2 w/FFP
and vitamin K. Fibrinogen wnl as above. Thrombin time 16.5.
Holding Coumadin until H&H normalizes and plt stable >50. Then
plan to bridge w/heparin to Coumadin. Plts 50 on discharge
#Breast Cancer: right breast IDC, pT2pN2aM0 ER+/PR-/Her 2
amplified, grade II s/p mastectomy, 6 cycles of TCH, every 3
week Herceptin, 12 months of Trastuzumab now found to have mets
to bone as of ___ s/p TDM-1 now most recently on pablociclib
and Fulvestrant. Pablociclib on hold due to pancytopenia
#History of DVT/PE: INR 1.2 from 2.3, reversed as above. Holding
Coumadin until H&H normalizes and plt stable >50 as above. Then
plan to bridge w/heparin to Coumadin. Continue pneumoboots for
now
#Rheumatoid arthritis: Continue home prednisone. Written for
tylenol or oxycodone as needed for pain.
#Thrush: Pt complaining of a burning sensation in her throat.
Has slight mucositis on soft palate, left side. Continued home
nystatin. Continue magic mouthwash.
TRANSITIONAL
============
- discharge weight 96.93 kg (213.69 lb)
- restart anticoagulation with lovenox/coumadin if platelet
count above 50 in follow up on ___
- discharged on potassium and magnesium supplements
- Lasix held as patient was not volume overloaded during
admission and had poor PO intake | 215 | 565 |
16116987-DS-3 | 22,572,328 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having low
blood pressures and fell at ___. Your heart rate was also
elevated.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your low blood pressures are related to your poor oral intake
as well as your medication, thorazine. While you were in the
hospital we monitored your blood pressure and heart rate
continuously.
- We gave you fluids through an IV in your arm to help your
blood pressure. You were able to stand up without feeling dizzy
or lightheaded after a few days of fluids.
- We placed a feeding tube to give you nutrition and to help
your low blood pressure.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your primary care physician.
- You are being discharged to ___. You are being discharged
with your IV.
- We recommend that you do not pull out your feeding tube. This
can cause bleeding and pain. Since you are at risk of self harm,
we kept you in your restraints during your hospital stay and
recommend continued restraints on discharge.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ y/o F with history of anorexia nervosa,
PTSD, GAD, borderline personality disorder, depression, and
bipolar disorder who is presenting from ___ on ___
with SI and orthostatic hypotension in the setting of refusal to
take in food or drink. Dobhoff with bridle was placed on ___ for
refusal to take PO. | 222 | 56 |
17585185-DS-6 | 27,255,839 | Ms. ___,
It was a pleasure meeting and caring for you during your most
recent hospitalization. You were admitted following a coughing
fit with respiratory distress. You were observed in the
intensive care unit and then transferred to the medicine floor.
You continued to have several coughing fits but never had a low
oxygen level. You slowly improved and were discharged to have
ongoing outpatient evaluation of your condition.
All the best,
Your ___ Care Team | BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ yo woman with
multiple pulmonary co-morbidities including obesity, question of
sarcoid (currently on weekly methotrexate), paroxysmal vocal
cord dysfunction, tracheobronchomalacia and severe asthma, who
presents with severe cough and shortness of breath found to be
in respiratory distress thought to be ___ exacerbation of her
paroxysmal vocal cord dysfunction. She was managed on an
antitussive regimen. ENT and IP were both called and did not
feel that there were any additional inpatient management options
at this time. The pt. was stabilized and discharged to continue
her outpatient work-up. | 77 | 98 |
19855167-DS-19 | 29,745,665 | You were admitted for pancreatic leak and intra-abdominal fluid
collection that was not amenable to drainage. You have completed
a course of IV antibiotics and are tolerating a regular diet,
and you are ready to be discharged home. You should continue to
eat a regular diet and drink fluids.
Please call the office immediately if you experience fevers,
chills, drainage from your wound, worsening redness around your
wound, dizziness, nausea or vomiting. | The patient was admitted to the ___ Surgery service for
pancreatic leak. His CT scan showed an undrained retrogastric
fluid collection, thus the patient was made NPO, started on IV
antibiotics, and initiated on TPN. He was also noted to be
hyponatremic so his free water intake was restricted to 1L. JP
drain fell out during his hospitalization. The patient did well
with this treatment and was eventually advanced to clears. After
he tolerated clears and had no fevers, chills, and white count
normalized, he was then transitioned to a regular diet and TPN
was discontinued. He completed a 7 day course of antibiotics.
After 24 hours the patient remained afebrile on a regular diet
and off of antibiotics, he was deemed safe for discharge home.
He was discharged home with plan to follow up with Dr. ___ in
clinic in 2 weeks with repeat CT scan to assess for improvement
or resolution of fluid collections. | 72 | 157 |
14975577-DS-16 | 24,924,339 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came because you were tired, confused and less responsive
than normal.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We monitored you for signs of seizures. We did not see any
evidence of seizures while inpatient.
- We held your sedating medications including your opiates and
sleeping medications
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | SUMMARY STATEMENT
=================
Ms. ___ is a ___ female ___ COPD, HFpEF (EF 66%),
seizure disorder, CVA 1 month ago presenting from rehab due to
increasing lethargy, mild leukocytosis, concern for toxic
metabolic encephalopathy from medication vs infection with
pulmonary infection being most likely source.
TRANSITIONAL ISSUES
===================
[] Discontinued all medications that could alter her mental
status including tramadol, gabapentin, and trazodone as she was
noted to be somnolent when on low doses of these and less
somnolent when off, including when taken off singularly.
The following transitional issues remain from recent prior
discharge:
[] Check BPs on LUE -- not RUE given R subclavian stenosis which
caused a spurious hypotension.
[] Consider MR in the outpatient setting to look at distal ileum
in order to rule out small bowel tumor
[] Repeat iron studies in ___ weeks
[] Consider IV iron as outpatient
[] 0.8 mm cystic lesion in the pancreatic head/neck, not seen on
prior imaging.
[] Continue low potassium diet for hyperkalemia
[] Follow up with outpatient cardiology as scheduled for further
monitoring of new TTE findings below.
[] Follow up with outpatient cardiology as scheduled for further
management of question of new atrial fibrillation.
RECOMMENDATION(S): For management of pancreatic cyst(s) between
6-15 mm in patients between ___ - ___ years at presentation,
recommend non-contrast MRCP follow-up every other year up to a
total of ___ years.
[] Repeat colonoscopy pending ___ conversation in ___ for
surveillance and polp removal. Recommend 7 day low residue diet
and 2 day extended prep for colonoscopy with MoviPrep (given
poor prep). A single 6mm polyp of benign appearance was found
45cm from the anus that was not removed.
ACTIVE ISSUES
=============
#toxic encephalopathy
Patient was readmitted because of lethargy and altered mental
status. Infectious workup was negative, and mental status
improved with holding narcotics including tramadol and oxycodone
and sedating medications. Continuous video EEG showed no signs
of epileptiform discharged. Encephalopathy completely resolved
during admission.
#Bronchitis
#Leukocytosis
#Mild hypoxemia
Chest x-ray and CTA negative for consolidations or pulmonary
embolism. Antibiotics were initially given but held as team had
low suspicion for infection. Negative urine and blood cultures
had no growth at discharge after 3 days.
# Chest pain
# Anterolateral STDs
# Elevated BNP
# HFpEF (66%)
EKG on admission was negative and pain resolved without
intervention. Her home diuretic was continued. TTE this
admission showed inferior posterior hypokinesis new since last
TTE on ___. Evidence of age-indeterminate inferior infarct
noted on also previous admission on ___, without
echocardiographic evidence at the time. She should have
follow-up as an outpatient with cardiology. ___ benefit from
stress testing and possibly outpatient cardiac catheterization
#MAT
#Concern for new paroxysmal atrial fibrillation
Patient had EKGs during this admission that were most c/w MAT
although paroxysmal Afib was on the DDx. In the setting of
previous GI bleed, team deferred changing anti-platelet,
anti-coagulation strategy as inpatient although if she were to
have afib, would be reasonable to consider DOAC + antiplatelet
agents rather than DAPT which is current planned regimen.
# History of seizures:
# R hand tremor:
Pt was evaluated for seizure disorder last admission in setting
of fall and left leg shaking. EEG did not show epileptiform
activity even in setting of right upper extremity tremors.
Valproic acid levels initially subtherapeutic on admission,
later therapeutic after continued VPA dosing. It was felt that
she was missing doses of valproic acid at rehab, leading to
subtherapeutic levels.
#R MCA/ACA Watershed strokes
#R carotid stenosis
Head CT without acute change, no focal deficits on exam. Aspirin
and statin continued.
#HFpEF
#COPD
2L 02 at baseline
Lasix and home inhalers were continued along with supplemental
oxygen via nasal cannula.
# R wrist pain:
# L knee pain:
# L wrist pain:
# L shoulder pain
Likely due to PMR, noted last admission as well, seen by
rheumatology in ___. Negative Xray, APAP standing, no opioids
or gabapentin. Started capsaicin cream. Continued lidocaine
patch, bengay topical. Will follow-up with outpatient
rheumatology.
CHRONIC/RESOLVED ISSUES
=========================
# Anemia: CBC
# Depression/insomnia: CONT home fluoxetine, CONT dose reduced
trazadone
# DM2: ISS while inpatient, hold home metformin, glipizide
# HLD/PVD/CAD: CONT home statin/asa/plavix
# Osteoporosis: Held home Alendronate while inpatient | 144 | 665 |
11344335-DS-28 | 28,384,057 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
You were admitted to the hospital because you were experiencing
shortness of breath and your heart rate was high. You also have
had decreased appetite recently and have lost weight and become
more fatigued.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital you were found to have a high heart rate and
high level of salt in your blood. This is probably because you
were dehydrated. You were given fluids and your heart rate and
sodium levels returned to normal. You received other tests,
including an EKG to rule out a heart attack and chest x rays to
rule out pneumonia.
-You were also found to have severe malnutrition and your
electrolytes were repleted. Renal transplant doctors ___
your ___ function, and concluded that you would
benefit from initiation of dialysis in order to improve your
appetite, fatigue, and malnutrition. You have an appointment
with your transplant doctor to discuss dialysis further.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Measure your INR this ___. If still >4, don't take
warfarin. If ___, take 2mg of warfarin. If <3, take 3mg of
warfarin. Then check it again on ___ and call the ___ clinic
to communicate the results; they can guide you from there.
- We increased your Humalog sliding scale a little bit to try to
keep your blood sugars more normal. For sugar 150-200, take 3
units of insulin. For 200-250, take 5 units; for 250-300, take 7
units; for 300-350, 9 units, etc. Please call your doctor if the
sugar is above 300 on more than 1 measurement. Your primary care
doctor can help you further adjust the insulin doses when you
see him on ___.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY
====================
Mr. ___ is a ___ year old man with history significant for
ESRD of renal graft s/p LURT ___, HFrEF (30%) with ICD, AR
and MVR s/p
AVR/MVR, DVT on warfarin, CAD with DES to RCA in ___,
presenting from home with
tachycardia and dyspnea, and found to have failure to thrive and
malnutrition in setting of persistent uremia. | 336 | 56 |
18422489-DS-2 | 20,972,006 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
================================
- You were transferred to ___ from ___, as you were
having fevers, and your heart rates were very high. There were
concerns that you had a severe infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
=======================================
- You had a very fast, irregular rhythm called atrial
fibrillation. We started you on new medications to control this,
and your heart rate improved.
- You were found to be in a heart failure exacerbation, likely
caused by your fast heart rate.
- You had a possible pneumonia, which is likely why you were
having fevers. This may have also contributed to your heart
failure exacerbation. You were treated with antibiotics and
improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
================================================
- Continue to take all your medicines and keep your
appointments.
- It is very important that you establish care with a
cardiologist at ___.
- You should follow up with interventional radiology and
vascular surgery to discuss removing your IVC filter going
forward. You have an appointment with Dr. ___.
We wish you the best!
Sincerely,
Your ___ Team | ___ with w/ Afib, HFrEF (40-45%), ESRD on HD MWF w/ recent UTI
c/b sepsis & course c/b hemorrhagic renal cyst s/p embolization,
who re-presented w/ atrial fibrillation with RVR & sepsis from
possible pneumonia, transferred to ___ from ___ for
further work-up, with course complicated by volume overload and
HFrEF exacerbation. | 207 | 53 |
12343156-DS-7 | 28,314,006 | You came in after passing out. We think that this was because
your blood pressure was low. This is likely related to having
the flu. We treated you with IV fluids and Tamiflu and these
issues improved.
Please return if you have worsening lightheadedness, dizziness,
palpitations, nausea, vomiting, or if you have any other
concerns. Please also try to stay off your feet and drink
plenty of fluids.
It was a pleasure taking care of you at ___
___. | ___ F with history of HTN, HL, AAA s/p repair in ___
presenting with syncope, likely orthostatic hypotension in s/o
flu.
# Sepsis/Flu A positive-- Pt presented with fevers, feeling
generally unwell, and nausea, found to have positive flu swab in
the ED. Pt otherwise denies focal symptoms but did also have
positive UA on admission as well. She was started on tamiflu
x5 days and ceftriaxone until urine cultures came back negative.
Fevers resolved by HD2 and pt reported feeling much better
overall.
# Syncope/Orthostastic Hypotension-- Pt presented with syncope
prior to admission, was found to be severely orthostatic in the
ED. Orthostasis likely ___ vasodiliation in s/o sepsis with
some possible component of volume depletion. S/p 3L bolus in ED
with improvement in orthostasis. She was ambulating without
lightheadedness on HD2 and was seen by ___ who cleared her to go
home with a rolling walker until her acute illness resolves.
# HTN-- Restarted home metoprolol in hospital and
enalapril/amlodipine at ___ due to improved blood pressure at
discharge.
# HL-- continued simvastatin | 83 | 178 |
16528873-DS-20 | 25,805,541 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you had low blood pressure and
diarrhea.
What happened while I was in the hospital?
====================================
- Your home antibiotics were stopped.
- Your home midodrine was increased to 5 mg 3 times daily.
- You had dialysis.
- He was started on a medication to control diarrhea.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please stop taking ciprofloxacin (Cipro) and metronidazole
(Flagyl), as we think these were contributing to your diarrhea.
- Please take loperamide (Imodium) 3 times daily with meals to
help with your diarrhea. You can reduce how often you take this
as your diarrhea starts to improve.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ___ with history of ESRD on ___ HD, venous thrombosis on
warfarin, epilepsy on AEDs, remote BKA ___ auto accident, ___
diagnosed ___ (has not yet undergone nephrectomy due to
multiple recent hospitalizations), chronic hypotension (on
midodrine) and recent admission for diverticulitis c/b sigmoid
abscess, who presented with acute on chronic hypotension likely
related to volume losses from diarrhea and decreased PO intake.
ACUTE ISSUES:
=============
#Hypotension
Presented from HD appointment with hypotension prior to
receiving HD. Patient was recently admitted from ___ to
___ for chronic hypotension that is reported to have
coincided with initiation of HD in ___. Has been worked-up
for acute blood loss and adrenal insufficiency in the past as
well which was negative. Currently anticoagulated on warfarin
(RCC and hx of RUQ clot ___ but no evidence of acute
bleeding. Etiology of this episode of hypotension likely chronic
hypotension (related to ESRD on dialysis) exacerbated by
hypovolemia in the setting of recent diarrhea from prolonged
course of antibiotics for recent complicated diverticulitis.
Septic pathophysiology excluded given lack of leukocytosis,
fever, and CTAP showing resolution of diverticulitis c/b sigmoid
abscess. He did have an elevated lactate to 3.0, consistent with
some element of hypoperfusion. Lactate normalized with IV
fluids. Antibiotics were stopped after he remained afebrile and
CT was negative for evidence of persistent abscess or other
infectious source. Home midodrine was increased to 5 mg 3 times
daily (from 2.5 mg 3 times daily), and diarrhea was treated
symptomatically with loperamide. Of note, his blood pressures
were checked in his left thigh this admission.
#Chronic diarrhea
Onset of the diarrhea coincided with starting antibiotics for
complicated diverticulitis during last admission in ___. Reported about two episdoes of watery, nonbloody diarrhea
daily over the last 6 weeks. Plan after last discharge was to
continue ciprofloxacin/metronidazole on discharge and return to
___ clinic in 2 weeks to discuss discontinuing. Patient missed
follow-up appointment but continued to take antibiotics up until
the time of this presentation. Workup this admission included
negative C.diff and stool culture negative for E. coli
(Campylobacter, Yersinia pending). Episodes of diarrhea related
to meals which suggested an osmotic component. Diarrhea improved
with stopping antibiotics and he was started on loperamide to be
taken with meals. He was discharged with a prescription for
loperamide to be taken with meals and plan to be referred to
outpatient GI for further workup by his PCP if diarrhea
continues. To be discussed at primary care appointment with Dr.
___ that is scheduled on ___.
#Lymphopenia
Absolute lymphocyte count on admission of 0.54 with white blood
cell count nadir of 3.0. Workup significant for negative HIV and
immunoglobulins that were within normal limits. On day of
discharge his white blood cell count had returned to normal
value of 4.9.
#Recent diverticulitis c/b sigmoid abscess (resolved)
Recently admitted from ___ and found to have a sigmoid
abscess in the setting of likely perforated diverticulitis. ACS
consulted at that time and deferred surgical intervention given
small size. He was treated with ciprofloxacin/metronidazole with
plan to continue until ID follow-up. CTAP ___ shows
resolution of sigmoid abscess.
#End-stage renal disease on dialysis ___
Continued on home dialysis schedule of ___,
___.
#Neck pain: During hospital course he complained of intermittent
bilateral neck pain in the anterior region of the neck. Pain was
intermittent, described as brief episodes of sharp pain that
occurred for seconds at a time, exacerbated at times by movement
of the head. An ultrasound of the soft tissue of the neck was
obtained given his history of invasive squamous cell carcinoma.
There was no evidence of soft tissue mass or lymphadenopathy.
Pain appeared most consistent with musculoskeletal pain possibly
in the setting of positioning in bed.
CHRONIC ISSUES:
===============
#Renal cell carcinoma
#Hx of RUE DVT
Biopsy-proven clear cell renal carcinoma (___). Followed by
Dr. ___ in urology with plan to discuss treatment options
after resolution of sigmoid abscess. He also has history of RUE
blood clot felt to be provoked in the setting of RCC. He was
continued on warfarin. An ultrasound of the soft tissue of the
neck demonstrated slow flow in the right internal jugular vein,
near the junction with the brachiocephalic vein. There was a
possible non mobile mural component that may reflect
nonocclusive thrombus or hematoma (though overall non-diagnostic
study). He recently has a history of right upper extremity DVT.
He was continued on home warfarin, though INR levels have been
variable recently.
#Epilepsy
During last hospitalization neurology was consulted to help
guide unclear AED regimen and recommended phenobarbital 64.8 mg
BID, Topamax 200 mg BID, and Keppra 1000 mg daily with 500 mg
after HD. He has previously followed with Dr. ___ for
his epilepsy but had plan to transition care to Dr. ___
discharge with follow-up appointment to be arranged by
neurology.
#Chronic Anemia
Chronically low in ___, at or slightly above baseline on
admission. Suspect ___ anemia of CKD. Remained stable.
#OSA - Continued home BiPAP.
#T2DM Diet controlled, last A1c ___ 5.6.
#PERNICIOUS ANEMIA - Continued home cyanocobalamin.
#HYPOTHYROIDSM - Continued home levothyroxine 75 mcg daily.
#Anxiety - continued diazepam PRN anxiety
#Chronic pain - Continued home Percocet Q6H PRN pain.
#R. Eye Blindness/Pain - Continued home eye drops
#Gout: Continued allopurinol renally dosed.
#Itching Continued hydroxyzine prn.
TRANSITIONAL ISSUES
===================
[ ] Per discharge summary on ___: patient has never had a
colonoscopy. It was recommended that he have a colonoscopy ___
weeks after resolution of his diverticulitis. This is still
recommended.
[ ] Renal cell carcinoma: Care connected for urology follow up
regarding his RCC (nephrectomy pending); urologist is Dr. ___
___ at ___.
[ ] AED regimen: Missed most recent neurology follow-up, patient
needs to reschedule appointment to discuss AED regimen.
[ ] Diarrhea: If diarrhea has not improved will need referral to
GI for outpatient workup of chronic diarrhea. At this point,
suspect related to his extended course of cipro/flagyl for
complicated diverticulitis.
[ ] Lymphopenia: Workup significant for a negative HIV and
normal immunoglobulins. Returned to normal value on discharge.
If recurs should pursue further evaluation.
[ ] On warfarin for renal cell carcinoma complicated by right
extremity DVT, continue monitoring INR
CORE MEASURES
=============
#CODE: Full (confirmed)
#CONTACT: Proxy name: ___ Relationship: brother
Phone: ___ | 161 | 1,024 |
17152298-DS-18 | 26,795,968 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight-bearing as tolerated
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
Physical Therapy:
Weight-bearing as tolerated.
Treatments Frequency:
Wound monitoring
Dry sterile dressing as needed | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for placement of a right trochanteric fixation nail wi
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
high risk for DVT 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. | 203 | 256 |
14871009-DS-22 | 26,404,004 | Ms. ___ was admitted to the ICU at ___ for elevated
heart rates, and concern for infection, as well as dehydration.
She was treated supportively with fluids, and a new medication
for her heart rate called digoxin, which was stopped after
resolution of symptoms.
She was supported with IV fluids. We had several discussions
about her current health with surrogate decision makers/family.
Hospice services are being set-up to establish more help at
home. | Ms. ___ is a ___ woman with a history of paroxysmal
a. fib, OSA, HTN, and cardiac arrest who presented with cough,
fever and altered mental status. She was found to have a. fib
with RVR and initially admitted to the MICU.
ACTIVE ISSUES
=============
# Altered Mental Status: She is oriented x1 at baseline and her
increased somnolence was likely toxic/metabolic in setting of
viral illness and aspiration pneumonititis as well as
dehydration. She was treated with IV fluids and free water
repletion. B12 and TSH were normal. RPR was negative. She was
also treated with Vancomycin and Ceftriaxone initially for
possible CAP and positive blood culture, though suspicion for
bacterial etiology was lower and CXR did not support bacterial
PNA. Her positive blood culture (staph in 1 bottle) was thought
to be a contaminant.
# Dementia: Patient's baseline is A+O x 1 and she is dependent
in her ADL's. SHe is being Hoyer lifted at home. She lives with
her daughter and her three daughters are providing her care.
Palliative care was consulted. Several goals of care discussions
were held with patient's daughters, ___, and ___.
She was ultimately made a DNR/DNI. Hospice evaluated her for
increased services at home. The family, while accepting DNR/DNI,
and hospice care. The family is considering DNH but have not
yet come to this as they process all of this end-of-life
planning, working in conjunction with Hospice.
# Hypotension: Most likely due to atrial fibrillation with RVR
vs. dehydration in the setting of poor PO intake from viral URI.
Lower suspicion for sepsis. Patient's RVR was controlled with
metoprolol and she was started on digoxin, with improvement in
blood pressure.
# Paroxysmal Atrial Fibrillation with RVR: CHADS2 = 2.
Reportedly not on anticoagulation due to bleeding complications
but this is not evident in record. RVR likely triggered by
infection. She was started on digoxin for additional rate
control, with improvement in HR to 80's. Digoxin was stopped
prior to discharge home.
# SIRS physiology: Patient presented with fever and tachycardia,
in the setting of hypoxia and worsening sputum production,
treated empirically for CAP, although admission CXR negative.
Patient empirically started on vancomycin/Zosyn in the ED,
changed to Ceftriaxone/Azithromycin upon admission, though this
was likely due to aspiration pneumonitis. Antibiotics were
quickly discontinued and she showed continued improvement.
Speech and swallow evaluated and felt a pureed diet with nectar
thick liquids was safest for her.
# Hypernatremia: Most likely due to poor PO in the setting of
illness. Patient received free water repletion.
CHRONIC ISSUES
--------------------
# ___ Disease: Per family, pt does not have neurologist.
She has had PD symptoms which have progressed.
TRANSITIONAL ISSUES
- Communication: Daughter/HCP ___ ___. Lives with
daughter, ___.
- Code: Patient was a full code while in the ICU. Given advanced
dementia, goals of care were discussed with her family and she
was made DNR/DNI and after further discussion she will be
discharged to home with Hospice care.
- Stopped digoxin | 72 | 494 |
13317579-DS-29 | 26,289,888 | You were admitted for evaluation of bleeding due to low
platelets leading to anemia. You improved with IVIG and
steroids. The hematology doctors are recommending ___ of
rituximab as an outpatient after some time has passed after
getting your pneumococcal vaccine. You had a positive hepatitis
B test (consistent with prior exposure and clearance of the
virus) and you were seen by the ID doctors who recommended ___
take entecavir to prevent infection recurrence | This is a ___ with ___ syndrome s/p splenectomy with multiple
recent admissions for management of thrombocytopenia/ITP in the
context of nonadherence with followup plans, who presented with
vaginal bleeding with platelet count < 5, consistent with ITP
flare. Characteristic of her prior flares, she quickly improved
with IVIG and dexamethasone.
# Thrombocytopenia
# ITP flare in setting of history of ___ syndrome
Has had frequent emergency room visits for flares of her ___
syndrome. She typically responds well to steroids and IVIG. She
has not been initiated on rituximab as an outpatient since she
does not often keep appointments. Presented with
vaginal bleeding and platelets were < 5. Evidence of hemolysis
by labs. S/p 1 dose of IVIG and high dose dexamethasone here.
Hematology was consulted. Given pt's compliance and frequent
admissions team recommended rituxan. However, pt with
prior splenectomy and will need pneumococcal vaccine prior to
this and per drug insert 4 weeks time after before rituximab. In
addition, pt with hep B core ab positive. Therefore, hematology
recommended ID consultation regarding opinion on need of anti
viral treatment if going to tx with rituxan. Hematology
recommended romboplastin x1, but she refused this, preferring to
discuss with her outpatient hematologist. Her counts improved
and she was dc'd with plans for outpt f/u and outpt rituximab.
- Outpatient followup with PCP and ___, scheduled at
discharge as below
# Vaginal bleeding
# History of Menorrhagia
On depoprovera as an outpatient. Presented with vaginal bleeding
likely secondary to profoundly decreased platelets. Improved
with treatment of thrombocytopenia.
- Outpatient gyn followup, scheduled at discharge as below
# Chronic hepatitis B
Hep B core + here (also sAb + and sAg -). ID consulted per above
prior to rituximab for opinion on tx prior to immunosuppression,
and recommended treatment with entecavir starting now and for 6
months after finishing rituximab therapy.
- FOLLOWUP HBV VIRAL LOAD. If +, patient should see the ID team
as outpatient prior to initiation of rituximab.
# Leukocytosis: Likely steroid related. No fevers or other
localizing symptoms during hospital stay.
# Chronic headaches: Head CT unrevealing. Provided with outpt
regimen for treatment with improvement.
>30 minutes spent coordinating discharge home | 74 | 350 |
17850903-DS-19 | 26,661,041 | Dear Ms. ___,
You were admitted to the hospital with right arm and leg
weakness. You were found to have multiple small acute strokes on
the left side of your brain, and a large thrombus (blood clot)
in your left carotid artery which was likely the source of the
strokes. You were started on an IV blood thinner called heparin
to dissolve the clot, but this caused you to develop a hematoma
(large bruise) on your flank so heparin was stopped. After
consulting with the hematology doctors ___ Dr. ___ we
decided to start you on the blood thinner Coumadin (Warfarin)
instead. Because you are still a bit weak from your stroke, you
are being discharged to rehab where you will work intensively
with physical therapy.
.
Please attend the follow-up appointments listed below with your
hematologist Dr. ___ your neurologist Dr. ___.
.
We made the following changes to your medications:
1. STARTED Coumadin (Warfarin) 4mg by mouth daily -- you will
need your blood levels checked several times at rehab to make
sure you are on the correct dose.
Please continue taking your other medications as you were prior
to hospitalization. | Patient was admitted to the Stroke service for further workup
and treatment. She had an MRI which revealed multiple small
multifocal acute strokes in the left hemispheric cortices and
left frontal subcortical white matter. Given this and presence
of large filling defect on CTA concerning for recurrent left ICA
thrombus causing embolic stroke, she was started on heparin
drip. Her stroke risk factor labs (HbA1C, full lipid panel) were
both WNL, and her home simvastatin was continued.
.
Overnight on HD#1, patient developed a subcutaneous flank
hematoma on heparin (PTT 58.8 at the time, had been
subtherapeutic before this), hemodynamically stable and with HCT
drop from 38->34. Out of concern for recurrent bleeding given
her PV/ET and h/o past bleeds on heparin, her heparin gtt was
stopped. Vascular surgery was consulted regarding potential
carotid endarterectomy but they felt that patient's thrombus was
resolving on heparin and recommended restarting heparin; did not
feel surgery was indicated. Heme-onc was also consulted
regarding appropriate choice of anticoagulation in setting of
her PV/ET, also spoke with her outpatient hematologist ___
___. They recommended either restarting Coumadin without a
bridge (as pt had tolerated this in past) or considering
Lovenox. Patient was subsequently started on Coumadin on HD #2.
Her INR on HD #3 was 1.1. Neuro exam on discharge notable for
improvement in RUE/RLE weakness, still present in UMN pattern
(distal>proximal). She is discharged to rehab where she will
undergo intensive ___.
.
===================== | 190 | 236 |
12994068-DS-8 | 21,287,018 | Your ___ Team
Ms ___,
It was a pleasure meeting you and taking ___ of you during your
hospitalization at ___. ___ you
were admitted to the hospital after falling and fracturing your
hip. You underwent surgery to repair this fracture, and had a
metal rod implant placed into your thigh bone (femur) to
stabilize the fracture. You had evidence of blood loss
following surgery and received a blood transfusion with recovery
in your blood cell count. After surgery, you were continued on
anticoagulation to treat the blood clot in your lung that was
diagnosed several months ago, and were evaluated by a physical
therapist and your team feels you will benefit from ongoing
physical therapy at a rehabilitation facility.
Regards,
Your ___ Team | ___ w/hx colon ca (stage IIIC [T4b, N1, M0]) on palliative
chemotherapy and recent PE (___) on warfarin who presented
___ after mechanical fall found to have right hip fracture s/p
operative fixation with long TFN system.
She suffered immediate pain in right hip and inability to bear
weight. On arrival to ___, an X-ray showed a right displaced
femoral neck fracture for which orthopaedics was consulted. She
was noted to be anemic to Hg 6.1 on presentation in the setting
of FOBT+ stool and received 2 U pRBCs with appropriate increase
in Hg to 8.9 (down trending to 7.5 but remaining stable over the
hospital course). She had no signs of melena or BRBPR. She was
taken directly to the OR and underwent right hip arthroplasty on
___. During the procedure, the patient was hypotensive to
___ during the procedure and phenylephrine gtt was started
and uptitrated during the case. EBL 50cc. The patient was
admitted to the PACU on vasopressors but was quickly weaned off.
Post-operatively she was admitted to the orthopedics service.
She was restarted on heparin gtt and remained stable overnight.
She was transferred to medicine service for further management.
Heparin drip was discontinued for INR in therapeutic range, but
given rise of INR despite being off warfarin, warfarin was not
started initially due to concern for slow drug metabolism, and
anticoagulation bridging was continued with lovenox. She was
discharged on warfarin without further bridging therapy.
Pain was controlled with oral hydromorphone and tramadol. She
was evaluated by physical therapy, who recommended discharge to
a rehab facility for further therapy and convalescence. | 127 | 272 |
17676327-DS-8 | 27,456,005 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication
(Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may restart aspirin 2 weeks from the date of hemorrhage
(___)
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Patient presented to ___ as a trasnfer from an OSH. Upon
arrivla iamgign was reviewed and decision was made to insert a
external ventricular drain. The EVD was placed in a sterile
fashion and without complication. The EVD was tenuous but
continued to function properly. He remained stable into ___.
On ___ his exam was stable and the EVD was noted to be not
working. The EVD was then replaced without complication in a
sterile fashion. Post-placement CT showed satisfactory
positioning.
On ___, The patient was on q 2 neuro asessments. The patient
was neurologically intact. The patient remained intubated. The
external ventricular drain was open at 10. The patient's son
was updated.
On ___, The patients Creatinine was elevated.
On ___, The patients temperature was 100. The patient remained
intubated. The patient was initiated on started SQH.
On ___, The patients external ventricular drain was elevated to
15. The neurology service recommended to initiate a statin. A
lipid panel was sent. The patients son was updated in ___
over the telephone by the neurosurgery service regarding the
CTA head. The patients insulin was increased to lantus to 15
and ISS. The patients RSBI was 81. A1C 10.0. The patient was
switched from propofol to precedex.
On ___, The external ventricular drain evd was raised to 20. At
___ the patient coughed and was aggitated and 30 cc drained
from his evd and the EVD was clamped for 1 hour. A insulin gtt
was initiated. The serum sodium was 148.
On ___, A ___ to assess ventricle size was performed prior
to am rounds which did not show any hydrocephalus. He was
extubated. His EVD was kept at 20 for the rest of the day with
plans to raise it to 25 the ___ if he tolerated it well.
On ___, the patient was stable over night. His EVD was
clamped. Speech and swallow cleared him for thin liquids/ground
solids. His sodium was drifting down. He did have an increase
in his white count to 14K but was afebrile, CSF cultures were
sent. A repeat CT was ordered for the following day.
On ___, The external ventricular drain remained clamped. The
CT was consistent with slight increase in ventricular size. The
patients exam was stable. The patients serum NA was 152 to 151.
The white blood count trended down from 14 to 10.
On ___, The external ventricular drain was clamped. The
ventricles were stable in size on imaging. The external
ventricular drain was left in place for one more day.
On ___, The patient was found to be neurologically intact. The
external ventriclar drain was discontinued and a serum sodium
was 145.
On ___, The patient experienced some overnight some word finding
difficulty. A NCHCT was performed and found to be stable. On
morning rounds the patient was found to be neurologically
intact. Aspirin 81 mg was restarted. The patient's serum
sodium was normal at 142.
On ___, The patient was neurologically intact. The patient ___
transferred to the floor in stable condition. A urine culture
was sent.
On ___, patient had one episode of nausea and vomiting. Zofran
was changed to reglan. He remained intact on exam. His CSF
culture was negative at this time. His nausea was improved later
in the day and he was eating a clear diet.
On ___, patient had improvement in nausea and vomiting with
reglan. Speech and swallow re-evaluated the patient and
determined that he can have a regular diet with thin liquids. He
was accepted to a rehab facility and was discharged in stable
condition. | 382 | 636 |
19355136-DS-18 | 25,625,396 | Dear Mr. ___,
You were admitted with difficulty walking and increased
shortness of breath. Difficulty walking is thought to be due to
deconditioning from your recent hospital stay and progressive
spinal stenosis. You were evaluated by physical therapy who
recommended that you work with aggressive physical therapy at
your assisted living ___. You had no further chest
pain or shortness of breath when working with physical therapy
here. Your symptoms could have been due to some anxiety with
your unsteady gait. We also increased your home imdur to help
prevent symptoms of chest pressure when you are doing more
physical activity.
Because your kidney function worsened while you were here in the
hospital, we stopped your lisinopril and started you on
amlodipine for your blood pressure control instead. You should
get repeat bloodwork on ___. Please consider avoiding orange
juice, soda, and bananas since it can cause your potassium to
increase.
We wish you all the best.
Sincerely,
Your ___ team | Mr. ___ is a ___ with hx HTN, T2DM, prostate cancer s/p
TURP, and stable CAD presenting with gait instability, chest
pressure, and dyspnea on exertion in the setting of spinal
stenosis and deconditioning.
# Dyspnea on exertion (DOE): Suspect chronic deconditioning as
opposed to acute pulmonary process given normal CXR. Patient
denied any symptoms of dyspnea or chest pressure when working
with physical therapy during inpatient stay. A component of
anxiety was also likely contributing to subjective symptoms of
DOE and chest pressure. Low suspicion for PE given lack of
tachycardia or hypoxia at rest or with ambulation. Stable angina
could be contributing to symptoms but less likely since most
recent cardiac perfusion study and stress test showed minor
perfusion defect. Patient had no evidence of volume overload on
CXR to suggest CHF.
# Frequent falls: Likely secondary to a combination of diabetic
neuropathy, osteoarthritis, and spinal stenosis. Patient also
with proximal muscle weakness in b/l lower extremities which
could be due to spinal stenosis. Of note, ___ wnl. Vitamin D
pending at discharge. Orthostatics were negative suggesting that
recent initiation of imdur was less likely to be contributing to
symptoms. CT head/neck without acute fracture or intracranial
hemorrhage. Patient was cleared to go to ALF with ___ services.
# Hypertension: Lisinopril was held in the setting of acute on
chronic kidney injury. Patient was continued on chlorthalidone
and started on new antihypertensive amlodopine on discharge.
# Acute Renal Failure on CKD Stage 3: Likely in the setting of
diabetes and uncontrolled hypertension. Creatinine 2.0 in early
___, but Cr 3.3 on admission compared to recent Cr at
___ ___ of 2.8. Lisinopril was held on discharge.
# Hyperkalemia, resolved: Likely related to kidney disease. EKG
without peaked T waves. Patient without chest pain.
# CAD: Recent cardiac workup at ___ notable for borderline
positive EKG criteria, small area of mid to distal inferior wall
and apical ischemia. Small troponin elevation appears more
likely secondary to AoCKD. Patient was noted to be poor
candidate for cardiac cath given CKD. He was not maintained on
metoprolol since patient is frequently bradycardic <60. Patient
was transitioned to higher dose of isosorbide mononitrate on
discharge and maintained on aspirin.
CHRONIC ISSUES:
# Type 2 DM with nephropathy: Continued insulin regimen with
glargine and ISS. Continued home Latanoprost and
Dorzolamide/timolol eye drops for glaucoma.
# GERD: Continue home famotidine and omeprazole.
Transitional issues
- f/u blood pressure given changes in antihypertensive regimen
(d/c lisinopril, initiation of amlodipine, initiation of higher
dose of imdur)
- Please repeat chem10 on ___ to assess renal function and
potassium levels
- reassess improvement in gait with ongoing work with physical
therapy
* ___ (wife) ___, HCP Son ___ ___ | 158 | 459 |
18429092-DS-24 | 21,432,760 | Dear Mr. ___,
It was a pleasure participating ___ your care at ___
___. You were admitted from your rehab
with a trach malfunction and severe sepsis. Here you had your
trach exchanged at bedside by our interventional pulmonary team.
You were treated with broad spectrum antibiotics for coverage
of a likely recurrent pneumonia. You were given medications to
help support your blood pressure which improved with ongoing
antibiotic therapy. You will soon finish all antibiotics while
at rehab.
We wish you all the best.
Sincerely,
Your ___ Team | ___ w/ pmh dCHF, afib, pHTN, OSA w/ obesity hypoventilation
syndrome, asthma, and DMII w/ neuropathy, who recently completed
14 day course of cefepime for VAP, also on daptomycin and
fluconazole for IE, presents as a transfer from ___ for fever,
leukocytosis, and poor tracheal balloon seal. | 93 | 47 |
19527552-DS-18 | 28,284,124 | Pacer/ICD:
You were admitted for a pacemaker/ICD because of bradycardia
due to complete heart block.
Activity restrictions and information regarding care of the
procedure site on your chest are included in your discharge
instructions.
Continue all of your medications with the following changes:
- An appointment was made for you to return in 1 week to the
device clinic to check the wound.
- If you have any urgent questions that are related to your
recovery from your medical issues or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ Heart Line at
___ to speak to a cardiologist or cardiac nurse
practitioner.
Additionally, you were noted to be in an abnormal heart rhythm
called atrial fibrillation. This rhythm puts you at particular
risk of stroke. You will need to continue Apixiban life long to
decrease your risk of stroke.
It has been a pleasure to have participated in your care and we
wish you the best with your health.
Your ___ Cardiac Care Team
Sincerely,
Your ___ Care Team. | ___ hx of rheumatoid arthritis and bradycardia who was seen
cardiology clinic for bradycardia found to have newly diagnosed
atrial fibrillation with complete heart block.
# Complete heart block: Unclear etiology, likely age related
conduction disease. Lyme exposure, but had complete treatment
course ___ years ago. ___ A dual chamber ___ with V lead in
His bundle position implanted via left subclavian vein without
complications. Excellent selective/non-selective HB capture
thresholds.
___ ___
PACEMAKER AZURE XT
___ ___
W1DR01
# Atrial Fibrillation: New regularlized AF. Started on apixaban
for AC. TTE ___: Nl Biv fxn (EF 69%), mild AR, mild MR, mild TR,
RVSP 38. | 199 | 99 |
19624898-DS-21 | 28,364,195 | Dear Ms. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having a seizure at home.
Imaging of your brain unfortunately showed progression of your
metastatic breast cancer as the tumors in your brain had grown
much larger. There was also dangerous swelling around these
lesions so you were started on a medication, dexamethasone, to
help decrease the swelling and a medication, levitiracetem, to
prevent seizures.
Your imaging was evaluated by Neurosurgery who did not feel
there was any surgical intervention; however, the Radiation
Oncologists felt you might benefit from whole brain radiation
again. You had your first session on ___ and will continue as
an outpatient. By the time of discharge, your speech and
thinking had improved.
Again it was our pleasure participating in your care.
We wish you the very best,
-- Your ___ Medicine Team | =============================
PRIMARY REASON FOR ADMISSION
=============================
___ with metastatic ER positive, PR negative HER2/Neu amplified
breast cancer (mets to bone,liver, lung, brain) s/p whole brain
radiation, on c9 of T-DM1, presenting with seizures and found to
have hemorrhagic brain lesions and midline shift of 5mm
.
.
# Metastatic Breast Cancer, hemorrhagic brain lesions: The
patient was on C9 of T-DM1 and s/p whole brain radiation who
presented after seizure likely caused by progressive brain
metastases. Imaging showed multiple hemorrhagic lesions and
vasogenic edema causing a 5mm midline shift. The patient had
cognitive deficits with language and communication but no other
focal deficits. She was started on high dose dexamethasone and
keppra with cognitive but no other focal deficits or seizure
activity. Neurosurgery did not feel any surgical would be
beneficial. Her outpatient Heme/Onc team recommended possibly
enrolling in a clinical trial of naratonib but her daughter
(HCP) felt her mother would not want to participate in a trial.
Radiation Oncology evaluated and initiated whole brain radiation
on ___ to be continued as an outpatient. Her mental status
improved with steroids and radiation treatment and she will
follow-up with her outpatient providers with the goal of
returning to ___
.
# GERD: Stable. Continued home omeprazole.
.
=============================
TRANSITIONAL ISSUES
=============================
- She will benefit from discussion re: continuing systemic
cancer tx with outpatient onc team. Family was directed to
contact ___ NP for earlier appointmen
- Dexamethasone taper: to be managed by ___ Onc. Will be
discharged on dex 4mg q8hr
- Should have keppra level monitored
- Full Code | 145 | 247 |
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