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16092696-DS-8 | 22,269,515 | Dear Ms. ___,
You were admitted to the hospital for a pancreatic leak with
intra-abdominal collections resulting in failure to thrive. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please ___ Dr. ___ office at ___ or Office RNs
at ___ if you have any questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. **We would like you to
continue the insulin regimen you were previously discharged with
except that your lantus will be reduced to 15 units before bed
instead of 18.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
JP Drain Care:
*To gravity drainage into urostomy pouch.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain. ___
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the bag frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions. | The patient s/p Whipple procedure on ___ for ampullary
adenoma, which was complicated by symptomatic pancreatic fistula
was re-admitted from home with increased abdominal pain and
general malaise. In ED, patient was afebrile, her WBC and other
labs were within normal limits. Abdominal CT scan demonstrated
decreased inflammation and intra abdominal fluid collection.
Patient was restarted on antibiotics, diet was advanced to
regular and was well tolerated. On HD 1, patient remained
afebrile, with normal WBC, and pain was well controlled. ID was
contacted and they recommended to continue current antibiotics.
Patient was discharged home in stable condition on HD 2.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 372 | 149 |
12651710-DS-7 | 20,164,503 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You had fast heart rate by your physical therapist and primary
care physician.
What did you receive in the hospital?
- You were given medications to help slow the heart rate. The
heart rate continued to be fast and your blood pressures
dropped. You were given a shock to fix the heart rhythm. Then,
you were given an ablation to prevent the heart from having this
rhythm again. Your heart still will have atrial fibrillation. We
are controlling this with your current medications. You should
discuss this further with Dr. ___ Dr. ___.
What should you do when you leave the hospital?
- You should follow up with your electrophysiology doctor ___.
___ and your cardiologist (Dr. ___.
- You should weigh yourself every day. If you gain 3 pounds or
more, please call your cardiologist.
We wish you the best,
Your ___ Care Team | ___ year old man with hypertension, hyperlipidemia, carotid
disease s/p R CEA ___, HFrEF (EF ___ recently diagnosed
atrial flutter on apixaban s/p successful TEE/CV, discharged on
___, who re-presented with recurrent atrial flutter on ___
treated with amiodarone drip and metoprolol now s/p EP
cavotricuspid isthmus ablation on ___.
# Atrial flutter/Atrial Fibrillation: Recently diagnosed atrial
flutter in ___ on apixaban for anticoagulation s/p
successful cardioversion on recent admission, now reverted back
into atrial flutter. He was not on any antiarrhythmics on last
discharge. During this admission, he was started on amiodarone
load ___ and continued oral anticoagulation (apixaban).
Additionally, metoprolol 6.25 mg q6hr was started rather than
digoxin, given his HFrEF. Plan was elective cardioversion with
discussion of ablation as an outpatient, but underwent emergent
DCCV overnight ___. He then underwent successful cavotricuspid
isthmus ablation on ___. He was transferred briefly to the floor
but returned the ICU with elevated lactate. He was discharged on
amiodarone 400 mg BID x 1 week total (___) that was then
discontinued per EP recommendations as he is s/p ablation. On
___ he was noted to have an irregular rhythm on telemetry. EKG
showed atrial fibrillation with ventricular rate in ___. EP team
was informed of atrial fibrillation was recommended discharge on
apixaban and metoprolol with EP follow up.
# Cardiogenic shock: He was transferred to CCU for cardiogenic
shock secondary to atrial flutter s/p successful emergent DCCV
on ___. Patient had cavotricuspid isthmus ablation on ___ and
remained in sinus rhythm. His lactic acidosis at that time was
improved 2.4 from peak of 4.2. He was transferred to the floor
briefly, and then transferred back to CCU for elevated lactate
(4.7 from 2.4). He was mentating appropriately, BPs and HRs
normal, and making urine. It was felt he was not in cardiogenic
or septic shock given this and that lactic acidosis may have
been from liver disease. Plan was for repeat lactate, but
patient refused (see capacity discussed below). The following
day, he agreed to have lactate drawn, which was normal at 1.6
and he was transferred out of the intensive care unit. He had no
further episodes of hypotension.
# HFrEF, Cardiomyopathy: Suspect tachycardia induced
cardiomyopathy in setting of atrial flutter with depressed LVEF
of 25%. He was diuresed with furosemide IV and transitioned to
home torsemide 20 mg daily. ACE-inhibitor was held in setting of
___, but lisinopril was re-started prior to discharge and
metoprolol succinate 12.5 mg was started.
# Capacity: During this admission, he requested to leave against
medical advice several times. He was evaluated by psychiatry who
felt 1) his decision making is poor as he has frequently changed
his mind about wanting and then not wanting medical therapy and
2) his understanding is poor given that he believes he can be
safe at home without first being monitored in the hospital.
Therefore, he was deemed to not have capacity to leave AMA. He
did not refuse care after transfer out of the ICU.
# ___: Cr elevation up to 1.8 from admission at 1.0. Likely ATN
in setting of shock. Urination and Cr improved to 1.4.
# Transaminitis: LFTs with peak of ALT 613, AST 772. Rising LFT
suspicious for shock etiology. RUQ ultrasound was unrevealing.
Hepatitis serologies were negative. LFTs improving at time of
discharge.
# Cough, leukocytosis: Had cough, likely secondary to volume
overload as above. No fevers or chills or CXR evidence of
pneumonia, although sputum culture with GPR. Therefore, treated
with 5 day course of Augmentin ___ - ___. Cough improved
with diuresis as well as symptomatic treatment. Leukocytosis
likely partly astress reaction in the setting of atrial flutter
with cardiogenic shock.
#Coagulopathy: INR up to 5.2, likely secondary to liver
dysfunction from shock. Improving at time of discharge. INR 2.2
on day of discharge.
TRANSITIONAL ISSUES
# Disposition: ___ (___) 'expected length of
rehab stay is less than 30 days'
# NEW MEDICATIONS
- Benzonatate 200 mg PO TID
- Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
- Docusate Sodium 100 mg PO BID
- Senna 17.2 mg PO BID:PRN Constipation
- Ramelteon 8 mg PO QHS insomnia
# CHANGED MEDICATIONS
- Metoprolol Succinate 12.5 mg PO DAILY
# STOPPED MEDICATIONS
- None
[] Follow up with electrophysiology for management of atrial
fibrillation and atrial flutter s/p ablation
[] Adjust lisinopril dose as needed for afterload reduction
[] Adjust torsemide as needed to maintain euvolemia
[] Adjust beta blocker as tolerated
[] Repeat TTE in 8 weeks from ___
[] Hep B vaccine needed
DISCHARGE WT: 67.5 kg
DISCHARGE CR: 1.4
# CODE: DNR/DNI
# CONTACT/HCP: ___ (wife) ___ | 159 | 754 |
18876079-DS-21 | 23,218,666 | Dear Mr. ___,
We had the privilege of taking care of you during your admission
to ___. You returned to the hospital after your recent stay
with us because you had persistent fevers from your blood
infection even though you were on antibiotic. During this
hospital stay, we found that you still had bacteria in your
blood even though you were on the correct antibiotic. You had
multiple scans which did not show a specific source of the
infection, but you will be continued on the vancomycin
antibiotic until ___.
Please follow-up with your primary care doctor at ___ (Dr.
___.
We wish you the very best,
Your ___ Team | ___ inmate with HCV, ESRD ___ IDDM2 with recent admission line
infection with MRSA, treated with line removal on ___ and
vancoymcin, returning with persistent fevers and bacteremia.
#MRSA bacteremia: concerning for foci of infection/abscess given
that he is persistently bacteremic despite line holiday and
vancomycin. TTE from prior admission was negative for
vegetations, and TEE this admission was negative for valvular
vegetations. No persistent back pain suggestive of epidural
abscess or osteomyelitis. Given unclear focus of infection, we
ordered a torso CT with contrast that showed pulmonary
infiltrates suggestive of "widespread infection". However, given
no clinical sxs of pneumonia and lack of fevers, further
antibiotics were not added on to vancomycin. Tagged WBC scan was
negative for focus of infection. Imaging of the spine with MRI
was not pursued as pt had no neck pain/tenderness and an intact
neurological exam; he did have mild numbness/tingling on the
dorsal R hand and distal forearm, but he had had this in the
past, and the tagged WBC scan was negative and further workup
was deferred. During this hospitalization, he defervesced on HD
3 and his mental status significantly improved with this.
***He is planned to have a total of 4 weeks of vancomycin dosed
with HD, last day ___, and needs weekly vancomycin
monitoring labs drawn and faxed to ___ (see transitional
issues below).
#Anemia: hgb dropped twice during admission to <7.0 and he was
transfused 1U each time. Unclear etiology of persistent slow
decrease given no sign of bleeding and negative hemolysis lab
workup, but may be related to his chronic renal disease. He
should continue to get EPO with dialysis.
#elevated troponins: stable trend after initial rise
(0.13->0.2->0.2), likely attributable to end stage renal
disease. Ckmb has been 1 and now <1, so less concerning for ACS
especially as patient is more clear and not complaining of chest
pain. EKGs unremarkable. Already on beta blocker, aspirin,
statin.
-follow-up with outpatient cardiology for any optimization of
cardiovascular risk factors.
# DM: Pt had mild asymptomatic hypoglycemia on ___ and ___
AM to ___, both times improved with orange juice. His nighttime
NPH was decreased from 10 to 7units; no further episodes of
hypoglycemia afterwards. | 107 | 360 |
15993209-DS-8 | 28,232,054 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of your low blood counts (anemia). There was no evidence
to suggest that you have bleeding from your GI tract. You were
given a blood transfusion, with improvement of your anemia. We
examined your blood smear and it appears that you may have
something called myelofibrosis which is concerning for your bone
marrow not producing red blood cells appropriately. Your primary
care doctor ___ help arrange for you to follow-up with your
hematologist-oncologist.
Your anemia is likely contributing to your chest tightness. You
may need another catheterization of your heart vessels in the
future. You are scheduled for follow up with your cardiologist
to discuss this further.
Please see the below "recommended follow-up" section for your
upcoming appointments.
Sincerely,
Your ___ team | ___ PMHx CAD, CABG ___, LIMA to LAD, SVG to PDA, SVG to ___,
AS ___ 0.9-1cm2 on ___, h/o SVT, T2DM, CKD (stage III, ___
DM) admitted with anemia (likely ___ chronic inflammation and
CKD, received 1U PRBCs), unstable angina (likely ___ worsening
anemia, progressive CAD), and AoCKD.
ACTIVE ISSUES
=============
# Anemia of chronic inflammation
Pt presented with worsening anemia associated with angina, with
a decline in hemoglobin from 13.1 (___) to 8.5 on admission
(___). Pt denied melena or BRBPR. Laboratory studies
notable for hypoproliferative anemia (RI 0.4%) with iron studies
suggestive of anemia of chronic inflammation. Folate and B12
levels were normal. Stool guaiac was negative during admission.
Pt received one unit of PRBCs for concern that the anemia was
contributing to his angina symptoms. He had an appropriate
increase in hemoglobin from 8.5 to 9.6 (post-transfusion). He
remained asymptomatic and hemodynamically stable during
admission. His anemia was felt to be secondary to anemia of
chronic inflammation, with no evidence of blood loss from a GI
bleed so endoscopy and colonoscopy were not pursued. An
abdominal and pelvic CT scan were performed which did not show
any overt evidence of malignancy. Blood smear was concerning for
increased tear drop cells and target cells suggestive of
myelofibrosis. Pt was discharged with follow up scheduled with
his PCP and cardiologist. We have asked that PCP arrange for
___ follow-up; peripheral smear results were reviewed with
pt and his wife at bedside prior to discharge.
# Angina and dyspnea on exertion:
Pt presented with vague symptoms of chest tightness and dyspnea
on exertion concerning for unstable angina in setting of
worsening anemia. EKG showed no evidence of active ischemia and
cardiac enzymes were stable (trop stable but slightly elevated
in setting of renal dysfunction, anemia, CKMB was normal). Last
TTE was concerning for worsening AS, which is likely
contributing to his symptoms in addition to his anemia. Pt was
continued on aspirin, metoprolol and statin during admission. Pt
was discharged with outpatient follow up with his cardiologist
for consideration of catheterization to assess the native
valves, the 3 bypass graft and aortic valve. Patient was able to
ambulate around the medicine floor without any chest pain or
shortness of breath.
# AoCKD
Pt has a history of CKD secondary to DM. Pt has had worsening
renal function over the past month (Cr 1.16 on ___, Cr 2.11
on ___, and 2.2 on admission). It is unclear if this is
subacute or chronic from chronic diabetes versus an acute
process. Creatinine remained stable during admission. Pt was
discharged with outpatient follow up with his PCP for further
management. | 141 | 431 |
18549835-DS-15 | 23,572,673 | Ms ___,
It was a pleasure treating you during this hospitalization. You
were admitted for a syncopal event while at your nursing
facility. This was thought related to something called
"vasovagal" event which is a transient drop in your blood
pressure. This can happen when you are nauseas and feel like you
need to vomit. Your lab work was relatively normal and
infectious work up negative. You were discharged in improved
condition without additional episodes. | ___ w/ history of vertigo who was admitted from ___
after a possible syncopal episode most likely vasovagal in
nature.
# Fall:
# Dizziness:
# Syncope:
History of nausea and urge to defecate followed by sudden onset
lightheadedness and weakness while standing quickly to get to
bathroom all consistent with a transient vasovagal event. This
resolved during admission and patient had no additional episodes
or nausea or vomiting or diarrhea. CT head negative for acute
process as was CT neck and shoulder films. She ambulated the
floor with assistance of walker and staff and appeared at
baseline though she reported unsteady gait. Continued home meds
though discontinued HCTZ due to admission labs appearing
dehydrated and normal BPs during admission. HCTZ may further
exacerbate risk of falls.
# Thyroid Nodule: unknown signficance, seen incidentally on CT
neck. Consider outpatient US though at patients age unlikely to
be on benefit.
# Chronic Constipation: continued home meds
# Hypertension: Continued Losartan, DCd HCTZ as above
# Hypercholesterolemia: Continued home meds
# Glaucoma/Macular degeneration/Cataracts: continued eye drops
# Vertigo: continued meclizine | 75 | 187 |
15995734-DS-8 | 26,100,160 | You were admitted for evaluation of abdominal pain, coffee
ground vomit, and dysphagia. EGD showed retained food in the
setting of inflammation and ulceration near the site of your
surgery, in your stomach, and in your esophagus. Biopsies were
taken. This was confirmed on CT scan, but with no obstruction
or new masses.
You were given a trail of a pro-motility drug called Reglan and
placed on twice daily acid suppression medication. Please
maintain a liquid or very soft food diet until follow up. | ASSESSMENT AND PLAN:
___ year old male with history of stage 1B gastric cancer s/p
resection and adjuvant chemotherapy in remission, remote history
of PUD, presents with abdominal pain, coffee-ground emesis, and
possible upper GI bleed.
# Epigastric pain/coffee-ground emesis/Dysphagia: Hct remained
stable here. He was maintained on a PPI BID. GI findings were
as above, with retained food, inflammation in the stomach and
esophagus, and ulceration. CT scan with no obstruction. He was
transitioned to clear liquids and a soft diet, with a trial of
Reglan and PO PPI BID. He tolerated this well with only one
episode of nausea. The case was discussed with GI and the
patient with family. He was given the choice to remain in the
hospital for possible re-scope next week, or discharge with a
liquid diet, reglan, and PPI, with close outpatient follow up.
Because he was clinically well, he preferred to be discharged.
He was given reports of his CT and EGD findings, and will follow
up closely next week.
- GI biopsies are pending at discharge, will need to be followed
up.
# History of stage 1B gastric cancer- as above, recurrence
unlikely. Gastric ulcer may have developed near anastomotic
site, although long term complications after Billroth II are
rare.
# Hypertension- chronic, unknown medication. Well controlled in
house. Resume home medication on discharge
- We discovered he takes Amlodipine 10mg daily. This was
continued on discharge
# CODE STATUS: full
# EMERGENCY CONTACT: ___, ___ | 87 | 255 |
14792232-DS-8 | 24,103,594 | Mr. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted for an infection of
your gallbladder and gallstones. You had a procedure, an ERCP,
and it improved your infection. Please continue to take your
antibiotics as directed.
Given the success of the ERCP and the risk of surgery, our team
does not recommend a surgery to remove your gallbladder.
Please DO NOT take your warfarin (or Coumadin) for the next 4
days. Please resume it on ___.
Please DO NOT take your home Lasix, as it may be causing you to
have light-headedness at home. Do not restart it until directed
by your doctor.
Please follow-up with your PCP as directed below.
You should eat a low-fat diet. This evening, you should a "BRAT"
diet - start with bananas, rice, apples, toast - these kinds of
bland foods.
Take care,
Your ___ Team | Mr. ___ is ___ man with history of afib, CHF and GERD
presenting with RUQ pain transferred from ___ with concern
for cholecystitis.
# Abdominal pain
# Cholecystitis
Patient with acute onset of abdominal pain with elevated LFTs
and bilirubin concerning for biliary obstruction vs
cholecystitis. RUQ US suggestive of gallbladder edema suggesting
cholecystitis vs choledocholithiasis. ACS evaluated patient and
recommended ERCP. Patient was taken for ERCP after INR < 1.6 and
sphincterotomy was performed and a large amount of sludge was
found with balloon sweeps of the CBD. He tolerated the procedure
well and was able to advance his diet on day of discharge
without incident. Given successful ERCP with sphincterotomy,
patient's age and multiple co-morbidities, ACS did not recommend
cholecystectomy.
# Atrial fibrillation: CHADS-vasc of ___ for age and report of
CHF though per patient has had peripheral edema without report
of true CHF. INR 2.2 on admission. Patient was given vitamin K
in preparation for ERCP. Warfarin was then held at discharge for
5 days post ERCP. Patient instructed to resume warfarin on
___.
# Light headedness: Patient reports he has been having light
headedness with standing at home without any further peripheral
edema and with ___ raises concern for orthostatic hypotension.
Home lasix was held on admission. Symptoms improved with IVF.
Given he had no evidence of volume overload, lasix was held at
discharge.
# ___: Presenting with elevated creatinine however unclear
baseline. Improved with fluid at OSH suggesting prerenal ___,
___ be related to infection vs overdiuresis in the setting of
the patient's report of weight loss recently and light
headedness with standing at home. Creatinine stable at 1.0 at
discharge.
# Left hip Lesion: Nonaggressive appearing lucent lesion of left
femoral neck on CT abdomen pelvis from ___. HIp xray showed
likely sclerosing myxoid fibrous, but could consider non-urgent
MRI for further evaluation.
# Gout: Home allopurinol continued.
# BPH: Home finasteride continued.
# GERD: Home omeprazole continued.
> 30 minutes were spent on discharge day management and care
coordination. | 146 | 336 |
14214341-DS-37 | 28,865,249 | Dear Mr. ___,
You were admitted for an infection ___ your bone both ___ your
hand and your foot, a condition called osteomyelitis. You were
treated with antibiotics and you underwent surgery to remove the
infected areas. The tests on your foot showed that there still
might be active infection left behind so the infectious disease
doctors would ___ to go home on IV antibiotics. You will
need to go to the ___ once a day to get the
antibiotic through your ___ line. It is very important for you
to arrive for your antibiotic infusion every day ___ order to
have the best chance of treating the infection.
Please keep the boot on your leg as well as the dressing until
your follow up appointment with podiatry on ___. It is ok
to remove the boot while showering but please be sure to cover
the dressing with plastic so that it does not get wet with
showering. The dressing does not need to be changed. The
podiatry team will do this at your follow up appointment this
week.
It was a pleasure taking care of you while you were ___ the
hospital.
-Your ___ care team- | ___ year old man with diabetic nephropathy, s/p failed
living-related kidney transplant ___, now s/p deceased-donor
transplant ___, uncontrolled DM (last A1c 10.6%), PVD s/p fem
bypass and multiple toe amputations, poorly-controlled HTN, with
recurrent admissions for osteomyelitis presented with
osteomyelitis of the right ___ metatarsal head and right second
phalanx now s/p right finger amputation and R TMA on ___.
Pathology with margins that had equivacal evidence of residual
osteomyelitis being discharge on ___ week course of IV
antibiotics.
Consults: ID, hand surgery, podiatry
# Osteomyelitis of right ___ metatasal head s/p TMA with
podiatry ___. margins were equivocal so continuing longterm abx
(ertapenem) per ID recs for ___ weeks via ___. ID will follow
patient as an outpatient to determine exact course. Patient with
plan for weekly OPAT labs.
# Right ___ phalanx osteomyelitis: s/p amputation of distal
right phalanx ___. Margins clear per path report. Patient
started on Gabapentin per hand surgery recommendations. He was
continued on sildenafil rx'd by outpatient hand surgeon to
increase blood flow to digits. He was treated with antibiotics
as above.
# HTN, poorly controlled. Patient was hypertensive despite
multiple agents at home including chlorthalidone, nifeipine, and
labetalol. Labetalol increased to 800 BID. Patient has been
hesistant to take this dose and has been dictating his own BP
regimen at home. He was continued on home dose Chlorthalidone,
nifedipine, doxazosin and labetalol. Labetolol was transiently
increased to 800 mg BID dose though patient continued to have
labile blood pressures and he was discharged on 600 mg BID dose
as intended by patient's PCP.
# ESRD, s/p renal transplant S/p failed LLRT ___ and now s/p
DDRT ___. Patient was maintained on immunosuppression
throughout hospital course with leflunomide (hx of BK virus),
tacrolimus, and prednisone. Tacro remained at goal of ___K virus was undetectable.
CHRONIC ISSUES:
# Type II DM complicated by diabetic nephropathy (HgA1C of
10.6%):
Patient was continued on glargine and ISS throughout hospital
course.
# PVD s/p fem bypass and toe amputations:
Patient with non-healing ulcers, s/p multiple toe amps and
stents. Vascular consulted on patient and felt that patient had
adequate blood flow to heal from procedure above. He was
continued on aspirin and pravastatin.
# Mass on right renal imaging being monitored: Per outpatient
urologist (___), should have repeat MRI ___ one year
(___) and see Dr. ___ at that time. | 196 | 399 |
13170445-DS-16 | 27,194,065 | Dear Ms. ___,
You presented to ___ on ___ with complaints of abdominal
pain. You had an ultrasound of your gallbladder which helped
confirm a diagnosis of Acute Cholecystitis, an inflammation of
your gallbladder. You were admitted to the Acute Care Surgery
team for further medical management.
You were taken to the Operating Room and underwent a
laparoscopic cholecystectomy where your gallbladder was removed.
You tolerated this procedure well and returned to the step-down
surgery floor for pain control and to await return of bowel
function.
You have tolerated a regular diet, pain medicine and ambulated.
You complained of right foot pain with ambulation and had a
right foot x-ray which was negative for injury. You may elevate
your foot and apply ice for relief. You are now medically
cleared to be discharged home. Please note the following
discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She was taken
to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
POD #1 to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On POD #1, she was discharged home with scheduled follow up in
___ clinic in 2 weeks. | 829 | 176 |
12514563-DS-11 | 28,667,595 | Dear Mr. ___,
You were admitted to the hospital for a respiratory infection
and electrolyte abnormalities. You were very dehydrated and
felt better after receiving IV fluids. We treated your
pneumonia with antibiotics and your symptoms improved.
Please continue levofloxacin for 5 more days.
One of the physicians from endocrinology ___ contact you on
___ to setup a follow up appointment where they can discuss
the lab tests that are pending at the time of discharge. | Patient is a ___ year-old male with Crohns disease s/p multiple
abdominal surgeries, who presented with fever and cough
concerning for pneumonia.
.
# Fever/cough: The patient presented with cough, leukocytosis
and possible infiltrate on CXR concerning for pneumonia. He was
started on levofloxacin for community acquired pneumonia.
Influenza DFA was negative, and legionella urine antigen was
negative. He was also treated with nebulizers for symptomatic
relief. Over the course of his hospitalization his symptoms
improved, and he was discharged with a plan to complete a total
7 day course of antibiotics.
.
# Electrolyte abnormalities: The patient presented with
hyponatremia and hyperkalemia, that were initially concerning
for a possible adrenal insufficiency. Endocrine was consulted
and suggested performing a cosyntropin stimulation test; the
patient had an appropriate cortisol stimulation. He was fluid
resuscitated with normal saline, and his electrolyte
abnormalities resolved.
.
# Elevated Lactate: This was likely elevated because of
infection and dehydration, and resolved with IV fluid
resuscitation.
.
# Crohn's - Patient was continued on home entecort.
.
# Pos PPD - Patient was continued on INH and B6. | 76 | 193 |
13595620-DS-20 | 21,557,620 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for infectious
colitis, which is an infection of your colon. You were found to
be infected by a bacteria called Clostridium Difficle. For this
you were treated with antibiotics. Please continue to take this
antibiotics as prescribed and follow up with your doctor as
scheduled. Please Weigh yourself every morning your current
weight 160 lbs, call MD if weight goes up more than 3 lbs.
We wish you a speedy recovery!
Sincerely,
Your ___ Team | ___ history of diastolic congestive heart failure, HTN, HLD,
a-fib w/ tachy/brady syndrome s/p pacer and aortic insufficiency
who presents with abdominal pain and diarrhea, found to have a
positive UA and colitis on CT and positive C.diff PCR.
# C.diff colitis: Patient had presented with abdominal pain and
diarrhea. CT scan done in the ED showed evidence of colitis. It
showed mild stranding and wall thickening of the distal
descending colon and sigmoid colon. Patient was empirically
given ceftriaxone for a UA. This was discontinued. C.Diff PCR
came back positive and patient was continued on flagyl for a
total 10 day treatment. Her pain was controlled with tylenol and
tramadol. During her hospital stay she started to have melena,
that probably was secondary to c.diff colitis. Patient had a
stable hemoglobin and hematocrit so upper endoscopy and
colonoscopy was deferred given acute colitis. The consistency of
stool improved and the dark stools subsided. Her iron studies
were normal. H.pylori is pending on discharge. Colonoscopy and
upper endoscopy should be considered as an outpatient.
# Positive UA: Patient was asymptomatic on presentation and has
a history of positive UAs in the past for which she has been
treated with ciprofloxacin. She was given ceftriaxone in the ED
which was discontinued when reaching the floor as it was
unlikely that she was suffering from a UTI. Culture grew back
mixed flora that was likely a contaminate. Patient most likely
has asymptomatic bacteriuria.
# Chronic diastolic CHF without acute exacerbation: Dry weight
155lbs. Weight on admission was 160.4lbs (72.9kg). Patient
appears euvolemic on exam. No evidence of elevated JVP and clear
lung sounds. Patient was initially continued on home
medications. Wide pulse pressure due to aortic insufficiency for
which she was being worked up for surgical treatment as an
outpatient. During her hospital stay she had low diastolic blood
pressures down to the ___, as per the patient her baseline is in
the ___. This was likely secondary to fluid loses from diarrhea.
Her BP medications were held until her pressures improved, at
which point she was restarted on her home medications.
# Atrial fibrillation, tachy/brady syndrome s/p PPM: Recently
with pocket infection requiring explantation and then
re-implantation. Anticoagulation discussed in the past, despite
CHADS2 of 3, patient declined. During hospital stay she was
continued ASA 325mg daily. Her metoprolol was held while her
blood pressures were low and restarted once pressures were back
to base line.
# Aortic insufficiency: Plan for AVR in ___, but needs LHC
prior to surgery. Patient reports that she recently had dental
eval per cardiac surgery requirements. | 89 | 432 |
17650982-DS-12 | 29,324,344 | Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain. .
Please keep your staples along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | #Right SDH
The patient was admitted to the ___ from the ED for close
surveillance with neurological checks every two hours. His blood
pressure was titrated to SBP < 160 and he was started on seizure
prophylaxis with keppra. Patient with increased left upper
extremity weakness and increased lethargy on ___ and a repeat
CTH was obtained. CTH revealed stable SDH size, however slightly
increased MLS and brain compression of about 3mm. Patient
remained in ___ under close neurological evaluation. Patient
underwent a repeat CTH on ___ AM which remained stable. Surgery
was discussed with the patient and he declined surgery; the
patient will remain in the ___ for close neurologic monitoring.
On ___ patient was more lethargic on exam with increased left
side neglect. NCHCT was obtained and while the size of the SDH
remained stable, patient had increased midline shift from 3mm to
5mm. His exam continued to remain poor and patient was taken to
the OR on ___ for right craniotomy ___ evacuation and
treatment of his brain compression. Surgery was uncomplicated
and patient tolerated the procedure well. Please refer to formal
op report in OMR for further intra operative details. A surgical
drain was left in place. Patient was extubated and transferred
to the pacu for post op management and then later back to ___
for continued care. Patient exam significantly improved after
surgical intervention. His drain was removed on ___. He
remained neurologically intact. He was evaluated by ___ who
recommended rehab. Patient was transferred to the floor on ___.
He was discharged to acute rehab in stable condition on ___.
#Bipolar/depression
Patient with significant psychiatric history of bipolar,
depression and anxiety. Psychiatry was consulted for additional
help in management of known psychiatric illnesses and medication
regimen. ___ Pharmacy was called on ___ to confirm
patient's home psychiatric medications. Medications were started
per psychiatry recommendations. Patient was placed on a nicotine
patch while inpatient to help prevent nicotine cravings.
Psychiatry re-assessed patient on ___ and stated that patient
was competent to make his own decisions. He was also evaluated
by Psych on ___ and was deemed competent.
#Leukocytosis
Patient had increasing white count on ___ Tmax 100.6 overnight
on ___. UA from ___ was negative. CXR was obtained and
negative. Patient's fevers resolved and WBC downtrended. He
remained stable.
#Dispo planning
___ evaluated the patient and recommended discharge to acute
___ rehab. He was discharged to rehab on ___. | 504 | 401 |
18800291-DS-21 | 24,802,494 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for anemia.
What was done for me while I was in the hospital?
- You received red blood cells transfusions for your low blood
count. We found that your low counts are due to chronic blood
loss and some degree of bone marrow suppression from chronic
inflammation from your pressure ulcers.
- You were also evaluated by Orthopedics and Plastic Surgery for
potential surgery for your chronic pressure ulcers.
- You were also seen by our Wound Care staff who recommended the
following:
Pressure relief per pressure injury guidelines
Support surface: SW Alternate
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times
Waffle Boots ( X ) Multipodis Splints ( )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
Standard Air ( )
ROHO ( ) Obtain from ___
OR ___ air full length chair cushion ( ) (Obtain from ___
Elevate ___ while sitting.
Moisturize B/L ___ and feet, intact skin only BID with Sooth
And ___ Ointment.
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
( )Apply moisture barrier ointment to the periwound tissue
with each dressing change.
( X )Apply protective barrier wipe to periwound tissue and
air dry.
To troch Apply Aquacel Advantage around fungating bone and
tuck into undermining, cover bone with Xeroform
Top with Sofsorb and secure with Hy Pink Tape
To sacrum to right glut, posterior thigh fill with Melgisorb AG,
cover with Sofsorbs and secure with Hy Pink tape
To medial ___ wounds fill loosely with Melgisorb AG, top with 4 x
4 and secure with Kerlix
To bilateral heels Xeroform, Sofsorb, Kerlix
Change all dressings daily
What should I do when I leave the hospital?
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no date listed, and you do not hear from
their office in ___ business days, please contact the office to
schedule an appointment.
- Please monitor for new/or worsening symptoms (listed below).
If you do not feel like you are getting better or have any other
concerns, please call your doctor to discuss or return to the
emergency room.
- Please note any new medications in your discharge worksheet.
Sincerely,
Our ___ Team | ___ is ___ h/o paraplegia iso T4/5 spinal cord injury
due to MVA, bilateral femur fractures s/p ORIF c/b recurrent
wound infections and osteomyelitis (requiring prior hardware
removal, girdlestone procedure, prior skin flaps). and chronic
extensive pressure ulcers who presents with acute on chronic
anemia in setting of ongoing blood loss from ulcers.
ACUTE ISSUES
==============================
# Anemia, normocytic:
Hgb 8.7 on previous discharge and per report had slowly
downtrended in setting of ongoing oozing from chronic wounds (L
trochanteric, L sacral decubitus, R heel). Hgb improved to 8.7
at time of discharge following 4u pRBC transfusion. Pt denied
bruising, SOB, or bloody stools reassuring for source of
bleeding elsewhere. Iron studies sent showed retic 0.05, w/ RPI
of 0.55, suggesting hypoproliferation together with elevated
CRP, elevated haptoglobin 405, low TIBC consistent with ongoing
component of anemia of chronic inflammation. Low iron also
suggests component of iron deficiency anemia. He was started on
a PPI given immobility as risk factor for GI bleed.
# Chronic left hip/sacral/lower extremity wounds: He had an
outpatient follow-up with Orthopedics on ___ but was unable to
make appointment. Previously planned to have trochanteric
osteotomy of infected bone with eventual flap placement. He was
evaluated by general surgery in ED, who saw no need for
immediate intervention. He was also seen by Orthopedics this
admission who recommended need for assurance of social support
(proper wound care, social support) prior to undergoing surgery,
which would be an extensive undertaking requiring colostomy,
multiple surgeries, and skin grafts. He was was also seen by the
wound nursing for ongoing management of left hip/sacral/lower
extremity wounds.
#Tachycardia:
He had intermittent tachycardia 130s this admission with history
of chronic intermittent tachycardia. Etiology includes d/t
chronic anemia although not consistent with variability vs. d/t
pain (resolved w/ pain medication) vs. element of autonomic
dysregulation iso spinal cord injury above T5-T6. CT A/P ___ to
look for possible fluid collection / abscess showed stable
ulcers, mild bilateral hydronephrosis stable from prior,
unchanged LAD, stable mild bilateral hydronephrosis and
non-obstructing R renal stone; no drainable fluid collection was
seen. CT PE from prior hospitalization (with similar episodes of
tachycardia0) found no PE and patient has been on
anticoagulation.
# Malnutrition: Albumin 2.2 on last admission in ___
suggestive of ongoing malnutrition. Currently trying to improve
nutritional status for future surgical planning. Patient reports
regular diet of milk / cereal, steaks, pizza for other meals,
although does note he eats small portion sizes. Nutrition was
consulted, and he received multivitamin supplement daily.
# Thrombocytosis: DDx includes reactive due to ongoing
inflammation from chronic wounds versus due to anemia.
# Leukocytosis (resolved): WBC initially elevated at 13.3. U/A
positive for leuks, nitrites, WBC, and bacteria however this
came from condom cath sample so likely contaminant. Urine, blood
cxs remained negative. Pt denied changes in smell or consistency
of urine and did not have any systemic signs/sxs, thus further
Abx were deferred given risk for Abx resistance.
.
.
.
Day of discharge: >30 minutes spent on discharge planning and
coordination of care today.
TRANSITIONAL ISSUES
==============================
[ ] ___ was consulted and recommended IVC filter exchange on an
outpatient basis given h/o interfilter thrombus & dislocation of
IVC prongs
[ ] Consider discontinuing Apixaban in ___ (3 months from
___ - date of R DVT) to decrease amount of blood oozing
and frequency of need for transfusions
[ ] F/u Heme outpt appointment for bone marrow
hypoproliferation, thrombocytosis, LAD on CT A/P (___).
Please arrange for patient to have transfusions at infusion
center to avoid hospitalization (hopefully hematology can
arrange this)
[ ] Patient has expressed a strong preference on multiple
occasions for future blood transfusions to be done as an
outpatient. In the setting of future hypotension, tachycardia,
we recommend rechecking a CBC and transfusing on an outpatient
basis to decrease hospital acquired infections if at all
possible.
[ ] Plastic surgery: recommend need for pressure offloading
mattress at home
[ ] Patient expressed concern over lack of resources for wound
care and lack of pressure offloading mattress at home, which is
contributing to worsening wounds upon d/c from ___.
Please help arrange for home PCA to provide wound care and
acquiring of mattress. | 494 | 681 |
17818674-DS-12 | 21,508,844 | Dear Mr. ___,
It was a pleasure taking care of you during this admission. You
were admitted for fevers and not feeling well. You were found to
have an elevated white blood cell count suggestive of infection.
You had a chest x-ray which was suggestive of infection. You had
a CT scan of your abdomen given abdominal pain, but this was
normal. You were given antibiotics for the pneumonia and your
symptoms improved.
The following medications were changed during this admission:
1. START Levofloxacin 750mg by mouth for 6 days
.
No other medications were changed or added.
.
Please continue all other medications you were on prior to this
admission. | ASSESSMENT & PLAN: Pt is a ___ y/o male with PMH HTN, HLD, on
anti-psychotics, who presents with fevers, cough, and abdominal
discomfort, difficult/poor historian at baseline. Ultimately
his workup proved unremarkable and he was discharged in stable
condition without any pain.
.
# Fevers: DDx includes PNA vs. viral bronchitis or influenza vs.
other source such as abdominal and less likely GU. Most likely
bacterial PNA given high fevers reported at group home, cough,
and LLL infiltrate on CXR. Influenza possible as well given HA,
possible myalgias (pt has difficulty characterizing this
further), and vague abdominal discomfort. Less likely is
intraabdominal process given negative CTAP and no reported
diarrhea. UA benign and pt denies urinary symptoms. Benign
abdominal exam
- now afebrile, WBC normalized
- f/u blood cultures
- continue coverage for CAP - PO Levo
- can try to obtain sputum cultures if pt is able to produce.
- given likelihood of influenza is less likely, will not place
on resp precautions for now; if develops high fever on Abx,
could consider precautions & send viral screen
.
# Abdominal discomfort: Pt with reported abdominal pain, vague
in description and exam is completely benign. DDx includes
discomfort from possible PNA or influenza as discussed above.
Less likely is constipation or infectious diarrhea given recent
normal BM's. Pt has high WBC count to 17.2 (even being on
Clozapine), which is quite impressive, which would be concerning
for C. diff though has not had diarrhea. Even less likely is
intrabdominal abscess given CTAP negative. Possible GERD is
contributing, though pt states this is different from his
typical GERD. Abdominal exam benign.
- monitor abdominal exam, benign and consistent
- tx PNA as above
.
# Tachycardia: resolved.
- now inactive
.
# Psych: unclear after d/w manager from group home what his
diagnosis is. However, per him, he has been stable on these
medications for some time.
- continue Clozapine 300mg po BID, Cogentin 1mg po BID, Klonopin
0.5mg po BID
.
# HTN: normotensive
- continue metoprolol 100mg po BID
.
# HLD:
- continue Gemfibrozil
.
# CODE: presumed full
# CONTACT: patient; ___ (from group home) ___
head manager ___
# Pending: Blood Cultures | 104 | 393 |
12788286-DS-18 | 28,397,764 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
=====================================
- You were admitted to the hospital because you were having
shortness of breath, and you had gained water weight.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
============================================
- You were given IV medications to help you urinate out all the
excess fluid.
- You were given breathing treatments (nebulizers).
- You had an ultrasound of your heart, which showed some
recovery of its function.
WHAT SHOULD I DO WHEN I GO HOME?
==================================
- Your discharge weight: 169 pounds. You should use this as
your baseline after you leave the hospital.
- Weigh yourself every morning, call your doctor at ___ if your weight goes UP OR DOWN more than 3 lbs from
your dry weight.
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
If you are experiencing persistent chest pain that isnt getting
better with rest or nitroglycerine you should call ___.
- You should also call the heartline if you develop swelling in
your legs, abdominal distention, or shortness of breath at
night.
We wish you the best!
Your ___ Care Team | PATIENT SUMMARY
===============
Mr. ___ is a ___ man with BCR-ABL+ CML which transformed to
ALL, HTN, BPH, COPD, pulmonary HTN, Dasatinib-induced HFrEF
(LVEF 35%), CAD (40% stenosis of ___ and mid-LAD) who presented
with weight gain and dyspnea. He was found to have an acute
HFrEF exacerbation. He was diuresed on an IV lasix drip to
euvolemia, then transitioned back to oral medications. A repeat
TTE showed a partially recovered EF to 45%. Patient's renal
function was stably worse than prior outpatient values,
suspected secondary to bosutinib toxicity.
TRANSITIONAL ISSUES
==================
- Discharge weight: 169 lbs
- Discharge creatinine: 2.6
- EF 45% (___)
- CORONARIES: 40% stenosis of proximal and mid LAD
#HFrEF:
[] Increased Torsemide to 60mg BID at discharge. Will have close
follow up with HF BP to determine whether this is an appropriate
dose for him or not. | 238 | 137 |
12738770-DS-3 | 21,263,921 | Dear Mr ___,
You were hospitalized due to symptoms of difficulty in your
speech resulting from an ACUTE hemorrhagic 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.
We performed an angiogram to look for underlying abnormal
vessels. We will also perform a repeat head MRI prior to your
follow-up appointment in neurology clinic, to see if there is
some abnormality that would predispose to bleeding - such
findings can be hard to appreciate immediately after the
hemorrhage.
We have added a bowel regimen to prevent straining (which can
cause re-bleeding), but have not needed to start other
medications.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | ___ yo man without known significant PMH who present with L sided
headache and fluent aphasia, found to have L temporoparietal
IPH.
His examination shows fluent aphasia with impaired
comprehension, naming and repetition. Cranial nerve and motor
examination do not seem to have obvious deficit, except for ? of
left eye visual issue, though patient is not able to explain it
further, and the field seems intact and fundus normal. It is
conceivable that there is a partial field cut owing to the
involvement of ___ loop.
He was admitted to ICU for overnight monitoring and after his
exam remmained stable he was transferred to the regular floor.
MRI was done and confirmed the IPH but could not exclude the
underling mass or AVM, so on ___ he underwent conventional
angiography which did not show an aneurism or AVM.
He was evaluated here by our occupational therapist and they
recommended ___ rehab for occupational and speech therapy.
He had a UTI on admission and was treated with two days of IV
ceftriaxone, then given one day of IM ceftriaxone (loss of
venous access on the day of discharge). | 339 | 186 |
16275728-DS-3 | 26,941,538 | Dear Ms. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you were
having abdominal pain. You were treated with a GI cocktail and
Nexium, and received an MRCP which looked at your pancreas and
surrounding organs. Your condition has improved and you can be
discharged to home.
The following changes were made to your medications:
NEW:
-Docusate and Senna and Miralax(for constipation)
-GI cocktail (to soothe stomach)
-Famotidine and Dexilant (for stomach; these replace the Nexium
and Zantac)
Please keep your follow-up appointments as scheduled below. | ___ yo woman with history of antral gastritis presents with 4
weeks of pain that has unclear etiology, possibly from
gastritis.
. | 90 | 23 |
15640714-DS-13 | 26,064,549 | Dear Ms. ___,
It was an absolute pleasure taking care of you during your
admission to the ___. You were
admitted for abdominal pain, nausea and vomiting. We recommended
that you stay in the hospital for further treatment but you
decided to leave against medical advise. Please eat regularly as
your phosphate level remains low. Please follow up with your PCP
and the GI doctor as listed below.
For your abdominal pain, we treated you with pain medication and
IV fluids and you got better. Your nausea and vomiting were
treated with zofran.
You were found to have a dilation of a duct in your pancreas. It
might be from having these pancreatitis episodes. It is
important to follow up with your PCP after discharge so they can
continue to manage it. You have an appointment with your PCP on
___ at 3pm. Also, you have an appointment with a GI
physician ___ on ___ at 2pm to follow up on the
pancreas.
On the day of discharge, you were eating and drinking well, able
to walk and having normal bowel movements. Please call your PCP
or come te the Emergency room if you have fevers, vomiting and
abdominal pain that doesnt go away, blood in your stools or
black stools. | ___ year old woman with a history of GI bleed ___
tear), Alcohol abuse who presents with abdominal pain and was
found to have acute pancreatitis.
# Pancreatitis: Pt was initialy admitted to MICU for severe
pancreatitis. Etiology likely ETOH induced. Less likely
gallstone given normal tbili and AST>ALT. Her Triglycerides
were 211. Patient initially aggressively fluid resuscitated with
LR and IV electrolyte repletions. She was kept NPO initially
for bowel/pancreas rest. RUQ U/S showed no cholelithiasis but
mild dilatation of pancreatic duct. This warrants outpatient
follow up with MRCP and she will follow with GI.
# EtOH abuse: Patient reports last drink was 2 weeks prior to
admission. Per her report, has had h/o withdrawal seizures.
Given banana bag and continued on thiamine, folate,
multivitamin. She was monitored on CIWA but did not score.
# Acid/base disturbance: Patient initialy with AG metabolic
acidosis likely from starvation and alcoholic ketoacidosis.
Less likely ingestion. Serum osm was negative. Urine with
ketones consistent with starvation ketoacidosis. AG closed with
IVF.
# EKG changes: Nonspecific TWI. Can be related to electrolyte
abnormalities vs pancreatitis. No chest pain. Cardiac
biomarkers negative x2. Cardiology evaluated pt and did not feel
there was an acute cardiac process.
#Left AMA: Pt left the hospital AMA.
TRANSITIONAL ISSUES
- outpatient evaluation of pancreatic dilation
- ETOH abuse | 209 | 220 |
15245319-DS-23 | 27,923,459 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
were having chest pain. We eventually discovered that you had
uremic pericarditis (irritation of the lining of the heart in
patient's who need dialysis) and that the pain associated with
may take ___ days to go away. Luckily, this condition is not
life-threatening as you are currently undergoing the ___
treatment (dialysis). We also made sure you did not have a
heart attack, clot in your lungs, or an infection. ___ of luck
to you in your future health.
Please take all medications as directed, attend all appointments
as scheduled, and call a doctor if you have any questions or
concerns.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___, a ___ yo M PMHx ESRD recently started on HD
___ and HTN presented with pleuritic chest pain during his ___
dialysis session worse when laying supine accompanied by
low-grade fever. Exam significant for improved heart failure
findings and friction rub ___ hours after start of chest pain.
Labs significant for elevated BNP and mildly elevated troponin
consistent with ESRD. CXR/CTA-Chest showed no pneumonia or
pulmonary embolism but improving heart failure. Given proximity
to dialysis initiation, typical symptoms, and lack of signs of
ACS/PE, patient was felt to have uremic pericarditis and should
continue to receive dialysis.
# Chest Pain / Uremic Pericarditis: Patient with significant
history of cardiovascular disease (CAD, CHF), cardiovascular
risk factors (ESRD, HTN, HLD), and pulmonary disease (ILD)
presents with pleuritic chest pain and possible fever in ED.
Differential includes ACS (known CAD but no ST-T changes, stable
trop 0.02 from prior, no exertional symptoms, unlike patients
prior ischemic disease), CHF (known CHF and very elevated BNP
but improving exam findings since starting HD), Pericarditis
(history would be typical but no EKG changes, effusion on ED
imaging, or friction rub and uremic pericarditis should not be
started after a ___ dialysis session), Pneumonia (fever and
pleuritic chest pain but no sign on chest plain film or
cross-sectional imaging or cough with purulent sputum),
Pulmonary Embolism (normal CTA-Chest), ILD flare (no worsening
hypoxemia), AAA (no vital sign abnormalities, pleuritic pain,
improving without interventions), GI (no heartburn, improving
nausea, no relation to food, patient hungry), and MSK (pain
nonreproducible, no change with body wall or arm movement). Of
note patient on ___ now has a friction rub (can occur >24 hours
after start of pain); differential includes viral/idiopathic
versus uremic (can occur around time of initiation and not just
before, treatment would just be dialysis) versus other
(hemorrhagic effusion from minoxidil, etc.). Repeated troponins
have been 0.02-0.03 compatible with ESRD. Given improvement
with dialysis, uremic pericarditis was the final diagnosis.
Patient was discharged with primary care, nephrology, and
cardiology followup appointments.
# Fever: Patient recently started on dialysis noted to have
fever and WBC 12 with 90% neutrophils in ED without any symptoms
or signs of infectious disease but given vancomycin/cefepime in
ED. UA/CXR unremarkable for infection, no other SIRS criteria
met, and negative for PE. Patient's leukocytosis normalized,
had no further fevers, and did not receive any further
antibiotics.
# Hypertensive ESRD / Dialysis Initiation: Patient with a
history of CKD V from hypertensive nephrosclerosis, presenting
from outpatient for initiation of dialysis (first session
___ given chronic uremic symptoms (nausea, pruritis,
anorexia, etc.). Patient tolerated two sessions of dialysis
without difficulty, was maintained on calcitriol and low
Na/K/Phos diet. He was continued on Nephrocaps and sevelamer
800mg PO TID with meals. It is possible that intradialysis
fluid shifts contributed to his chest pain presentation as
discussed above. On admission from ___ dialysis session,
patient has normal electrolytes. He was dialyzed on ___ and
will undergo a subsequent ___ and ___ dialysis
# Hypertension: Well-controlled on admission but requiring many
antihypertensives. Continued on home Amlodipine 10 mg PO DAILY,
Isosorbide Mononitrate 60 mg PO DAILY, Metoprolol Tartrate 50
mg PO BID, Minoxidil 2.5 mg PO DAILY, and HydrALAzine 25 mg PO
TID with appropriate holding parameters.
# Chronic Systolic Congestive Heart Failure: Chronic issue with
more elevated BNP than usual but improving physical exam
findings continued on home torsemide (held on dialysis days) and
will be further helped by dialysis.
# Prolonged QTc: Noted to have prolonged QTc on admission with
other sign of arrhythmia; will avoid QT prolonging drugs as much
as possible.
# Coronary Artery Disease: Chronic issue continued on home
aspirin and clopidogrel; role in chest pain discussed in chest
pain section
# Hyperlipidemia: Chronic stable issue maintained on home
pravastatin, ezetimibe, and fish oil | 140 | 644 |
19924597-DS-6 | 25,269,610 | Dear ___,
You were admitted after you began to have abdominal Pain at
home. You had an MRI of your liver which showed infection of
your bile ducts. The gastroenterology team was consulted and
given your usual anatomy felt that a repeat ERCP would not be
successful. You were treated with IV antibiotics and improved.
You will be discharged on two antibiotics and will need to
complete two full weeks. You were also given a medication for
nausea. It was a pleasure caring for you. | Ms. ___ is a ___ woman s/p ccy and hepaticojejunostomy with
recurrent episodes of cholangitis presents again with fevers and
abdominal pain c/w cholangitis now stable on antibiotics. | 84 | 27 |
18902344-DS-82 | 21,379,417 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted after a fall and were found to have a
bloodstream infection (bacteremia).
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with IV antibiotics for your infection.
- You were placed on your home diuretic (Torsemide) for volume
removal.
- You were followed by our ___ endocrinology team for your
diabetes and our podiatrists for your foot ulcers.
- Your foot wound was infected. You were treated with
antibiotics and our podiatry team removed bad tissue in the
operating room.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications, adhere to your diet and fluid
restriction, and go to your follow up appointments as described
in this discharge summary.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your discharge weight is :430LB.
- If you experience any of the danger signs listed below,
please call your primary care doctor or go to the emergency
department immediately.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with morbid obesity, chronic
abdominal wounds from prior hernia repairs (prior cultures
growing MRSA, VRE), HFpEF, CKD, IDDM, and chronic foley who
presented after a fall and was found to have acute hypoxemic
respiratory failure, and Morganella bacteremia, course notable
for superinfected diabetic foot ulcer and ongoing hyperglycemia
in the setting of dietary indiscretion.
# Complicated UTI.
# Morganella bacteremia
Patient with temperature of 100.3 in the ED, complaining of
dysuria. UA consistent with infection. History of resistant
organisms, has chronic foley. AM of ___ had ___ blood cultures
from ___ growing Morganella from anaerobic bottle. Source
likely urinary though will also consider abdominal wound
infection; urine grew only yeast. Foley was exchanged on ___
and per patient had not been in more than 6 weeks prior. Again
exchanged ___. He was treated for a total 2 week course
(___.) with cefepime, which was broadened to
meropenem in the context of recurrent sepsis for soft tissue
infection as below, and eventually transitioned to
ciprofloxacin. Of note, qtc became prolonged on ciprofloxacin
which was then discontinued. Caution should be exercised with
introduction of additional qtc prolonging medications in the
future.
#Sepsis, resolved
#soft tissue infection R heel ulcer:
Fevered with apparent rigors and hypotension with mental status
changes am ___, fluid responsive. Rapidly improved with
broadening of antibiotics to meropenem, vancomycin. Initial
evaluation concerning for right heel soft tissue infection
overlying ulcer, repeat foot Xray showing interval development
of worsened calcaneal ulceration. He was taken for bilateral
ulcer debridement ___ which showed no penetration to bone.
Cultures from swab ___ grew pansensitive enterococcus;
intraoperative tissue cultures grew mixed bacterial flora, with
bacteroides identified. Podiatry followed, placed bilateral
wound vacs, taken down ___ with plan to replace ___. He
completed 9 days of antibiotics.
# Acute hypoxemic respiratory failure
# COPD.
Mr. ___ presented after 2 falls and in the ED was noted to
desat to 85% on RA while talking. Patient has been diagnosed
with likely complicated apnea and Trilogy/CPAP have been
recommended in the past. Patient has adamantly refused.
Outpatient providers have recommended O2 4 L when sleeping and
keeping head of bed elevated. Last PFTs were in ___ showing
mild restrictive defect. Mild evidence of volume overload on
exam and patient reported that he was 23 lbs greater than his
perceived dry weight (423 lbs on presentation from 400).
Presentation consistent with combination acute HFpEf and
atelectasis +/- contribution of COPD. He improved with diuresis
and oxygen requirement resolved. Discharged on torsemide 80mg
daily.
# Acute on chronic HFpEF:
TTE performed ___ with EF > 55%, was actively diuresed during
last admission with Lasix gtt. Dry weight ~400lbs. Appeared
mildly volume overloaded on exam though hard to appreciate given
body habitus, and above dry weight as above. Diuresed with home
torsemide 80mg daily in setting of bacteremia. Attempted fluid
restriction to 2L however patient continued to consume >6L daily
despite numerous attempts at education. Held home Carvedilol,
amlodipine given normotension/hypotension and home lisinopril
for normotension. After resolution of sepsis, carvedilol was
restarted. Will need reintroduction of lisinopril as tolerated.
Discharge weight 430 lbs.
# IDDM:
Poorly controlled diabetic with recent A1c 9.1. ___ was
consulted and assisted in glycemic management. Patient with
noncompliance with diet with frequent snacking which was noted
to cause significant hyperglycemia. Note should be made that due
lantus dosing likely covers intermeal snacking; because of this
patient noted to have pattern of HYPOglycemia when NPO while
awaiting procedures or if access to intermeal snacking is
limited; in future admissions CONSIDER DECREASING HS LANTUS DOSE
BY 50% IF NPO FOR PROCEDURE (RATHER THAN 80%.)
# HTN:
Held home lisinopril, amlodipine, carvedilol initially as above.
Recommend reintroduction of lisinopril, then uptitration of
carvedilol, then amlodipine if needed.
CHRONIC/STABLE PROBLEMS:
===============
#Recurrent abdominal wounds:
Long history of abdominal wound infection. Wound appeared
uninfected. Wound consulted recommendations followed. Plan for
rescheduling plastics appointment missed due to transportation
issues in ___.
# Chronic pain:
# L5 radiculopathy (refer to lumbar MRI ___:
Continued home methadone 10 mg PO BID. Home gabapentin was
increased to 600mg TID.
# Tobacco dependence:
40 pack year history, most recently approximately 1.5 packs per
day. 21 mg nicotine patch daily was provided during admission.
# Hyperlipidemia:
Continued home atorvastatin 80 mg QHS, aspirin 81mg daily.
# Insomnia:
Continued home trazodone 50 mg PO QHS:PRN.
# History of PUD/H. pylori:
Continued omeprazole 20 mg daily.
# Depression/anxiety
Continued home citalopram, buspirone, hydroxyzine.
Transitional Issues
===================
DISCHARGE WEIGHT: 194.87 kg (429.61 lb)
DISCHARGE DIURETIC: 80 mg torsemide daily
DISCHARGE CR: 1.2
[] Please place wound vacs to bilateral heels on arrival to
rehab. He is non-weight bearing.
[] Consider oxycodone 5mg once prn debridement
[] Please trend daily weights and increased diuretic dosing as
needed
[] Lantus was reduced from 105U BID to 80U BID on day of
discharge given propensity for hypoglycemia if enforced
adherence to diet. Please measure fasting sugars and uptitrate
as needed.
[] Home anti-hypertensives held in setting of sepsis. Please
trend blood pressure and restart lisinopril, then uptitrate
carvedilol, then reintroduce amlodipine as needed
[] Patient is on suppression with augmentin for chronic
abdominal wounds which will be ongoing
[] Consider PFTs in outpatient setting
[] Caution with use of qtc prolonging medications as on several
chronic medications with this side effect
[] Please ensure podiatry, plastics follow up
[] Please continue to encourage patient to adhere to
nonweightbearing status, fluid restriction, diabetic low salt
diet
[] Hypoglycemia when NPO while awaiting procedures or if access
to intermeal snacking is limited; in future admissions CONSIDER
DECREASING HS LANTUS DOSE BY 50% IF NPO FOR PROCEDURE (RATHER
THAN 80%.)
> 30 min spent on discharge planning including face to face time | 204 | 922 |
13042664-DS-25 | 28,432,524 | Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for evaluation of
increased shortness of breath and an abnormal heart rhythm. You
were given medications to remove excess fluid from your body.
In addition, you underwent a procedure to convert your abnormal
heart rhythm to a regular one which was successful. Also you
were started on medications to better control your heart rhythm.
You improved and it was determined you were safe to be
discharged to home. Your kidney function was also noted to be
depressed, this was thought secondary to your congestive heart
failure. You have a follow up appointment with Dr. ___ on
___ to continue to monitor your kidney function and at
that time you should discuss whether or not you need dialysis.
Your INR was elevated on discharge to 3.4, we thus recommend you
do NOT take your dose TODAY, and starting TOMORROW take 2mg a
day and get your INR checked on ___. Please follow the
instructions of your ___ clinic after discharge in regards
to the dose.
Your discharge weight was 102.6kg or 226 pounds. Should you
gain more than 3 lbs in a short period of time, develop
progressive shortness of breath, or notice increased swelling of
your legs, please call your cardiologist as this may indicate
you require a change in your medications. Please keep your
follow up appointments as scheduled and take your medications as
prescribed. We wish you all the best on your recovery!
-Your ___ Team | ___ y/o M with systolic CHF (EF of 43% w/ moderate/severe AR),
dual chamber pacemaker, presenting in florid CHF of rapid onset
with concomitant worsening renal function, supratherapeutic INR
and decompensation despite receiving outpatient diuretics. ___
represent exacerbation of his chronic kidney disease leading to
fluid retention and increased need for lasix or may represent
loss of atrial kick from atrial fibrillation with lower ejection
fraction and thus decreased renal function.
# Paroxysmal Atrial Fibrillation - CHADS-VASC of 5 (HIGH RISK),
yearly stroke risk of 6.7%
- Has failed multiple cardioversions from atrial fibrillation,
but on ___ received cardioversion while in the hospital
and remained out of afib and in normal sinus at the time of
discharge.
- Coumadin is supratherapeutic with INR of 3.4 at the time of
discharge so lowered coumadin dose to 2mg daily and asked him to
hold his dose on the day of discharge.
- Pacer settings changed from VVI of 70 to DDI to 75, and
patient discharged on amiodarone 400mg PO daily to maintain
sinus rhythm after discharge.
# CHF
Patient was very volume overloaded on exam at admission with
lower extremity edema, signficant JVD, crackles in the lungs,
and an elevated pro-BNP at admission. Cause for the CHF is
unclear at this time, may be related to progressive renal
disease, given creatinine of 4.3 at admission, or may be due to
progressive CAD. ___ also be due to Atrial fibrillation causing
decreased cardiac output and slow buildup of fluid ___ CHF.
Troponins remained negative. On ___ nitro gtt was weaned down
and patient started on Hydralazine 10mg TID and Isirdil 10mg TID
with plan to uptitrate as needed to obtain a systolic BP close
to 100. On ___, patient continued on hydral 10TID, and
isosorbide dinitrate raised to 20 TID. Nitro gtt off.
- On ___ - Hydralazine raised to 30 TID, tolerated well.
- Plan was to place patient on Torsemide 60mg PO daily, but did
not receive dose on ___.
- On ___ - Raised Isosorbide to 30TID, will f/u blood
pressures.
- On ___ - Raising standing Torsemide dose to 80mg given that
patient is stable but perhaps has some slight volume overload.
Also gave one additional ___ dose.
- ___ - Patient euvolemic, with some leg swelling, given 1
extra dose torsemide and will continue Torsemide 80 daily.
- ___ - Torsemide 80mg PO daily and patient euvolemic,
discharged on this dose with close followup as an outpatient.
- Had strict ins/outs/ and weights measured during
hospitalization.
- Patient will need to contact physician after discharge if
weight gain >3 lbs within the span of days, or any increased
shortness of breath. This was explained to Mr. ___ and ___
acknowledged.
- S/P cardioversion can cause cardiac stunning and decreased EF,
with increased CHF. Patient was monitored for 24 hours after his
cardioversion, and no increased CHF was seen.
# Decreased Renal ___ (STAGE IV)
Known stage IV ___, however his creatinine (as shown in lab
section) was above his baseline of 3.0. Given that patient has
had a right renal nephrectomy, he has only one working kidney.
This may thus indicate ___ on ___ or may indicate progression of
renal disease, and could explain CHF resistant to current doses
of diuretics. Management of CHF as above. Alternatively, the CHF
could have led to renal hypoperfusion and thus caused the bump
in creatinine. His renal ultrasound was normal, showing no clear
etiology of the worsening renal function. In discussion with Dr.
___ was felt that this worsening of renal function
may be ___ worsening CHF and cardiac function from atrial
fibrillation and the decreased cardiac output. Dr. ___ was
contacted, and will see the patient on ___, 3 days
before Mr. ___ is scheduled to receive an AV fistula for
outpatient dialysis. If at the time of that appointment his
renal function has normalized, then the patient can cancel his
AV fistula appointment and continue close followup with both
nephrology and cardiology.
# Macrocytic Anemia
Chronic issue that was seen at admission to the hospital. ___
represent either folate, B12 or thiamine deficiency. Provided
these medications at discharge, and asked patient to speak with
PCP about this lab work.
# CAD
Continued medical management using both home medications and
some new medications as noted below.
# Unsteady gait
Should have outpatient followup with neurologist. R/o
neurodegenerative changes.
# Groin rash
Was present at admission, resolved with miconazole powder.
Likely represents candidal infection. | 263 | 730 |
19437900-DS-2 | 27,400,153 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had pain your
chest and loss your vision in your left eye.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a surgery to restore vision to your left eye.
- You had a images taken of your abdomen to evaluate your pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with Habit Opco
- Follow up with ___ Ophthalmology clinic with Dr. ___
___ or Dr. ___ on ___ ___.
- Follow up with your primary care doctor.
- Continue to use your eye drops as prescribed until you see the
eye doctor
___ wish you the best!
Sincerely,
Your ___ Team | ADMISSION
=========
___ male who injects drugs (fentanyl and heroin),
endocarditis of tricuspid and mitral valves in ___ treated
nonoperatively with 11 months vancomycin, who presented with
four days of abdominal pain and acute loss of vision in his left
eye.
ACUTE ISSUES
============
#Vision Loss
___ (mac-off)
The patient was evaluated by Ophthalmology in the emergency
department. He was found to have a macula-off retinal
detachment. It is unclear whether this is acute or acute on
chronic as he reports being seen in ___ and sent to
Mass Eye and Ear for follow-up, although he never kept those
appointments. On ___ he was taken for a 23-gauge pars plana
vitrectomy, epiretinal membrane peel, air-fluid exchange,
cryotherapy to all the holes and infusion of C3F8 14%.
Postoperatively he followed with Ophthalmology on ___.
#Opiate Use Disorder
He was reportedly using large amounts of fentanyl/heroin daily
prior to hospitalization. During his first day of
hospitalization he required up to 16mg q 4 h of morphine for
pain control. He expressed an interest in MAT Therapy and was
seen by Addiction Medicine. He was transitioned to 40mg
Methadone which he tolerated well and linked with an outpatient
___ clinic.
#Abdominal pain
Pt had abdominal and substernal pain in character and duration
initially concerning for pancreatitis, despite no leukocytosis,
amylase and lipase within normal limits. CT Abdomen and Pelvis
showed no evidence of pancreatitis, but mild dilation of the
common bile duct and distal pancreatic duct with no definite
mass or obstructing stone visualized. Workup for HBV and HAV
(his wife was concurrently hospitalized with HAV) were negative.
He has chronic HCV and was meant to start ___ prior to
hospitalization. His abdominal pain resolved with initiation of
methadone and was thought to be perhaps constipation or diarrhea
pain in the setting of narcotic use and withdrawal symptoms.
Gastritis and duodenal ulcer also remain in the differential
given his post-prandial pain. If this pain persists as an
outpatient would recommend follow-up with MRCP as clinically
indicated.
#Chest Pain
There was concern for endocarditis given his history of IVDU and
valve lesions. His EKG was normal sinus. His TTE showed a small
1cm echodensitiy on the right side of the tricuspid valve
(consistent with chronic fibrotic vegetation). Cardiac enzymes
were negative.
CHRONIC ISSUES
==============
#Chronic Hepatitis C Virus
Viral load was pending at time of discharge. He should start
___ as managed by outpatient primary care doctor.
TRANSITIONAL ISSUES
===================
[ ] Follow up with ___ Ophthalmology clinic with Dr. ___ or Dr. ___ on ___.
[ ] Follow up with PCP regarding starting ___
[ ] Consider MRCP if abdominal pain persists
[ ] Recommend treatment of HCV as planned per patient
[ ] eye drops should be continued until optho f/u
[ ] Last dose methadone ___ mg
[ ] Recommend following up LFTs post treatment of HCV to monitor
for resolution
[ ] Patient left prior to receiving his discharge paperwork. He
was given his last dose of methadone letter and scheduled for
follow up at the Eye Center and Habit Opco for his methadone
treatment. I telephoned his listed cell and home telephone
numbers, as well as those of his wife/HCP ___, however
listed cell phone is not correct, and none of the other numbers
answered or had voicemail set up. Left message with PCP
answering service to call back to inform them of transitional
issues and get pharmacy to send d/c prescriptions to. | 157 | 554 |
12480689-DS-19 | 25,802,158 | You were admitted to the hospital for evaluation and management
of neutropenic fever. It was felt this was caused by
methimazole, which was stopped. Your endocrinologist was
notified of this change. You initially received IV antibiotics
for your fevers but were transitioned to oral antibiotics; a
source for your fevers was not found.
Your blood count recoved well, and you will only need one more
day of antibiotics
You will no longer take methimazole
You will be taking a lower dose of propranolol.
Please have your blood checked in one week. Dr. ___ has placed
the order, and you can go to any ___ lab to have
them drawn. Dr. ___ will follow up the result.
Please see below for your follow up appointments. | ___ y.o female with h.o Graves disease who presents with fever,
cough, diarrhea, found to have neutropenia.
# Neutropenic fever: Due to methimazole , possibly worsened by a
concomitant viral infection. CXR, CT abd/pelvis and chest were
wnl and all cultures remained negative. Diarrhea and cough
self-resolved. She was treated with Vancomycin and Cefepime
while neutropenic, however switched to vanc/aztreonam when she
developed a rash after about a week of treatment, with
subsequent resolution of the rash. Given that she remained
afebrile, she was swtiched to oral levofloxacin/clindamycin.
Methimazole was stopped and patient's counts slowly improved.
___ was over 1300 on day of discharge, and trending up. She will
complete one more day of clinda/levofloxacin, with repeat CBC in
one week to ensure counts have fully recovered (CBC to be
followed up by Dr. ___ ___ hematology). Patient counseled
to monitor for any fever, and will contact her PCP if fever
develops.
# Grave's disease-last TFTs ___ ___ TSH but appropriate
Ft4 (see ___.
Methimazole and propranolol were initially stopped in the
setting of her febrile neutropenia and borderline low blood
pressures. Her endocrinologist was notified of her admission and
recommended close follow up on discharge for alternative
treatment, likely radioactive iodine. Propranolol was restarted
for sinus tachycardia and symptoms of graves prior to discharge,
at 10 mg TID.
# Anemia- Iron studies consistent with anemia of chronic
disease; more acute drop likely secondary to bone marrow
suppression. Repeat CBC in one week as an outpatient.
Full code | 119 | 246 |
15911120-DS-8 | 20,661,344 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with abdominal pain. You were very constipated when you
arrived. You were given an enema and were disimpacted to improve
this issue. Your bladder catheter stopped draining urine so you
had a lot of urine built up in your bladder, so the catheter had
to be replaced by the urologists. You were also found to have a
urinary tract infection for which you were started on
antibiotics.
Please follow-up at the appointments listed below. Please see
the attached list for updates to your home medications. | ___ with h/o DM2, HTN, HLD, and BPH w/ recent admission for L
femoral neck fracture and repair (___) who presents from
rehab with RLQ pain.
.
>> Active issues:
# Abdominal pain ___ constipation and urinary retention: Pt with
RLQ pain and tenderness likely related to constipation and/or
urinary retention given relief of symptoms w/ bowel movement
after enema and disimpaction in the ED and exchange of foley and
urine output of 1200cc in the ED. Urinary retention likely
related to opioid use and underlying BPH. Constipation likely
caused by opioids as well. CT abd without acute process; no
ileus but did note trace free fluid in the RLQ of unclear
etiology. Initial foley in the ED inflated in the prostate so
urology replaced the foley via flex cystoscopy. Opiates held.
Standing tylenol for pain. Pt given aggressive bowel reg. Pain
resolved shortly after admission with above measures. No
recurrent pain during admission.
.
# UTI: Likely occurred in setting of urinary retention from
opioid use and underlying BPH as well as possible foley
obstruction given urinary retention on admission in the setting
of indwelling foley. Pt denied h/o dysuria but had indwelling
foley and did not appear altered on exam. Pt started on CTX for
tx of UTI on admission. Bl and urine culture sent. ABX changed
to cefepime on ___ given pseudomonal growth. Ucx sensitivities
returned on ___ so narrowed ABX to Cipro. Pt to complete 14d
course of ABX for complicated UTI to end ___.
.
# ___: Likely obstructive in nature given put out 1200 cc when
new Foley was place. Also possibly prerenal in the setting of
poor PO intake and based on urine lytes with FENa of 1%. ___
resolved with Cr 1.2 the morning after admission after relief of
obstruction and IVF overnight. Lisinopril held initially for
___. Cr improved further to 1.
.
# Leukocytosis: WBC of ___ this admission from 17 on discharge
___. Likely acutely related to UTI and possible stress
component, but given significant elevation and recent
hospitalization C. diff should be ruled out. C diff sent but not
able to run because of formed stool. Pt non-toxic exam currently
and CT w/o ___ or ileus reassuring. Received CTX and
flagyl in ED. Also think about leukemoid reaction with such
significant leukocytosis. Pt continued on UTI tx per above.
Flagyl held given low likelihood of C diff.
.
# Anion gap metabolic acidosis, resolved: AG of ___ with normal
lactate so likely related to ___. AG resolved with resolution of
___.
.
# L femoral neck fx s/p repair: Underwent left hip
hemiarthoplasty on ___ w/o complications. Continued lovenox 40
mg SC daily x3wks per ortho recs. Tylenol for pain. ___
consulted. Ortho followed pt and removed staples prior to
discharge on ___. Ortho also obtained f/u x-rays on ___ as
well to serve as his postop check. He should f/u in ___ clinic
in ___.
.
# Tachycardia: Regular on exam, EKG confirming sinus tach. ___
be related to intravascular depletion vs. pain and anxiety. Was
in sinus tach during last admission. Pt given IVF on admission.
Treated pain. HR in ___ prior to discharge.
.
>> Chronic issues:
# DM2: Last A1c 8.0. Metformin and glipizide held while in house
and restarted on discharge. SSI while in house.
.
# BPH: continue finasteride. F/u with urology given foley.
Started pt on flomax as well.
.
# HTN: Midly hypertensive currently. Continue amlodipine. Held
lisinopril and restarted on discharge given normal renal
function.
.
# HLD: continue simvastatin
.
>> Transitional issues:
- Full code
- Pt to complete 14d course of ABX for complicated UTI: last day
of Cipro ___
- DO NOT REMOVE FOLEY IN REHAB. Pt will f/u with urology for
voiding trial and possible foley removal. If foley stops
draining urine, please call the urology office.
- F/u in ___ clinic in 3months time. Staples removed, steri
strips in place. Pt may shower and leave steri strips in place
until they fall off.
- Studies pending at time of discharge: L hip x-ray (reviewed by
ortho resident prior to discharge), bl cx (NGTD) | 100 | 665 |
10844468-DS-20 | 29,064,085 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | She was admitted on ___ for further work up. A
transthoracic echocardiogram on ___ demonstrated a
moderate pericardial effusion without tamponade physiology. A
repeat echocardiogram the next day revealed a moderate
pericardial effusion with mixed evidence of increased
pericardial pressure (absence of augmented inflow variation
across mitral valve suggests pericardial pressure not elevated,
but delayed/blunted expansion of right ventricle in diastole.)
She was taken to the cath lab for pericardial drain placement on
___.
She tolerated this procedure well and transferred to CVICU in
stable condition. She developed AFib/flutter with rates into
the 130s/140s. Beta blocker titrated, amio given and lytes
repleted. She converted to SR. Drain discontinued on POD 2 and
colchicine initiated. ___ continued to follow for glucose
management. Statin discontinued for intolerance. She reports a
history of muscle cramping and fatigue as well as nausea. The
patient will discuss alternatives with Dr. ___. The patient
is discharged home with ___ services on hospital day 10. She
will follow-up with Dr. ___ week with a repeat echo. She
will be discharged with detailed Insulin instructions and is to
follow-up with ___ in one week. | 117 | 199 |
18346402-DS-17 | 28,954,935 | Dear Ms. ___,
You were admitted to the hospital for shaking of your
extremities and chills. You were seen by neurology, orthopedic
surgery, and internal medicine. You were found to have a clot in
your right leg, for which you were started back on Coumadin with
lovenox injections until your Coumadin level is high enough. You
are now safe to go home with close follow up.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Medicine Team | ___ year-old with obesity, afib on ASA only, GIB, and chronic
back pain with recent treatment for L1/L2 discitis s/p L1/L2
vertebrectomy & fusion (___) on chronic Flagyl who presents via
EMS with shaking in all four extremities and syncope found to
have RLE DVT now on Coumadin with lovenox bridge.
#Syncope - unclear etiology. Neurology consulted; unlikely
seizures given the nature of the event and the patient's memory
of event, lack of post-ictal state. Does not appear to be
orthostatic as patient was seated at the time, denies any
dizziness or lightheadedness. rigors would be atypical in
absence of any evidence of focal infection and the patient was
afebrile, VSS, and felt well without further complaints or
recurrence of convulsions/shaking movements. No events on
telemetry and not felt likely to be cardiogenic or orthostatic.
#DVT
- has history of ___, +lupus anticoagulant
- US RLE showed DVT in setting of lupus anticoagulant, ___ edema
R slightly > L, some very mild RLE posterior calf pain -- no
clinical concern for PE and she was not evaluated for this
- started on Coumadin with lovenox bridge
- contact ___ clinic to coordinate outpatient follow up
#RUL lung consolidation in setting of prior R pleural effusion
- no evidence of active infection, asymptomatic
- consider CT chest for further characterization
#s/p spinal fusion
- wound c/d/I
- continue to eval
- wound care per Dr. ___
- brace PRN
CHRONIC ISSUES
#Afib previously on ASA; changed from Coumadin to ASA in ___
- restarted on Coumadin for DVT treatment; hold ASA
- does not require TTE at this time
#osteomyelitis/discitis: worsening acute lower back pain ___
found to have L1/L2 osteomyelitis / discitis and possible psoas
abscess who underwent L1/L2 vertebrectomy & fusion (___)
followed by posterior decompression fusion of T11-L3 on ___
with multiple cultures from ___ growing C. perfringens (one
swab also grew CoNS). She is on a 6 week recommended course for
C. perfringens osteomyelitis with ceftriaxone and metronidazole
(due to penicillin allergy noted in childhood), ceftriaxone
d/c'd on ___ due to
a rash and eosinophilia consistent with a drug reaction without
signs of systemic involvement or DRESS.
- followed closely by ___ clinic
- continue metronidazole 500mg q8H | 82 | 352 |
18751336-DS-6 | 20,636,177 | Dear Ms. ___:
You were admitted to ___ because you had abdominal pain and
passed out. You most likely passed out as a reaction to choking
on your food. You had no abnormal heart rhythms while you were
in the hospital.
As we discussed, the cat scan of your belly showed thickening in
the bladder. This can be a sign of bladder cancer. If you want
to have further evaluation of this, you can talk to your primary
care doctor ___ it.
___ was a pleasure to care for you,
Your ___ Team | ___ year old female with PMH T2DM, alzheimers/vascular dementia,
admitted after a syncopal episode.
ACTIVE ISSUES:
# Syncope: Patient with h/o syncope s/p PPM in ___ though ___
sinus arrest, no syncope since PPM placed. On admission,
neurologically intact. History was suggestive of vasovagal event
after aspiration (coughing at end of feeding reported by
daughter). She was monitored on tele which showed intermittent
pacing, no sinus pause or bradycardia to suggest pacemaker
malfunction. No TTE was obtained as no murmur on exam or history
of valvular disease, and pt not exerting at time of syncope. She
had no further episodes while inpatient and was discharged home
w/close PCP ___.
#Agitation, Alzheimer's, bipolar disorder: On arrival daughter
reported pt had not slept for several nights after abrupt
discontinuation of Ativan which she'd been taking 4x/day.
Intermittently anxious/agitated while inpatient. Spoke with
outpatient cognitive neurologist who recommended: resume Ativan
0.5 mg PO BID, start olanzapine 2.5 mg qHS, continue sertraline
currently at 50 mg daily. This regimen was initiated while
inpatient.
#Goals of care: Previously on hospice. Spoke with patient and
family with interpreter. In general family wishes to avoid
invasive procedures or anything that would cause Ms. ___
significant discomfort. While in hospital the family expressed
a preference that she be DNI but otherwise full code, which is
an illogical combination and should not be offered as an option.
Family plans to readdress code status.
#Hyponatremia: Chronic and at baseline. Has been thought
ADH-mediated hyponatremia that is consistent with SIADH (or its
variant reset osmostat) with low solute also contributing.
Improved with 1L IVF further suggesting element of low solute
diet.
Continued on 4 g salt tabs/day. Did not restrict fluid as
already not taking in much POs.
#Pneumobilia: Seen incidentally on CT a/p. Most cause likely
given min symptoms and AP at baseline is sphincter of oddi
dysfunction. No symptoms or clinical evidence of infection, and
she had no recent instrumentation. LFTs remained normal with
exception of stably mildly elevated alk phos (150s). Discussed
with daughter, and decided to hold off any additional work up
unless vomiting or abdominal pain recurred. Patient tolerated
POs while inpatient.
# Concern for choking/aspiration event: Daughter reported one
episode of choking on liquids on the day prior to admission.
This did not recur while inpatient, and she was observed
swallowing liquids and solids without coughing. Speech and
swallow came to assess patient formally but she was not able to
cooperate with their exam, so decision was made after talking
with daughter for her to continue closely observed full diet.
#AG metabolic acidosis (AG 16) + urine ketones: suspected due to
ketosis - hypovolemic on exam and ketones in urine, h/o poor PO
intake. Resolved with IVF.
#Bladder wall thickening on CT a/p: CT a/p showed bladder wall
thickening. Discussed w/family that this can be a sign of
bladder cancer. Family voiced understanding (via interpreter)
and decided not to pursue further work up at this time.
CHRONIC ISSUES:
# DM: held home sulfonylurea, ISS
# HTN: not on home meds, hypertensive intermittently in setting
of agitation
Transitional issues:
[] CT a/p showed pneumobilia most likely due to sphincter of
oddi dysfunction. Her LFTs remained at baseline (has stably
elevated alk phos) and she had no signs of infection. If she
develops RUQ discomfort would consider additional evaluation
with RUQ ultrasound.
[] CT a/p showed bladder wall thickening. Discussed w/family
that this can be a sign of bladder cancer. Family voiced
understanding (via interpreter) and decided not to pursue
further work up at this time.
[] Neuropsych regimen changed while inpatient after consultation
with outpatient provider ___ to:
Ativan 0.5 mg PO BID
olanzapine 2.5 mg QHS
continued on sertraline 50 mg daily
[] CODE STATUS: daughter reported ___ about patient's
code status and we did not have a MOLST on file. She was sure
that her mother would NOT want to be intubated but felt
uncertain about the role of CPR or defibrillation.
Unfortunately the status of DNI and otherwise full code is not
logical and should not be offered. We would recommend
additional conversations about code status going forward. The
patietn's daughter plans to discuss further with her siblings,
but we suspect that these conversations would benefit greatly
from guidance by a physician. | 93 | 701 |
18486805-DS-30 | 20,747,451 | Dear Mr. ___,
You were admitted to the ___ for intermittent vertiginous
episodes with left ear fullness which was thought to be due to
exacerbation of prior stroke symptoms. We believe your symptoms
were related to left peripheral ear pathology, therefore we
recommend you follow up with your ENT doctor and have repeat
hearing testing. Though your symptoms were concerning for
stroke, fortunately your MRI showed no new stroke. Please return
to the emergency room if you have more symptoms like the ones
you came in with. You will be discharged home with prescriptions
for your medications and a follow up appointment with your PCP
___ ___ weeks. Please keep your appointment with your ENT doctor
tomorrow. It has been a pleasure getting to know you.
Sincerely,
Your ___ team | Mr. ___ is a ___ year old mane with HLD, HIV (CD4 1021, viral
load <20) and history of left inferior cerebellar infarct
___ left vertebral artery dissection, who presented
with transient vertiginous symptoms x2 and left ear fullness.
Exam was notable for left-sided conductive and sensorineural
hearing loss, left-beating nystagmus on left lateral gaze (none
on primary gaze), and catch-up saccade with head impulse to the
left on HINTS exam (no skew, no saccade with HI to the right).
Labs notable for HbA1c 5.1%. MRI brain showed no diffusion
abnormality. MRA showed no progression of vertebral dissection
with some flow via the left vertebral artery at this time. He
will continue on aspirin 81mg daily. His symptoms were
attributed exacerbation of prior stroke symptoms in the setting
of left peripheral ear pathology (e.g., sensorineural problems).
He did complain of left ear fullness, tinnitus, and hearing
loss, and will need outpatient ENT (which is scheduled over the
next days) as well as PCP follow up. | 128 | 169 |
18172623-DS-31 | 29,025,220 | Dear Mr. ___,
You were admitted to the hospital with difficulty breathing,
fever, and low oxygen saturation, which is attributed to
pneumonia. Your sputum culture grew an organism called
Pseudomonas and you were treated with targeted antibiotics and
you completed your course, but you are still at risk for
aspirating. You were seen by the speech and swallow team in the
hospital and are still advised not to eat or drink anything, but
ice chips are okay with supervision.
While in the hospital you also had some extra fluid in your
lungs and this was treated by adding a diuretic and cutting down
on the amount of free water you are receiving with your flushes.
You also had some slightly lower blood pressures so your dose of
amlodipine, which you take for blood pressure, was cut in half
and moved to night time. Additionally, your dose of baclofen was
increased to help with leg spasms. Please follow up with the
___ clinic to see if there are any other therapies
that may work for you. You also had some abdominal pain and an
X-ray showed that your colon was a bit dilated, a repeat X-ray
showed ileus likely secondary to too much narcotis. Additionally
your chest CT scan showed similar size of the nodules in your
lungs. You will need a follow up CT in a few months, please
follow up with your PCP to discuss when to pursue this (likely
___ months since you are a former smoker).
You will be sent back to your facility for rehab. We wish you
the best!
Sincerely,
Your care team at ___ | Mr. ___ is a ___ y/o M w/ DM, chronic oropharyngeal dysphagia
w/ J-tube, hx of CVA w/ multiple residual deficits, including L
hemiplegia, neurogenic bladder, hx of recurrent aspiration
pneumonias and recent hospitalization at ___ for 52 days,
discharged ___ who presents with acute onset of cough, SOB,
hypoxia, encephalopathy and fevers with imaging suggestive of
aspiration event.
He had been started on meropenem and vancomycin by his skilled
nursing facility and once in the hospital, a sputum culture grew
pseudomonas. His antibiotics were narrowed to meropenem alone
and he completed a course of this while in the hospital. His
oxygen requirement initially improved and subsequently dipped
again, prompting imaging. A chest X-ray showed concerns for
interstitial lung disease and he had a CT scan to better
evaluate this. CT scan showed pneumonia and pulmonary edema, but
rather than ILD showed findings consistent with emphysema. He
was subsequently treated with IV diuresis and ultimately PO
diuresis which he tolerated well. At the time of discharge he
has an oxygen requirement around ___ which can be further
weaned at rehab.
Additionally during his hospitalization his blood pressures were
noted to be a bit on the soft side, his dose of amlodipine was
moved to bedtime and decreased. His home lisinopril was not
resumed while in the hospital and will need to be addressed when
back at rehab. The dose he takes is 30mg daily and he will
likely need to initiate this at a lower dose. One consideration
for his hypotension is that his baclofen was increased to help
with spasms, which may be lowering his BP. He did well on an
increased regimen of baclofen. His daughter is interested in
having him follow up in the ___ clinic (contact info
provided in ___ paperwork).
He did experience some abdominal pain in the hospital and a KUB
was performed which showed some dilated loops of bowel
consistent with colonic ileus. His ileus improved with reduction
in his narcotics and bowel rest for several days. Given
stability of his medical issues he was felt stable for discharge
back to his skilled nursing facility.
# Sepsis w/ acute encephalopathy
# Acute hypoxic respiratory failure
# Aspiration pneumonia versus pneumonitis
His sputum culture grew pseudomonas. He was treated with 8 days
of meropenem. He has copious white thick secretions and is still
very high risk for aspiration, it is possible that there was a
component of aspiration pneumonia with his illness as well.
Regardless he improved with antibiotics. His oxygen requirement
persists at the time of discharge, attributed to mild diastolic
HF as outlined below.
# Question of ILD
His Xray raised the concern for interstitial lung disease but a
follow up CT scan was more consistent with emphysema. This may
contribute to his difficulty weaning off of oxygen. His
pulmonary nodules are unchanged.
# Acute on chronic diastolic CHF (EF 50%)
His JVP was initially elevated and he was digressed with IV
lasix. He was maintained off diuretics and underwent treatment
of pneumonia but subsequently his oxygenation worsened which
prompted imaging as above. He underwent IV diuresis and was
ultimately euvolemic on discharge. His and his free water
flushes were decreased in an attempt to minimize diuresis. . An
echo showed an EF of 50% with single vessel CAD and mild
pulmonary hypertension, similar to prior findings. Tapering of
oxygen can be continued at rehab as can adjustment of his
diuretic regimen.
[ ] Consider PO lasix to maintain euvolemia and assess volume
status
# Hyponatremia
He developed hyponatremia to 131 which resolved with diuresis.
Attributed to hypervolemic hyponatremia.
[ ] f/u BMP
# LLQ pain
He continued to complain of LLQ pain at his J tube site, which
is not a new complaint. However he did have some leaking from
the tube and an X-ray was performed which showed findings
consistent with colonic ileus. Clinically he had been
constipated at this time and with distension of his abdomen his
LLQ pain became worse. His pain is attributed to abdominal
distension and his ileus to his bowel habits. Especially with a
history of stercoral colitis it is very important for him to
stool on a regular basis. His pain improved with
defecation/decrease in distension, and his tube feedings did not
leak any further.
# Malpositioned PICC
On admission an X-ray showed that his PICC line was
malpositioned and it was removed. The PICC had been in place
since the ___ per his daughter, and had been kept in
place given frequent hospitalizations and need for IV
medications. While in the hospital he had adequate peripheral IV
access and a new PICC line was not felt to be indicated since he
had already completed his course of antibiotics and had no IV
requirement.
# Hx of CVA w/ residual deficits
# Chronic oropharyngeal dysphagia
# s/p J-tube, cont tube feeds
Chronically bed bound post stroke with dysphagia. He is tube
feed dependent, and his aspiration risk is high even in spite of
minimizing PO intake. Ice chips are okay with supervision. This
is very important for him and his family, as there is
significant concern with PO intake, but they accept the risk of
aspiration and wish for him to be comfortable with ice chips. If
okay by whichever facility he is in, a Popsicle with direct
family supervision once daily is also acceptable. A repeat
speech and swallow evaluation was conducted in the hospital and
there was no recommended change to staying NPO.
# Leg muscle spasms
# Chronic leg pain
His baclofen dose was increased to 10mg TID (from 5mg TID) which
helped a lot with his spasms. He was continued on gabapentin.
His daughter is interested in having him see a neuromuscular
specialist and contact info was provided on the discharge
paperwork.
# Hypertension
He was continued on his home metoprolol, and his amlodipine dose
was cut in half (5mg) and moved to bedtime given softer BP's
during the day. The cause of his borderline hypotension is
thought to be from up-titration of his baclofen (BP's low
100-110s). With the addition of AM diuresis and movement of
amlodipine to bedtime his blood pressures remained in the
120-130's and stable. Notably his lisinopril was not resumed in
the hospital and likely this will need to be initiated back at a
lower dose, which should be done when he goes back to his
skilled nursing facility as BP tolerates.
# Nocturnal desaturations
He had been on CPAP before but was not compliant because of
ill-fitting face mask. He desaturates when he sleeps and
requires oxygen at bedtime. He will need a new mask or repeat
sleep study.
# Neurogenic bladder w/ chronic foley
Exchanged ___.
# Chronic constipation
# Hx of stercoral colitis
Was continued on his bowel regimen. His habit tends to be
constipation for about 2 days followed by massive bowel
movement. Perhaps adjusting his regimen to ensure daily bowel
movement would help him, this could not be achieved in the
hospital and will need to be carried on going forward.
# CAD
S/p PTCA and bare metal stent to OM2 in ___. Aspirin and
clopidogrel were held prior to chest tube placement during last
admission. It was held on discharge given bleeding during last
admission. Given there is no clear indication for plavix it was
still held. He was continued on metoprolol and aspirin as well
as atorvastatin. His EF is not low enough to require ACE
inhibitor but as above it should be resumed when BP can
tolerate.
# Chronic pain
# Fibromyalgia
Continued home regimen of standing acetaminophen and reduced
dose of Methadone to 5mg TID and Oxycodone 5mg q6h PRN. He was
previously on Methadone 5mg q6h and Oxycodone 10mg.
gabapentin 400mg TID. Baclofen increased as above. Despite
patient request, methadone was not increased. He did not appear
to have uncontrolled pain requiring an adjustment.
# ___
Continue insulin sliding scale and lantus 5U daily.
# Depression
Continued home sertraline 50 mg QHS.
# GERD
Continued home lansoprazole 30mg daily and calcium
# VTE ppx
Patient declined heparin subq because of prior hemoperitoneum
during last hospitalization.
# Code status: Full
# Dispo: d/c to SNF
Time spent: > 30 minutes | 268 | 1,341 |
16436189-DS-18 | 29,512,132 | You were admitted for nausea and were found to have a mass
obstructing your intestine which was found to be a cancer. You
had a feeding tube placed for nutrition. You ultimately were
taken to the operating room to have a procedure to bypass this
obstruction.
Your hospitalization was also notable for a gout flare, which
was treated with steroids. | ___ year old man with HTN, HL, DM, and gout, who presented to his
PCP with one week of nausea and vomiting and was referred to the
ED after CT showed pyloric lesion, now
with NG tube, tolerating tube feeds.
#Gastric adenocarcinoma
#Gastric outlet obstruction, pyloric mass
#Lower mediastinal, celiac, and RP adenopathy
#Mediastinal mass
The patient presented with a gastric outlet obstruction due to a
mass which was concerning for malignancy. NGT placed in ED which
relieved obstruction and patient remained strict NPO. EGD showed
mild esophagitis and mass in stomach and mass in duodenum. Bx
with high grade dysplasia but not diagnostic. Underwent an EUS
for repeat biopsy. This biopsy was consistent with invasive
adenocarcinoma. In addition to the mass in his stomach, CT chest
showed unexpected mediastinal mass, MRI of this showed it was
likely thymic hyperplasia. The patient also had a PET CT scan
and the mediastinal mass was non FDG avid. CEA and ___ were
checked and were not elevated. Surgery and advanced endoscopy
teams were consulted and the decision was made for
gastrojejunostomy with port placement. The patient was also seen
by ___ oncology and will follow with Dr. ___ on ___ 2PM
at discharge.
#Nutrition:
Patient initially had NJ placed by ERCP team but it was not
postpyloric. He was tolerating tube feeds at 10 cc/h but given
desire to increase TF, the tube was exchange and post-pyloric TF
were started.
# Toxic metabolic encephalopathy: Slowed response to DOWB on
admission, but resolved (likely just from fatigue), non focal
exam otherwise. MR brain ___ acute finding or met.
# Acute Gout: Patient with history of gout with wrist pain
concerning for acute gout. Placed on steroid taper. Held
allopurinol and colchicine while NPO.
# Anemia: iron deficient mildly. Likely ___ chronic blood loss
from mass. Received IV iron x1 dose.
#HTN: held home PO BP meds while strict NPO, so given IV
hydralazine in place of metoprolol and amlodipine.
#GERD: IV PPI in place of home PO PPI while NPO.
#HLD: held home statin while NPO
#DM: held home metformin, started sliding scale
==========
TRANSITIONAL ISSUES
- Port sutures need to be removed around ___.
- PET scan suggestive of dental disease. Pt should follow up
with his dentist.
===============
Follow up:
You have an appointment with Dr. ___ on ___ at
2PM.
Address: ___, ___., ___
___
Ph: ___
You should follow up with Dr. ___ in 2 weeks.
You should hear from the surgery team with details of your
appointment in the next 2 days. If you do not hear from them,
you may call their office at ___.
Address: ___, ___ | 60 | 428 |
11530308-DS-11 | 23,792,420 | you were hospitalized for evaluation of abnormal liver function
tests. we suspect this may due to a gallstone that past through
your bile ducts and is no longer blocking bile flow, but some of
your liver tests remain abnormal and thus these need to be
followed.
please get liver function tests and bilirubin (blood work)
checked weekly with results sent to PCP and Dr. ___.
we discussed warning signs to contact your doctor or return to
emergency room including abdominal pain, nausea/vomiting,
jaundice, bleeding
we also ask that you hold your statin, (Lipitor/atorvastatin)
because it sometimes can cause drug induced liver injury.
please speak with your pcp and the liver doctor we are sending
you to about when to resume this medication.
some labs for auto-immune hepatitis are pending.
if the labs do not normalize you may need additional testing
with imaging (MRCP) and even a liver biopsy, so follow up is
essential | ASSESSMENT AND PLAN:
___ year old lady with history of type 2 DM, recent STEMI s/p DES
___ (c/b cardiogenic shock, systolic CHF), presenting with 5
days of epigastric discomfort and newly elevated liver enzymes.
#Cholestasis/Transaminitis: Suspected to be from
choledocolithiasis no longer seen on CT scan and ultrasound that
may indicate a passed stone vs. drug induced liver injury from
statin vs. auto-immune liver disease/hepatitis.
Notably, when labs were checked in primary care setting Last
week on ___ ALT 24, AST 31 and this was while she had been
on high dose Lipitor for at least a week following discharge
from ___ after STEMI.
Radiology felt that missing a biliary stone was unlikely given
CT and ultrasound both not showing stones or ductal dilatation
and thus MRCP was not pursued as she had no clinical evidence of
cholangitis.
Hepatology consulted. They felt this could be lab pattern
consistent with passed choledocolithiasis vs. liver injury from
statin vs. auto-immune hepatitis. They will help arrange f/u in
___ clinic at ___. Dr. ___ the patient.
T bili improved although alk phos rose slightly before discharge
from 450 to 500 although transaminitis improved. THese values
were reviewed with hepatology. They said next step would be to
offer her MRCP but that she did not need to stay for it and that
if her LFTs did not normalize she should have MRCP and then
potentially a liver biopsy pending results of auto-immune
hepatitis serologies.
We will continue to hold atorvastatin until repeat labs show
improvement.
# CAD: Continue home metoprolol, ASA 81 mg, ticagrelor 90mg BID,
hold atorvastatin.
# Chronic systolic CHF: On previous admission, she was found to
have EF 40%
with moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the distal ___ of the
anteroseptum, anterior, and distal anterolateral wall and apex.
She was started on metoprolol but did not tolerate captopril
(became hypotensive to ___ with baseline BPs 120s). Last
discharge weight 66.9 kg. Check daily weights, continue meds.
CHRONIC ISSUES:
================
#DM2: Maintain on ISS while in house; Last A1c 6.8%. resume
metformin on discharge
#Hypothyroidism: Continue home levothyroxine 75mcg
#Hyperlipidemia: Hold statin
#Healthcare maintenance. Continue MVI, vitamin D, calcium
carbonate. | 150 | 366 |
16131197-DS-8 | 25,833,349 | You were admitted to the hospital with alcohol withdrawal, your
withdrawal resolved. You also had diarrhea, we sent off stool
studies most of which are still pending, please follow-up with
your primary care physician for further testing for your
diarrhea. It is very important that you take your medications
as prescribed on a daily basis. | ___ year old female w/PMH of HIV, schizophrenia/depression, EtOH
abuse, stool incontinence, stroke in ___ (states on
Coumadin,
but not confirmed on chart review), history of pulmonary
embolism
in ___ in presenting with chest pain, dyspnea brought in by
ambulance from fire station on ___ with c/o SOB from
"walking around the heat all day." now with abdominal pain,
diarrhea, and shortness of breath.
#Alcohol withdrawal
#Cocaine abuse
She has started drinking heavily again, reports daily drinking
of
brandy, ETOH level 241 in ED. Placed on CIWA protocol with PRN
valium with resolution of withdrawal. Social work consulted, she
is planning on staying with her daughter.
-Continue Thiamine, folate, MV
#HIV/AIDS
Patient is noncompliant on HIV medications, last CD4 count
obtained in ___ and was 307 with HIV viral load 312
copies/ml. She reports non-compliance due to being overwhelmed
with the number of pills she has to take, being homeless and her
substance abuse. She reports that now that she is staying with
her daughter she will try to be more compliant with her
medications.
-have restarted her HIV medications including Prezista, Truvada,
Norvir
-continue Bactrim SS daily
#GI:
Having non-bloody watery diarrhea, she reports it has been for
days to weeks but has had similar symptoms during prior
admission. Stool cultures negative so far including c. diff.
Her LFTs were mildly elevated initially but are
improving (likely due to mild alcoholic hepatitis) and lipase is
normal.
-Follow-up final stool culture results
-Omeprazole BID
#Chest pain
Reports chest pain which has been a chronic complaint, ECG
normal
without any concerning findings, troponin negative. She was
diagnosed with a PE in ___ but CTA chest on ___ negative
for PE when she presented with similar complaints. Overall low
suspicion for PE. Possibly cocaine induced chest pain.
#Asthma
-continue Advair
#Psych: Substance abuse disorder, PTSD, possible schizophrenia
and depression. Psychiatry was consulted in ED as she was
initially refusing therapies to assess for competence but this
was in setting of acute intoxication. Per psychiatry no acute
needs and medically safe for discharge.
-Continue home psychiatric regimen: Bupropion 150 mg PO qam,
Paroxetine 40 mg PO daily, Hydroxyzine prn, Trazodone qhs prn.
-Encouraged to follow-up with her outpatient psychiatrist.
#Neuropathy:
-Lyrica 150 mg BID
#Hx of thyroid nodules:
-needs outpatient thyroid ultrasound follow-up in ___
#HSV: continue acyclovir for prophylaxis
#FEN/PPX: regular diet, Heparin subq BID
#Code Status: FULL CODE | 57 | 370 |
15589519-DS-16 | 21,392,037 | You were admitted to the hospital for shortness of breath. Your
heart failure and pneumonia were likely contributing. You were
treated with medications to remove fluid, as well as
antibiotics. You had a number of changes to your medications
(see below).
During your stay you had an unwitnessed fall. Imaging of your
head, neck, and hips was normal. However, you should get
assistance when standing and walking due to your chronic
dizziness. | Ms. ___ is a ___ year old woman with an extensive medical
history including CAD ___ CABGx2, AVR/MVR in ___, restrictive
heart and lung disease on 2L home O2 on heart/lung xplant list
who presents with progressive DOE and cough over the last 6
months with diffuse infiltrate on CXR and coarse crackles
throughout her lungs treated for HCAP.
#Dyspnea. Her dyspnea on exertion appears to be acute on
chronic, per her report she has had a progressive decline over
the last 6 months, with a chronic productive cough during the
same period. Also per report she has had low grade fevers.
Presented without leukocytosis but thrombocytosis to 705 (from
400's in ___. Since she has been in rehab, there was
concern for HCAP and she was started on vanc/levo empirically.
Of note, she has required increasing doses of diuretics in the
week before admission, her BNP was up at 7545 but has been
chronically elevated and her weight is reportedly 5 pounds below
baseline. Pulmonary hypertension may also be contributing. PE
unlikely given she is supratherapeutic and ___ were negative.
She received 40mg IV lasix in ED and additional 60mg on floor
and is net negative 2L since she arrived. Likely multifactorial
from HCAP + acute on chronic systolic biventricular failure.
She clinically improved with Vanc/levaquin and diuresis with IV
lasix and finished her course of antibiotics on ___. She
required increasing doses of diuretics (120mg lasix IV bid with
5mg metolazone BID) to continue to diurese. Pulmonary was
consulted and recommended that she should undergo a formal sleep
evaluation as an outpatient, as well as a trial of sildenafil
once euvolemic, a repeat trial of sildenafil could also be
attempted by her outpatient providers.
#Chronic diastolic CHF and restrictive cardiomyopathy. Likely
secondary to XRT, but other causes such as amyloidosis,
sarcoidosis are possible. Previous RHC ___ showed likely
restrictive cardiomyopathy. We were judicious with diuresis as
she likely has elevated filling pressures and is preload
dependant. Metoprolol has been stopped in the past, likely
because an increased rate enhances cardiac output with her
restrictive physiology but intact EF. She has been rejected for
transplant per ___ coordinator, due to psychosocial
circumstances, lack of support system, CKD, liver function,
short-term memory loss. A dobutamine stress ECHO was obtained
during this admission which showed no evidence of ischemia.
#Chronic RLE and LUE edema
Ultrasounds were obtained of both RLE and LUE and did not show
DVT or cause for edema. There were small incidental fluid
collections found in the R thigh.
# Restrictive and obstructive lung disease: Likely exacerbated
by presumed infection. On 2L O2 at home. She was maintained on
supplemental O2 to maintain sats >92%, and continued home
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID, Albuterol
0.083% Neb Soln 1 NEB IH TID, Montelukast Sodium 10 mg PO DAILY,
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
#Pulmonary Hypertension. RHC on ___ showed significant
pulmonary hypertension with PA mean 42, PCWP 21, with PVR 3.7
woods units (with significant response to 100% 02). She had
workup for pulmonary htn including HIV, neg hep serologies, neg
___ and anti-SCL70. PFT's showed moderately reduced FVC and
FEV1/FVC ratio with severely reduced FEV1 c/w severe obstructive
ventilatory defect and coexisting restrictive defect. Her
advair dose was increased and spiriva was added with some
improvement. Concern for pulmonary hypertension from lung
irradiation. She was tried on sildenafil 20mg TID in the past
but did not tolerate it. She may benefit from a repeat trial as
an outpatient, as above.
#Chronic Pain: Her lower back pain remained difficult to
control. She was continued on home gabapentin, and percocet
frequency was increased to qid. Warm packs to her lower back
also offered some relief, as well as tylenol. She requested
dilaudid but was not continued on this due to her respiratory
status and mental status. She has impaired short term memory,
dizziness and unsteady gait at baseline. Palliative care was
consulted for symptomatic management.
# CAD ___ CABG: ECG without significant changes. Had no anginal
CP. Recent LHC showed stable three vessel native coronary
artery disease, patent LIMA to LAD, occluded SVG to OM and PDA.
Subsequent nuclear stress showed only mild distal/apical fixed
perfusion defect. Trop .04 and .05, likely in the setting of
demand and depressed renal function. Continued aspirin 81mg
qd. ___ 5 mg qd was held due to concern that it could
be causing her cholestatic pattern of elevated Alk Phos, GGT,
and coagulopathy.
# AVR/MVR: Maintained goal INR 2.5-3.5 for mechanical mitral
valve, and was on heparin gtt while subtherapeutic.
#Elevated Alk Phos and coagulapathy. Per medical record, patient
has peliosis hepatis based on a GI note referencing a liver bx
in ___. Alk phos 504 on admission, stable with elevated
GGT. INR 5.4 on admission, we initially held coumadin and yet
it trended up to 6.3 on ___ and she was given 1mg PO vitamin K
and it began to trend down and she was restarted on coumadin.
Heme onc was consulted for coagulopathy and thrombocytosis to
769. Likely chronic with splenectomy, and acute infection
contributing. DIC labs neg, RUQ US normal. ___ was
d/c'd as it can cause a cholestatic picture. ___ of ___ noted
to have petechiae and patch of purpura 4-5cm on L leg, as well
as resolving skin lesions on L thigh which per boyfriend began
as purpura a few weeks ago. Thrombin time elevated. At time of
discharge mixing studies and inhibitor screen were borderline,
lupus anticoagulant was positive (in the setting of coumadin)
and should be repeated in 12 weeks.
#Urinary frequency: Initial UA with 84 RBC's, 44 WBC's, few
bacteria. Also had hematuria which was thought secondary to
coagulopathy and traumatic foley insertion. Hematuria resolved
when INR went down. Repeat UA and culture were negative, but she
continues to have symptoms of urinary frequency.
# Fall/elevated INR. Patient got up from commode and fell,
striking head. Head CT x2 and trauma survey were negative.
Neuro exam remained non-focal. Back pain was controlled with
tylenol and lidocaine patch.
# DM: Continue humalog/sliding scale and fixed dose 75/25 mix.
Held home glipizide.
# GERD: continued home omeprazole 40 mg PO BID, Lubiprostone 24
mcg PO BID
# Hypothyroidism: Continue home Levothyroxine Sodium 100 mcg PO
DAILY
# Depression/psych/chronic pain: Seen by palliative care,
increased percocet frequency but did not start other meds.
Lumbar plain film negative for fracutre. Continued home meds
including LaMOTrigine 200 mg PO QHS and 100mg PO qAM, Quetiapine
Fumarate 100 mg PO BID, Clonazepam 2 mg PO QHS and 1mg PO qQM,
Sertraline 150 mg PO QHS, traZODONE 175mg HS
#Anemia - continued home Ferrous Sulfate 325 mg PO BID
#Health care mainteneanece - continued home multivitamin,
ascorbic acid, Vitamin D | 78 | 1,162 |
11681549-DS-16 | 20,428,250 | You were admitted with abdominal pain and found to have
diverticulitis. Because of your previous allergies to
antibiotics, an antibiotic desensitization protocol was used and
you were started on Augmentin. On the day of discharge you were
tolerating oral intake. Please continue taking Augmentin for a
total of 14 days and follow up with your primary care physician
___ medication
1. Augmentin for 14 day course | Assessment and Plan:
___ with a h/o multiple antibiotic allergies, who presented with
her third epsidode of recurrent diverticulitis with possible
colonic microperforation, now s/p augmentin desensitization and
being transferred back to the medicine floor.
# DIVERTICULITIS - The patient presented with left lower
quadrant pain and low grade fevers, with evidence of
diverticulitis of the sigmoid colon on CT imaging. She required
Augmentin treatment and completed a course following
desensitization noted above. She was maintained NPO above, given
IV fluids and Dilaudid for pain control. Colorectal surgery
followed the patient and agreed with antibiotics and noted she
had no acute surgical needs. After amoxicillin
desensitization(see below) she was continued on augmentin and
was able to tolerate po. No fevers or leukocytosis on day of
discharge. Patient discharged on augmentin to complete a ___nd atarax for prn for rash. She will follow up with her
pcp..
# AMOXICILLIN DESENSITIZATION - Patient has a history of
multiple allergies to medications with reactions that have
included swelling, pruritis and generalized rash. She presented
with an episode of diverticulitis requiring antibiotic therapy,
and thus she was transferred to the ICU for antibiotic
desensitization. With the assistance of the Allergy specialist,
she was dosed step-wise with Augmentin over several hours with
no allergic response and she tolerated the final dose well. Once
she completed the full dosing she was monitored for 1-hour in
the ICU and transferred back to the Medicine floor. Epinephrine
and steroids were made available but were not required.
.
# ASTHMA - continued on home albuterol and fluticasone inhalers
.
# HYPERTENSION - continue lisinopril on discharge
.
# HYPERLIPIDEMIA - We continued her home dosing of Zocor 40 mg
PO daily (patient unable to tolerate generic Simvastatin). | 67 | 285 |
12661570-DS-9 | 28,882,541 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted for hip and leg pain
after your recent back surgery. You were evaluated by the ___
surgery team and had an X-ray which were reassuring. You are
being discharged to a rehab center to work on pain control and
to recover from your surgery.
Please keep all of your follow-up appointments and take your
medications as prescribed.
Until you see your surgeons, avoid twisting or bending at the
back. Do no lifting >10 lbs. You may wear your brace for
comfort. The staples in your back may stay in until you see your
surgery team.
We wish you the best!
Your ___ Care Team | ___ s/p L4/5 TLIF with Dr. ___ on ___, discharged ___
with a brace, who presents w/ persistent severe bilateral leg
pain. Admitted for pain control, on PO oxycodone.
#Hip and leg pain s/p L4/5 TLIF
-chronic, mildly improved since surgery on ___. Neurologically
intact. ___ evaluated in ED and recommended no changes in
follow-up plan. ___ consider SNF for pain control, though she
continues to improve on acetaminophen, gabapentin, and
occasional low dose oxycodone for breakthrough. Evaluated by ___
who recommended SNF. ___ evaluated on morning of discharge and
recommended to maintain follow-up plan, okay to leave staples
until ___ follow-up. No twisting or bending. No lifting >10
lbs. She evaluated by Pain Service while inpatient and was
stable on gabapentin 600mg TID, APAP 1000mg PO q8H, and
oxycodone ___ PO q4H PRN for breakthrough.
#Constipation
-patient having 1BM daily, compared to typical up to 5 daily
-Treated with senna/colace/miralax
#Anxiety
#Depression
-continued home clonazepam and Pristiq
-cetirizne PRN at night for insomnia
#HLD
-continue home aspirin and atorvastatin
#GERD
-continue home omeprazole | 117 | 161 |
13769226-DS-12 | 26,304,119 | It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
carotid endarterectomy. This surgery was done to restore proper
blood flow to your brain. To perform this procedure, an
incision was made in your neck.
You tolerated the procedure well and are now ready to be
discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Carotid Endarterectomy
Patient Discharge Instructions
WHAT TO EXPECT:
Bruising, tenderness, mild swelling, numbness and/or a firm
ridge at the incision site is normal. This will improve
gradually in the next 2 weeks.
You may have a sore throat and or mild hoarseness. Warm tea,
throat lozenges, or cool drinks usually help.
It is normal to feel tired for ___ weeks after your surgery.
MEDICATION INSTRUCTIONS:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
You should take Tylenol ___ every 6 hours, as needed for neck
pain. If this is not enough, take your prescription pain
medication. You should require less pain medication each day.
Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
Narcotic pain medication can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
CARE OF YOUR NECK INCISION:
You may shower 48 hours after your procedure. Avoid direct
shower spray to the incision. Let soapy water run over the
incision, then rinse and gently pat the area dry. Do not scrub
the incision.
Your neck incision may be left open to air and uncovered unless
you have a small amount of drainage at the site. If drainage is
present, place a small sterile gauze over the incision and
change the gauze daily.
Do not take a bath or go swimming for 2 weeks.
ACTIVITY:
Do not drive for one week after your procedure. Do not ever
drive after taking narcotic pain medication.
You should not push, pull, lift or carry anything heavier than 5
pounds for the next 2 weeks.
After 2 weeks, you may return to your regular activities
including exercise, sexual activity and work.
DIET:
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, heart healthy diet,
with moderate restriction of salt and fat.
SMOKING:
If you smoke, it is very important for you to stop. Research
has shown that smoking makes vascular disease worse. Talk to
your primary care physician about ways to quit smoking.
The ___ Smokers' Helpline is a FREE and confidential
way to get support and information to help you quit smoking.
Call ___
CALLING FOR HELP
If you need help, please call us at ___. Remember your
doctor, or someone covering for your doctor is available 24
hours a day, 7 days a week. If you call during non-business
hours, you will reach someone who can help you reach the
vascular surgeon on call.
To get help right away, call ___.
Call the surgeon right away for:
· headache that is not controlled with pain medication or
headache that is getting worse
· fever of 101 degrees or more
· bleeding from the incision, or drainage the is new or
increased, or drainage that is white yellow or green
· pain that is not relieved with medication, or pain that is
getting worse instead of better
If you notice any of the following signs of stroke, call ___ to
get help right away.
· sudden numbness or weakness of the face, arm or leg
(especially on one side of the body)
· sudden confusion, trouble speaking or trouble
understanding speech
· trouble seeing in one or both eyes
· sudden trouble walking, dizziness, loss of balance or
coordination
· sudden severe headache with no known cause | Mr. ___ presented to emergency department at ___ on
___ with amaurosis fugax, he was noted on CTA to have a
high stenosis of the internal carotid artery. He was taken to
the operating room on ___ for a left carotid
endarterectomy with Dr. ___. He tolerated the procedure
well without complications (Please see operative note for
further details). After a brief and uneventful stay in the PACU,
the patient was transferred to the floor for further
post-operative management.
In the immediate postoperative period the patient was noted to
be neurologically intact throughout all four distal extremities.
Patient was also evaluated by the on-call neurology service, who
determined that he likely had a TIA, and a brain MRI was done,
which showed what is likely a chronic left ICA watershed
infarct. The neurology team determined that the patient was
stable for discharge with outpatient followup.
On postop day 1, the patient's left carotid endarterectomy
incision site at the staples taken down, and replaced with
Steri-Strips in the usual fashion.
Neuro: Pain was well controlled on oral medications¦
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
had an arterial line which was taken out on post op day 1.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. Had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge. Patient's intake and output were closely
monitored
GU: Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient was closely monitored for signs and symptoms of
infection and fever.
Heme: The patient had blood levels checked daily during their
hospital course to monitor for signs of bleeding. The patient
received subcutaneous heparin and ___ dyne boots were used
during this stay, he/she was encouraged to get up and ambulate
as early as possible. The patient is being discharged on aspirin
and a statin as routine.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in one
month with a carotid artery duplex of the affected side. This
information was communicated to the patient directly prior to
discharge. | 813 | 397 |
15294037-DS-3 | 26,828,485 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We looked at your heart using an ultrasound, and saw that the
heart was not squeezing well. This was likely causing fluid to
back up into your lungs.
- We looked at the blood vessels of your heart (with a
"catheterization"). We did not see major blockages in your
heart arteries.
- We believe that your heart is not squeezing well due to how
much alcohol you drink.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Your discharge weight: 200.84lbs (91.1 kg). You should use
this as your baseline after you leave the hospital.
- Please continue to abstain from alcohol. Drinking more
alcohol can make your heart even weaker than it is. Talk to
your Primary Care Physician if you need help with additional
resources to maintain abstinence.
- Weigh yourself every morning, call your doctor, ___
___, at ___ if your weight goes up more than 3
lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
Your ___ Care Team | Mr. ___ is a ___ year old man with a past medical history of
recently diagnosed atrial fibrillation, hypertension,
hyperlipidemia, prostate cancer s/p resection who presents with
ongoing atrial fibrillation, shortness of breath and chest pain
found to have non-ischemic dilated cardiomyopathy and severe
mitral regurgitation.
# CORONARIES: Mild nonobstructive CAD (30% mLAD), Right dominant
system
# PUMP: EF ___
# RHYTHM: Atrial fibrillation
ACUTE ISSUES
============
# HFrEF (___) (NEW)
# Non-ischemic dilated cardiomyopathy
# Mitral Regurgitation
# Chest pain
# SOB
Presented to outside hospital in ___ with new chest
pain. He underwent an evaluation and was told he has coronary
disease but he did not receive paperwork and is not certain of
the evaluation; he ultimately left with plans to return to
___ for further medical evaluation. Here, Pt reported a
history of one month of chest tightness and DOE that quickly
resolved with rest. Of late he has had recent episodes of more
severe chest tightness, new sharp chest pain, and SOB not on
exertion that were concerning for unstable angina. Troponins and
D-dimer negative on arrival, EKG without new ischemic changes.
Pt underwent TTE on ___ which demonstrated new LVEF depression
to ___. Coronary angiogram ___ revealed only Mild CAD
with elevated filling pressures.
Ultimately, findings were consistent with non-ischemic
cardiomyopathy due to alcohol use disorder (see below). Pt
encouraged to maintain abstinence from alcohol. He was diuresed
as needed with IV furosemide, ultimately transitioned to regimen
below. Given no evidence of LV thickening on TTE, low suspicion
for amyloidosis. TSH normal, HIV, HepB, HepC negative. Iron
studies within normal limits. | 244 | 257 |
14417366-DS-17 | 29,276,293 | Dear Mr. ___,
It was a pleasure taking care of you on this hospital stay at
___.
Why was I admitted to the hospital?
- you were admitted for new chest pain and found to have a
pericardial effusion around your heart
What happened while in was in the hospital?
- You were started on treatment for your pericarditis with two
new medicines call indomethacin and colchicine
- You had imaging of your heart which showed that it was weaker
than it should be
- You had tests done to look for the cause of your pericarditis
What do I need to do once I leave the hospital?
- You should continue to take all of your medications as
prescribed
- You should see a heart doctor as scheduled to follow up for
your pericarditis and heart failure
- You should attempt to stop smoking as this will help your
blood pressure and your heart strengthen
- It is advised to attempt to not work on roofs or high places
with your resolving pericarditis | ___ male with PMHx of pericarditis, who initially presented to
OSH with 2 weeks of positional chest pain, SOB, and myalgias,
found to have a moderate pericardial effusion on chest CT,
subsequently transferred to ___ for further workup and
consideration of pericardiocentesis, admitted to CCU for close
monitoring hemodynamically-significant pericardial effusion.
#CORONARIES: No prior caths
#PUMP: EF 41%, mild global left ventricular hypokinesis
#RHYTHM: Sinus tachycardia, frequent PVCs
ACUTE ISSUES:
=============
# Myopericarditis
The patient's presentation of symptoms was very consistent with
pericarditis,
especially given his history of prior idiopathic pericarditis.
On arrival, he lacked characteristic EKG findings and had no
pericardial friction rub on exam, but TTE on ___ confirmed a
diagnosis of myopericarditis. Causal etiology was unclear, and
differential diagnosis included viral, bacterial, autoimmune, or
hypothyroidism. He had no uremia, no history of thoracic
surgeries, no diagnosis of malignancy (as well as no concerning
symptoms or risk factors for cancer), and no recent medication
use that could have contributed to his pericarditis. CRP was
notably elevated at 221, while ESR was mildly elevated at 29.
Troponins remained negative at <0.01. A thorough infectious
work-up was sent, and ID was consulted. Work-up revealed a
normal TSH, (-) HIV, (-) hepatitis serologies, and ####. Unclear
etiology of myopericarditis at discharge. Will be treated
empirically with doxycycline and have close followup at
discharge. Was HDS at discharge.
# Pericardial Effusion
The patient was noted to have a 1.8cm pericardial effusion on
bedside TTE at ___, and this was also visualized on
chest CT; likely a result of his myopericarditis. On
presentation to OSH, he was thought to have tamponade physiology
on his limited bedside echo, prompting a transfer to ___ for
consideration of pericardiocentesis and drain placement. TTE at
___ showed a small effusion of 0.67cm in size, without
tamponade physiology, so the procedure was ultimately not
performed. He remained HD stable, with normal-high blood
pressure and a normal pulsus of 8 mmHg - suggesting that he has
good reserve, and has been able to compensate. His
myopericarditis was managed medically, as outlined above.
#Acute Heart Failure with Mid-Range Ejection Fraction
EF of 41% and mild global left ventricular hypokinesis were
noted on TTE from ___ most likely causal etiology of his
new-onset HF is his myopericarditis. He remained euvolemic on
exam, and preload-dependent given his pericardial effusion, so
no diuresis was started. For afterload reduction and NHBK,
lisinopril and metoprolol were considered (as the patient
remained borderline hypertensive while in the CCU), but
ultimately deferred in the setting of decompensated, new-onset
HF with a mild pericardial effusion. The patient was transferred
from the CCU to the ___ service for further management.
# Recent Tick Bite, with Rash on Left Buttock
# Possible Lyme Disease
Patient had recent tick bite 4 days prior to admission, and had
a worsening rash
on his left buttock at time of admission. Tick was brought in by
the patient, confirmed to be Ixodes scapularis; unclear exactly
how long it was attached to him. He presented with subjective
chills/night sweats and diffuse myalgias, concerning for Lyme
disease vs anaplasma or other tickborne illness, although these
symptoms could have also been caused by his myopericarditis.
Patient had empirically been started on PO doxycycline while at
___ on ___, and this was transitioned to IV
ceftriaxone on admission. The ID team followed the patient, and
recommended PO doxycycline to cover for tickborne illnesses.
Given his presentation with neck pain and headache a/w
photophobia, an LP was considered to rule out Lyme meningitis,
but was ultimately felt not to be necessary by the ID consult
team. Tickborne serologies from ___ ultimately revealed
positive lyme serologies, although lyme PCR still pending at
time of discharge.
- Sent home on 1mo course of doxycycline
- Will f/u with ID in outpatient clinic.
# Left Pleural Effusion
Patient had a left pleural effusion documented on chest CT from
OSH, as well as atelectasis/consolidation in LLL, likely due to
splinting from his inability to take deep breaths. The
consolidation was initially concerning for PNA in the clinical
context of prolonged SOB and subjective chills/night sweats,
although the patient had very few respiratory infectious
symptoms during his admission, with only a mild cough, no O2
requirement, and only intermittent low-grade fevers. He was
treated with ceftriaxone for Lyme disease (as above), which also
covered CAP; coverage of atypical infections was considered but
ultimately held due to low clinical suspicion for PNA. Flu swab
and RSV panel were both negative.
# Leukocytosis
Possibly reactive from pericarditis vs an infectious source
(particularly
with neutrophil predominance). Of note, however, leukocytosis
would not necessarily
be consistent with Lyme or other tickborne illness. Pericarditis
and effusion were managed as above, and patient was also
prophylactically treated for Lyme disease with IV ceftriaxone,
as outlined above. Leukocytosis resolved, with normal WBC at
discharge.
# Hyponatremia
Na of 132 on admission, likely a side effect of patient's
pericardial effusion/early
cardiac tamponade; hyponatremia has been documented in prior
case
reports as being associated with both conditions. Unclear
etiology, likely related to reduced effective volume and
decreased CO. His sodium levels increased with treatment of his
pericarditis, normalized at discharge.
#CODE: FULL confirmed
#CONTACT: ___ (mother), ___
(No formal documentation of HCP on file) | 168 | 857 |
13226852-DS-10 | 22,088,466 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital for changes in your mental
status.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, you had multiple scans of your body which
showed that you have multiple strokes in your brain, and likely
metastatic cancer in your liver and lungs.
- Ultimately, you were discharged to a ___ facility.
Sincerely,
Your ___ Team | ___ hx of bladder cancer, laryngeal cancer, colon cancer, and
CAD s/p CABG admitted with subacute left MCA stroke, found to
have many small strokes in all brain lobes, also found to have
widespread metastases, on lovenox. Family decided DNR/DNI and
have decided upon hospice center.
# Goals of care
- In discussion with patient's family, decision was made for
discharge to hospice
# Subacute stroke: Left MCA stroke, as well as numerous
bilateral small infarcts across various arterial distributions
c/f cancer thromboembolism. Ultimately in discussion with
neurology and patient's family, lovenox was started for
secondary stroke prevention, though this was discontinued at
time of discharge after speaking again with patient's wife.
# Malignancy with widespread mets: Unclear primary given repeat
imaging and history (colon, vs lung > laryngeal > bladder).
Dx
- Not a candidate for palliative chemotherapy and not within
GOCs, patient discharged on hospice
Tx
- Pain control with PO morphine, though patient was not
requiring this during hospitalization, a prescription was
provided at time of discharge
# Peripheral arterial disease
# CAD h/o CABG
Tx
- Home atorvastatin and beta blocker were discontinued given
transition to hospice care
# DMT2: on glyburide at home, had minimal insulin requirements
this admission
Tx
- stop fingersticks and SSI as controlled
# BPH
Tx
- Discontinued home tamsulosin given transition to hospice care
TRANSITIONAL ISSUES
===================
- Patient DNR/DNI, MOLST filled out prior to discharge
- Patient discharged with prescription for oral morphine, though
he did not require this throughout his admission
- Patient was discharged on prn olanzapine for agitation
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes. | 84 | 324 |
14260397-DS-6 | 25,158,810 | Dear Mr. ___,
Why you were hospitalized:
==========================
- You had difficulty breathing because you had influenza ("the
flu").
What happened in the hospital:
==============================
- You were monitored in the ICU.
- You were given a medication to treat the flu called Tamiflu
(Oseltamivir).
- You were also given antibiotics to treat a potential bacterial
pneumonia.
What you should do when you leave the hospital:
===============================================
- Please continue all of your medications as described below.
- Please attend all of your follow-up appointments as described
below.
We wish you the best!
Your ___ Team | Mr. ___ is an ___ with history of AF s/p PPM on dabigatran,
BPH, hypertension, likely CHF (per med rec) and asthma who
presented with acute hyeprcarbic and hypoxemic respiratory
failure secondary to influenza A infection with suspected
superimposed RLL pneumonia.
===============
ACUTE ISSUES
===============
#Influenza A
#Sepsis
#RLL PNA
#Acute Hypoxic-Hypercarbic respiratory failure
Patient presented with fever, cough, wheezing, dyspnea with
positive flu-A swab at OSH and CXR demonstrating possible RLL
opacities vs. atelectasis. Initial BPs ___ with improvement
after IVF. WBC wnl though PMN predominant with 1% bands. He was
treated for influenza A with oseltamivir and for a potential
superimposed bacterial pneumonia with a course of ceftriaxone
and azithromycin. The ceftriaxone was transitioned to oral
cefpodoxime to finish the course. Course of abx D1: ___,
ending ___
# Acute Respiratory Acidosis
Initial ED VBG with pH 7.27, pCO2 57, and HCO3 27. Likely in the
setting of flu-induced exacerbation of his asthma. He was given
inhaled ipratropium, albuterol and Advair. He never required
BiPAP.
# BPH
# Urinary retention
Presented with urinary retention s/p Foley, with foley removed
after successful voiding trial. He was continued on his home
Finasteride.
CHRONIC ISSUES
===============
# Asthma: Continued home Advair and Albuterol.
# CHF: He was restarted on home furosemide upon discharge
# Open-angle glaucoma: Continued eye drops that were available
inpatient.
# GERD: continued home PPI with Maalox as needed.
# Atrial Fibrillation s/p PPM: continued home dabigatran and
metoprolol tartrate was fractionated.
# Hyperlipidemia: continued atorvastatin.
TRANSITIONAL ISSUES:
====================
- to complete 5 day course of abx with cefpoxime/azithro on ___
- to complete course of Tamiflu on ___
- restarted on home Lasix upon discharge; please monitor renal
function on Lasix
#CODE STATUS: full code (confirmed)
#EMERGENCY CONTACT: ___ (daughter) | 88 | 281 |
19815230-DS-4 | 22,179,750 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
- You were bleeding from your stomach
WHAT WAS DONE WHILE I WAS HERE?
- A camera was used to look at your stomach and throat. You were
bleeding in your stomach
- You were given blood
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should talk to your doctor about warfarin in the future
- Continue to talk your other medications as prescribed and
attend your follow up appointments.
Be well!
Your ___ Care Team | Mr. ___ is a ___ with ESRD ___ HTN nephrosclerosis on
HD, PVD, COPD, HTN, HLD, CAD s/p CABG, anxiety & depression who
presents as a transfer from ___ w/ GIB found to have
esophageal varices on EGD.
ACUTE ISSUES:
# Esophageal Varices/GIB: EGD ___ demonstrate grade III varices
(3 cords) in upper esophagus, non-bleeding, as well as mosaic
appearance of stomach mucosa with 2 spots of spontaneous
bleeding. Clip placed and thermal therapy applied with
hemostasis. Likely the source of melena/anemia. Hgb stable since
___. Continued on PPI BID. Per GI, upper esophageal varices
are at risk for bleeding, but not as high of a risk as more
distal varices given location. No indication for nadolol from
variceal standpoint at this time. No recommended interval to
repeat EGD and no indication for banding given location. Varices
should not prevent anticoagulation if other indications. No need
to repeat CTA unless other indication. Source of varices likely
increased pressures from significant history of catheters and
lines placed causing SVC syndrome and vascular congestion.
#Hypotension: Suspect false hypotension given preserved MS,
normal lactate, no tachycardia. Known vasculopathy as seen on
___ CTA. Anuric at baseline so cannot use UOP to gauge
perfusion. ___ records patient persistently in with
SBPs in the ___ there. Started on midodrine in ICU, tapered down
and discontinued given lack of improvement in BPs.
#Afib: In sinus and rate controlled on admission; afib history
is reportedly from prior hospitalization in ___. Chads-Vasc =
2. Per his PCP, no history of blood clots. His SVC syndrome is
___ vascular scarring from numerous lines and procedures in his
vasculature causing stenosis. This is likely the source of his
varices as well. Anticoagulation held iso recent GIB, risks may
outweigh benefits of anticoagulation, and patient in agreement
with discontinuing warfarin. Can continue to discuss risks and
benefits of anticoagulation with patient in the future.
#Pain Management
#Anxiety Management
Patient on high doses of narcotics and anxiolytics at home,
confirmed with PCP that these are chronic doses of these meds
and patient maintained on this regimen for numerous years.
#Depression/Homicidal ideation: Patient reported he had a bad
year and his wife died in ___. he believes the nursing home she
was in "smothered her with a pillow." He expressed at one point
that he wanted to kill these employees, evaluated by psychiatry
who felt this was frustration rather than actual HI. Felt low
safety risk to others given his lack of access to weapons,
physical limitations, general debilitation. Patient denied HI at
time of discharge and was able to admit that this was just said
out of anger.
# Scrotal pain:
Patient reported scrotal pain ___. We obtained scrotal US which
showed no evidence of testicular torsion, but did show small
hydrocele, left varicocele, & microlithiasis of the left testis.
Per urology, no need for intervention or further imaging for
microlithiasis or other findings on U/S. Will set up for
urologic outpatient follow up for further management/evaluation
should symptoms persist.
CHRONIC ISSUES:
===============
#ESRD on HD:
Nephrology consulted, inpatient HD. Normally ___ HD via right
tunneled catheter. S/P multiple failed fistulas and numerous
failed grafts.
#Hypothyroidism:
Continued levothyroxine PO 150 mcg QD
#PVD sp R SFA stent
ASA held iso GIB, then restarted. Discussed statin with patient
who agreed with starting. Started atorvastatin 40 mg qpm.
#Chronic diastolic HF
#MR ___ TR
___ managed through HD. | 88 | 558 |
11379931-DS-4 | 24,167,244 | Dear ___,
___ were admitted to ___ and
underwent ___ drain placement and antibiotics for your sub
hepatic fluid collection. ___ are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | General:
The patient presented to Emergency Department on ___ with
symptoms of diffuse abdominal pain, fevers and decreased PO
intake. In the ED, patient was noted to have a leukocytosis,
concerning for infection. A urinalysis was notable for a UTI; CT
scan was performed and showed a fluid collection near the liver
concerning for recurrent hematoma. Given findings, the patient
was started on broad-spectrum antibiotics and admitted to
surgery for drainage of the sub-hepatic hematoma. Interventional
radiology placed a drain; there were no adverse events during
the procedure. Please see interventional radiology's note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for continued management and
observation. Microbiology cultures of the drained fluid grew
Klebsiella pneumoniae sensitive to cefepime and bactrim. Patient
was started on IV cefepime and transitioned to PO Bactrim prior
to discharge.
Neuro: The patient was alert and oriented throughout
hospitalization; she did not have any pain and did not require
pain meds.
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: Patient maintained and tolerated a normal diet
throughout hospitalization. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection. Microbiology cultures of the drained sub-hepatic
fluid grew Klebsiella pneumoniae sensitive to cefepime and
bactrim. Patient was started on IV cefepime and transitioned to
PO Bactrim prior to discharge.
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. | 331 | 351 |
18916626-DS-27 | 28,074,004 | Dear Mr. ___,
You were seen at ___ for
worsening abdominal pain and nausea. We think that this pain is
most likely caused by a defect in your stomach's ability to move
food along into your bowels. This has been a chronic issue for
you; the medical term is "gastroparesis."
In order to evaluate for other potential causes for your pain,
we also imaged your abdomen with a CT scan. However, we did not
see any worrisome issues.
Your pain improved overnight with nausea and pain medications.
We discharged you on your home nausea and pain medication
regimen, which was managing your pain well at the time of
discharge.
MEDICATION CHANGES:
none | This is a ___ year old man with a history of HIV, HCV,
pancreatitis, history of gastroparesis who presents with
abdominal pain and nausea likely secondary to chronic
gastroparesis. | 108 | 29 |
13667181-DS-20 | 27,780,651 | Dear Ms. ___,
You were admitted to the hospital because you had RLQ abdominal
pain. CT imaging showed that your appendix was inflamed and
perforated. You were taken to the OR and had your appendix
removed laparoscopically. You have since been tolerating a
regular diet, voiding without issue, ambulating, and your pain
has been well-controlled on oral pain medications. You are now
ready for discharge home to continue your recovery. Please
follow the discharge instructions below:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ presented to the Emergency Department on ___. Pt
was recently admitted to ___ for perforated appendicitis and
was already on a course of Cipro/Flagyl. Upon this admission, CT
imaging done showed perforated appendicitis. Patient was brought
to the OR for laparoscopic appendectomy on ___. There were
no adverse events in the operating room; please see the
operative note for details. Pt was extubated, taken to the PACU
until stable, then transferred to the floor for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid and
then transitioned to oral analgesics in the post-operative
period.
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 the plan for
the OR.
Her diet was advanced to a regular diet on POD1, which was well
tolerated. On POD1, she was voiding without issue and passing
gas. Patient's intake and output were closely monitored
throughout hospitalization.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. Her hematocrit stayed
stable.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay. She 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. She will follow up with Dr.
___ in ___ clinic. | 748 | 311 |
19533432-DS-6 | 25,815,868 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
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 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.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
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 | Ms. ___ was admitted under the acute care surgery service
for management of her cholecystitis. She was taken to the
operating room and underwent a laparoscopic cholecystectomy.
Please see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She we subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced to regular, which
she tolerated without abdominal pain, nausea, or vomiting. She
was voiding adequate amounts of urine without difficulty. She
was encouraged to mobilize out of bed and ambulate as tolerated,
which she was able to do independently. Her pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed. | 761 | 151 |
12442165-DS-10 | 28,012,882 | Dear Mr. ___,
You presented to the hospital after a fall at home. You were
found to have multiple rib fractures and spine fractures, which
included left ribs ___ displaced and left ribs ___ non
displaced , and for your spine T7-9 transverse process
fractures. Your pain was controlled with oral pain medication.
You were seen by physical therapy who recommended you continue
your recovery at rehab. You are now stable for discharge, please
follow these instructions to aid in your recovery
* Your injury caused left ribs ___ displaced and left ribs
___ non displaced rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
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.
Best Wishes,
Your ___ Surgery Team | Mr. ___ is a ___ year old male who presented to the hospital
several days after a fall at home, he was found to have multiple
rib fractures which included left ribs ___ displaced fracture,
and left ribs ___ nondisplaced rib fractures as well as a T ___
transverse process spine fracture. He was admitted to the acute
care surgery service for further management and observation.
He was advanced to a regular diet, which was well tolerated, his
pain as well controlled on oral medication. His home medications
were restarted. He ranged from being incontinent of urine to
being unable to void and requiring to be straight cathed once.
He received heparin subcutaneously and had venoboots in place
for DVT prophylaxis. He continued to use in incentive spirometer
and remained comfortable on room air
Due to his multiple falls, he was seen by the Geriatrics
service, who recommended checking orthostatics ( which were
negative), have a home safety evaluation, and to follow up with
his geriatrician Dr. ___ ___
___ to discuss the multiple falls as well as to start him on
a osteoporosis medication.
He was evaluated by physical therapy who felt he should be
discharged to a rehab.
At the time of discharge, he was afebrile and hemodynamically
stable, tolerating a regular diet, his pain was well controlled
on oral pain medication, he was out of bed and ambulating with
assistance, he was voiding with a condom cath in place due to
incontinence, and he was deemed stable for discharge to rehab to
continue his care. He verbalized agreement and understanding of
the plan. | 538 | 268 |
11579936-DS-16 | 23,082,956 | Dear ___,
___ were admitted to the gynecology service after your
procedure. ___ have recovered well and the team believes ___ are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* ___ may eat a regular diet.
* ___ may walk up and down stairs.
Incision care:
* ___ may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Leave the steri-strips in place. They will fall off on their
own. If they have not fallen off by 7 days post-op, ___ may
remove them.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where ___ are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if ___ are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was admitted to the gynecology
service after undergoing diagnostic LSC, evacuation of
hemoperitoneum for likely ruptured hemorrhagic cyst, cannot r/o
heterotopic pregnancy or tubal abortion. Her post-operative
course was uncomplicated. Immediately post-op, her pain was
controlled with IV dilaudid,.
On post-operative day 1, her urine output was adequate, so her
foley was removed, and she voided spontaneously. Her diet was
advanced without difficulty, and she was transitioned to
oxycodone/acetaminophen.
On post-operative day 2, she had a repeat HCG level with a 38%
increase in 48 hours and a transvaginal ultrasound that showed a
gestational sac w/ visible yolk sac, no fetal heartbeat
consistent w/ possibly viable intrauterine pregnancy of EGA 5wks
(LMP ___. The right adnexa was poorly visualized due to
post surgical changes. By this time she was tolerating a regular
diet, voiding spontaneously, ambulating independently, and pain
was controlled with oral medications. She was then discharged
home in stable condition with outpatient follow-up scheduled,
with plan for a repeat pelvic US and serum HCG on ___. | 303 | 173 |
15031793-DS-17 | 21,968,530 | Please call Dr. ___ office ___ if you have
any of the following: fever, shaking chills, malfunction of
tunneled line, bleeding at tunneled line or right groin site.
Please see printed instructions for preop OR for ___:
Nothing to eat or drink after midnight prior to the day of
surgery. Take half of NPH (long acting insulin) and no regular
(short acting) the morning of surgery.
You should continue aspirin and plavix
If you have any questions, please call ___ at
___
Please use antiseptic "soap" the night prior and am prior to
coming to hospital to ___ do sponge bath per printed
instructions to prevent infections. A bottle of Bactoshield soap
has been given to you to wash (not drink) | Ms ___ was admitted to the medicine service from the Emergency
Department for a thrombosed LUE fistula. She went to
interventional radiology for a thrombectomy, which was
unsuccessful. Thrombosis of the fistula was noted and a hematoma
was found. Thrombolysis was attempted and unsuccessful. A
temporary right femoral line was placed for access. She was
admitted to the ___ surgery service
post-procedure. Overnight, she had some bleeding from the left
upper extremity site. Stitches were placed but due to the
friability of the skin, did not stop the bleeding. Pressure was
held in total for approximately one hour, which caused the
bleeding to temporarily stop. THe next day, she had one hour of
dialysis, then went to the operating room for a ligation of the
left brachiocephalic AVF and closure of a brachial artery
pseudoaneurysm. She tolerated the procedure well. See operative
note for full details. She went back to the floor. TH enext day,
she had a right sided upper extremity venogram and had a left
sided tunneled IJ placed. She tolerated this well, ate a regular
diet, and was otherwise doing well. Her right femoral line was
removed. Pressure was held and a dressing applied. She was
discharged home with plan for follow up in the OR on ___ for
RUE fistula vs graft. During this admission, she was also noted
to have an abrasion on her right stump, and during the admission
xeroform and dressing was applied to it. | 118 | 243 |
11579240-DS-5 | 24,905,277 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
Touchdown Weight Bearing Right Lower Extremity
Splint until f/u
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
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R ankle, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient was able
to ambulate with crutches, indicating that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
Touchdown weight bearing in the right lower extremity, and will
be discharged on Aspirin 325 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. | 319 | 257 |
15974128-DS-31 | 23,222,368 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. If your wound have worsening pain or drainage please
call your PCP or podiatrist. | #b/l Heel Ulcers
#Cellulitis
Patient known PAD presented with bilateral heel ulcer with
cellulitis. She was seen by podiatry who felt unlikely to be
osteomyelitis. WBC of 14 on arrival. Plain films b/l w/o
evidence of osteo. B/l ABIs performed and of poor quality but
with decreased blood flow w/o evidence of obstruction. Referred
for outpatient Podiatry and Vascular f/up. Initially started on
Clindamycin/CefePIME and transitioned to PO Keflex prior to
discharge (no purulence).
-f/up with Podiatry and Vascular
-Plan for 5 days of Keflex ___ to complete total 7 day
course.
- Local wound care per podiatry recommendations:
Bilateral heels with betadine, DSD and should be offloaded with
waffle boots.
#DM2-
- Insulin for DM2 - reduced from 90 qam and 18 qhs to 70qam and
14 qhs due to glucoses in ___ I/s/o NPO status. Can likely
return to home regimen once discharged.
-Continue 90 qam and continue 18 qhs, with additional sliding
scale at meals with continued monitoring
#PAF, chronic systolic CHF with chronic hypoxemia - Pt is on
ASA/clopidogrel, metoprolol, metolazone, spironolactone. TTE
prior with preserved EF, mild pHTN.
-Would benefit from outpt sleep if w/in ___.
#Hypothyroidism - home Levothyroxine
#Anxiety - Lorazepam
#Residence: ___ - consulted gerontology team | 28 | 194 |
16372073-DS-7 | 28,397,244 | It was a pleasure looking after you, Mr. ___. As you know,
you were admitted with abdominal pain, low white blood cell
count and low platelet count. Extensive workup - including
blood tests, imaging tests and bone marrow biopsy - revealed
that there was no active vasculitis, cyroglobulinemia, or
infection.
The results of the bone marrow biopsy can be followed up as
an outpatient. Your symptoms (low blood count and possibly abd
pain) may be attributed to your active hepatitis C infection.
(There was a high viral count). For this, you were seen by the
liver specialist, and preauthorization papers for the new drug,
Harvoni, was submitted on your behalf. You will be notified by
the liver team when this is process through and when you can
initiate this medication.
You were given pain medications to relieve your pain - and
were given a course of pain medications (oxycodone) at home.
Please follow up with your primary care doctor if you feel these
medications need to be continued on a longer-term basis. You
should also continue the acid suppressant medications to deal
with the evidence of intestinal swelling seen on the CT scan. | ASSESSMENT & ___ yo M h/o marginal zone B-cell lymphoma s/p
chemo, Hep C cirrhosis, cryoglobulinemic vasculitis (previous
plasma exchange therapy, rituxan) and chronic pain admitted with
abdominal pain, and pancytopenia with
neutropenia/thrombocytopenia.
# Pancytopenia: h/o Marginal cell lymphoma, Cryoglobulinemia,
monoclonal IgM. Mr. ___ was admitted with significant
neutropenia/thrombocytopenia - these are possibly subacute in
nature since the last CBC on record was ___. He no
significant clinical signs of bleeding from thrombocytopenia.
His CBC were stable and he had no significant epistaxis or GI
bleed.
The cuae of the pancytopenia is presently unclear and was
initially attributed to multifactorial etiologies: splenic
sequestration (although no significant splenomegaly), viral
etiology, MDS or other BM failure, Cryoglobulinemia/ vasculitis.
Infiltrative process from lymphoma was considered less likely -
given LDH nl and there was no significant ___ on CT scan.
Ultimately extensive workup (including HIV, CMV, EBV, Vit
B12, Folate, ferritin, C3/C4, ESR/CRP, SPEP, cryocrit, HPylori)
were all unremarkable. Vascular imaging of mesenteric vessels
negative. Presently only the EBV PCR, parvovirus serology are
pending. Bone marrow biopsy was performed on ___ - and the
results are still pending. This will be followed up by the
hematology team as an outpt. The thought was that the
pancytopenia was consistent with myelosuppression from active
hep C infection.
He tolerated the hospitalization well -without any signs of
infection or bleeding. He was kept on a neutropenic diet.
Of note, workup revealed he had low haptoglobin with spur
cells on blood smear: he has a component of spur cell hemolysis
in setting of liver disease
# Abd pain: Mr. ___ has diffuse abdominal pain of unclear
etiology (albeit has history of chronic pain). He had evidence
of duodenitis on CT scan as well as mild-mod constipation. For
this, he was placed on sucralfate and PPI with minimal
improvement. MRI and MRA of the mesenteric vessels were
negative for vasculitis. EGD was considered by the Liver team,
but deferred due to the pancytopenia. He was treated with
dilaudid and then subsequently oxycodone PRN, bowel regimen,
simethicone PRN.
# Liver: h/o Hepatitis C with previously high viral load, signs
of evolving cirrhosis. He has evidence of good synthetic
function (INR 1.1, alb 3.9). Now HCV viral load 2,570,000 IU/ml.
AFP elevated but liver MRI unremarkable. As noted, liver was
consulted during this stay. Ultimately, he was recommended to
initiate Harvoni as an outpt to treat Hep C. The
preauthorization paperwork were initiated and he will be
notified of the timing of the medications shortly.
Of note, there was no signs of hepatic encephalopathy, varices.
Minimal amount of ascites on CT scan.
# Tob dependence:
- nicotine Patch PRN
# Depression: social support
# OTHER ISSUES AS OUTLINED.
.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
Ensure supplementation
#DVT PROPHYLAXIS: none for thrombocytopenia
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: Neutropenic
#COMMUNICATION: pt and wife
#CONSULTS: ___, +/- Liver
#CODE STATUS: [X]full code []DNR/DNI
. | 211 | 537 |
11413236-DS-123 | 23,336,707 | Dear Ms. ___,
You were admitted to the hospital because of chest pain and
shortness of breath. You believed this was most consistent with
a flare of your mast cell degranulation syndrome. You were
treated in the emergency department with medications under the
mast cell protocol. You were stabilized on the floor with your
home medications and benadryl. You were not found to have any
life threatening cause for your symptoms. Your symptoms improved
on the day of discharge. | ___ with past diagnosis of mast cell degranulation syndrome, CAD
s/p CABG x2 in ___, hypothyroidism, ADHD/Depression/Anxiety,
and GERD, s/p Dor fundoplication and ___ myotomy ___
presents with dyspnea, pruritis, and chest pain consistent with
her prior mast cell degranulation flare. Patient requested to be
discharged multiple times on her last day of admission.
# Mast cell degranulation flare. Patient received mast cell
protocol in ED, with IV diphenhydramine, IV Zofran, IV dilaudid,
IV Solumedrol, IV pantoprazole, and 2L NS. Unclear diagnosis in
the past. From Dr. ___ note: "Inconsistent with this
diagnosis in the past is that blood histamine and/or Tryptase
levels have never been abnormal with any ___ admissions
including for what appears to be significant symptoms of
?anaphylaxis. In these instances, we would expect to see florid
increases in blood histamine and tryptase." Patient's home
medications were continued. On the floor, she had several
episodes of severe subjective chest pain and audible wheezing
with positive ___ sign and requested IV Benadryl by name.
Patient had normal lipase, troponin, and unchanged ECG. She was
noted to be calm in her room alone, but became subjectively
aggravated and distressed when providers entered her room. She
received Benadryl 12.5mg IV Q6H PRN which treated her symptoms
appropriately. She was discharged on all of her home meds with
no changes or additions.
# GERD, reflux symptoms. Status post myotomy and partial
fundoplication on ___ which was uncomplicated and stable on
outpatient followup on ___. Her outpatient GI Dr. ___ has
suggested an outpatient pH/impedance testing given her
persistent symptoms. Her thoracic surgeron Dr. ___ not
think her reflux is GERD related as she had a
myotomy/fundoplication with no change in symptoms and she is not
responsive to PPIs. Per request of Dr. ___ had a
barium swallow study which showed esophageal dysmotility while
drinking. No problems with swallowing barium tablet.
# Elevated ALT and alkaline phosphatase. Unclear etiology.
Patient was not complaining of RUQ abdominal pain. No risk
factors for hepatitis. No ___ medications started per patient.
Recommend outpatient followup as patient was clinically stable
and this was not relevant to her presenting complaints.
# Hypocalcemia. Calcium 6.9 with albumin 3.8. This resolved with
calcium gluconate 2g IV and discharge calcium level was 8.4. PTH
was normal. Vitamin D level was pending. Patient was continued
on her home calcium supplement. Saponification in pancreatitis
would not be possible given normal lipase. ___ have element of
malnutrition. Suspect hyperventilation in acute anxiety flares
leading to respiratory alkalosis, in which hydrogen ions
decrease, albumin is freed to bind to calcium, and calcium level
is lowered as a result.
# ACCESS: Port-A-Cath Right chest wall
# CODE: Full (confirmed ___ with patient)
# CONTACT: HCP/son ___ ___
### ___ ISSUES ###
1) Follow up with PCP and Dr. ___ dysmotility and
next steps.
2) Outpatient pH/impedance testing if clinically needed.
3) No changes in medication list during this admission.
4) Follow up abnormal LFTs. | 78 | 479 |
17194276-DS-56 | 27,565,891 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___.
You were admitted with fevers and concern for a serious
infection. You received antibiotics, but a source was never
found, and you showed no signs of infection once antibiotics
were stopped.
You had a CAT scan of your abdomen which showed no new changes
compared to prior. | PRIMARY REASON FOR HOSPITALIZATION:
Ms. ___ is a ___ F w/ secondary Biliary cirrhosis c/b varices
& hepatic encephalopathy who presents with two day history of
fevers w/ weakness and was noted to have possible new murmur
prompting concern for endocarditis. | 60 | 42 |
15262628-DS-18 | 25,085,333 | You were admitted to the hospital after you are found to be
confused. This was thought to be multifactorial and due to a
urinary tract infection, dehydration, acute kidney injury, and
polypharmacy.
For your urinary tract infection you were seen by infectious
disease specialists. Your urine culture grew out Klebsiella,
and initially were treated with cefepime and once culture showed
sensitivities you were narrowed to ciprofloxacin. Due to your
multiple recent UTIs infectious disease wondered if you have
prostatitis and you underwent a prostate ultrasound and a renal
ultrasound. You will be discharged on a long course of
ciprofloxacin and you will need to make a follow-up appointment
with infectious disease after discharge. We also recommend that
you see your urologist to determine if you need cystoscopy/UDS.
As we discussed you are very sensitive to sedating medications
and you should not prescribe yourself any sedating medications
going forward. We also recommend that you seek out an
independent evaluation by physician health services their number
is ___.
After intravenous fluids your kidney function returned to
normal. You also describe diarrhea but did not have any
episodes while in the hospital. If you begin to have diarrhea
again please call your primary care doctor or come back to the
emergency room.
It was a pleasure caring for you | Dr. ___ is a ___ y/o M w/ HTN, DM, CKD,
with a history of self prescribing sedating medications and
presenting with confusion who presents as a referral from his
PCP
for confusion, diarrhea, and UTI.
# Acute toxic metabolic encephalopathy
Presenting altered and disoriented. Likely multifactorial and
___ to both metabolic encephalopathy in
the setting of UTI and polypharmacy in the setting of self
prescribing baclofen. He has had multiple protracted work-ups
for altered mental status which has included a CT scan, MRI, and
multiple request to see cognitive neurology and LP for possible
NPH. He has remained adamant that he does not need further
neurological workup. Over the course of 3 days mental status
improved and at discharge he was oriented x 3 (person, place,
date).
# Acute on chronic renal failure: Cr was 2.7 on admission up
from baseline of 1.7-1.9. Likely prerenal in the setting of poor
PO intake and diarrhea. Creatinine has improved to
baseline in the setting of giving IV fluids which supports
dehydration and hypovolemia. Postvoid residuals were checked
and were normal
no evidence of obstructive uropathy.
# Urinary tract infection
Patient has had recurrent urinary tract infections. Initially he
was treated with cefepime. His urine
culture here grew Klebsiella which was sensitive to
ciprofloxacin. consulted infectious disease to discuss if he
would benefit from prophylactic antibiotics after he completes
treatment. They wondered if he could possibly have prostatitis
or
a prostate abscess versus a renal abscess. He underwent a renal
and prostate ultrasound which were negative for abscess. Given
the frequency of infections ID recommended six weeks of
ciprofloxacin to treat possible prostatitis. They also
recommended he follow in infectious disease clinic. Discussed
with him that taking many sedating medications like trazodone,
Seroquel ect and cipro can cause prolonged qTC and that he
should avoid sedating medications for many reasons going
forward. Also recommended he see his urologist for possible
cystoscopy and urodynamic studies.
-Ciprofloxacin for 6 weeks
-Will need infectious disease follow-up after discharge from the
hospital
-Will need urologic follow-up after discharge from the hospital
#Concerns on self prescribing
It has been well documented in the chart that patient prescribes
himself medications. He has not prescribed himself any
scheduled
medications. He states he needs to prescribe some medications
to
help him with multiple medical problems including hiccups and
insomnia. Several providers have voiced concerns in their notes
on whether
he is safe to continue to treat patients. I had offered for
psychiatry to evaluate him while he is in the hospital which he
adamantly declined. I have only cared for him for the last 3
days and have watched his mental status rapidly improve but it
is
not possible to know what he is like outside of this
hospitalization. He was offered the information to physician
health services and have given him their phone ___ and
have recommended that he get an independent evaluation to see if
he is fit to continue to see patients. I also discussed this
recommendation with his partner ___. I have also reached
out
to his continuity provider and expressed the concerns that have
been well-documented over time.
# Diarrhea:
Initially endorsed diarrhea but had no episodes while in the
hospital.
# Insomnia: Patient has a history of self-medicating due to
significant insomnia. Advised him to stop taking Doxepin and
trazodone. Did restart his Seroquel.
- QUEtiapine Fumarate 100 mg PO
- stop Doxepin HCl 25 mg PO TID, and TraZODone 50-100 mg PO
QHS:PRN | 223 | 556 |
15295452-DS-14 | 27,143,432 | you are being referred to ___. Please continue
to follow up with your physicians when you leave. | Mr. ___ is a ___ male with a PMH of stage 4 appendicle
cancer s/p resection and intraabadominal chemotherapy at ___ and initially presented to ___
with
worsening of his chronic abdominal pain over the
last 48 hours and was found to have large intraperitoneal fluid
collection within the mesentery containing
an air-fluid level. He was subsequently transferred to ___ for
further surgical management. On arrival he was evaluated by our
surgical team and was concern about an SBO. Our providers had an
extensive discussion with the patient and wife (cell:
___ who is on her way from ___ and told her
about the CT findings suggesting perforation. Based on her
discussion with her husband a few days ago about starting to
pursue comfort-focused care, we think a trial of conservative
management with antibiotics, gastric decompression, and fluids
is reasonable. She is aware though that things may not go well
and then a transition to comfort care would likely be
appropriate. Given his complex medical history and advance stage
of cancer, the surgical team did not have any surgical
recommendations. An NG tube was placed for decompression and 1L
of gastric content was removed. He was also medically managed
with IV dilaudid for pain control and was later transferred to
BWH for further management. | 17 | 212 |
18288849-DS-16 | 28,622,819 | Dear ___,
You were admitted with a long seizure that required IV
medications to stop. Your Keppra (anti-seizure) medication was
increased and you did not have any more seizure activity.
You had an MRI that showed that you have had old strokes in the
right back part of your brain as well as small strokes. There
was also a significant amount of atrophy that is likely from
your alcohol use.
We performed a workup for stroke risk factors since you had
evidence of old strokes - This showed that your cholesterol was
within normal limits, your thyroid studies were normal, and your
HbA1C was normal as well indicating that you do not have
diabetes. Your echocardiogram of your heart showed normal
function and no clot in your heart. We did not set you up with a
cardiac monitor as even if we found an abnormal heart rhythm
such as atrial fibrillation, you had evidence of prior bleeding
and falls with alcohol intoxication that taking a blood thinner
would likely not be safe for you.
You were also evaluated by occupational therapy who felt that
given your cognitive decline you would not be safe to live
alone. The issue of a longer term skilled nursing facility can
continue to be addressed at your rehab. | ___ is a ___ old man right handed man with a history
of "conversion disorder with seizures" and polysubstance abuse
who presented in status epilepticus. He was intubated in the ED
after 3mg IV Ativan and successfully extubated shortly
thereafter. His seizures here were most likely focal onset with
secondary generalization given his eye deviation and post ictal
___ paralysis on the left. He was loaded with 1000mg of
keppra and his home dose of was increased from 500 BID to ___
BID. He was monitored on cvEEG which showed right sided
epileptiform activity consistent with prior stroke but there
were no seizures after admission.
.
There was initially some concern for conversion disorder
regarding his seizure but there were multiple ancillary
objective findings that were consistent with seizure including
lactate elevation, leukocytosis, and fever that quickly resolved
on repeat labs. Mild rhabdomyolysis downtrending after admission
with fluids.
.
MRI showed old stroke in R PCA territory as well as significant
small vessel disease Risk factors - HbA1C wnl, LDL within goal,
TSH wnl, no afib on tele. Echo showed normal EF and no
intracardiac clot or shunt. Given the embolic appearance of the
R PCA infarct, we considered setting the patient up with Holter
monitor to evaluate for atrial fibrillation. However, after
discussion - the appearance of evidence of prior hemorrhage on
brain MRI, prior history of falls in the setting of ETOH
intoxication and falls likely renders Mr ___
anticoagulation candidate. He was continued on aspirin and
atorvastatin for secondary prevention.
.
Occupational therapy evaluated him and recommended 24 hr
supervision given cognitive issues likely ___ to years of ETOH
abuse and possibly old strokes.
.
Toxic/ Metabolic/ Infectious workup - CXR
with atelectasis and UA bland. Cultures negative. LFTs wnl. Tox
screens negative.
.
# Rhabdomyolysis
Cr 1.3 on arrival and improved with fluids. CPK trended
downward.
.
# Stable Normocytic Anemia
Follow up with primary care physician.
.
# TRANSITIONAL ISSUES
- Increased Keppra to 1000mg BID
- Normocytic Anemia
- Follow up with neurology. | 212 | 327 |
18996991-DS-6 | 23,709,896 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with numbness of your left hand and
face which was concerning for a possible stroke versus cervical
disc/vertebrae problems. You had a CT scan of your brain and
neck which did not show evidence of an acute stroke. However, a
MRI is necessary to further investigate for a stroke. Our MRI
scanner here could not accomodate you and you will need to have
an MRI (without contrast) as an outpatient. I have contacted
___ open MRI and they will call you to schedule this. You
will also need insurance approval for this MRI. The details of
this are listed below.
You will also need to have an echocardiogram of your heart which
will also be done on an outpatient basis. You will be contacted
by the cardiology echo department with an appointment. If you
do not hear from them in a few days, please call ___ to
follow up on this.
In this event that your symptoms represented a transient stroke
or as we call it "transient ischemic attack," we have started
you on medical treatments to prevent further episodes. You were
started on Aspirin 325mg daily and simvastatin 20mg daily.
Please continue these when you are discharged home. You have
been given prescriptions as well.
When you return home, you will need to follow up with both your
PCP and our ___ Neurologist, Dr. ___. Please call Dr.
___ to schedule an appointment in the next 2 weeks.
Your appointment with Dr. ___ is listed below.
If when you return home, you have further concerning symptoms
such and numbness and tingling or weakness, please seek urgent
medical attention. | Mr. ___ is a morbidly obese ambidextrous man who presented
with one day of left face and arm tingling that was initially
concerning for TIA on ED exam (? left decreased pinprick and
left facial weakness). CT head and CTA neck/head did not show
any evidence of an acute stroke or vessel abnormalities. With
regards to stroke risk factors, he had elevated cholesterol with
an LDL of 112 and was started on a statin. He was also started
on Aspirin 325mg daily (formerly he was taking aspirin
frequently for pain at home). MRI was not obtainable inpatient
given his body habitus. TTE was planned to be done on an
outpatient basis. He did not have notable neurologic deficits
during his ___ hospital stay. No recurrence of his
presenting symptoms or other concerning symptoms. He was
discharged with below ___ plans | 303 | 148 |
12051602-DS-8 | 26,150,303 | You should consider replacement of the stent that was placed in
approximately a year.
If you are to have more yellowness, fevers and increased
abdominal pain please call your doctor or go to an emergency
department. | Patient had minimal abdominal pain. Was taken to ERCP on ___
and a metal stent was placed in distal CBD at area of stenosis.
Unfortunately was not amenable to taking brushings. Good bile
drainage afterwards. He was observed overnight and discharged.
His jaundice was imporved as had his PO intake | 35 | 50 |
16164308-DS-9 | 20,487,925 | Dear Mr. ___,
It was a pleasure taking ___ of you here at ___.
Why you were admitted:
- You were admitted after suddenly experiencing shortness of
breath and chest pain as well as several days of a cold.
- In our ED, you were found to have inflammation and irritation
of your airways, most likely from your cold.
What we did while you were here:
- We treated your symptoms with nebulizers and also started you
on a steroid to help reduce the inflammation and decrease your
wheezing.
- Your heart rate was running slow while you were in the
hospital, and we stopped a couple medications that ___ have been
contributing to this.
- We simplified and narrowed down many of the blood pressure
medications that you were taking at home. Please see the
discharge medication list for specific changes.
Your next steps:
- Please continue the Prednisone 40mg tablet daily through
___.
- You have been discharged with an inhaler and a spacer, which
you should use if you are having shortness of breath or
wheezing.
- Please take all your other medications as they have been
prescribed to you. Please make special note of the medications
we have stopped - including Coumadin, Metoprolol, and Clonidine.
- Please keep your upcoming follow-up appointments with your PCP
and Dr. ___ will arrange for you to have an ultrasound of
your heart as an outpatient.
- It is important that you speak with your primary ___ doctor
about scheduling a repeat sleep study and mask fitting to treat
your obstructive sleep apnea (OSA).
We wish you well,
Your ___ ___ Team | Mr. ___ is a ___ gentleman with a history of HTN, OSA,
Afib on Coumadin who presented to the ED with sudden onset chest
pain and dyspnea found to have likely acute bronchitis with
reactive airways. He was started on treatment with inhalers and
prednisone burst. He was significantly improving prior to
discharge. No evidence of acute coronary syndrome or heart
failure during this hospitalization. He had episodes of
asymptomatic bradycardia overnight in setting of severe OSA so
metoprolol and clonidine were discontinued with improvement in
heart rates. He was able to ambulate without desaturation and
had appropriate HR compensation with activity. As he was stable
and respiratory status was continuing to improve he was
medically cleared for discharge. He will follow up with primary
___ and has established ___ with Dr. ___ as his cardiologist.
#Acute Bronchitis: Patient presented with dyspnea, wheezing,
chest pain in the setting of recent viral URI. Negative cardiac
workup while inpatient. He was treated with prednisone and
nebulized inhalers, and his respiratory status was significantly
improved prior to discharge. He will continue prednisone course
for total five days: Prednisone 40mg PO daily (___). He
was prescribed Albuterol inhaler and given a spacer. Patient can
continue Benzonatate 100mg PO TID for cough.
#Sinus Bradycardia: Patient was having asymptomatic sinus
bradycardia of ___ bpm overnight, most likely secondary to
severe OSA as well as effects from Metoprolol and Clonidine.
When these medications were discontinued, his HR mostly
stabilized with rare bouts of sinus brady. Can consider holter
monitor for further evaluation as an outpatient.
#Atrial Fibrillation: Patient has not been adherent with
Coumadin; his INR was 1.2 on admission. He was on telemetry and
off Metoprolol without any A fib. Given his CHADs VASc score of
1, we discussed with Dr. ___ agreed to discontinue Coumadin
and start Aspirin 81mg upon discharge.
#Hypertension: Patient has been on aggressive antihypertensive
regimen of up to 5 medications in the past, but he has had poor
adherence to this regimen. During his hospitalization, we
discontinued Metoprolol and Clonidine given bradycardia and he
was having rebound hypertension up to SBP 190s. He was
discharged on Lisinopril and Amlodipine. He will follow up with
primary ___ and Dr. ___ further adjustments to
antihypertensive regimen.
#Obstructive sleep apnea: Patient has tried CPAP in the past but
states that he could not tolerate the discomfort. While
hospitalized, his overnight O2 sats dropped to ___,
requiring temporary 2L O2. He will need follow-up sleep study
and mask re-fitting to find suitable CPAP vs. BiPAP.
#Elevated BNP: BNP 1281 on admission, but patient had no
clinical or radiologic evidence of volume overload. Furthermore,
inpatient cardiac workup was negative for acute ischemia.
Patient will get TTE as outpatient with Dr. ___.
#Acute Kidney Injury: Patient presented with Cr 2.3 likely
pre-renal from hypovolemia as it readily resolved after fluid
administration. Discharge Cr 0.8.
#Nocturia: This is a chronic issue for the patient, likely
secondary to BPH. He was treated with Tamsulosin 0.4mg PO daily.
TRANSITIONAL ISSUES
===================
#CODE: Full, limited trial
#CONTACT: ___ (wife): ___
[ ] Prednisone course: Prednisone 40mg PO daily (___)
[ ] Incidental finding of multiple pulmonary nodules measuring
up to 5 mm in the left lower lobe (3:169). If patient has
elevated risk factors for lung cancer, chest CT in 12 months can
be considered. If not, no additional imaging follow-up is
recommended. This is per ___ guidelines on
incidentally found pulmonary nodules.
[ ] Pleasure ensure follow up with sleep medicine for repeat
sleep study and mask fit given severe untreated OSA
[ ] Patient will receive TTE as an outpatient with Dr. ___ to
evaluate for systolic or diastolic dysfunction
[ ] Continue to monitor blood pressures, has history of
non-adherence, simplified regimen and discontinued unnecessary
medications, was hypertensive as inpatient following
discontinuation of clonidine; can consider adding HCTZ as
clinically indicated if still hypertensive
[ ] Did not tolerate metoprolol due to bradycardia overnight,
would continue to monitor heart rates given prior paroxysmal
atrial fibrillation and consider rate control as clinically
indicated
[ ] Consider holter monitor as outpatient given episodes of
asymptomatic bradycardia while asleep in setting of severe OSA
[ ] Anticoagulation discontinued given CHADsVASC of 1, consider
restarting DOAC vs. Coumadin as clinically indicated; of note
patient has poor adherence | 257 | 699 |
12678882-DS-15 | 27,735,536 | Dear ___,
___ was a pleasure caring for you during your hospitalization for
congestive heart failure and blood clot in your heart.
Please keep the following appointments we have made for you.
MEDICATION CHANGES
- START warfarin, you should have your INR checked on or before
___
- START thiamine 100mg daily
TRANSITION OF CARE
- Please contact Dr. ___ at ___
___, as soon as you know that you will be sent home
from rehab, so that your primary care physician, ___
initiate your referral to the Healthcare Associates
___ clinic.
- You may wish to consider outpatient workup of amyloid
cardiomyopathy as an outpatient. You should discuss this with
Dr. ___ your new cardiologist, Dr. ___. | ___ yo woman with ESRD on dialysis, HTN, admitted for 6 weeks of
worsening cough, posttussive emesis, waxing and waning mental
status, found to have elevated lactate as high as 8 and new echo
with dramatically reduced EF, 3+ TR/MR, mild RV failure,
pulmonary hypertension, and LV thrombus.
# CHF: Pt was found to have new biventricular heart failure (EF
20%) on echo with LV thrombus. ___ TTE which showed
systolic dysfunction with EF of 45-50%. DDx includes recent
silent MI (unlikely given lack of qwaves) or balanced ischemia
from 3 vessel disease since stress MIBI was negative (patient is
not a good candidate for CABG per discussion with family,
nephrologist), chronic deterioration of hypertensive
cardiomyopathy, or amyloid cardiomyopathy. Trop 0.04 in ED
without EKG changes, and remained stable. P-MIBI ___ showed
no reversible or fixed myocardial perfusion defects, diffuse
hypokinesia, EF 24%. Based on this interpretation, we cannot
rule out balanced ischemia, but since patient not candidate for
CABG, it was agreed upon that cardiac catheterization was not
necessary. Per Dr. ___ heart failure may be due to
amyloid cardiomyopathy.
- CT of head was negative for any intracranial process, so
patient was given heparin bolus and heparin gtt was started for
LV thrombus, until therapeutic on warfarin.
- Continued home valsartan, started metoprolol at decreased dose
(25mg TID) then uptitrated as tolerated back to home dose
- Cont simvastatin 20 mg PO/NG DAILY
- Cannot get spironolactone given ESRD
- Continue HD for fluid removal qSaTuThu
- Thiamine levels were not drawn prior to starting IV thiamine,
empirically treating with daily thiamine supplementation as wet
beri-beri is on the differential for cardiomyopathy with
elevated lactate.
- Consider outpatient workup of amyloid cardiomyopathy. If
cardiac amyloid were present, most likely this would be from
ESRD or senile, but have not yet ruled out light chain amyloid.
As outpatient, could get SPEP/UPEP, serum light chains, and
immunofixation, but deferred as inpaitnet.
# LV thrombus: Apical hypokinesis and severely depressed LV
function likely cause.
- Heparin gtt bridge until therapeutic on warfarin
# Elevated lactate: Rose to lactate of 8 on day of admission and
then decreased to 1.8 with HD. Etiology of lactate elevation is
unclear.
- Normal serum osms. VBG (pH. 7.45, CO2 40).
- There has been no known infectious process. No leukocytosis,
CXR showed no consolidation, UA negative, blood cultures no
growth. Got Vanc, cefepime, levofloxacin for one day but was
discontinued on HD2 because no evidence of infection. Continued
azithromycin for 4 days for possible atypical pneumonia vs
pertussis given history of 6 weeks of severe cough with
post-tussive emesis
- HIV pending at time of discharge
- Hep serologies pending at time of discharge
- CT abd/pelvis negative for bowel ischemia, transplant surgery
saw and felt no surgical issues
- LV dysfunction without hypotension unlikely to cause this kind
of lactate elevation.
- Other etiologies include toxic ingestions: Patient has
arthritis and dementia but does not endorse taking increased
amounts of over the counter pain medications such as tyelenol or
aspirin. LFTS only mildly elevated. Sertraline toxicity has been
seen in a case study in rats to cause mitochondrial dysfunction
and a lactic acidosis so this is a possibility. Sertraline was
held per toxicology recommendations, but restarted with no new
elevation in lactate. No blood in stool to suggest iron or
colchicine ingestion. Negative serum tox screen.
- Thiamine deficiency can also cause a lactic acidosis. Thiamine
empirically repleted.
# Cough: Cough for a few months with some emesis after coughing
fits. Cough improved with diuresis, most likely etiology is
pulmonary edema. Also possibly viral or pertussis given
increased incidence recently. Sent serum studies for pertussis
to state since swab will be negative 6 weeks out. Rec'd
azithromycin ___. Infection control stated that patient
does not need to be on droplet precautions because onset was 6
weeks ago and cough is improved.
# AMS: Was brought in with confusion by her daughter that had
been worsening over the days before admission. Improved during
hospitalization but the patient per report has some baseline
dementia.
# ESRD on HD ___ schedule: When she was admitted she had
missed a day of dialysis because of fatigue. On ___ she received
dialysis and then received a partial dialysis on ___ to get her
back on schedule. Received dialysis ___ prior to discharge.
# HTN: Kept on home valsartan. Lopressor restarted on ___ and
uptitrated back to her home dose on ___.
# HLD: Kept on home dose of simvastatin
# Osteoarthritis: Home tylenol was discontinued because of
concern for toxicity while in the hospital.
# Hypothyroidism: TSH 5.0 and free T4 0.99. Kept on home
levothyroxine.
# Depression: Held home sertraline in hospital for concern of
toxicity and contribution of lactic acidosis. Restarted without
any increase in lactate.
# Anemia: HCT remained stable around 34. | 115 | 810 |
13505524-DS-19 | 28,876,219 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You developed a fever and diffuse muscle aches
What happened while you were here:
- You briefly stayed in the intensive care unit to get
medications to help your blood pressure
- You were also given intravenous fluids and intravenous
antibiotics
- Imaging showed that you had pneumonia
- There was also concern for ongoing influenza infection, which
was treated with an antiviral medication
What you should do once you leave the hospital:
- Continue taking your medications as prescribed and follow up
with the appointments outlined below
- Please continue meropenem three times a day until ___
- Please call clinic or return to the emergency department for
fever (temp >100.4)
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old female with acute megakaryocytic
leukemia s/p MRD alloSCT in ___ c/b GVHD of eyes/skin/GI
tract/liver on MMF/abatacept and two recent admissions for
influenza who presented with fever and myalgias concerning for
persistent influenza. She initially was admitted to the ICU from
___ due to hypotension requiring levophed. Ultimately, she
was treated for HCAP and influenza, with concern for oseltamivir
resistant-influenza. | 127 | 68 |
13696148-DS-14 | 27,977,275 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain. You were seen by GI and GYN doctors, as
well as pain doctors. You underwent a CT scan and endoscopy
that were reassuring.
As we discussed, please follow up with your primary care
physician, gynecologist (you stated that you will make
arrangements for these follow up appointments), and your
gastroenterologist Dr. ___.
You are now ready for discharge home. | ___ year old female with past medical history of
intermittent abdominal issues including prior recurrent C.
difficile colitis requiring fecal transplant, admitted ___
with reported weight loss, status post inpatient workup without
signs of acute process, weights stable, maintaining nutritional
status, able to be discharged home with close GI ___.
# Generalized Abdominal pain
Patient with history of abdominal concerns--has had recurrent
cdiff in the past, but remainder of diagnoses remain uncertain
given conflicting reports. She presented with persistence of
chronic abdominal pain of unclear etiology as well as chronic
weight loss. Obtained prior records from ___
___ (where a majority of her care has occurred recently),
which showed recent CT, EGD, colonoscopy without clear etiology
identified. She was evaluated by ___ GI consult service and
additional history was obtained suggesting that patient has not
had acute changes in weight recently. GI recommended MRI pelvis
to look for signs of endometriosis (none seen on transvaginal
ultrasound, but was an inadequate study) , which patient
declined unless done with anesthesia--GI felt risk outweighed
benefit given stability of patient's weight and lack of acute
changes to her pain. GI recommended ___, and patient
declined colonoscopy and was unable to be convinced to complete
this--she did agree to EGD which showed normal esophagus,
stomach, duodenum. She was seen by GYN consult and declined
pelvic exam. She was seen by chronic pains service to discuss
if any pharmacologic additions/changes to her regimen might
allow her high dose opiates to be weaned as an outpatient--she
declined any changes. GYN recommended outpatient ___ with
her primary GYN. ___ GI agreed to obtain all her prior
records (including path slides and imaging CDs) to review in
hopes of identifying an underlying pathology and obtain clarity
about prior patient reported diagnoses of endometriosis, SMA
syndrome, ischemic colitis. Plan for outpatient GI ___ to
discuss once all had been reviewed. No additional inpatient
management was recommended. She was discharged home with
___ with Dr. ___ of ___ GI, PCP ___,
recommended ___ with primary GYN (pt is to make
appointment as this is outside our system), and ___ pain
clinic ___. Would readdress trials of desipramine,
dicyclomine or hyocyamine as outpatient as pt did not want to
start these on discharge.
# Chronic back pain - Continued home Fentanyl and morphine,
confirmed with pharmacy and ___. As above, would consider
weaning as outpatient, given concern for opiate induced motility
disorder.
# Dysfunctional uterine bleeding - patient with history of
chronic heavy bleeding with menses and associated cramping. GYN
consult team saw patient, felt that given the location and
nature of her abdominal pain, it was less likely to be chiefly
caused by a Gynecologic etiology. They discussed with her
regarding potential medical and surgical options for
endometriosis or adenomyosis, but deferred to her longitudinal
GYN regarding whether any were indicated in her particular case.
Given her history of migraines with aura, she should have a
risk/benefit about estrogen-containing medications given risk
for stroke. They recommended discussing endometrial biopsy with
her primary GYN. Continued levonorgestrel-ethinyl estrad
# Migraine Headache, resolved
Course notable for migraines. Resolved with sumatriptan. See
above re: transitional issue re: outpatient discussion re:
risk/benefit of OCPs.
# Anxiety
Continued Diazepam. Transitional issue regarding black box
warning about
co-administration of benzodiazepines and opiates
# Barriers to care - during admission patient frequently
declined care. Prior OSH records show concern for borderline
personality with splitting tendencies.
Patient benefited from close coordination with her family, and
unified visits by entire team. | 79 | 595 |
11865363-DS-23 | 27,945,537 | Dear Mr ___,
It was a pleasure taking care of you at ___. You were
admitted for high blood pressures. You were treated
aggressively with blood pressure medications. You had some
problems with low blood pressures when standing so your
medications were adjusted further to find a good balance. You
also had some leg swelling and shortness of breath from heart
failure so you were treated with diuretics to help you take off
fluid.
While you were in the hospital, you developed an infection of
the cephalic vein in your left arm. You completed your course
of antibiotics for this infection while you were in the
hospital.
You were found to have worsening of your aortic dissection, so
you will have a repeat CT scan in 6 months to evaluate for
changes and follow up with vascular surgery.
You are approaching dialysis needs. In preparation for this,
you were seen by transplant surgery, had an AV fistula placed,
and are scheduled for an outpatient appointment with them.
The following changes were made to your medications:
FOR BLOOD PRESSURE:
DECREASE labetalol to 800 mg twice a day
STOP furosemide
START Torsemide 20 mg daily
START amlodipine 10 mg daily
START sertraline 50 mg daily for depression
STOP Citalopram
STOP Clobetasol cream. You can stop taking this for two weeks,
and then restart again for a two week period. If you keep
taking it without breaks, your skin will get thin and it will
prevent healing.
START sevelamer 1600 mg three times a day with meals because of
your kidneys
It is also very important that you keep all of the follow-up
appointments listed below. Please weigh yourself every morning,
call MD if weight goes up more than 3 lbs. It is also very
important that you continue to avoid smoking as this will have
bad effects on your heart, your kidneys and raise your blood
pressure.
It was a pleasure taking care of you in the hospital! | Mr. ___ is a ___ year old man with poorly controlled
hypertension in the setting of medication non-compliance and
chronic kidney disease (CKD) stage IV who presented with
hypertensive emergency and volume overload from acute diastolic
failure treated with labetalol, amlodipine, clonidine, and
diuresis. He developed progression of type B chronic aortic
dissection while hypertensive. He also developed left cephalic
vein suppurative thrombophlebitis in the hospital with blood
cultures positive for methicillin-sensitive staph aureus (MSSA)
originally treated with nafcillin and transitioned to vancomycin
for ease of dosing. Because his CKD was nearly end-stage and
dialysis dependence, he underwent an AV fistula creation. | 335 | 103 |
18720900-DS-5 | 27,946,568 | Dear Ms ___,
You were admitted to the hospital because you had perforated
appendicitis. You were managed medically at first then you
underwent a laparoscopic appendectomy on ___. Post-op was
complicated by pelvic fluid collection. You were given
antibiotics and you received a JP drain placement by ___.
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. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed perforated appendicitis.
The patient was started on an antibiotic trial, but due to
elevating WBC and worsening pain, the patient was brought to the
operating room on ___ and underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor,
hemodynamically stable.
Post-operatively, the patient's course was complicated by
worsening abdominal pain with distention and tachycardia
persisting in the 110-120's. She was made NPO and underwent a
CTA on ___ which showed no PE. She also received a 1L bolus
of NS for low urine output and 250cc of 5% albumin with
improvement.
On HD # 7, an NGT was placed due to ileus with improvement and
she then underwent CT-guided RLQ fluid collection drain
placement by ___ which she pulled later that afternoon in
addition to her foley catheter. At night patient was more calm
and mental status began to gradually clear. Patient then worked
with Physical therapy on ___ and was able to be restarted on
home medications and diet was progressively advanced as
tolerated to a regular diet with good tolerability.
During this hospitalization, the patient voided without
difficulty, ambulated 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. | 321 | 309 |
15255120-DS-12 | 28,554,435 | Dear Mr. ___,
You were hospitalized due to symptoms of Headach, nausea and
emesis resulting from an intraventricular hemorrhage, a
condition where blood is found in your ventricles. The brain is
the part of your body that controls and directs all the other
parts of your body, so damage to the brain can result in a
variety of symptoms.
Intraventricular hemorrhage can have many different causes, so
we assessed you for medical conditions that might raise your
risk of having for this condition. In order to prevent this from
happening in the future , we plan to modify those risk factors.
Your risk factors are:
HTN
Anticoagulation
We are changing your medications as follows:
We are changing your coumadin to Apixiban
We are changing your Lopressor 100 mg daily to Lopressor 25mg
BID
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body | ___ year old male with pmhx significant for AFib on coumadin,
renal disease with intraventricular hemorrhage of unclear
etiology. Presented ___ with worst headache of his life and AMS.
#Intraventricular hemorrhage
On admission, found to have INR of 2.3, for which he received
Kcentra, FFP, and mannitol in the ED. He was also intubated for
airway protection. Levetiracetam was started for seizure
prophylaxis. CT in the ED showed extensive intraventricular
hemorrhage and an EVD was placed. He received one dose of
intrathecal tPA given severity of hemorrhagic burden evident in
the ventricles; however, repeat CT scan showed a track hematoma,
and tPA was subsequently withheld. He was treated with mannitol
and hypertonic saline. Exam continued to improve. On HD2,
patient converted to atrial fibrillation with RVR, with his
mental status subsequently declining. When converted to sinus
(see #Atrial fibrillation below), his exam improved. On HD4, his
mental status improved to the point that he was extubated to
minimal oxygen requirement, which he tolerated well. Hypertonic
saline was weaned off (he was never truly hyperosmolar during
this treatment). CT head on ___ was stable. MRI on ___ did not
show any underlying mass or subacute infarct and CTA showed no
vascular malformation. Repeat MRI in 3 months is recommended to
look for an underlying lesion. The etiology of his bleed remains
unclear; there is no clear history of trauma, his INR was within
goal, and there is no underlying lesion to explain his
hemorrhage. Given his significant hemorrhage on Coumadin, we
transitioned him to apixaban 5 mg BID on discharge which he
should continue for stroke prevention indefinitely. [Of note:
BID admission notes document that he was on aspirin and Coumadin
on admission; this was erroneous. He was on Coumadin monotherapy
at the time of his hemorrhage].
His most prominent neurologic deficit after his hemorrhage is
abulia which presents as decreased verbal output and hypophonia,
slowness in following commands, decreased appetite and
occasional urinary and fecal incontinence.
#Atrial fibrillation
Patient had known atrial fibrillation treated with metoprolol
and anticoagulation with Coumadin. Notably, when patient was in
a-fib with rapid ventricular rate, his neurologic exam was noted
to be poor, possibly due to hypoperfusion to the brain secondary
to poor cardiac output. After trial of beta-blockers, we decided
to attempt electrical and chemical cardioversion. He was loaded
on amiodarone, and we attempted DC cardioversion twice at 200J,
which did not convert the patient to sinus rhythm. He was also
briefly treated with phenylephrine. Subsequently, however, he
spontaneously converted to sinus rhythm with improvement of his
mental status. We continued amiodarone and beta-blockade with
mostly sinus rhythm. Anti coagulation was held during admission.
He was started on an ASA bridge and was restarted on
anticoagulation on discharge with apixaban.
# Hypertension
During his ICU stay his metoprolol was changed to labetalol TID
for blood pressure control to maintain strict normotension given
his intraventricular hemorrhage. He remained normotensive after
transfer to the floor and his labetalol was transitioned back to
metoprolol. Goal blood pressures for him are normotension.
#S/p renal transplant
Renal transplant service was consulted on admission for
management of his immunosuppression from recent kidney
transplant. We collected daily tacrolimus levels and titrated
his medications based on troughs as well as BK viral load.
During admission pt developed mild ___ which per renal was
thought to be ___ dehydration, for which he received IVF.
He was also noted to be Hypercalcemic which was thought to be
multifactorial due to hyperparathyroidism and immobilization.
Patient was on cinacalcet as per outpatient
records, which was held during admission and restarted as levels
improved.
-Tacrolimus was adjusted based on creatinine and BK level.
-Transition to Evrolimus was discussed, but rehab would be
unable to give this medication so he was continued on
tacrolimus.
His BK viremia was noted to be uptrending and he underwent a
course of three days of IVIg (he started a fourth dose which was
not completed due to an adverse reaction)
He will have follow up in renal transplant clinic with Dr.
___. Renal transplant service asked for a full set of
labs to be drawn during first week at rehab facility and to be
faxed to Renal transplant clinic at FAX: ___.
#Fever
Mr. ___ was febrile on ___ and ___, no leukocystosis,
asymptomatic. He was pan cultured with urine cx negative, cxr
w/o signs of infection and blood cx did not show any growth. CSF
was consistent with intraventricular hemorrhage without sign of
superimposed infection. He developed loose stools and stool
cultures and studies were sent and were negative. After
extensive workup, his fevers were thought to be central in
origin.
-CMV PCR viral loads and BK viral loads were checked Q weekly.
His CMV became detectable and ID was consulted but it was
decided not to treat him until after repeat draw. Repeat draw
was negative.
-BK virus was also noted to be increasing, the patient underwent
treatment with IVIG in order to enhance his own immune system to
be able to combat the virus. He has follow up with renal
transplant who will follow his levels.
#Nutrition
Pt initially received nutrition via TF via NGT. Passed swallow,
but not motivated to eat. TF restarted eventually pt more
motivated to eat and NGT was removed and TF stopped. Pt
currently on regular diet with thin liquids. He was started on
megace on ___ to stimulate his appetite. Pt needs his weight
taken at rehab facility and if noted to have decrease in weight
needs either supplemental nutrition or NGT with TF.
#Hematology
Patient had decrease in his white count which was attributed to
his immunosuppression. He had asymptomatic anemia at admission
with downtrending hematocrit during his hospitalization without
a clear source of bleeding. At one point he had guiaic positive
stools in the setting of a rectal tear. No further workup was
performed.
# ST abnormality
On ___ he was noted to have ST elevation for which his
troponins were measured x 3; these were negative and EKG was
stable. This was attributed to repolarization abnormality in the
setting of LVH, no further workup was performed.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No | 260 | 1,099 |
14856789-DS-14 | 20,089,465 | Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted for cough and weakness in your
right arm. You had several tests that showed evidence of
pneumonia and received antibiotics for this infection. You also
had a CT Scan of your head that did not show evidence of a
stroke. You will continue the antibiotics and follow-up with Dr.
___ in clinic for these problems going forward.
It was a privilege to participate in your care.
Best Wishes,
Your ___ Team | Mr. ___ is a ___ year old gentleman with a history of RCC,
afib on warfarin, bradycardia s/p PPM who presented with
complaint of non-productive cough and stable RUE weakness, found
to have CAP.
#COUGH: Mr. ___ presented with a non-productive cough for
the past ___ weeks. CXR and Chest CT findings were concerning
for CAP in the L lower lobe. He was started on CTX and
doxycycline with Day 1 as ___. He was discharged on
doxycycline with a plan to follow-up for a repeat CXR in ___
weeks.
#RUE WEAKNESS: Mr. ___ complains of subjective RUE
weakness. This symptom has been stable since it began several
weeks ago. His PCP referred him for work-up of this complaint.
Exam of the RUE was normal. Patient without signs of DVT as an
alternate etiology. Also no report of trauma. CT Head negative
in the ED. ___ worked with the patient and felt he was safe to
return home with 24-hour accompaniment, which is
enthusiastically provided by pt's family.
#HTN: Continued home amlodipine and ACEi.
#sCHF: Mr. ___ has sCHF (EF 25%) but did not appear to be
decompensated on admission. Continued home lasix, ACEi.
#AFIB: Continued warfarin and amiodarone.
#CAD: Continued aspirin.
#HL: Continued Lipitor.
#L BLINDNESS: Continued prednisolone drops in R eye to prevent
rejection of corneal implant.
#DM: Diet controlled.
TRANSITIONAL ISSUES:
- Patient was treated for PNA with CTX and doxycycline. He is
being discharged on doxycycline. Please obtain a CXR ___ weeks
after discharge to ensure resolution of this pneumonia. | 85 | 249 |
15108590-DS-52 | 26,633,982 | Dear Ms. ___,
You were admitted to the hospital with nausea, vomiting, back
pain, and elevated blood sugars.
You were seen by the ___ Diabetes team, who made changes to
your insulin regimen to help keep your sugars under better
control. During your hospital stay, your nausea and vomiting has
improved. It is now safe for you to be discharged home with
follow up in the following week.
Please check your blood sugars before each meal, and 1 hour
after each meal, as well as in the morning when you wake up. | Ms. ___ was admitted to the high risk antepartum service for
management of N/V and lower back pain in the setting of poorly
controlled T1DM.
For her nausea and vomiting/lower back pain:
On the day of admission, patient was noted to have an elevated
blood glucose at 275 and UA positive for glucose and ketones.
Urine cultures were sent, which returned consistent with mixed
flora of skin and genital tract. Patient treated with IVF,
antiemetics and continued on her home insulin regimen leading to
resolution of her nausea and vomiting. Throughout her hospital
stay, her appetite improved.
For her lower back pain:
Patient's lower back pain improved on acetaminophen. She
remained afebrile throughout her hospitalization and UA did not
show signs of urinary infection.
Patient was also noted to have a history of palpitations. She
had normal ECG and echo on ___. | 89 | 143 |
17163097-DS-4 | 25,816,986 | Dear Mr. ___,
You were admitted because of a seizure. Changes were made to
your medications to help prevent more seizures. You were also
treated for a urine infection.
Please take your medications as prescribed and see all your
doctors.
___,
Your ___ ___ Team | ___ yoM w/ ___, moderate developmental delay, ESRD ___
IGA nephropathy (on dialysis since ___, and chronic
constipation who presented to ED after a seizure with
headstrike,
found to have UTI.
#UTI
Patient with abnormal UA and leukocytosis concerning for UTI. No
Grwoth on Cx but taken after initiating abx. given 2doses CTX
then will convert to cefpodoxime for total 5 day course.
#Leukocytosis
Likely related to UTI vs recent seizure.
# S/p headstrike
# Facial laceration
NCHCT and neck CT WNL. S/p laceration repair in ED. Needs to
remove sutures in ___ days.
# ___
# Uncontrolled Seizures
Patient presenting after a drop attack and seizure with
headstrike. Overall, per group home, has seizures on days with
dialysis, so seems as though this is at baseline. Suspect extra
clearance of antiepileptic leading to subtherapeutic levels on
dialysis days. Neuro consulted and made changes to his Keppra
dosing noted in transitional issues and in med list. Other AEDs
stayed the same.
# ESRD ___ IGA nephropathy
On dialysis MWF.
Transitional Issues
=====================
[] Please make sure patient has close follow up with PCP and
neurology, ___ need sutures removed in ___ days. Would
reschedule current neuro appointment for sooner date.
[] Please note new antiepileptic regimen: He should receive
500mg LevETIRAcetam BID EVERY DAY, making sure that he gets his
AM dose PRIOR TO HD on HD Days. On HD days he should get an
additional 1500mg LevETIRAcetam immediately after HD.
[] He will need 2 more post-HD doses of cefpodoxime for UTI
treatment
[] Need to remove sutures in ___ days.
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge. | 41 | 262 |
10911403-DS-11 | 23,965,139 | Discharge Instructions
Aneurysmal Subarachnoid Hemorrhage
Surgery/ Procedures:
You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
You had surgery to clip the aneurysm. You incision should be
kept dry until sutures or staples are removed.
You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
Your shunt is a ___ Delta Valve which is NOT
programmable. It is MRI safe and needs no adjustment after a
MRI.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. 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:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
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 | This is a ___ year old female that presented to ___ as a
transfer from an OSH with intraventricular hemorrhage after
experiencing headache and confusion status post fall 5 days ago
with questionable head strike and no imaging was done. Imaging
revealed diffuse IVH. The patient was admitted to the intensive
care unit under the care of neurosurgery. A CTA head was
performed which was 3-4 mm, narrow necked saccular aneurysm in
the distal portion of a
tortuous left ___. Extensive acute intraventricular hemorrhage
and resultant ventriculomegaly has progressed from the prior
study performed 3.5 hr earlier. An EVD was placed at the
bedside.
On ___, the patient underwent diagnostic angiogram. A left
___ aneurysm was found and it was determined that the best
treatment would be an open clipping of the aneurysm. The
patient went to the operating room for clipping of Left
Posterior communicating artery aneurysm. The NCHCT post
operatively was consistent with unchanged extensive
intraventricular hemorrhage and moderate ventriculomegaly. A
chest xray revealed new right infrahilar consolidation could be
pneumonia or RLL collapse at 2:30 pm.
On ___, the patient's exam worsened. A repeat NCHCT was ordered
and showed improved hydrocephalus. A Dexamethasone taper was
weaned.
On ___, the patient underwent a CTA showed basilar spasm; her
blood pressure was pressed to 140-180. A KUB was ordered for
persistent high OG output of bile. She was unable to receive
Nimodipine due to high OG output.
On ___, the patient's neurologic examination remained stable.
CSF was sent for gram stain and culture. She continued to
receive Nimodipine without any
___: CSF sent for ___ and culture. Receiving Nimodipine. EVD
remains at 15.
On ___, the patient's neurologic examination remained stable.
The EVD remained at 15 and showed a good waveform. She underwent
a CTA of the brain which showed left ___ vasospasm. While in
Radiology, she experienced extravasation of contrast from the
right antecubital IV site. SICU is aware and managing.
On ___, the patient's neurologic examination was improving. She
intermittently was showing thumbs up bilaterally and
consistently wiggling her toes to command. She continued to be
pressed for a SBP goal of 140-180. Her IV fluids remained
running with a goal input-output of equal. She had high urine
output throughout the day. Fludrocortisone was started in the
early evening and her serum Na was checked every 6 hours. She
underwent TCDs which showed left MCA hyperemia and a slight
increase in right MCA velocity. The technician was unable to
obtain left ACA, left ___ or BA results.
On ___ On rounds patient was bright and nodding head
appropriately to questions. Noted to be more lethargic around
10am but continued to follow commands. Around 11am very
lethargic and no longer following exam no commands. She was
re-intubated for airway protection. She went for a stat CTA/CT
which appeared stable. Incision noted to be boggy-dressing
changed- monitor for drainage. She was also noted to have
improved TCDs when compared to ___.
On ___, she was noted to have an improved exam and was also
noted to be febrile. Her TCDs continued to show no spasm. Her
EVD was raised to 20cm. Her repeat NA was 142.
On ___, the patient remained stable on exam. Her drain was
clamped at 10am, CSF culture was sent for continued fevers
despite administration of Tylenol. She was also pan cultured. A
family meeting was held today to discuss plan of care, and the
family is in agreement of pursuing the tranche and PEG.
On ___, the EVD remained clamped and a head CT was obtained and
showed stable vents. Her ICP's were slightly higher but normal
with EVD clamped. Her systolic BP was liberalized.
On ___, the patient had a poor exam and the EVD was opened at
20cm with improvements in exam. She remained febrile and another
CSF culture was sent along with pan cultures. TCDs were obtained
and showed right MCA velocity 156, and lindeguard right 4.9,
hyperemia on left MCA 90. The patient was on levophed to
maintain a SBP between 120-180 and her IVFs were increased to
100ml/hr with a 500ml bolus. Trache and PEG on hold for now ___
fevers and vasospasm. Her fluids were increased further to
125ml/hr. She was started on Bactrim for VAP.
On ___, she continued with low grade fevers of 100.9, bilateral
lower ext ultrasound was obtained to r/o DVTs and was negative.
A CTA head was obtained to r/o vasospasm and was consistent with
vasospasm. She was pressed to a SBP between 140-180. On exam she
is slightly improving. TCDs were obtained and showed no
vasospasm. Her NA was stable at 138.
On ___, a CTA head was obtained and showed some improvement in
vasospasm. At 0400 her NA dropped to 120 and she was started on
3% NA at 40cc/hr. She was ordered for Q 6hrs NA checks and her
EVD remained open at 20. SBP was liberalized to SBP >160. The
vasopressors are slowly being weaned off. Later in the afternoon
she was negative 600cc and she was given a 500cc bolus. Her NA
dropped to 116 and she was given a 23% bolus and her 3% was
increased to 60cc/hr. Will continue to check NA levels and will
titrate NA drip accordingly.
On ___, the patient's sodium was stable in the 140's.
Hypertonic saline was stopped and she was on normal saline at
40/hr. Exam improved and her EVD was subsequently clamped at
12:45. Her WBC was trending down. She was still febrile with
positive urine/sputum and remained on Rocephin. TCD's showed
increased velocity in the R ICA/PCA.
On ___, the patient's exam was stable and her EVD was clamped.
A repeat CT was ordered for the following day. TCD's showed
increased spasm in R MCA. Her sutures were removed. She spiked
a fever over night but her WBC continued to trend down. CSF
cultures were sent off. She remained on Rocephin. Her neuro
checks were relaxed to Q2h and Q4h over night.
On ___, The patient had a CT/CTA head and based on imaging the
patients systolic blood pressure goal was liberalized > 120.
The external ventricular drain remained clamped and cerebral
spinal fluid was sent for culture. The external ventricular
drain was removed later in the day. The patients serum docium
remained stable. The hematocrit was low and trending down to a
level of 22.
On ___, A respiratory ventilator wean was initiated. The
vasopressors were weaned as tolerated.
On ___, The patient was mobilized out of bed to the chair. The
patient was following commands and the patients systolic blood
pressure goal was liberalized to 90-180. The goal was to wean
vasopressors to off. The patient had a fever to 101.2. The
patient fluid volume balance was kept even. transcranial doppler
studies were performed and consistent with bilteral MCA
vasospasm mean velocities 140, right lindeguard ratio 3.4/ left
3.9. Dr ___ and given the patients clinical exam the
patient was not thought to be in vasospasm. A Decadron wean was
initiated.
On ___, The patient went to the operating room for placement of
trach and peg. The patient finished a course of ceftriaxone.
The patient underwent transcranial doppler studies that were
shown o be improved. A urine culture was sent and was found to
be positive for urinary tract infection and a course of cipro
was started. Blood cultures were sent and consistent with
********
On ___, The patient was febrile to T 101.5. The patient was
transfused with packed red blood cells for HCT of 20. The
patient was tolerating a tracheostomy mask all morning since 7
am. The femoral arterial line was discontinued. A rehab screen
was initiated. Tube feedings were started.
On ___, the patient was stable. She did have a temperature of
100.6 over night but her white count was normal. Her urine Cx
grew out fungus and she was on cipro and miconazole. She was
transferred to the step down unit as she tolerated trach mask
for >24 hours. Her Hct was improved at 24.
On ___, the patient's neurologic examination remained stable.
Her Hct was 26.5 and her serum Na was 138. The Cipro was
discontinued as the urine culture was positive for yeast; she
was started on Monostat. She remained in the ICU pending a bed
on the neuroscience floor.
On ___, the patient vomited her tube feeds earlier today. She
became tachycardic and tachypneic and her Rehab bed was
cancelled to further work up. A KUB was ordered, and was WNL and
her tube feeds were restarted. A CXR was obtained to r/o PNA and
reveled atelectasis; RN to start pulmonary toileting. A CTA of
the chest was obtained to r/o PE and was negative for PE. The
staples were removed from the right EVD site, incisions c/d/i.
Her labs were WNL. Bilateral lower extremity lenis were obtained
to r/o DVTs were negative. An EKG was obtained and showed NSR,
troponins x1 negative.
On ___, the patient was found to have a large psuedomeningocele
at the posterior fossa crani site. A CT head was obtained and
revealed slightly increased vents and large posterior
collection. She was consented and preoped for placement of a
right VPS.
On ___, the patient remained stable, she was brought to the OR
for placement of a right VP shunt for pseudomeng. Her
intraoperative course was uneventful, she was extubated in the
OR and brought to the PACU for close monitoring. She was
transferred to the floor over night in stable conditions.
On ___, the patient remained stable. Her dressing was dry and
intact. She was re-screened for rehab and was discharge to rehab
in stable conditions. | 383 | 1,639 |
17126702-DS-19 | 26,008,014 | You were admitted to the hospital with fevers and bacteria in
your blood. You were seen by our infectious disease doctors and
treated with antibiotics. Ultimately, it seems that you may have
had a mild pneumonia, which caused these findings. You will
continue antibiotics for 1 more week (until ___. You also
developed diarrhea while here and we sent your stool for
analysis of a certain kind of infection called "C. Diff." You
should make sure your outpatient doctors ___ on the result
of this test. You also should have repeat blood cultures drawn
after your antibiotics are completed.
It was a pleasure taking part in your medical care.
Regards,
Your ___ Team | ___ y/o F with PMHx of ovarian CA currently undergoing IV and
intraperitoneal chemotherapy, as well as papillary thyroid CA
s/p thryoidectomy, HTN, GERD, who was referred in after
outpatient BCx (drawn for low grade fever) came back with GPC's
in one set.
# Fever / Bacteremia: ID consulted. Cx ultimately resulted as
non-viable organism, no subsequent positive blood cultures.
Given cough, these was concern for possible s.pneumo pneumonia;
however, CXR negative. Flu PCR negative x 2. She was initially
treated with vanc, then narrowed to CTX per ID recs. She was
transitioned to PO cefodoxime prior to discharge to complete a
___ompleting ___. She will need surveillance blood
cultures drawn once antibiotics are complete. Of note, urinary
s.pneumo assay pending at the time of discharge, will need to be
followed up.
# Diarrhea: Developed diarrhea ___ episodes/day without any
fever, abdominal pain, leukocytosis. Low suspicion for C. diff
but given immunocompromised substrate and antibiotics, sent C.
diff PCR upon discharge. Outpatient providers emailed to
___ on result.
# Anemia: Suspect related to chemo, stable.
# Ovarian CA: Followed by Dr. ___. Chemo currently on hold
given acute illness.
# Papillary Thyroid CA: S/p thyroidectomy, on home
levothyroxine.
# HTN: Continued home meds.
# Contact: ___ (son) ___
# Code status: Full code
TRANSITIONAL ISSUES
===================
[] Repeat blood cultures after completion of cefpodoxime on ___
[] F/U pending C. diff PCR at discharge. PCP/outpatient onc
providers emailed. | 113 | 229 |
11256275-DS-21 | 20,867,722 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because you have not been
feeling well. You had signs of heart failure, which means that
fluid had built up in your lungs and your body. We think that
this may have been partially due to your pacemaker not working
appropriately. Your pacemaker was interrogated and we found out
the battery was very low. Thus, you had your pacemaker replaced.
During admission, your medications were adjusted. Please make
sure you review the changes.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow-up at the appointments listed below. Please see
the attached list for updates to your home medications. | ___ with PMH significant for CAD, systolic CHF, atrial
fibrillation, SSS s/p pacemaker placement who presents with
shortness of breath.
# Acute systolic CHF exacerbation:
Pacemaker interrogation revealed low battery, therefore the
patient has been being paced (HR ___. Because of low battery it
is unclear if the patient is also in atrial fibrillation.
However telemetry did not reveal any P waves. Patient's labs
also indicate hypothyroidism (see below), which could also
contribute to her symptoms. Echocardiogram with EF 30%, apical
akinesis, and pacing-induced mechanical dyssynchrony. Patient
underwent pacemaker replacement, and will need antibiotics until
___. Patient was disured with lasix 40mg IV with good response.
She was later transitioned to 20 mg po lasix prior to discharge.
Carvedilol was also initiated as she was hypertensive on
admission. The patient's ___ were held due to
acute kidney injury, but low dose lisinopril (2.5 mg daily) was
restarted prior to discharge. Discharge weight 74.9 kg.
# Atrial fibrillation:
Patient was being paced with HR ___. As above, the pacemaker
battery was low therefore it is unclear if she is also in atrial
fibrillation. The pacemaker was replaced on ___. The patient
was continued on amiodarone and pradaxa.
# ___:
Baseline Cr 1.5 per PCP records, on admission 1.9. BUN:Cr <20
and FEUrea >35%, which suggests intrinsic disease. ___ likely
secondary to poor forward flow secondary to CHF as above.
___ were held. Cr improved to 1.5 on day of
discharge.
# HTN:
Patient was started on carvedilol 3.125mg BID due to CHF. As
above ___ were held. Lisinopril 2.5 mg started
prior to discharge.
# HLD: Continued simvastatin 20mg daily.
# CAD:
Patient chest pain free. Troponin of 0.03 is her baseline.
# Hypothyroidism:
Possibly secondary to amiodarone. She does not endorse any
symptoms of hypothyroidism. She was started on levothyroxine
25mcg. Would follow up TSH/T4 in ___ weeks.
# Macrocytic anemia:
H/H at baseline. B12 and folate were within normal limits. | 119 | 320 |
15452591-DS-4 | 26,465,384 | Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with increasing pain in your
scrotum that was likely due to the combination of blood
formation and an infection. You were given antibiotics to treat
the infection through your vein and did very well.
You had some mild kidney injury for which your lisinopril was
held. For improved blood pressure control, we increased your
home amlodipine dose to 10 mg daily. Because your INR levels
were too high, we also decreased your home Coumadin dose to 2 mg
daily.
Please follow-up with your outpatient providers as instructed
below.
It was a pleasure caring for you. All best wishes for your
health.
Sincerely,
Your ___ medical team | Mr ___ is a ___ CM with PMH HTN, T2DM, Systolic CHF, Recurrent
DVT/PE lifelong anticoag, recently admitted ___ for
endovascular repair of left common iliac artery aneurysm and
right renal artery stent with small R scrotal hematoma presents
to the ED with scrotal swelling and discharge.
# Scrotal cellulitis
# Scrotal hematoma
Patient with scrotal hematoma which has been present since his
recent procedure. No evidence per Urology evaluation to suggest
a vascular leak. At admission, felt to be superinfected without
any signs of systemic infection. Scrotal US was obtained which
shoed no evidence of any drainable fluid collection, confirmed
by Urology and vascular. He has no culture data from ___, but
cultures here of his wound have only demosntrated mixed
bacterial flora. He was initially placed on vanc/zosyn, but per
ID, was ultimately narrowed to doxycycline/augmentin. He was
discharged to complete a total 10 day course (d10 on ___.
# Acute on Chronic Kidney Disease stage III
Cr 1.9 modestly elevated to from baseline 1.5-1.7. His home
lisinopril was discontinued in this setting and his discharge Cr
was 1.8.
# T2DM- controlled. Continued home glipizide at discharge.
# Peripheral vascular disease, aneurysm with endovascular
repair. Patient has not been taking his home aspirin 81 mg
daily; per discussion with Dr. ___ patient was placed on
aspirin 81 mg daily. Continued statin and beta-blocker.
# h/o DVT/PE, recurrent. Patient's INR supratherapeutic to 3.4.
His home Coumadin regimen was decreased to 2 mg daily per
discussion with inpatient Pharmacy. Patient to have INR checked
on ___ and will continue to follow-up with his ___ clinic at
his PCP's office.
# Essential HTN - controlled. Held home lisinopril as above.
Continued home metoprolol and uptitrated his home amlodipine to
10 mg daily.
# Contact: ___ (mother) ___.
# Full code
***TRANSITIONAL ISSUES***
-ensure BP and creatinine is stable after; consider resuming
lisinopril at f/u with PCP
-___ cellulitis is improving on po abx
-plan for total 10 day course, stop date on abx ___
-patient to get repeat INR and electrolytes drawn on ___ for
ongoing monitoring of his renal function and INR | 120 | 357 |
16732790-DS-14 | 25,473,365 | Dear Ms. ___,
Thank you for choosing to receive your care at ___. You were
admitted for altered mental status after being found to be
agitated at your nursing home.
On admission, it appeared you might have a urinary tract
infection so you got a dose of antibiotics; we eventually found
out that you did not have a urinary tract infection, so no more
antibiotics were given. However, you were also found to be
dehydrated, with signs of kidney injury function. We gave you
fluids and stopped a medication called spironolactone that you
were recently started on, with a return of kidney function.
Finally, we stopped a medication you were taking for your heart,
digoxin, which was found to be present in too high levels in
your blood and may no longer need.
You should continue to Weigh yourself every morning, and call
your MD if weight goes up more than 3 lbs.
It has been a pleasure working with you, and we wish you the
best with your ongoing recovery.
Sincerely,
Your entire ___ care team | This is a ___ year old ___ female with PMHx atrial
fibrillation on warfarin, CHFpEF, Alzheimer's, Depression, HLD,
and osteoarthritis presenting with altered mental status, found
to have ___ and elevated digoxin levels.
ACTIVE ISSUES
=============
# Altered mental status:
Patient has a history of Alzheimer's with some agitation at
baseline presenting with acute agitation and altered mental
status at ___, which was confirmed in the hospital by
her son. ___ showed ___ with BUN:Cr > 2 suggesting
hypovolemia. Source is likely hypovolemia in the setting of
dehydration with concurrent spironolactone use, digoxin
toxicity, and disorientation due to being on an ___ speaking
rehab floor, with likely several of these etiologies
contributing. Patient was given fluids and spironolactone was
discontinued, with subsequent resolution ___ and symptoms.
Digoxin was also discontinued given limited clinical utility for
her atrial fibrillation and h/o heart failure. Contribution of
bacterial urinary tract colonization is unlikely with patient
improving to baseline at discharge.
# ___:
Patient presented with Cr 1.7 from a baseline of 0.8. ___ is
consistent with a prerenal etiology given BUN:Cr ratio > 20 and
possible hemoconcentration seen in her CBC; FeUrea 22.4% also
consistent with prerenal etiology. She was recently started on
Spironolactone in ___, which could be contributing to her
hypovolemia. Furosemide held during this admission, and pt was
given gentle fluids with correction of her ___.
# E.Coli urinary tract colonization:
Patient was found to have a mildly dirty UA with positive urine
culture for E.coli; however, we suspect this is colonization as
opposed to a symptomatic UTI given her mild WBC count at her
baseline, with no left shift, no fever, and no symptoms. Patient
was given one dose of ceftriaxone in the ED, but discontinued on
the floor with no fevers or elevations in WBC.
# Supratherapeutic digoxin levels:
Elevated to 2.9 on admission, returned to 1.5 by discharge
following discontinuation of digoxin. Given limited clinical
benefit, discontinued moving forward.
# Leukocytosis:
Patient presenting with WBC 14. Most likely due to
hemoconcentration given rise in other cell lines from baseline.
Resolved by discharge.
# Hyperkalemia:
Patient presenting with K 5.6, denying chest pain or
palpitations. EKG with no notable changes. Discontinued
patient's K supplementation and spironolactone.
CHRONIC ISSUES
==============
# Chronic Diastolic CHF:
Patient has history of CHFpEF. She appeared euvolemic on exam
during this admission with no overt pulmonary edema/congestion
on CXR. We held her Furosemide in the setting of ___, and
continued her Aspirin 81 mg daily. Furosemide was restarted on
discharge.
# Atrial fibrillation:
Patient with CHADS2 = 2, on Warfarin. Patient is also s/p
pacemaker placement. She was continued on her Metoprolol Succ 25
mg daily and Warfarin 3mg daily; we discontinued her digoxin.
# Depression:
Continued on Duloxetine 60 mg daily and Mirtazapine 15 mg QHS
# Osteoarthritis:
Continued on home pain regimen (Tylenol PRN)
# Gout:
Continued Febuxostat 20 mg daily
TRANSITIONAL ISSUES
===================
-Patient had ___ due to hypovolemia. Please ensure adequate
fluid intake to avoid dehydration but in context of known heart
failure. Avoid restarting discontinued spironolactone given
hyperkalemia and ___.
-Please continue monitor blood K levels. Potassium
supplementation and spironolactone have been discontinued.
Supplementation should not be resumed unless she becomes
hypokalemic. Please check CMP in next few days (___) to
ensure improvement of Cr and normalization of electrolytes.
- Digoxin levels were found to be elevated, and digoxin was
continued given unclear clinical benefit moving forward. Can
consider cardiology evaluation if needed.
- Please attempt to move patient to a ___ floor or
in with ___ peers, if possible, to minimize
disorientation.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (Son) ___, (cell) ___ | 175 | 608 |
16939579-DS-9 | 27,710,657 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
=====================================
- You were transferred here because of a Crohn's flare and
concern for an abscess.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
=====================================
- You were seen by the colorectal surgery team and the
gastroenterology teams.
- You were started on antibiotics to treat any infection that
may have been triggered by the Crohn's disease.
- You had a CT of your abdomen/pelvis that showed inflammation
in the intestine.
- You had an ultrasound of your pelvis and this showed a left
ovarian cyst.
- You chose to leave AGAINST MEDICAL ADVICE. We wanted you to
stay in the hospital because risk of worsening intestinal
inflammation, intestine rupture, infection, and potentially
death if any of the above is untreated. You repeated these risks
back to us, and you still chose to leave AGAINST MEDICAL ADVICE.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
============================================
- Please take 40 mg of prednisone until you see your GI doctor.
- Please speak with your gastroenterologist AS SOON AS POSSIBLE
for follow up and treatment of your Crohn's disease.
- Please follow up with the OBGYN as scheduled below for
evaluation of the ovarian cyst. This needs to be evaluated for
cancer.
- Please seek immediate medical attention if you develop fevers,
chills, nausea, vomiting, worsening abdominal pain, abdominal
distension, inability to eat or drink, or if you stop passing
gas or having bowel movements.
We wish you the best of luck in your health.
Warmly,
Your ___ Care Team | ****PATIENT LEFT AGAINST MEDICAL ADVICE****
Ms. ___ is a ___ year old woman Crohn's disease and COPD not on
home O2 who presented as transfer from ___ with
Crohn's ileitis and concern for pelvic abscess.
#Ileitis
#History of ___'s
Patient diagnosed in ___, and reported four flares prior
to this hospitalization. She has not had prior surgeries, and
her only prior treatment has been high dose steroids. She has
never had a colonoscopy for biopsy diagnosis. GI and colorectal
surgery were consulted upon admission. MRE was recommended for
further evaluation but patient refused, and CTE was done
instead. This showed inflammation of the distal ileum, and a
left adnexal mass (see below). Patient was started on
ceftriaxone/flagyl for infectious coverage in setting of
potential abscess, and this was discontinued after repeat CT
showed no abscess. GI explained to patient that ideal treatment
would be high dose steroids to calm inflammation and allow her
to advance her diet beyond clear, but she chose to leave AGAINST
MEDICAL ADVICE. Risks were reviewed with her and she chose to
leave. Prednisone was increased to 40 mg daily until she sees
her GI.
#Left adnexal cyst
Seen on CT and again on transvaginal US. Imaging unable to
determine if this is malignant or not. Patient was informed of
this and has GYN outpatient follow up scheduled. She understood
the importance of this workup.
#Hypoxia
#COPD
#Active smoking
Patient smokes 2 packs per day. She was on 2L of oxygen while
inpatient but was weaned prior to discharge. Chest Xray was
concerning right consolidation, but clinically did not appear to
have a pneumonia. Home Spiriva and Symbicort were continued. She
was given a nicotine patch and counseled on smoking cessation.
TRANSITIONAL ISSUES
#PATIENT LEFT AGAINST MEDICAL ADVICE.
#Patient discharged on prednisone 40 mg daily until she sees her
GI
#Patient needs outpatient colonoscopy and evaluation for
treatment of ileal inflammation and Crohn's disease (has NEVER
had a colonoscopy)
#Patient needs further follow up of left adnexal mass to rule
out malignancy
#On CT AP lung nodules and adrenal nodules noted, needs
dedicated imaging and further workup to ensure not malignant | 257 | 339 |
15407766-DS-6 | 25,698,299 | Dear ___,
___ presented with nausea/vomiting to an outside hospital and
___ were transferred to ___ with concern for acute
cholecystitis (gallbladder inflammation). ___ were admitted to
the ICU for stabilization of sepsis (infectious complications)
and underwent a procedure called an ERCP and had a stent placed.
This improved your condition greatly with most of your
infectious/inflammatory signs improving. Your liver function
tests remained elevated but eventually improved so ___ did not
require another procedure. ___ were treated with an antibiotic
for 7 days to treat infection in your biliary system. ___ will
need to follow up with the ERCP team as an outpatient in ___
weeks for a repeat ERCP.
___ had blood cultures drawn, which grew a type of bacteria that
most likely was a contaminant from your skin. ___ had repeat
blood cultures drawn that were still in process at the time of
discharge. ___ had not had fevers for days prior to discharge,
so a blood infection is unlikely.
Your blood pressure was high, so your Amlodipine dosage was
increased to control it better.
Thank ___ for allowing us to care for ___,
Your ___ Team | Ms. ___ is a ___ year old female with history of HTN, AFib on
apixaban, CVA with mild residual left sided weakness, GERD,
transferred from ___ to ___ given concern
for acute cholecystitis with obstructing stone at CBD neck and
total bilirubin of 2.9. She was admitted to the ICU for sepsis.
#Sepsis/cholangitis:
Although she was transferred to ___ with concern for acute
cholecystitis with obstructing stone at the CBD neck, ERCP team
was consulted and reviewed with radiology and felt the suspicion
for cholecystitis was low and CBD was 1 cm. She had a
leukocytosis to 19, was in sepsis, and ERCP team felt the
presentation was more consistent with choledocholithiasis (also
cholangitis) than cholecystitis. She was started on Zosyn for
cholangitis. ACS was also consulted, and recommended
percutaneous cholecystostomy in the setting of rising Tbili
without evidence of biliary ductal dilation. After some
discussion between ACS and ERCP, decision was made to proceed to
ERCP. She underwent ERCP on ___ and was found to have an
8mm filling defect in the CBD consistent with a stone. She had
a CBD stent placed, but no sphincterotomy since she was on
Apixaban. Due to rising LFTs (particularly total bilirubin)
after the ERCP with stent placement, there was a tentative plan
with ___ to repeat biliary imaging on ___ and proceed with
percutaneous cholecystotomy tube, as well as repeat ERCP for
stent pull and sphincterotomy in the future. She was bridged
with heparin infusion while awaiting potential surgery and
repeat ERCP, with Apixaban held. Ultimately, her LFTs including
total bilirubin trended down without further intervention and
she did not require surgery or repeat ERCP while hospitalized.
She was continued on IV Zosyn through ___ and sepsis had
resolved. She was transitioned to IV ceftriaxone and flagyl to
complete a 14 day course for cholangitis. (given good bowel
coverage and risks with Cipro in the elderly) She will need
follow up with ERCP team in ___ weeks for stent pull. Last day
of antibiotics is ___
#Positive blood cultures: Her blood cultures from ___ grew
Corynebacterium (diphtheroids), which seemed most likely to be a
contaminant. Repeat blood cultures were drawn on ___ and are
pending on discharge.
#Asymptomatic bacteriuria: Urine culture grew pan-susceptible E.
coli. She was not having urinary symptoms. She completed
course with Zosyn which she was on for cholangitis.
#Atrial fibrillation: She remained relatively stable, but had
occasional tachycardia associated with physiologic stress and
volume depletion. She was continued on on metoprolol after
initial resuscitation. Apixaban was held with heparin infusion
bridge given CHADS2VASc score of 6. Apixaban was resumed on
___ after it was determined that she did not require further
procedures.
#HTN: Her Amlodipine was initially held on admission in the
setting of sepsis. Later in her course when she was out of the
ICU, her SBP was up in the 180s, so Amlodipine was restarted at
home dose of 2.5mg daily. She was still hypertensive to the
160s, so it was increasd to 5mg daily.
==================== | 191 | 513 |
10355745-DS-15 | 24,924,037 | Dear ___,
___ were admitted to the hospital because they were having
difficulty waking ___ up at ___. ___ were found to
have a urinary tract infection, and were started on antibiotics.
___ were also mildly dehydrated.
Changes to your home medications include:
-Bactrim DS 1 tablet BID for 5 days
It was a pleasure taking care of ___ during your hospitalization
and we wish ___ the best. | ___ year old female with history of t2DM, CAD s/p CABG, and HTN,
with newly altered mental status and found to be in hypercarbic
respiratory failure, s/p re-intubation x2 with subsequent trach
placement.
# Respiratory failure: Given her unresponsiveness on the medical
floor and hypercarbia, pt was transferred to the MICU and
started on BiPaP. However, she failed this and was intubated.
Given improvement in her mental status and ABGs, extubation was
attempted on on ___ and ___ but patient failed each time
requiring reintubation. Etiology of her failure on extubation
was felt to be from supraglottic edema from multiple
intubations. Less likely neuromuscular weakness or Polymyositis
(EMG not overwhelming for NM weakness, and rheumatology did not
think this was an acute presentation of polymyositis). She was
started briefly on pyrdostigamine given concern for NM weakness
but this was stopped after EMG findings. SHe was started on
mythylprednisone for possibility of polymyositis which was
eventually stopped given lower concern for this. She will
remain on low dose 5mg prednisone until she follows up with
rheumatology. Her CXR showing new RLL opacity concerning for
pneumonia, and was started on HCAP coverage with vanc/cefepime
to be completed on ___. The patient eventually underwent
tracheostomy on ___ successfully, and a PEG was placed on ___
with tube feeds initiated. Please note that the patient often
requires restraints to avoid pulling at her trach tube. Low
dose seroquel was started to help with this. The patient
tolerates trach collar well, but also requires occasional
ventilatory support with PSV or CMV.
# VAP: RML consolidation on CXR and increasing mucus
production. As above, this was treated with vanc/cefepime to be
completed ___
# metabolic alkalosis: Likely in setting of chronic hypercarbia
compounded by overdiuresis. Bicarb peaked at 37 but improved to
31 on discharge after diuresis was stopped
# Guardianship/dispo: Dispo/guardianship was an issue for the
patient. However, a court date was held and her niece was named
HCP. SHe consented to trach/peg
# h/o polymyositis: Rheumatology was consulted given concern
that polymyositis (which the pateint has a history of) was
contributing to her respiratory failure. She was initially
stared on IV methylprednisone to treat this, but it was
eventually determined that his was very low on teh differential
and she was weaned back to low dose prednisone 5mg daily. She
should remain on this until her outpatient rheumatology follow
up. She is on BID famotidine for ulcer prophylaxis.
# Type 2 diabetes mellitus: Home insulin regimen was adjusted
throughout admission and on discharge was lantus 15U QHS and Q6H
humalog. Blood sugars well controlled on discharge has been
relatively well-controlled during this hospitalization, but she
does have evidence of glucosuria and ketonuria.
# CAD s/p CABG: Cont home carvedilol, ASA 81mg daily, lisinopril
10 mg daily, simvastatin daily
# Unresponsiveness: Unclear etiology of original unresponsive
episode based on limited history, though most likely a syncopal
episode as opposed to seizure given she denies aura, post-ictal
symptoms, or h/o trauma. Syncope ___ orthostasis is possible as
she appeared hypovolemic on exam. Though she has a h/o CAD,
cardiac syncope was less likely w/ her baseline troponins and
EKG. Neurologic less likely, though she has known hydrocephalus.
Hypoglycemic episode possible though less likely given her blood
sugar was not markedly low. Patient did have an episode of
unresponsiveness in the hospital on ___, where she was found
slumped in chair and drooling and then opened eyes and scanned
but did not respond. She returned to baseline in a few minutes,
with no new neurologic deficits, possibly consistent with
seizure and post-ictal phase. Blood sugars were normal.
# Hyponatremia: Patient found to have Na of 120 on ___.
Thought to be component of prerenal/SIADH, and improved over
admission to 137 on discharge.
# ? Hydrocephalus: Noted on CT head on ___ for her AMS.
Noted to have stable disproportionate enlargement of the
ventricles relative to the sulci, most likely due to central
atrophy. Non-communicating hydrocephalus is less common, but
could be considered if the patient has associated symptoms.
# UTI: UA on ___ w/ >182 WBC, lg leuks, and few bacteria. She
was asymptomatic and started on ceftriaxone in the ED. She
remained afebrile overnight w/ WBC wnl. Her ceftriaxone was
d/c'ed after receiving her AM dose on ___. She was put on a 5
day course of cephalexin but refused it. The abx for her HCAP
would cover most UTIs
.
# HTN: Had several episodes of high BPs (SBPs in 180s) on the
floor as she intermittently refused antihypertensive meds. BPs
well-controlled on days she adhered to med regimen.
.
# Elevated troponins: Troponins 0.5-0.7 during prior admission,
stress test at that time showed fixed wall motion abnormality.
Patient was asymptomatic w/ EKG and troponins similar to
baseline which were stable x 2.
.
# Depression: We held her amitriptyline and continued her
fluoxetine. Amytriptiline was added back on discharge
. | 64 | 834 |
19136566-DS-12 | 26,834,642 | Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___. You came into the hospital
because of a change in your mental status. We found that you had
an infection in your urine (urinary tract infection) and started
you on antibiotics to treat this infection. Please continue to
take the antibiotics (bactrim) as directed (twice daily for a
total of 7 days, last dose ___. You had imaging of your head
which did not show any signs of bleed or stroke. You returned to
your normal self without any concerning findins on exam.
You also had left sided upper back pain. This is most likely
musculoskeletal and not related to infection. Please continue to
use heat packs/cool packs as needed for comfort as well as
tylenol ___ every 4 hours as needed for pain.
Additionally you have intermittently high blood pressures. Your
blood pressures were well controlled while you were here. We
recommend you take your isosorbide mononitrate in the morning
and the lisinopril in the evening to try to better control your
blood pressure.
We also started you on a medicine (colace) to help with your
constipation. Do not take this if you are having loose stools.
Please stop taking the naproxen as this can increase your risk
of bleeding.
Please take your medications as directed and follow up with your
primary care physician as scheduled below.
Be well and take care.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with history of hypertension,
atrial fibrillation on apixaban, CAD, and NIDDM who presents
with confusion. Patient found to have UA concerning for UTI
treated with antibiotics for complicated UTI.
# Altered mental status: Patient presented with isolated episode
of confusion, confusing buttons on telephone with bridge tiles.
Symptoms most likely secondary to UTI given UA with positive
WBC, leuk esterase, and few bacteria. Head CT negative for acute
process. Patient was evaluated by neurology consultants who
noted no further deficits and did not feel further workup
necessary at this time. No other significant electrolyte
abnormalities to explain patient's brief episode of confusion.
Patient was started on IV antibiotics, transitioned to PO
bactrim with plan to treat for 7 day course for complicated UTI.
Her confusion was much improved by the time of discharge,
although she did make one reference to bridge (inappropriate)
just as we were preparing to d/c her from the hospital. Given
that we felt a UTI was causing her altered mental status, we
felt it best for her to recover in her home environment.
#Question Pneumonia: Patient noted to have left base
heterogenous opacity on chest xray, started on empiric
antibiotics for pneumonia. As patient did not have fever,
leukocytosis, or cough, felt pneumonia unlikely and discontinued
antibiotics. Lung exam also clera.
# Hypertension: Patient noted to be hypertensive to systolic BP
180s however returned to normal range with home medications.
Given increased risk of hypotension and fall in this elderly
female, did not adjust medication dosage but altered timing so
that patient will take isosorbide mononitrate in the morning and
lisinopril at bedtime to prevent fluctuations in blood pressure
throughout the day.
#Elevated LFTs: Patient with slightly elevated AST, ALT with
normal alk phos and t bili to suggest acute hepatocellular
injury. Suspect likely secondary to infection. Patient will need
repeat LFTs at outpatient follow up.
#Left low back pain: Most likely musculoskeletal as reproducible
on exam. No CVA tenderness of septic physiology to suggest
pyelonephritis. While patient did have hematuria on UA, no
significant flank pain to suggest nephrolithiasis. Treated with
conservative treatment hotpacks and acetaminophen. | 238 | 368 |
18371257-DS-12 | 23,558,539 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because of a cellulitis of your right leg. You received
a dose of IV antibiotics and then we transitioned you to
antibiotics by mouth. You did well. You will continue the
antibiotics at home for 9 more days for a total of 10 days of
antibiotics.
Please follow-up at the appointments listed below. Please see
the attached list for updates to your home medications. Please
note the following changes:
- START Bactrim DS 2 tabs twice daily for 9 more days until
___
- START Cephalexin 500mg every 6 hours for 9 more days until
___
- START Chlorthalidone 25mg daily; this is a medication for your
high blood pressure | ___ with h/o HTN, hyperlipidemia, bilateral ___ lymphedema,
obesity referred to ED for ___ cellulitis.
.
# RLE cellulitis: No signs of systemic infection as pt without
fevers or leukocytosis. Pt received IV Vanc in the ED.
Cellulitis relatively mild as skin not overly warm to touch. No
evidence of DVT on U/S. DDx would also include stasis dermatitis
but acuity suggests otherwise. Pt put on PO Bactrim on admission
to cover community acquired MRSA and Keflex added for strep
coverage. Marked borders of pinkness and had pt elevated RLE. No
advancement of pinkness beyond marked borders. Pt discharged on
PO Bactrim + Keflex to complete total of 10d course.
.
# HTN: poorly controlled in OP setting and pt has declined
anti-HTN. BP on admission 167/89 so started pt on chlorthalidone
with improvement in SBPs to 140s.
.
# HLD: not currently on meds
.
>> Transitional issues:
- Pt will f/u in HCA in 1wk. Should have chem7 checked at next
visit as pt starting chlorthalidone.
- Studies pending at time of discharge: bl cx (NGTD) | 123 | 168 |
18942246-DS-3 | 25,534,797 | Dear Mr. ___,
Why was I hospitalized?
You were hospitalized for evaluation of your cancer and
treatment of an infection.
What was done for me while I was in the hospital?
- You were seen by our ENT surgery team and they confirmed your
airway was clear. This is good news.
- We had a long conversation with our Oncology, Radiation
Oncology and ENT teams about the next steps for your treatment.
You will be evaluated for chemotherapy and radiation when you
leave the hospital.
- To treat the infection of your face, you were given IV
antibiotics.
- To help with your nutrition you were given tube feeds. A nurse
___ come to your house to help you with this.
What should I do when I leave the hospital?
- Please continue your daily Ceftriaxone and Metronidazole. If
you notice you are having high fevers, increased drainage from
your mouth or a new small you should let the visiting nurse
know. Additionally you can call ___ R.N.s at
___ or the on-call ID fellow when the clinic is
closed.
- Please try to avoid placing anything in your feeding tube
other than tube feeds. It is best to avoid crushing tablets and
placing them in your tube as this can cause the tube to be
clogged.
- If you have questions or concerns for Dr. ___
please call ___ to leave a message with his office.
- You will have your labs checked weekly and sent to the ID
team. They will contact you if there are any concerns.
- Your treatment with the Oncology team will continue once you
leave the hospital.
- If you are experiencing new symptoms like pain, please call
your PCP, if you feel that your symptoms are severe I recommend
you go to the closest emergency room (___). If the
matter is less urgent you can also present to ___.
We wish you the very best! | PATIENT SUMMARY FOR ADMISSION:
===============================
Mr. ___ is a ___ male with a history of
papillary squamous cell carcinoma who presents with concern for
super imposed infection and increasing size of mass. Currently
being evaluated by ENT, Oncology, Radiation Oncology likely
pursuing palliative chemotherapy with management of superimposed
infection. He was treated for a complicated infection and will
require ___ weeks of antibiotic therapy. His chemotherapy will
likely occur following discharge. He was also initiated on tube
feeding while inpatient and set up with home ___. | 310 | 85 |
15193172-DS-8 | 29,431,509 | You were admitted to ___ after a mechanical fall and fractured
your left ribs ___ and your left spinous transverse process
fracture ___. Your pain was managed and you were seen by
Physical Therapy, who recommended you go to rehab when medically
clear for discharge. You also developed severe constipation,
with a very distended abdomen, that required a nasogastric tube
for decompression. This was removed, and you are now tolerating
a regular diet and moving your bowels. please note the following
discharge instructions:
* Your injury caused 4 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Mr ___ is a pleasant ___ year old male who presented to an OSH
s/p mechanical fall at his assisted living, with no LOC. He was
hemodynamically stable and complaining of left sided chest pain,
imaging at the OSH revealed left rib fractures ___ and left
thoracic transverse process fractures ___. The patient was then
transferred to ___ for a trauma work-up. The patient was
admitted for pain control, pulmonary toileting, and ___
consult. From a respiratory standpoint, the patient has a
history of COPD and wears home O2 at night. He was requiring
___ of oxygen and his oxygen saturation was about 99% on
this. He was using the incentive spirometry with prompting.
Physical therapy evaluated the patient and felt he was
functioning below baseline and recommended he go to rehab when
medically cleared. On HD3 the patient became very nauseated and
developed a distended abdomen. X-Ray revealed dilated loops of
colon, indicative of a severe ileus. The patient was put on
bowel rest with gentle IV fluids, and started on an aggressive
bowel regimen. By HD4-5, the patient was passing flatus and
having bowel movements, and repeat KUB showed decrease in
distention. Diet was progressively advanced as tolerated to a
regular diet with good tolerability. The patient was voiding
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. | 325 | 251 |
15680940-DS-30 | 22,860,022 | Mr ___,
You were admitted to ___ with acute ruptured appendicitis. You
were put on bowel rest and kept nothing by mouth and given IV
fluids and IV antibiotics for several days, until the pain and
inflammation had subsided. Your diet was slowly advanced and you
are now tolerating a regular diet and your pain is well
controlled. You are ready to be discharged home to continue your
recovery. You will follow-up in the ___ clinic in about 2 weeks
to see how you're doing and discuss a possible interval
appendectomy. 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. | The patient presented to Emergency Department on ___. Upon
arrival to ED, patient was found to have CT findings suggestive
of ruptured appendicitis. Given findings, the patient admitted
to the Acute Care Surgery service for non-operative management
with NPO/IVF and IV Antibiotics (Ciprofloxacin/Flagyl).
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intravenous
pain medication as needed which were disconitinued when there no
further pain requirements on HD3.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. His
Clopidogrel was continued throughout the hospitalization.
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 for possible
operative intervention and until improvement in pain/pain
control and thereafter (HD#3) the diet was advanced sequentially
to a Regular diet, which was well tolerated. Patient's intake
and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and was
encouraged to get up and ambulate as early as possible. He was
evaluated by physical therapy who recommended home physical
therapy.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching to
completed his course of oral antibiotics and follow up with ACS
in 2 weeks for discussion of interval appendectomy with
understanding verbalized and agreement with the discharge plan. | 291 | 283 |
10431655-DS-19 | 26,995,036 | You were admitted with confusion and memory problems. We
determined that you likely had some delirium superimposed on
your dementia, and that your dementia may have worsened
recently. We initially thought you might have a urinary tract
infection, but your urine culture did not end up growing the
type of bacteria we would normally suspect. As a result, we
considered other causes of delirium, and asked for input from
our Neurology colleagues.
We suspect you may have cognitive deficits resulting in memory
troubles. | ___ man brought in for worsening mental status, possible
delirium superimposed on dementia. Initially thought this may
have been precipitated by a UTI, but that's now unclear.
Possible Korsakoff syndrome so also treating with thiamine given
significant confabulation.
Dementia and possible Korsakoff syndrome, w/h/o daily EtOH ___
beers daily), with prior concern for delirium
- causes of delirium have been considered, but none identified
- absence of ataxia on neurologic exam or urinary incontinence
made NPH an unlikely etiology of his dementia, and a PHQ-9 score
of 10 suggested moderate depression which might be contributing,
though pseudodementia unlikely to be primary process
- as a result, Neurology was consulted and agreed with formal
neuropsychiatric testing. He had negative lyme, rpr, b12 and
tsh testing for medical metabolic or infectious causes of
cognitive decline. MRI brain performed showed No acute
intracranial abnormality including hemorrhage, infarct, or
suggestion of mass.
2. Moderate global atrophy without focal predominance. No
disproportionate
medial temporal lobe atrophy. 3. Two punctate areas of
nonspecific right frontal white matter signal abnormality,
likely of no clinical significance, which may represent the
sequela of chronic small vessel ischemic disease. 4. Paranasal
sinus disease, as described.
- dementia is most likely Alzheimer's type, dx by PCP in ___, ___'s could be considered -- Neurologist told the
son that he thought pt had Korsakoff's dementia -- continued
with PO thiamine
- vascular dementia could be considered given impaired executive
function (CT head with small-vessel ischemic disease)
- ___ and OT evaluations indicate that he has very poor safety
awareness, and they both recommend rehab
- per son has ___ appointment for neurocognitive
evaluation (at ___ per report)
He did not have evidence of UTI on repeat UA.
H/o falls - ___ evaluated the patient and recommended rehab
Mild stable normocytic anemia - unclear etiology -- B12 and iron
testing normal
Osteoarthritis of knees and C-spine degenerative joint disease -
continued gabapentin and provided APAP PRN
HTN, HLD - continued metoprolol
Depression - continued citalopram (which patient may easily be
forgetting to take as an outpatient)
Mild constipation - bowel regimen
Insomnia - trazodone
H/o vitamin B12 deficiency -- level normal here
Dispo - deficits in several IADLs and appears unsafe to return
home in
his current state - long term may need more help at home, vs.
getting him into
assisted living, plan has been to discuss ___ application
with case mgmt. - SW consulted for son coping
Advance care planning
- HCP: needs form completed -- is son as per ___
- Care preferences: full code for now | 85 | 410 |
16987914-DS-7 | 29,884,001 | Complete the solumedrol dose pack as indicated, omitting the
first 1 day of pills. Other medications will be restarted once
it is clear he is completely at his baseline. | Mr. ___ came to us with cough and fever to 102 degrees, and
was given a single dose of levofloxacin IV in the emergency
room.
Upon transfer to the floor, he felt his old self, except with a
lingering cough.
That night, he developed swelling of the lips, which did not
involve the airway, but did resolve with IV benadryl. His Abx
were stopped.
Over the next few days, his cough resolved,all cultures were
negative while fine bibasilar rales persisted as is his
baseline, but he kept developing hives and worsening renal
function, with no other associated symptoms.
He was also found to have incidentally elevated LFT's with a
pattern inconsistent with viral infection, gallbladder disease,
or alcohol intoxication. He has a history of transaminitis of
unclear origin. Of note, he has not drunk significant amounts of
alcohol having totally discontinued vodka since his episode of
alcoholic pancreatitis in ___.
His hive outbreaks were associated with a decline in systolic
pressure in the 80___ which may have accounted for a rise in BUN
and creatinine which resolved when his urticaria abated. He
improved after po solumedrol. His renal function also improved
to close to his baseline, consistent with the CKD that he
presented with on PMH, after the start of solumedrol and IV
infusion.
He was discharged today in excellent condition, with rash and
cough resolved. His PCP is aware of his LFT abnormalities, and
will follow up accordingly.He will have repeat BUN,Cr and
electrolytes on ___ as an outpatient. | 29 | 245 |
12370706-DS-3 | 29,942,936 | Dear Ms. ___,
It was a pleasure to participate in your care at ___. You were
admitted for insomnia, which we thought was from several issues,
including becoming dependent on your medications, going to bed
too early, and depression. We started you on a medication called
mirtazapine which should improve your appetite and help you
sleep. You should take this medication and attempt to take less
ambien or ativan. You should follow-up with your new primary
care provider as listed below.
We wish you all the best!
Your ___ team | Ms. ___ is a ___ old female with uterine
carcinosarcoma, stage IA, s/p primary debulking surgery in
___ on ___ and 5 cycles of adjuvant ___,
afib on Xarelto, who presented with insomnia. | 88 | 33 |
12352080-DS-8 | 25,819,794 | Dear Mr. ___,
You were admitted to the hospital for management of a small
bowel obstruction. You underwent an exploratory laparotomy where
we found multiple adhesions that were causing your obstruction.
We were able to lyse the adhesions and perform a component
separation with mesh to bring your abdomen back toegether. You
are now ready for discharge home. Please see the following
instructions for discharge.
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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Sincerely,
___ Surgery | Mr. ___ was admitted on ___ to the surgical service for
management of a small bowel obstruction. He failed NGT
decompression with worsening abdominal pain and distention
overnight and the following day. He was taken to the operating
room on ___ and underwent exploratory laparotomy, hernia
repair, component separation with overlay and underlay. Please
see the surgeon's operative report regarding details of the
operation. 2 subcutaneous JP drains were placed prior to skin
closure. Foley was also placed for close urine output monitoring
and NGT remained in place for gastric decompression. He
tolerated the procedure well and after an uneventful stay in the
PACU, was transferred to the surgical floor.
His main postoperative issue was pain control. Acute pain
service was consulted on POD1 and placed a thoracic epidural.
Foley and NGT were removed on POD2. His epidural was dislodged
on POD2 and he was switched to a dilaudid PCA. He was transition
to PO pain meds. In addition to the usual oxycdone/tylenol
regimen, he required MS contin and flexeril for better pain
control. His diet was advanced the next few days. At time of
discharge, his vital signs were stable, he was tolerating a
regular diet, he was having bowel movements, his pain was well
controlled with oral pain meds, and his JP output was minimal
(15cc & 30cc per day). He was discharge home and asked to
schedule a follow-up appointment in 2 weeks. He was in agreement
with the discharge plan and we answered his questions and
concerns. | 435 | 252 |
17402093-DS-19 | 24,302,858 | Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for weakness and fast heart rate. You were found to be in
an abnormal heart rhythm called atrial fibrillation. We treated
you with medications to slow down youe heart rate and your
rhythm converted back to normal prior to discharge. We started
you on an additional blood thinner called warfarin to prevent
strokes while you are occasionally having this abnormal heart
rhythm. You will follow-up with cardiology after discharge. | ___ year old female with reported p-Afib, CAD s/p MI wih DES to
LAD c/b stent thrombosis, uterine cancer s/p hysterectomy, left
breast cancer s/p mastectomy, hepatitis C admitted for rate
control for a-fib with RVR after fall at home. | 88 | 40 |
18455039-DS-8 | 22,723,917 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital for cellulitis. Your symptoms
improved with IV antibiotics. You were transitioned to oral
antibiotics, and will complete a total 14-day course.
It is very important that you complete your course of
antibiotics and keep all of your follow up appointments. | ___ yo male with no significant PMHx who presents with right leg
erythema and pain consistent with cellulitis.
# Right lower extremity cellulitis: Patient presented with right
leg erythema/pain/edema and fever after kneeling on horizontal
screws while at work. Patient was wearing pants, and there was
not any puncture wound, but there were a few small visible
breaks in the skin. Received a Tdap booster in the ED.
Cellulitis improved with slowly IV Vancomycin and patient was
transitioned to oral Keflex/Bactrim to complete a total 14-day
course. He did have a ___ evaluation and was eventually able to
ambulate with crutches when the pain and erythema improved. He
was discharged with PCP ___. | 60 | 112 |
17986729-DS-15 | 20,379,673 | You were admitted to the hospital after you were found on the
floor of your apartment. You underwent a cat scan of your head,
chest, and neck. You were found to have a mediastinal hematoma
and a fractured sternum. You were admitted to he intensive care
unit to watch for increase in the hemtoma. Your vital signs
remained stable and you were discharged to the surgical floor
where you had a chance to recover. You were seen by physical
therapy and recommendations made for discharge to an extended
care facility where you can further regain your strength and
mobility. | The patient was admitted to the hospital after a fall. He was
taken to an outside hospital where he underwent imaging of his
head, neck or torso. He was reported to have a mediastinal
hematoma and a sternal fracture. The patient was transferred
here for further monitoring. Alcohol level upon admission was
233. Repeat imaging of his mediastinal hematoma showed increase
in size and the patient was admitted to the ___ intensive
care unit for monitoring. During this time, he reported right
wrist, shoulder and elbow pain. Imaging studies done did not
show any fractures. His course was notable for new onset of
paroxysmal atrial fibrillation. Troponins were sent and were
negative for acute coronary syndrome. The patient was started
on metoprolol for rate control and aspirin. During this time, he
began exhibiting signs of alcohol withdrawal and was placed on a
CIWA. On HD #3, he was transferred to the surgical floor, still
agitated, but without seizures. He continued on the CIWA scale
for alcohol withdrawal. The CIWA scale was discontinued on HD #
7. During this time, he was reported to have a urinary tract
infection and was started on a 3 day course of bactrim with a
last dose on ___.
As the patient became more alert, he was evaluated by physical
and occupational therapy. The social worker was available to
provide support to the patient's family.
During his hospital course, the patient resumed a regular diet
and his vital signs remained stable. He was voiding without
difficulty. His respiratory status remained stable and he
maintained an oxygen saturation of 98% on room air. His white
blood cell count normalized. On HD #9, the patient was
discharged in stable condition to a rehabilitation facility. An
appointment for follow-up was made with the acute care service. | 104 | 314 |
10514659-DS-13 | 27,133,899 | Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
after a fall from standing. You were found to have a small left
sided head bleed that has been stable on CT scan. You were seen
and evaluated by the neurosurgery team who determined no
surgical intervention was needed, although you continued to have
word finding difficulty which was worse than your baseline and
you were also intermittently confused. You were transferred to
the medicine team for management of these issues that are likely
related to the brain bleed. While on the medicine team, your
confusion and word finding difficulty improved and repeat CT and
MRI imaging showed that your head bleed was reducing in size.
You will likely improve as your bleed continues to resolve, and
you will likely benefit from physical therapy, occupational
therapy, and speech therapy.
Following discharge, please make sure that you:
#Please call your PCP, ___ (___), to set
up an appointment to be seen within one week of discharge.
#Please also call Neurosurgery at ___ to set up a follow-up
appointment with Dr. ___ (___) to be seen
within one week of discharge.
#Please also call your rheumatologist, Dr. ___,
(___), to schedule an appointment to be seen within two
weeks of your discharge. | Ms. ___ is a ___ lady (R-handed) woman with normal
pressure hydrocephalus characterized by gait difficulty, s/p VP
shunt placed on ___, recent subdural hematoma (___)
with residual word finding difficulty, RA s/p b/l TKR, HTN, HLD,
GERD, hypothyroidism, and anxiety, who presented from ___
___ after a fall with headstrike on ___ w/o acute
CT abnormalities, and another fall on ___, with CT notable
for left lateral convexity acute on chronic SDH.
#Subdural hematoma: Patient, who has NPH (primary gait
abnormalities) w/VP shunt (placed ___, was admitted to ___
s/p fall with headstrike iso attempting to walk w/o walker on
___, with OSH CT on ___ demonstrating acute on chronic SDH in
left lateral convexity (L temporal area) measuring up to 1.3 cm,
w/o midline shift or mass effect. Of note, pt had a recent SDH
resulting from a similar fall while pt was on vacation in
___ on ___, for which she received a craniotomy, and
since when she has had residual word finding difficulty. Pt was
admitted to neurosurgery at which point VP shunt was adjusted to
2.5. She was also started on keppra 500 mg BID for seizure
prophylaxis. Patient had no FNDs on neurologic exam and in the
absence of mass effect/shift, there was no need for
neurosurgical intervention. Repeat CT scans on ___ and ___
demonstrated that acute on chronic SDH was unchanged and
remained w/o midline shift. On ___, patient and family felt that
her word finding difficulty had worsened and that she was
"severely confused." Patient was transferred to medicine for
management of these issues.
On the medicine floor, patient was initially A&Ox1 (only to her
first name) with poor attention on exam, difficulty with
calculation, days of the week backwards, naming, repeating,
following complex left-right commands, and had persistent word
finding difficulties, which frustrated her. She was treated with
nonpharmacologic delirium treatment including frequent
re-orientation, light/day orientation, minimization of
repetitive stimuli (sounds, lights), maximization of cognitive
stimuli (conversation w/family and friends), and placement near
nursing station. In addition, patient's alprazolam and melatonin
were discontinued in order to minimize sedative medications.
Neurology was consulted and they recommended repeat imaging and
EEG. NCHCT on ___ and MRI on ___ show reduction in size of SDH,
and no e/o new infarct or hemorrhage. VP shunt setting
placement/setting were checked by neurosurgery following MRI
(set at 2.5). EEG on ___ was notable for left sided slowing
likely ___ left sided cerebral dysfunction iso patient's acute
on chronic SDH. Given no e/o seizure on EEG, patient should stop
keppra 500 mg BID after finishing 14-day course (___).
At the time of discharge, patient's orientation had improved to
A&Ox2 (thinks it is ___, she was able to calculate that 7
quarters is $1.75, had improvement in naming ("pen, stethoscope,
and cup"), and was able to follow complex left-right commands,
although her word finding difficulties persisted. Patient's
residual word finding difficulty and impaired mental status will
likely improve with continued resolution of the subdural
hematoma and with a combination of physical therapy, occupation
therapy, and speech therapy.
#Hyponatremia: Pt admitted with Na 132, which decreased to 129
on ___, with repeat Na 132 following administration of salt tabs
and IVF on ___. Urine lytes on ___: UreaN:876, Creat:97, Na:137,
Osmolal:717, FeNa 0.5%. SOsm 285. Given improvement in Na with
IVF and FeNa<1%, initially thought that hyponatremia was likely
___ to hypovolemia, although considered an additional component
of SIADH given high UNa and high UOsm, and patient's significant
neurologic disease. Na 132 on ___ and 134 on ___ s/p 1L IVF on
___. Na decreased again to 132 on ___ and ___ with continued
mIFV, with repeat urine lytes on ___: Uosm: 482, UCreat:107,
UNa:84 on ___, FeNa 0.3%, more c/w SIADH. Likely that patient
has SIADH, and was having superimposed hypovolemic hyponatremia
on top of that. Na 131 on ___. Instituted 2L PO fluid
restriction, held mIVF, with Na 131 at time of discharge.
#UTI: Patient had UA on initial workup in ED on ___ notable for
WBC, RBC, bacteria, and large leukocyte esterase. She denied any
dysuria, urinary frequency, and did not have a Foley. Urine cx
obtained, and she was started on empiric ciprofloxacin PO 500 mg
q12hrUrine cx ___ negative. Urine cx resulted negative on ___,
and empiric ciprofloxacin was discontinued.
#HTN: Patient's BPs ranged from ___ throughout
hospitalization. Patient continued on home amlodipine and
atenolol.
#HLD: Patient was continued on home pravastatin.
#RA: Patient is s/p bilateral TKR. She has some slight ulnar
deviation and Swan neck deformities on exam. Says her joints
hurt intermittently, but that this is her b/l right now. Patient
was continued on home prednisone 4 mg QD and home plaquenil.
Patient's home leflunomide was held while receiving empiric
antibiotics for c/f UTI and was started at time of discharge,
per patient's outpatient rheumatologist, Dr. ___,
___.
#Hypothyroidism: Patient was continued on her home
levothyroxine.
#GERD: Patient was continued on her home pantoprazole.
#Lumbar spinal stenosis/back pain: Patient was continued on her
home gabapentin and home lidocaine patch.
#Anxiety/Insomnia: Patient was continued on her home sertraline
and home trazodone.
Her home alprazolam and melatonin were discontinued iso waxing
and waning orientation and not restarted for discharge. | 212 | 862 |
11052273-DS-23 | 27,386,767 | You were admitted to ___ with worsening shortness of breath.
This was felt to be due to worsening anemia (low blood count).
You underwent an evaluation for source of bleeding
(endoscopy/colonoscopy) and it was found that you have multiple
areas of abnormal blood vessels. These were treated. You also
received IV iron. It may be the case that you have more
bleeding thus its important for you to monitor your symptoms.
In addition, you were found to have an infection in your blood
for which you were treated with an antibiotic.
Please ensure to follow up with all of your appointments.
Please also obtain blood work as prescribed so that your doctors
know ___ your blood levels are
The following changes were made to you medications:
START:
- Ciprofloxacin for infection
- Tiotropium for breathing problems
STOP
- Ipratropium
CHANGE
- Increase Omeprazole to 40mg daily
Should you develop any symptoms concerning to you, please call
your doctor or go to the emergency room. | A charming ___ yo woman with hx of GIB (duodenal AVMs s/p cautery
___ and hx of ? LGIB [adenoma, diverticlosis]), DM, HTN and
COPD who presented to the ED from her PCP's office for
evaluation of worsenign SOB and was found to have profound
anemia (HCT 22 from 36 1mo ago), developed GNR bacteremia while
awaiting colnoscopy/EGD as well as ARF and HCAP.
.
# SOB was felt to be due to profound anemia, subacute. There
were no si/sx of acute CHF. No evidence of COPD flare. SOB
improved markedly with administration of pRBCs. Ipratropium was
changed to tiotropium.
# Anemia. Profound Fe defficiency anemia (ferritin of 5). She
received 500mg of IV Fe as well as 2units of PRBCs. Given prior
hx of GIBs (see above) she underwent EGD and Colonoscopy which
revealed Schatzki's ring, angioectasias in the fundus (injected,
thermal therapy) otherwise nl mucose in the entire duodenum,
gastric polyp and Colnoscopy showed extensive diverticulosis of
the whole colon, polyp in the descending colon x2, angioectasias
in the cecum and proximal ascending colon (thermal therapy).
She was continued on PO PPI while inpatient and received an
additional PRBC unit prior to discharge. Her HCT at time of d/c
was 29.9%. She was restarted on PO Fe. GI follow up was
arranged and she may require intermittent transfusion or IV Fe
therapy and/or intemittent thermal therapy for angioectasias
which were felt to be the cause of her slow hemorrhage.
Omeprazole was increased to BID dosing.
# GNR bacteremia (___). Etiology unclear, however felt to be
due to either GI translocation vs. Pulm (new opacity and had
respiratory distress over 1 day ___, see below). She was
treated with Cefepime IV and was afebrile within 24 hours of
initial symptoms of fever, tachycardia nad hypoxia. UA was
negative. Subsequent BCx were negative and stool cultures were.
# Hypoxic respiratory distress. It was unclewar if this was due
to a transient aspiration event reported by patient or due to an
underlying PNA with subsequent GNR bacteremia. There was a
question of LLL infiltrate on CXR and patient was treated
empirically for HCAP with Cefepime given the GNR bacteremia.
She remained respiratorily stable after initiation of Cefepime
and was transitioned to Ciprofloxacin within 48 hours. At time
of discharge patient was afebrile, normotensive and without
other signs of systemic infection.
# ___. Pre-renal in setting of infection and NPO awaiting
colonoscopy. UA w/o casts. FeNA 0.2%. With IVF and PRBC
transfusions Cr improved to 0.9.
# DM. Held metformin while inpatient and treated with ISS. FBG
was 139 on day of discharge.
# HTN. Normotensive. Continued norvasc, BB.
# Code: DNR/I confirmed with patient. | 162 | 467 |
11545787-DS-28 | 29,050,970 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay.
As you know, you were admitted for weight gain and shortness of
breath, which was caused by your heart condition. Your heart is
not beating as efficiently as it once was, which caused fluid to
be retained in your legs and in your lungs. We treated you with
diuretics (water pills) to remove the fluid.
Moving forward, it is essential that you
1) take all of your heart medications regularly,
2) avoid salty foods (less than 2 g of sodium per day) -- speak
with Meals On Wheels to see if you can get low salt/sodium meals
- and limit the amount of fluid that you drink to 2 liters,
3) weigh yourself every morning, and call your cardiologist's
office if your weight goes up more than 3 lbs,
4) attend a follow-up appointment with your cardiologist to
check your progress and change your medications if necessary
We wish you a speedy recovery and good health.
Your ___ Care Team | ___ with PMH of CAD s/p NSTEMI in ___ s/p CABG x5, CHF with EF
45% in ___, PVD s/p carotid endarterectomy (with residual >50%
___ stenosis), HTN, DM, HLD, morbid obesity, and 100 pack year
smoking history who presented with CHF exacerbation &
bradycardia.
ACTIVE ISSUES
# Acute on chronic systolic heart failure (EF 40-45%): Weight
increased 16 lbs from discharge on ___ after admission for CHF
exacerbation. He was started on torsemide 10mg daily, increased
to 20mg daily ___ by CHF team after patient was noted to
have weight gain. Diet compliance is unclear given meals on
wheels. Wife monitors meals at home. Rx compliance is good. The
patient was diagnosed with IV furosemide with good effect and
discharged home on torsemide 20 mg PO daily. Discharge weight
was 122.4 kg.
# Falls: Patient was noted by his wife to be very unsteady on
his feet and reportedly has had multiple recent falls at home.
CT scans of the head and neck were negative for any fracture or
hemorrhage. Etiology is unclear, but given bradycardia on
admission secondary to metoprolol, could've been contributing.
Furthermore, had history of orthostatic hypotension for which
was previously on midodrine (though stopped during last
hospitalization for CHF exacerbation). Metoprolol stopped.
Midodrine restarted and tolerated well. Noted to have
orthostatic hypotension, though asymptomatic.
# Orthostatic hypotension: Normotensive on arrival, but history
of orthostatic hypotension and noted to be unsteady at home with
multiple recent falls at home since discontinuation of midodrine
during recent admission. Metoprolol dc-ed. Midorine re-started.
Continues to be orthostatic to SBP in high ___ or low ___, but
not symptomatic. Midodrine 5 mg BID restarted and tolerated
well.
# Bradycardia: Patient was started on metoprolol succinate 25 mg
daily during recent admission for CHF exacerbation. Since that
time he has been noted to have heart rates in the ___ at PCP
follow up visit on ___, in cardiology clinic and emergency room
today as well. He has also been having unsteadiness and falls at
home. Metoprolol stopped, with HR returned to ___.
CHRONIC/INACTIVE ISSUES
# CAD s/p NSTEMI in ___ s/p CABG: In ___: Coronary artery
bypass grafting times 5 with LIMA-LAD, and SVG to diagonal
artery and sequential SVG to the OM1, OM2 and the PDA. He has no
chest pain today and no ischemic changes on EKG. Very slight
troponin elevation most likely consistent with CHF exacerbation
and CKD. Aspirin & atorvastatin continued.
# Bilateral knee pain. Not swollen, warm, erythematous on exam.
Pain relieved with lidocaine patches.
#CKD: Patient admitted with Cr of 1.8, downtrending from recent
discharge. Patient did have AoCKD during recent admission, but
baseline ranges from 1.8-2.2. On discharge, Cr 2.2.
# IDDM c/b neuropathy, retinopathy, autonomic dysfunction and
Charcot foot: Followed by ___. Continued home regimen.
# OSA: Continued home CPAP
# Depression: Continued duloxetine
# Mild dementia: Continued memantine
**** TRANSITIONAL ISSUES *****
## DISCHARGE WEIGHT: 122.4lb
## DISCHARGE DIURETIC REGIMEN: Torsemide 20mg daily
##Home midodrine was restarted in the setting of othostatic
hypotension and recent history of falls at home. Recommend
monitoring blood pressures for excessive hypertension given his
CHF.
##Metoprolol was discontinued given patient's bradycardia, which
puts patient at risk for CAD and worsening CHF. Consider
restarting if heart rate climbs.
##Started on lidocaine patches for knees. Low suspicion for gout
given lack of swelling, effusion or erythema, and mild pain. ___
need alternate pain relief if patches are not covered by
insurance.
##Consider ACEi as an outpatient
# CODE: Full
# CONTACT: ___, wife, Phone number: ___,
Cell phone: ___ | 173 | 589 |
19081511-DS-3 | 28,991,751 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with a painful mass in your mouth and were found to have high
calcium ("hypercalcemia"). You were seen by ear nose and throat
doctors (___), as well as endocrinologists.
Testing of your blood showed you have a condition called
hyperparathyroidism, where one (or more) of your parathyroid
glands are overactive--this causes high calcium levels. In
some instances this can be caused by parathyroid cancer (in
other instances it is not caused by cancer).
You underwent a biopsy of the mass in your mouth. It was
suggestive that this mass was being caused by your
hyperparathyroidism. The testing was reassuring that there was
not cancer in your jaw.
Your high calcium levels were treated with fluids and
medications, and they returned to normal. You are now ready to
leave the hospital.
The endocrinologists and ENTs recommended the complete removal
of your thyroid and parathyroid glands to help resolve your
hyperparathyroidism and determine its cause. The hope is that
with treatment of your hyperparathyroidism, the mass in your jaw
will improve.
When you leave the hospital you will have appointments with the
endocrinologists, the ENTs, and a new primary care doctor. They
will help with scheduling:
- testing of your calcium and phosphate (to make sure they are
stable)
- additional testing you may need prior to surgery
- your surgery
Of note, during your hospital stay your phosphate levels were
low. This was due to your hyperparathyroidism. The
endocrinologists recommended you drink 3 glasses of low fat milk
per day to keep your phosphate levels up.
Of note, during your hospital stay you underwent a CT scan which
showed a possible cyst in your L ovary. The radiologist
recommended you undergo an ultrasound. We will communicate this
to your new primary care doctor. | This is a ___ year old female with history of ocular albinism,
opiate dependence on suboxone, hyperparathyroidism, admitted
___ with several months of progressive ulcerative oral
mass, found to have serum calcium 14, initial workup consistent
with hyperparathyroidism, treated with IV fluids, calcitonin and
bisphosphonate with subsequent normalization of calcium, workup
otherwise notable for suspected thyroid vs parathyroid nodule,
oral mass biopsy returning suggestive for brown tumor,
suspected to be systemic effect of her hyperparathyroidism, seen
by ENT and endocrinology and recommended for rapid follow-up for
additional outpatient testing and operative planning for thyroid
and parathyroid resection, able to be discharged home.
# Oral Mass
# Suspected Brown Tumor
Patient presented with multiple months of progressive ulcerating
mass in her R inferior oral mucosa. Given concern for
malignancy, she underwent biopsy with Rush pathology. After an
extended period of time (see below regarding other management
that occured during this time interval) biopsy results
subsequently returned showing a giant cell lesion within the
mucosa, felt to be consistent with brown tumor of jaw vs central
giant cell granuloma. Patient was seen by endocrinology and ENT
services. There was uncertainty about whether tumor would
improve with surgical management of parathyroid issues described
below. As below, patient planned for operative management of
hyperparathyroidism with plan to observe for subsequent
improvement in jaw lesion. Pain controlled with tylenol and
ibuprofen while inpatient--patient adamant that she did not want
to use opiate agents. At discharge, scheduled for ENT follow-up
for pre-operative planning as below. Throughout the admission
she was able to handle oral secretions, had no difficulty with
swallowing or eating, and maintained her nutritional and
hydration status without issue.
# Hyperparathyroidism
# Concern for parathyroid cancer
# Hypercalcemia
# Acute metabolic encephalopathy
Patient admitted with calcium 14 with subacute onset of memory
and cognitive difficulties. Workup notable for PTH >500.
Imaging of neck was notable for enlarged nodule that radiology
felt arose from thyroid, but given clinical picture,
endocrinology and ENT felt was likely an enlarged parathyroid
gland. Patient initially treated with IV fluids. Given lack of
significant improvement in serum calcium, patient was started on
calcitonin and received a single dose of zolendronic acid with
slow improvement in calcium over subsequent days. Mentation and
cognition improved to baseline. IV fluids were stopped and
calcium remained normal. Concern for primary hyperparathyoidism
vs parathyroid cancer. Per multidisciplinary discussion,
consulting services recommended total resection of thyroid and
parathyroids. She was scheduled for rapid follow-up with
endocrinology and ENT. Per endocrine recommendations, patient
completed a sestamibi scan, the read of which was pending at
discharge (per endocrine service, this would not impact her
immediate management, and they would follow it up at her
appointment 1 week post discharge). ENT scheduled patient for
outpatient 4DCT scan of parathyroids as part of her operative
planning. Patient remained stable and was able to be discharged
home with rapid follow-up, including new PCP appointment at ___.
Would consider checking Calcium and Phos at follow-up.
Discharge Calcium 10.2.
# Vitamin D Deficiency
Found to have Vit D level of 16 on admission. Given
hypercalcemia this was initially not treated, due to concern it
might worsen serum calcium. Once serum calcium was normalized
as above, prior to discharge patient received 1x dose of 50,000
units ergocalciferol.
# Hypophosphatemia
Patient course notable for persistent hypophoshatemia requiring
daily repletion. Felt to be secondary to her
hyperparathyroidism. At discharge endocrinology recommended,
instead of continuing oral prescription phosphate repletion, to
have patient drink 3 glasses of milk per day. Would consider
phos check at follow-up. Discharge phos 2.1.
# Hypoglycemia
Patient course notable for several episodes of hypoglycemia
during first days of her admission, requiring addition of
dextrose to her IV fluids. This was attributed to poor PO
intake in setting of her metabolic encephalpathy (as above).
Resolved once her mental status returned to normal and she was
eating regularly, and did not recur.
# ADHD
Continued home adderall
# Anxiety
Continued home clonazapam
# Opiate use disorder
Continued home suboxone.
# Ovarian Cyst
CT Abd/Pelvis incidentally showed showed cholelithiasis, Large
left nonobstructive renal stone, and "Possible left-sided
ovarian cyst measuring more than 3.0 cm." ___ radiology
recommends pelvic ultrasound evaluation. Defer to outpatient
setting regarding this and whether additional longitudinal
management for other incidental findings would be indicated
Transitional issues
- Discharged home with rapid ENT and endocrinology follow-up, as
well as appointment to establish with new ___ PCP; ENT working
on more rapid follow-up appointment and will call patient with
updated information post-discharge
- Would check calcium and phosphate at follow-up to ensure
stability; discharge calcium 10.2, Phos 2.1
- CT Abd/Pelvis incidentally showed showed cholelithiasis, Large
left nonobstructive renal stone, and "Possible left-sided
ovarian cyst measuring more than 3.0 cm." ___ radiology
recommends pelvic ultrasound evaluation. Defer to outpatient
setting regarding this and whether additional longitudinal
management for other incidental findings would be indicated
> 30 minutes spent on discharge | 323 | 832 |
13031024-DS-18 | 23,074,087 | Dear Ms. ___,
You were admitted to the hospital for chest pain. We checked an
EKG to look at your heart rhythm. We also did blood tests that
showed that you did not have any damage to your heart muscle. We
did a chest x-ray and a CT scan of your chest to make sure that
there were no problems with your lungs or blood vessels. We gave
you medications for your pain, including morphine and tylenol.
Your chest pain improved and you were discharged home.
You should ask your primary care doctor or cardiologist to
arrange to have an echocardiogram (an ultrasound of your heart)
done to ensure that the heart is beating properly.
We made several changes to your home medications and started you
on one new medication. All of your medications are detailed in
your discharge medication list. You should review this carefully
and take it with you to any follow up appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ with PMHx of dCHF, DM II, asthma, HLD, and htn who presents
with chest pain and EKG changes concerning for pulmonary
hypertension.
# Chest Pain: Burning and ripping in quality. Neg trops, ekg
changes concerning for pulmonary HTN but not ischemia. CXR only
showed mild cardiomegaly without significant mediastinal
widening. CTA showed no evidence of PE or dissection.
-Aspirin 81
-Home simvastatin
-Tylenol PRN for noncardiac chest pain
# Diastolic CHF: EF 55 % in ___. BNP 138 currently.
-Home torsemide.
#HTN: sys BP 140's on presentation. became hypotensive to
___ on full HTN regimen.
-discontinued nifidipine 90
-changed home carvedilol 12.5 bid to metoprolol 25mg PO daily
-home lisinopril changed from 40mg to 20mg.
# Back pain: chronic per patient. DDX includes posterior hip
osteoarthritis ___ morbid obesity vs lumbar radiculopathy vs
paraspinal muscle strain
-tylenol PRN for pain | 172 | 131 |
12415528-DS-9 | 29,270,893 | Ortho Spine D/C Instructions:
Immediately after the operation:
Activity:You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You do not need a brace
Wound Care: Drains removed. Dry dressing should
remain in place for ___ hours. Mepilex dressing applied to
lumbar incision. This dressing may remain in place for 7 days.
Another mepilex dressing may be applied to surgical site
dressing for another 7 days or until her follow up appointment.
Please call the ___ with any new signs of infection or
wound drainage.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain as recommended by the Pain Service. You
should follow up with your pain provider ___ op for further
pain medications going forward.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Infectious Disease D/C Instructions:
ID OPAT Program Intake Note - Order Recommendations
OPAT Diagnosis: MSSA endocarditis, spinal
osteomyelitis/discitis,
and SSTI superinfection of spinal wound
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: ceftazidime-avibactam 2.5g IV Q8; flagyl po 500mg
TID, vancomycin 1000mg IV Q12
Start Date:
Projected End Date: continue through ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough, CRP
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY CRP for patients with bone/joint
infections
and endocarditis or endovascular infections
FOLLOW UP APPOINTMENTS: see OMR
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE
RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER
THE DATE/TIME OF THIS OPAT INTAKE NOTE.
ID OPAT Intake Note - Transition of Care Summary
Clinical Course:
Ms. ___ is a ___ year old female with history of HCV, OUD (last
___ c/b MSSA TV endocarditis w/ pulmonary septic emboli, Rt
empyema s/p drainage and epidural abscess ___ s/p laminectomy
decompression ___, Rt SI joint septic arthritis and L5-S1
OM/discitis, discharged previously on IV cefazolin for these,
who
was re-admitted ___ with lumbar wound dehiscence just 24 hrs
after her most recent discharge.
Superficial wound swab and deep tissue cultures with growth of
multiple GNRs including E.coli, PsA, B.fragilis, and a
pan-resistant Klebsiella pneumonia (S to avycaz). Unclear where
she picked up this MDR organism during short time out of the
hospital. Now s/p second I&D of wound in OR on ___ with
intra-op cultures with growth again of Klebs, E.Coli, B.frag.
Her last debridement was ___ and cultures from OR that date
are
still without growth. Given lack of growth from most recent OR
cultures ___, we are hopeful we have source control at this
point of this polymicrobial post-surgical SSTI with MDR
Klebsiella, B.fragilis and Ecoli. We will plan for 8 week course
with IV vancomycin for MSSA IE and lumbar iskitis/osteo/phlegmon
(favor 8 weeks given complicated course, extensive infection at
baseline) so the original vanc course will be extended by 2
weeks
and she will complete 8 weeks total of IV vanc on ___. Will
continue avycaz/flagyl for the Klebs/B.frag for 2 weeks from ___ (last SSTI debridement); suggest 2 week course for beyond
the last debridement surgery for surgical site infection.
In summary she will complete all three antibiotics on ___.
Pain Service Recs:
___ y/o F with hx of IVDU (previously maintained on ___ s/p
multiple lumbar wound debridements on consulted by orthopedic
team regarding pain management. Discussed with patient the risks
of increasing opioid regimen given her history of IVDU. Would
like to augment current opioid regimen with multimodal therapy
at
this time.
1. Pain Management Plan:
- Continue current opioid regimen: morphine SR 45 q8h, morphine
45 ___ q8h prn
- gabapentin (max dose)
- tizanidine 4mg TID
- Standing APAP, 1g q6h
- diazepam ___ q8h prn
- lidocaine patch
- ___ consider starting TCA, rotating muscle relaxants
(Baclofen/Flexeril), or starting duloxetine
- consulting addiction medicine specialist
Addiction Psychiatry D/C Instructions:
DSM 5 DIAGNOSIS:
1)opioid use disorder
2)panic disorder with agoraphobia
3)generalized anxiety disorder
ASSESSMENT: Ms. ___ is a ___ year-old woman with PMH of opioid
use disorder on agonist therapy, HCV, hypothyroidism, anxiety
disorders and recent L5/S1 compression surgery admitted with
likely wound infection. She has been hospitalized for the past
5
weeks with infectious issues that required one surgery so far
with another on the schedule. In this context, she describes
considerable lower back pain, rating it at ___ most of the
time during her stay. At its best, it is ___. Her pain
management is likely complicated by her long history of OUD
which
has been managed with ___ ___ mg SL as an outpatient. That
regimen was successful prior to her recent difficulties that led
to this hospitalization. Her hope is to return to that regimen
upon her discharge.
PLAN:
1)Discussed her ___ regimen. It appears reasonable at this
point. Would aim to restart ___ after her acute pain needs
have been met.
2) Emailed her psychiatrist Dr. ___.
3) Should follow up with Dr. ___ as an outpatient as he has
managed her care for last ___ years and has been very
involved.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Wound Care: Drains removed. Dry dressing should remain in place
for ___ hours. Mepilex dressing applied to lumbar incision.
This dressing may remain in place for 7 days. Another mepilex
dressing may be applied to surgical site dressing for another 7
days or until her follow up appointment. Please call the spine
center with any new signs of infection or wound drainage. | Ms. ___ is a ___ year old female with history of HCV, OUD (last
___ c/b MSSA TV endocarditis w/ pulmonary septic emboli, Rt
empyema s/p drainage and epidural abscess ___ s/p laminectomy
decompression ___, Rt SI joint septic arthritis and L5-S1
OM/discitis, discharged previously on IV cefazolin for these,
who was re-admitted ___ with lumbar wound dehiscence just 24
hrs after her most recent discharge. Superficial wound swab and
deep tissue cultures with growth of multiple GNRs including
E.coli, PsA, B.fragilis, and a pan-resistant Klebsiella
pneumonia (S to avycaz). Unclear where she picked up this MDR
organism during short time out of the hospital. Now s/p second
I&D of wound in OR on ___ with intra-op cultures with
growth again of Klebs, E.Coli, B.frag. Her last debridement was
___ and cultures from OR that date are still without
growth.Given lack of growth from most recent OR cultures ___,
we are hopeful we have source control at this point of this
polymicrobial post-surgical SSTI with MDR Klebsiella, B.fragilis
and Ecoli. We will plan for 8 week course with IV vancomycin for
MSSA IE and lumbar diskitis/osteo/phlegmon (favor 8 weeks given
complicated course, extensive infection at baseline) so the
original vanc course will be extended by 2 weeks and she will
complete 8 weeks total of IV vanc on ___. Will continue
avycaz/flagyl for the Klebs/B.frag for 2 weeks from ___
(last SSTI debridement with wound closure); suggest 2 week
course for beyond the last debridement surgery for surgical site
infection. In summary she will complete all three antibiotics on
___.
___ I&D VAC placement
___ I&D VAC Change
___ I&D Wound Closure with Spine and Plastics
Drains Removed ___
-Infectious Disease followed for antibiotic management based on
OR tissue cultures
-Acute and Chronic Pain Service followed for Pain management
recommendations given opioid use disorder history
-Addiction Psychiatry and social work was consulted for opioid
transition planning post discharge
-Plastic and Reconstructive Surgery was consulted for wound
closure management. | 1,209 | 321 |
18255016-DS-12 | 20,276,578 | Ms. ___,
It was a pleasure taking care of you while at ___. You were
admitted for a fall and found to have a small fracture of your
pelvis. An MRI of your hip was obtained which showed no occult
fracture, but did confirm known hematoma and also showed
hamstring injury.
Please continue to use tramadol for pain. When moving, you can
use oxycodone to minimize the discomfort
Please ensure you follow up with orthopaedic surgery at your
appointment below | Impression: Pt is a ___ y/o F with PMHx of HTN, HL who presents
with a mechanical fall with subsequent fracture of the pubic
ramus and hamstring partial tear.
#Pelvic Fracture from fall, with concomitant hamstring partial
tear- Pt's fall is mechanical in nature, and there was nothing
in the history to suggest syncope or pre-syncope. A CT pelvis
was obtained which showed a fracture of the right pubic rami.
Orthopaedics was consulted who did not recommend surgery, and
that patient should be weight bearing as tolerated. However,
patient was having severe pain with weight bearing, so ortho
recommended MRI of the hip to rule out occult fracture which
showed no occult fracture, but did confirm known hematoma and
also showed hamstring injury. Pt was seen by ___ who recommended
___ rehab. Ortho recommended that she be protective
weight bearing on L side and WBAT on R side.
# Osteoporosis: The patient reports she previously completed a
___ course of a bisphosphonate. She may benefit from an
endocrinology referral to discuss secondary treatment options
for her osteoporosis, given her new fractures.
#HTN: Continued clonidine patch 0.2 mg TD and lisinopril 10 mg
daily
#HL: Continued simvastatin
#Transitional Issues
-Pt needs hct drawn on ___ and one more on ___
-Pt should be protective weight bearing on L side and WBAT on R
side | 82 | 230 |
18763350-DS-12 | 26,320,880 | Dear ___
___ were admitted due to high sugars, abnormal renal function
and anemia.
- Elevated sugars: ___ were recently diagnosed with diabetes for
which ___ are being treated with insulin. ___ were evaluated by
the ___ team and we recommend ___ follow up with your PCP and
get referred to a diabetes doctor within the atrius system.
- Abnormal kidney function: This improved through your
hospitalization stay. We suspect it was a combination of
dehydration and your medications. And we have stopped the
Hydrochlorothiazide and decreased the lisinopril
- Low blood count: Your blood count ended up being stable though
it was low. We have thus recommend following up with a
hematologist
It was a pleasure being part of your care.
Your ___ team | Ms. ___ is a ___ female with history of HTN, CKD,
recently started on insulin for new diagnosis of diabetes and
with recent worsening renal function and anemia sent in by PCP
at recommendation of outpatient renal at ___ for inpatient
workup of worsening kidney failure with anemia out of proportion
to her CKD and new diabetes diagnosis which seemed atypical in
that evolved pretty rapidly with A1C of 5.2 in ___ of this
year now up to 10.
# Progressive renal failure - Improved to 1.0 by discharge.
Recent decline in kidney function likely pre-renal in the
setting of diabetes and fluid loss combined with usage of
thiazide. Renal function improved with fluids. On admission we
felt her progressive anemia, new rapid onset of diabetes and new
trace/subjective right foot drop were all interesting new
changes that seem to have all started around the same time.
Unclear what the unifying diagnosis driving all of this was but
autoimmune work up so far has been negative
# Anemia - Unlike other issues which are stable/resolved, her
anemia was of unclear etiology. She never required transfusion
but she was ranging from 7.3-8.1. Hgb at discharge was 7.5.
Hemolysis labs were negative. Iron stores were appropriate (the
only abnormality was elevated ferritin to 1720). Smear had no
obvious findings. Coombs was negative. Guaiac was negative. It
is thus unclear why patient has new anemia. Given stability
however and extensive inpatient workup, she was discharged to
follow up with hematology .
# Diabetes
# Hyperglycemia - A1c was 5.9 in ___ and increased to 13.9 in
___ in atrius records. Recheck here was 10.0. Onset of
diabetes seemed a little too rapid with essentially normal A1C 6
months ago.
Recently has been on 14 ___ but given few episodes of
hypoglycemia to 65 day prior to admission, and changing renal
function, dose decreased to 10 units while inpatient. ___
recommended lantus 10units QHS with sliding scale. Stop
glipizide. Diabetes teaching was done and labs for Anti-Gad,
C-peptide, and islet cell antibody were sent.
#HTN - held ACE and thiazide as above. But restarted
ace-inhibitor on discharged. Stopped Thiazide. Atenolol was
switched to metoprolol given atenolol is renally cleared and in
the setting of risk of ___, safer to be on metoprolol. Continued
nifedipine
#HLD - continued home statin
#Allergic rhinitis - continued Flonase
TRANSITIONAL ISSUES
======================
- Please recheck Hgb as outpatient and ensure it is stable.
Patient needs hematology work up for new onset anemia given
inpatient workup was unrevealing
- F/u on anti-gad, c-peptide and islet cell antibody sent prior
to discharge given suspicion for Type 1 diabetes
- Stop HCTZ
- Switched atenolol to metoprolol given risk ___ and atenolol
being renally cleared
- Lisinopril decreased from 40mg to 20mg daily given blood
pressures very well controlled in the hospital even in the
absence of medications
>30 minutes spent on discharge planning and coordination | 119 | 470 |
14444869-DS-7 | 27,005,229 | You were evaluated in the hospital for abdominal pain and were
found to have bacteria in the urine that was causing a UTI. You
were treated with antibiotics and this improved. Please finish
the antibiotic ampicillin for your urine infection and the
antibiotic flagyl for the C diff infection. | Patient is a ___ year old woman with history of IDDM, PUD,
diverticulosis, and chronic constipation, C diff colitis in
___, recently admitted ___ for C diff colitis and
discharged on Flagyl who presents with abdominal pain.
# Epigastric abdominal pain, nausea/vomiting: Initially
presented with epigastric pain, nausea/vomiting with mildly
elevated LFTs in the setting of recent flagyl use. There were no
peritoneal signs on her exam. Imaging was unremarkable with
known diverticulosis. Per chart review, she has chronic history
of self limited episodes of abdominal pain associated with
intermittent diarrhea and constipation. Her symptoms improved
while hospitalized. Her diarrhea resolved completely, but she
still endorsed intermittent epigastric abdominal discomfort.
She was continued on a PPI; she had been started on sucralfate
for this during her last admission, but it was unclear that it
was helping and she refused it in the hospital, so it was
stopped.
In terms of workup, EGD in ___ showed distal gastritis biopsy
positive for H pylori. RUQ US has shown mild intrahepatic
biliary duct dilation. She was also recently admitted in ___
and thought to have PUD/gastritis in the setting of NSAID use
for back pain. (since stopped using NSAIDs). Last endoscopy was
in ___. Outpatient providers may consider testing for
eradication of H Pylori, and referral to GI to determine if this
is functional abdominal pain vs gastroparesis vs due to
PUD/gastritis.
During the hospitalization, the patient complained of dysuria,
and her urine culture returned positive for enterococcus, so
ampicillin was started on ___ for a planned 7 day course.
# Recent C diff colitis, on treatment: Patient is undergoing
current treatment for presumed mild C diff colitis. It is
unclear if she has true infection vs colonization, however will
complete course of therapy. She was treated with IV flagyl while
not tolerating PO's. She will take additional 11 days of
flagyl for this.
Chronic Issues
==============
#DMII:
- 24U Glargine at breakfast -->reduced dose as she normally
takes 30 units of lantus at home; PACT team should counsel
patient to increase dose back to 30 units if her sugars are
persistently elevated. I asked ___ staff (Dr ___ if
we could stop her Januvia to reduce her pill burden but he
prefers continuation.
# Hyperlipidemia
- continue pravastatin 40 mg PO QPM
#HTN
- continue amlodipine 2.5 mg PO daily. Pressures were slightly
elevated on day of discharge; may need escalation of treatment
as an outpatient. I don't know if she has been trialed on an
ace inhibitor.
#Chronic back pain:
- continue gabapentin 300 mg PO TID
#PUD, hx of HPylori:
- Continued home PPI. Sucralfate stopped - she refused it and
did not believe it helped her.
#Asthma:
- continue Albuterol inhaler 2 PUFF IH PRN SOB
- continue Flovent | 50 | 457 |
17991013-DS-18 | 28,107,417 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain and
concern for a partial small bowel obstruction. We recommended
bowel rest, IV fluids and pain control. Fortunately you quickly
improved and were able to tolerate advancing your diet over the
next two days.
The GI consult team saw you and recommend budesonide 9mg daily
to take until your follow up GI appointment. The colorectal
surgery team also saw you and they recommend surgery. They will
call you to schedule this appointment, but if you do not hear
from them, please call them at the number below to ensure that
you will be seen soon.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | #Partial Small Bowel Obstruction
#Crohn's Disease
#Terminal Ileal stricture
Patient presenting with acute on chronic abdominal pain and
nausea but abdomen soft and aperitoneal with no active vomiting
and continues to pass gas with recent BM, and quick improvement
in pain. Initially given IVF, then advanced to clears, full
liquids and then regular diet. The GI consult team saw the
patient and recommended a colorectal surgery consult (for
coordination of care given poor f/u in past and need for surgery
as definitive plan) and also budesonide 9 mg daily until his
follow up appointment.
He has known structuring Crohn's disease and has been on
Remicade for the past 6 months (last dose given ___ but
continues with intermittently uncontrolled symptoms. Although he
quickly improved on this admission, it is concerning that he has
had poor follow up in the past with following through on
recommendation for surgery. The patient is now amenable for
surgery. He was seen by the colorectal surgery service who
agreed that given his long segment stricture confirmed on
imaging, it is unlikely to resolve with further medical
management and resection of the strictured segment is indicated.
This appointment is being scheduled and the office will call the
patient. | 114 | 201 |
19351036-DS-5 | 26,161,905 | You were admitted with a bowel obstruction and underwent an
exploratory laparotomy and small bowel resection.
Post-operatively, your bowels were slow to wake up at first but
by discharge, you were tolerating a regular diet and having
bowel movements. You will be discharged home with a drain ___
place, which will be removed at your followup appointment ___ the
___ CLinic. You will continue antibiotics until you see the
infectious disease MD, who will then determine the course.
You are being discharged with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond ___ 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 ___ 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 ___ a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change ___ 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.
___ some cases you will have a prescription for antibiotics or
other medication.
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 ___ drainage from the wound
Drain care:
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation | Mrs. ___ presented to the emergency room with nausea and
vomiting secondary to a small bowel obstruction. The patient was
admitted to the acute care surgery service for management of her
bowel obstruction; a nasogastric tube was placed and the patient
was kept on bowel rest and intravenous fluids.
On ___, the patient underwent an exploratory laparatomy and a
small bowel resection. Please refer to the operative note for
full details.
The patient's foley catheter was discontinued POD 1, however her
nasogastric tube was kept ___ place ___ the setting of abdominal
distention. The patient was not passing flatus at this time, and
the nasogastric output was still high. On ___, the nasogastric
tube was discontinued and the patient was started on sips. There
was evidence of pus draining from her abdominal wound, and the
superior aspect of the wound was opended and packed with wet to
dry dressings. Her pain was well controlled with a Dilaudid PCA.
After experiencing nausea, the patient's nasogastric tube was
replaced on ___ and the patient had 750 cc of bilious drainage
soon after it was placed. The patient underwent cat scan imaging
on ___ which revealed "5.6 cm air containing extraluminal fluid
collection anterior to the uterus is at least partially
rim-enhancing". She was started on intravenous cipro and flagyl
since the colelction was too small for drainage. Dilaudid PCA
was continued for pain management.
On ___, the patient underwent ___ drainage of the fluid
collection that was found after speaking with the interventional
radiologist. Drainage cultures grew out mixture of gram negative
rods, gram postive cocci and gram postitive rods.
On ___, the patient still had significant amount of distention
and was not yet passing flatus. ___ light of having been kept NPO
since admission, TPN was ordered for nutritional support and a
PICC line was placed. The nasogastric tube was clamped and there
wasn't a residual after 8 hours time. On ___, the patient's
nasogastric tube was discontinued. At this time, wound cultures
demonstrated pseudomonas, and Cefepime was added to the
antibiotic regimen. The patient underwent a repeat Cat Scan
which demonstrated "Pigtail catheter ___ fluid collection
anterior to the uterus with resolution of fluid collection.
Small second fluid collection, slightly larger ___ size than on
the most recent prior study". A sinogram demonstrated a fistula
between the pelvic collection and small bowel. Pathology results
came back and demonstrated a lymphangioma ___ the
ileum/intestinal segment.
On ___, the patient was advanced to clears, which she tolerated
well. Subsequently she was advanced to a regular diet and did
not have any nausea or vomiting. She was passing flatus and had
a bowel movement.
On ___, the patient did have emesis of 200 cc and she was backed
down to clear liquids. She continued to have emesis the
following evening of approximately 2 liters. An abdomen xray was
performed and did show air fluid levels. The patient declined
having a nasogastric tube placed and thus was kept NPO.
On ___, due the recurrent vomiting, the patient underwent
another cat scan which revealed "Recurrent complete small bowel
obstruction the level of the transition
point ___ the mid abdomen with distally collapsed loops of small
and large bowel with some residual dense enteric contrast
opacifying the collapsed distal small bowel and cecum from a
prior CT". Resolution of extraluminal fluid collection anterior
to the uterus with a percutaneous pigtail catheter ___ place
compared to ___. Adjacent 2.4 cm rim enhancing fluid
collection lateral to the existing catheter is likely too small
to effectively drain." The patient was kept NPO. She was started
on oral reglan. The patient's midline abdominal staples were
discontinued.
Despite the obstruction, the patient was passing flatus and
having frequent bowel movements. Her diet was advanced and she
was able to tolerate it, and her obstruction ultimately resolved
on its own.
Upon discharge, the patient had one JP drain ___ place which will
be discontinued at her followup appointment. She was tolerating
a diet and had bowel function. The patient's wound cultures were
thrown out, thus the sensitivities that were requested were
unable to determined. Infectious disease was consulted prior to
the patient's discharge regarding the most appropriate
antibiotic course. They recommended that the patient continue a
course of IV Cefepime and oral Flagyl until her followup
appointment.
On ___, the patient was discharged home with followup ___ the
___ ___ 2 weeks. Her vital signs were stable and she was
afebrile. She was ambulating independently. Her white blood cell
count was 9.6. | 999 | 758 |
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