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14950449-DS-2 | 28,000,087 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to hospital after suffering a
fall at the rehab facility you were residing in. After
performing several imaging studies we determined that you have a
fracture in your cervical spine. The spine surgeons evaluated
you and determined that you should continue to wear a cervical
collar for ___ weeks post discharge.
The following changes have been made to your medications:
START: Ciprofloxacin for 6 more days to treat your urinary tract
infection
STOP:
Omeprazole
YOUR CERVICAL COLLAR SHOULD NOT BE REMOVED AT ANY TIME UNTIL ___.
___ YOU THAT IT IS OK TO DO SO. | Ms. ___ is a ___ w h/l Alz Dementia, CVA who at baseline is
non communicative and non mobile presents to ED after suffering
fall at ___. She was found to have suffered a cervical
fx as well as a R femoral neck fracture.
# C2 Cervical fracture- The pt suffered a C2 anterior plate tear
drop fracture after suffering a fall at a rehab center. She was
evaluated by ortho spine who determined no surgical intervention
was warranted. She was placed in a cervical collar which should
remain in place for ___ weeks. She has a follow up appointment
with Dr. ___ in ___. It was originally thought on a
preliminary read in the emergency room that she may also have
suffered a hip fracture as well. On further imaging studies this
was determined to not be the case. She did not suffer a hip
fracture during this fall and is OK to resume prior activities.
# UTI- Per ___ records she has had recurrent UTIs in
the past. Current U/A is positive for infection. She was started
on ceftriaxone to treat her UTI. She was then switched over to
Ciprofloxacin renally dosed to complete a 7 day course.
.
# DM II- she was placed on an ISS for meal time coverage. We
held metformin and Glyburide.
#Alzheimer's Dementia- per records and HCP pt's baseline is
immobile and non-communicative. She is not on medications at
home for this disorder. She remained at her cognitive baseline
during this admission.
#GERD- pt is currently taking omeprazole at home. Considering
her age and co-morbidities we recommend she not continue to take
this medication as it pre-disposes pt's to bone density loss and
increased bone fracture occurrence.
#Transitional:
1. Pt should complete a 7 day course of Ciprofloxacin for her
UTI
2. Discontinue Omeprazole
3. F/U with Dr. ___ for re-evaluation | 105 | 314 |
11940376-DS-15 | 22,485,297 | Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | This is a ___ year old ___ female who reported sudden onset
headaches 2 days ago that progressed. The patient was taken to
___ where a head CT showed a SDH and was loaded with
1 gram of phosphenatoin and sent to ___ for further
management. The patient continued to experience complains of
headache. The patient denied any nausea,
vomiting, weakness or paresthesia. The images were shown to
patient
and family. Natural history was discussed in detail and the
possible need for surgical intervention. The patient was
admitted to the surgical intensive care unit for close
neurological assessment and kept NPO for possible surgical
intervention in case patient decompensated.
On ___, A repeat NCHCT was performed at 1100 am which was
found to be stable and the images were shown and explained to
the patients and her husband. The patient was transferred to
the Step Down Unit and a regular diet was initiated. The
patient continued to report headache and was given oxycodone and
fioricet for pain. The patient reported that following dilaudid
and morphne doses she experienced pruitis and these medications
were documented as allergies. She had no further issues while in
the hospital. She was discharged home with 24 hour supervision
per OT recs on ___. | 128 | 214 |
14363902-DS-16 | 23,853,783 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds) for
2 weeks.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 2 weeks and while
Foley catheter is in place. | The patient was admitted to Dr. ___ service from the
___ ED after presenting with an obstructing left ureteral
stone. The next day he underwent cystoscopy, left ureteroscopy,
laser lithotripsy, and left ureteral stent placement. No
concerning intraoperative events occurred; please see dictated
operative note for details. The patient received ___
antibiotic prophylaxis. Patient's postoperative course was
uncomplicated. On POD0 the pt was tolerating a regular diet,
nausea had resolved, and pain was well-controlled on PO
analagesics. Flomax was given to help facilitate passage of
stones. At discharge, patient's pain was well controlled with
oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He was given
explicit instructions to call Dr. ___ follow-up. | 317 | 122 |
19838167-DS-12 | 23,930,640 | You were admitted because tests for liver injury were higher
than normal. While you were in the hospital we investigated a
cause for why there was liver injury. To date your tests were
negative and your liver function tests are coming back down. The
current thought is that the liver injury was from the antibiotic
Augmentin (amoxicillin/clavulanate)
Please do not take the antibiotic Augmentin
(amoxicillin/clavulanate).
Please follow up with your outpatient gastoenterologist Dr.
___ follow up labs in 2 weeks with labs. | Primary Reason for Hospitalization:
___ with a history of Crohn's disease s/p partial colectomy and
recent additional partial colectomy for bowel perforation after
colonoscopy who presented with transaminitis and nausea was
found to have likely drug-induced hepatitis. | 80 | 36 |
11539240-DS-14 | 21,962,932 | Dear Miss ___,
We evaluated you for your fall and found you to have a fracture
of your spine. You were also found to be in mild congestive
heart failure and we continued to give your higher dose of lasix
while in the hospital. We had the spine surgeons come and see
you and they believe that you need to go for followup in 2 weeks
and you must wear your collar at all times. For showering you
may use a separate collar and then replace it after your shower.
You had a laceration to your left arm that was repaired on
___ you will need to have those sutures taken out between
___. You should Weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
Here is the information about your neck injury:
You have the following injury: C2 fracture
-Activity: You should not lift anything greater than 5 lbs for 2
weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
-___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
-Swallowing: Difficulty swallowing is not uncommon in the
collar. Please take small bites and eat slowly. Please limit
movement of your neck while eating.
-Cervical Collar / Neck Brace: You need to wear the brace at all
times until your follow-up appointment which should be in 2
weeks. You may use a second collar when in the shower and then
allow it to dry while while you put on the dry one. Limit your
motion of your neck while the collar is off. You will need help
with changing collars.
-Follow up:
oPlease Call the office at ___ and make an appointment
for 2 weeks with Dr. ___ Dr. ___.
o At the 2-week visit we will take X-rays and answer any
questions.
Please call the office with questions. | ___ F w/ bivent pacer, mechanical mitral valve on coumadin, a
fib, dialted cardiomyopathy w/ c2 stable fracture s/p fall on
___ and a CHF exacerbation clinically and on chest xray.
Patient received iv diuertics in emergency department we
continued her higher home dose of oral lasix in order to try and
bring diueris her. Her respiratory status continued to improve
throughout the stay and stayed for the weekend in order for
rheab placement. She continues to improve, but has a very poor
baseline cardic status therefore minimal interventions should be
attempted for changes. | 340 | 96 |
11544860-DS-16 | 22,429,647 | Dear Ms. ___,
It was a pleasure caring for you. You were admitted for an
infection in your abdomen caused by a connection between your
kidney and your colon. While you were here, we also found that
you had an infected hip so this was removed. You have a drain in
the collection in your abdomen and will continue antibiotics
until instructed by your physicians. You were also found to have
low blood pressure and kidney injury and have been receiving
diuretics to help remove more fluid.
Given your goals to be closer to family, you are being
transferred to ___.
We wish you the best. | SUMMARY
___ year old woman with PMH of afib on coumadin, IDDM,
obstructing R colon mass s/p colectomy (2mo ago), L hip fracture
from fall s/p repair 2wks prior to admission, urinary
incontinence and frequent UTIs who was transferred from ___
___ with abdominal pain/distention and CT findings
concerning for possible emphysematous pyelonephritis, found to
have anastomotic leak with adjacent abscess. It appears that she
had an anastomotic leak from her colectomy, causing an
intraabdominal fluid collection. This collection fistulized to
the ureter on the right (causing UTI also with ___ although
also growing E.coli), which likely caused transient bacteremia
and seeded her left prosthetic hip, now s/p explant of hardware
which is growing ___, VRE, CONS. Her course is complicated
by septic shock, AFRVR, volume overload, and ___.
1. Prehospital course
Patient had an obstructing R colon mass that was removed via
colectomy (~2 mo PTA). She was convalescing when, 2 weeks PTA,
she fell and fractured her L hip. She underwent ORIF and was
again convalescing at rehab when she started to endorse
abdominal pain and distention. Her family noted her to have
decreased PO intake and increased confusion from her baseline.
Given worsening symptoms, she was transferred to ___
___, and CTA abd/pelvis showed extensive air around right
renal collecting system. Surgery and urology were consulted and
recommended broad spectrum antibiotics but did not feel that she
was a surgical candidate. She was subsequently transferred to
___ for ongoing management on ___.
2. Initial ICU Course (MICU/SICU)
___ - admitted to MICU
___ - ___ drain placement to colonic abcess
___ - transferred MICU to SICU (ACS B)
___ - hip ___ with Ortho. Called out from SICU to
Medicine; due to hypotension, admitted to MICU.
___ - transferred from MICU to Medicine
She was seen by urology who felt that findings were not classic
for emphysematous pyelonephritis and were more consistent with
intra-abdominal abscess/anastomotic leak from prior colectomy
which appears to be fistulized to the ureter on the right
(causing UTI). She underwent ___ guided percutaneous drain
placement on ___ with drainage of purulent material. Her
infection likely caused a transient bacteremia and seeded her
left prosthetic hip, now s/p explant of hardware which is
growing ___, VRE, CONS.
ID was consulted. She initially received Vancomycin
(___) and meropenem (___) and then zosyn
(___). Ucx from ___ & ___ grew ___ albicans and
E.Coli. JP drain Cx from ___ grew ___. Infectious disease
was consulted for assistance, and given that the urine and JP
drain grew yeast, they recommended initiation of fluconazole
(___). The patient was then found to have drainage at the
incision site of her prior left hip ORIF. Orthopedic surgery was
consulted; she underwent removal of hardware, antibiotic spacer
placement and wound vac placement ___.
Postoperatively, she was readmitted to MICU for hypotension,
felt to be due to bacteremia/fungemia from joint washout with
contribution from sedation. She remained on pressors for several
days. TTE was done to look for endocarditis and was negative for
this finding. She developed AFRVR and received amiodarone
loading and heparin gtt. She had gross volume overload with
anasarca, c/b hypoxemia, due to crystalloid resuscitation and
malnutrition; she was intermittently diuresed with lasix
bolus/gtt. She had ___. She also has a left radial head fracture
(a consequence of her earlier fall) and is in a splint for
comfort. Infectious disease following; a course of antibiotics
for her multiple infections has been outlined.
Given clinical stability, she was called out to the floor.
Cipro was started on ___ and continues on.
Fluconazole was started on ___ and continues on.
Linezolid was started ___ and continues on.
3. Initial floor course (___)
The patient was transferred to the Medicine floor. On the
Medicine service, she continued to receive antibiotics as
recommended by ID. She was diuresed with lasix boluses for
anasarca. The ID service informed us that the patient's
intraabdominal infection was unlikely to resolve without
surgery. A goals of care discussion was held ___ this
information was shared with the family. They hoped to hear the
opinion of surgery prior to proceeding.
On ___ The acute care surgery service felt the patient not to
be a surgical candidate due to frailty and her other
comorbidities. Additionally, the patient became progressively
hypotensive (SBP ___ with acrocyanosis and increased
somnolence. We contacted the family to pursue further ___
discussions at this time, but they were unavailable by phone. We
therefore consulted the MICU, and the patient was transferred to
___ for further care.
4. ___ ICU Course (___)
Patient was transferred to the FICU in the setting of
hypotension and worsening mental status on the medical floor on
___. She was restarted on a Lasix gtt with bolus as it was felt
that her hypotension was in the setting of volume overload. The
patient's respiratory status and hypotension improved with Lasix
gtt. She also developed a worsening ___ which improved with
Lasix gtt. There was low suspicion that the patient's underlying
infection was contributing to her hypotension and no changes
were made to her antibiotics.
Finally, ___ discussions were continued in the ___. After
discussion, code status was transitioned to DNR/DNI however the
patients daughter was not interested in hospice care but was
interested in transfer back to a facility or hospital closer to
the patient's home in the hopes that she could eventually
tolerate definitive surgical management of her intraabdominal
abscess.
5. ___ Service (___)
Patient was transferred to the medicine service. Was continued
on her antibiotics as above. Confirmed with surgery that they
did not feel surgery was indicated given the fact that patient
could eat, but that if surgery were absolutely necessary (eg in
acute worsening, she could theoretically be a surgical
candidate). ID agreed therefore to continue the current
antibiotic regimen with plans for interval follow up of her
abdominal imaging once creatinine allowed contrast to help
determine plan for abdominal abscess. She was also seen by
ophthalmology given the presumed candidemia given multifocal
___ infection and did not find any evidence of
endophthalmitis. Patient continued on Lasix gtt at 5mg/hr with
robust urine output and ___ negative per day with stable
hemodynamics. Her creatinine on ___ was 2.1 (and had been
downtrending from peak of 2.5 on ___ and continued to
downtrend with diuresis, to a low of 1.7 on ___, but then rose
on ___ so diuresis was stopped. Creatinine dropped when
diuresis stopped, but given her obvious anasarca efforts to
resume furosemide were begun (as bolus of 60mg) but each time
creatinine rose, so patient is being given a break for diuresis
for now, though is still very grossly volume overloaded in her
total body, but potentially not intravascularly. Patient had
been noted to be aspirating in the ICU, but given her goals of
care, family opted to allow her to eat for comfort, recognizing
the risk of aspiration. She has tolerated PO reasonably well
without overt aspiration. Patient and daughter were both very
clear that they recognize significant decline but are hoping for
a time limited trial of therapy to assess for improvement and
failing that there can be consideration of moving towards
hospice or comfort. She was seen by the palliative care team who
affirmed this plan/goals. On ___ she developed leukocytosis
without fever or other symptoms. Non contrast scans of
chest/abd/pelvis did not demonstrate an obvious cause, discussed
with orthopedics who did not feel she had any infection in the
hip given the surgery and the spacer in her hip, urine continued
to be dirty but as expected, and blood cultures were drawn and
NGTD. C diff was sent given diarrhea and abx, but this was
negative. Wound on back is not grossly infected, but this can be
considered as a possible source. | 104 | 1,274 |
16892632-DS-15 | 26,964,561 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | This is an ___ patient, with extensive coronary artery
disease history with multiple stents in the past, who presented
with recurrent pain and was investigated, and coronary angiogram
showed left main stem disease with severe 3-vessel disease with
ongoing chest pain, and hence she was admitted for urgent
coronary artery bypass grafting. On ___ the patient underwent
an urgent coronary artery bypass graft x5, left internal mammary
artery to left anterior descending artery, and saphenous vein
grafts to obtuse marginal 1 and 2 as a sequential graft, and
saphenous vein graft to diagonal, and saphenous vein graft to
posterior descending artery. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. Out of
the OR, chest tube drainage was high and she was given FFP and
3 units RBC's. Her bleeding slowed post op night and she was
hemodynamically stable and weaned off vasoactive medications by
POD 1. EP interrogated her PPM and increased her atrial pacing
rate to 80, which improved hemodynamics. This was reprogrammed
to atrial pacing 60's prior to discharge. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. She was on
a 2 liter fluid restriction for hyponatremia (Na 130->132 prior
to discharge.) Sodium should be rechecked in ___ days at rehab.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating with assistance, the wound
was healing well and pain was controlled with Ultram. The
patient was discharged to ___ in good condition with
appropriate follow up instructions. | 132 | 314 |
10868254-DS-20 | 25,209,566 | You will have multiple follow up appointments to keep. Please
call ___ if you have any questions.
You were seen at ___ for falling and injuring your jaw. After
being evaluated by the Trauma surgery team, the ENT surgeons,
and the Oral Maxillo Facial surgeons, it was determined that you
were safe to go home without surgery and to have a follow up
appointment with your primary care provider to evaluate the
cause of your fainting episodes. You should schedule this
appointment as soon as possible.
You should take all of your medications before as prescribed,
and take your new medications as directed. In addition, it is
important to follow the following recommendations:
- Please use the Ciprodex ear drops as prescribed 4 drops in
right ear BID x10 days
- Do the best you can to keep your ear dry other than the ear
drops
- Follow-up with Dr. ___ in clinic in 5 days for wick
removal and re-evaluation.
- It is okay if the ear wick falls out on its own prior to
follow-up. This is a good sign that suggests that the swelling
in
the patient's EAC has improved. Continue using ear drops even if
the wick falls out.
Using Ear Drops
1. Lie down with the affected ear up. You cannot do this
when sitting
2. Place the prescribed number of drops in the ear.
3. Stay in this position for 5 minutes.
4. While you are lying there:
Pull on the earlobe a few times;
Push in front of the ear a few times;
Open and close the mouth a few times.
5. When you sit up, the excess drops will come out. Blot this
excess with a tissue.&
-If the ear drops make you dizzy, try warming them up by holding
them in your hand or against your body.
-If you taste the drops, this is okay, as long as they do not
hurt.
-You can use a cotton ball in the ear to catch the excess
drops, or the discharge from the infection or blood if the ear
is
bleeding. However, do not leave the cotton ball in the ear
longer than necessary.
You should also begin taking a multivitamin daily and ensure
plus with each meal as you can tolerate it to help with your
nutrition.
If you notice any fevers, chills, swelling, new drainage or
swelling in your jaw, difficulty breathing, or anything else
that concerns you, please don't hesitate to call or return to
___. | The patient was evaluated in the ED s/p fall. Found to have an
open R mandibular condyle fracture on CT. Evaluated by ___,
Neurosurgery and ENT.
CT head and C-spine were obtained in the ED, given the mechanism
of injury and obvious resulting mandible injury, and revealed
comminuted mandibular fracture as well as atlanto-occipital
subluxation. He was then placed in a hard cervical collar and
neurosurgery was consulted. The CT was reviewed with Dr. ___,
___ neurosurgeon on call, and determined not to have any
features suggestive of acute traumatic component. In light of
the patient having gotten up post-injury and self-mobilized his
head and neck with a fully intact exam on arrival, it is safe
to clear the cervical spine without the need for MRI, per
discussion with Dr. ___. No further imaging or neurosurgical
intervention necessary for the finding of subluxation at this
time. Management of the remaining mandibular injuries per
ED/trauma surgery. Of note, Mr. ___ brother reports that he
has had several falls in the past year, and that he has a long
history of heart murmur, primarily followed at the ___.
Appropriate recs were provided by the consulting services. Per
___ Surgery was not indicated, and the patient was scheduled
for outpatient followup. Pt was trialed on a full liquid diet
after a Speech and Swallow evaluation demonstrated no
aspiration. He tolerated the diet well without pain or
aspiration and was then transitioned to a pureed diet. After
discussion with the patient's care provider and brother, it was
determined he would be safe at home, on a pureed diet, with
appropriate follow up.
Throughout the patient's hospitalization his vital signs and
I/Os were closely monitored. He reported no pain and was not in
any apparent distress. He was discharged ambulatory, voiding
without difficulty, and tolerating a pureed diet. His caretaker
was given instructions for post hospitalization care and follow
up along with contact information, and agreed to provide for his
further care needs. | 413 | 336 |
12192352-DS-21 | 26,465,918 | Dear Mr ___,
You were hospitalized due to symptoms of unsteadiness resulting
from an acute ischemic stroke, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are: high blood pressure
<>
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. | Mr ___ is an ___ year old right handed man with with PMH of
HTN, who presented with
acute-onset balance and coordination problems as well as double
vision, in the setting of three recent episodes of dizziness
that may have been posterior circulation TIAs. With CT evidence
of old pontine infarct. His exam, demonstrated impaired vertical
gaze and convergence-retraction nystagmus strongly suggestive of
a dorsal midbrain injury likely secondary to small-vessel CVA;
also veering to left, perhaps due to involvement of cerebellar
outflow fibers.
He was admitted to the floor and an MRI of the brain
demonstrated a small acute left anterior pontine infarct and a
left posterior tectal pontine infarct. No bleed seen. Bilateral
periventricular and subcortical small vessel disease. Vessel
imaging with a CTA brain/neck: No significant intracranial or
extracranial
disease. There is a fenestration of the right vertebral artery
in the V3 segment.
Therefore the most likely etiology was an occlusion at the
origin of a pontine circumferential artery or lipohyalinosis.
Risk factor includes HTN. Less likely etiology would be cardiac
embolism. He was in normal sinus rhythm but a cardiac echo
demonstrated a patent foreman ovale. As the stroke did not have
an embolic appearance he was continued on Aspirin for an
antiplatelet, and we will obtained lower extremity venous
dopplers as an outpatient to assure no source of paradoxical
emboli. Additionally there was no sign of vertebral artery or
basilar artery large vessel disease. Therefore, he was
continued on Aspirin 81 mg daily. For risk factor redcution
Fasting lipids demonstrated LDL of 79 and hba1c 6.1, which were
both within range. He was seen by physical therapy and
occupational therapy who cleared him for discharge home.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =79) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 280 | 475 |
15552829-DS-8 | 24,955,768 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were admitted to the hospital for an episode of chest
pain following an abnormally high elevation of your blood
pressure.
What was done while I was in the hospital?
- Pictures were taken that showed you did not have a bleed in
your brain and no changes in your heart and lung.
- You were started on a IV medication to drop your blood
pressure rapidly. You were then transitioned to your home
medications and weaned off the new medication. This allowed your
blood pressure to stabilize without further chest pains.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have severe headaches or chest pains, please tell
your primary doctor or go to the emergency room.
- You should start taking your amlodipine at night
Best wishes,
Your ___ team | Mr. ___ is a ___ year old man with HTN and LVH, with recent
admission (discharged ___ with chest pain and demand ischemia
in the setting of hypertensive emergency, who presented with
chest discomfort in the setting of hypertension. He was found to
have no acute intracranial or cardio-pulmonary issues. His BP
was dropped utilizing a nitroglycerin drip, which was gradually
transitioned into his home med regimen through incremental
changes. The drip was terminated ___ around 5PM, with
stabilization of his BP within a reasonable range about SBP 120
through ___. According to his involved wife and the
patient, psychological stressors may play a significant role,
and he would benefit from outpatient psychology or psychiatry
therapy. | 182 | 116 |
15336238-DS-6 | 24,209,150 | Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
==================================
- You had a low blood count.
WHAT WAS DONE FOR ME?
====================
- You were transferred to ___ from ___.
- You received blood at ___ before you were
transferred.
- You had an endoscopy which showed ulcerations and a "Dieulafoy
lesion" (a small artery) that was clipped. This was likely the
source of your bleeding.
WHAT TO DO NEXT?
===============
- You should follow up with your primary care doctor as
scheduled.
- Please take the protonix (pantoprazole) twice daily as
prescribed.
- You are scheduled for a repeat endoscopy ___ to evaluate
the lesion that caused you bleeding.
- Please call your doctor if you develop severe fatigue or
weakness, black stool that is different from your usual stool,
bloody or dark red stool, or vomit blood.
It was a pleasure taking care of you,
Your ___ Care Team | Mr. ___ is a ___ year old man with PMHx CAD s/p CABG ___,
HFpEF (60%), papillary thyroid CA s/p resection ___ Dr.
___ @ MEEI), benign renal tumor s/p nephrectomy ___, CKD4,
left renal mass s/p biopsy positive for oncocytoma, colon CA s/p
colectomy ___, bladder cancer ___ s/p bcg and TURPT and recent
diagnosis of anemia ___ on Procrit (10,000 U Q14 days) who is
transferred from ___ in the setting of anemia.
# Acute post-hemorrhagic anemia:
# Gastrointestinal hemorrhage due to Dieulafoy lesion
Initial Hgb 5.1 at ___, then transfused 2 units. He was
transfused another unit of PRBCs on arrival to ___ ED. He has
a baseline anemia from CKD, on Procrit at home, and presumably
had a microcytic anemia c/f iron def at some point since he was
started on iron sulfate ~ ___ year ago. Has now required 6
transfusions this year, and previously was not transfusion
dependent (last transfusion prior was in ___ per him). Stool
was guaiac positive at ___ office and at ___. Laboratory workup
not suggestive of hemolysis. He was started on IV pantoprazole
BID, and underwent EGD which noted 2 mm raised red spot was
found at the fundus, consistent with a Dieulafoy lesion.
Endoclip was placed. Ulcers were also noted in the stomach body.
A submucosal mass was seen in the antrum. His hemoglobin
remained stable post-procedure and he will need GI followup as
described below.
# Type II NSTEMI
# Dypsnea on Exertion
# HFpEF
# CAD s/p CABG
Patient has known CAD w/ CABG ___ yrs ago and chronic diastolic
heart failure. He presented with elevated troponins in the
setting of type 2 demand ischemia from profound anemia (Hgb 5 at
OSH), and further retention of troponins in setting of known
stage 4 CKD. EKG w/out ST elevations/depressions. His trop T
were elevated to 0.11 at ___ ___, when he was admitted for SOB
and found to profoundly anemic earlier this year, and at that
point they commented that he has a baseline trop elevation. He
received transfusions as above. Troponins and CK-MB stabilized
with no further evidence of myocardial ischemia. Continued home
torsemide 30 BID.
# Asymmetric lower extremity edema: Patient reports weeks of LLE
worse than RLE. Denies history of VTE or calf pain or
tenderness. Left lower extremity ultrasound without evidence of
venous thrombosis. Continued home torsemide.
# HTN: Blood pressure was well controlled. Continued home
hydralazine, isosorbide mononitrate, amlodipine, and metoprolol.
# CKD IV: Baseline is 2.7 to 3.0. He remained at baseline during
this admission. Continued sodium bicarbonate.
# Hypothyroidism: Continued home levothyroxine.
# HLD: Continued home atorvastatin.
# BPH: Continued home finasteride, tamsulosin. On day of
discharge, patient reported some weakening of his urine stream.
PVR was 399 and patient was completely asymptomatic without urge
to void. Patient preference was to follow up outpatient with
PCP. We offered foley placement but patient declined. We
discussed the risks of urinary retention including infection and
renal injury. Flomax increased to 0.8mg QHS on discharge. Please
obtain PVR at next PCP office visit and encourage follow up with
patient's urologist as needed.
# Asymptomatic bacteruria:
On admission, an asymptomatic UA was obtained notable for 3 WBCs
but negative ___ or nitrite. Of note, on day of discharge,
patient reported symptoms of weakened stream in setting of
prostatic hypertrophy. After discharge on ___, his urine
culture resulted positive for enterococcus. Mr. ___ was
called at his home on morning of ___ and he reports a strong
urination stream. He specifically denied dysuria, hematuria,
malodorous urine, change in urine color, urinary frequency, or
urgency. He denies fevers, chills, abdominal pain or back
discomfort. He would like to defer antibiotic treatment for now
and would like to have a UA repeated at his next PCP ___. | 139 | 630 |
17545257-DS-16 | 21,041,500 | Dear Mr. ___,
It was a pleasure looking after you during your stay at the
___.
You were hospitalized due to symptoms of right facial weakness
resulting which was likely a transient ischaemic attack or a
"mini stroke" resulting in a transient blockage of a blood
vessel supplying an area of the brain or a fluctuation in
perfusion in an area of your prior stroke. We perforemd an MRI
which revealed evolution of your previosu stroke around the time
of your operation in ___ but not a new stroke. Due to our
___ vessels with your new operation, there may be varying
blood supply to the brain and can put you at risk for stroke. As
such we have set up an outpatient appointment with Dr ___ who
is a neurosurgeon with expertise in the management of mo___
in addition to neurology.
We also performed an echocardiogram which showed that there was
a very slight decrease in heart function with it not pumping
quite as well as expected for someone of your age. It is unclear
when this occurred as you have been previously asymptomatic and
whether this was due to a viral or other cause and will need
further workup as an outpatient. For this, your PCP should refer
you to cardiology.
The echocardiogram also revealed a small communication between
the two sides of the heart called a patent foramen ovale which
can be normal but can also lead to a possible but rare cause of
stroke from a blood clot travelling from the venous circulation
to the heart and crossing to the other side causing a stroke. A
such we evaluated you with ultrasounds of your legs to look for
any evidence of blood clots which were normal.
Given that aspirin is the best treatment for ___ we will
continue you on this.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- ___ disease
- Patent foramen ovale
We have made no changes to your medications.
Please continue to take your aspirin 81mg daily as prescribed.
You have both neurology and neurosurgery follow-up in addition
to your PCP as below. If you have further symptoms, please
present to your nearest ED for evaluation.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake | Mr. ___ was admitted to the stroke service, floor
with telemetry, following several episodes of mental fogginess
and right facial droop.
His MRI brain at ___ from ___ was compared with his MRI
brain from ___ from ___. Per Dr. ___
___ of the imaging, this comparison did not reveal any
acute or subacute ischemic changes in the area of the known
chronic left lenticulostriate infarct that was seen on the
___ MRI of the brain. His episode of transient right lower
facial droop from two weeks ago was diagnosed as a transient
ischemic attack. This is most likely due to poor perfusion in
the left hemisphere due to the ___ disease. This area of
poor perfusion may have been in the area of the chronic left
lenticulostriate stroke.
Neurosurgery was consulted and an angiogram was initially
planned to check his extracranial to intracranial bypass
patency. However, the Neurosurgery team contacted Dr. ___,
___ Neurosurgeon from ___,
and found out he had had a encephaloduroarteriosynangiosus
procedure and NOT an intracranial bypass, the conventional
angiogram was not performed. His CTA showed that both M1
segments of the middle cerebral arteries were occluded just
after their origins with distal reconstitution, and the
supraclinoid internal carotid arteries were narrowed, consistant
with his diagnosis ___ disease.
He underwent an echocardiogram as part of the stroke workup
which was abnormal - showing an EF of 50% , with mild
biventricular hypokinesis and a PFO. Therefore, LENIs were
obtained - they did not show DVT in the lower extremities. His
lipid panel and HbA1c were normal.
The etiology of his transient ischemic attack was determined to
be poor perfusion in the setting of stenosis due to ___
disease. He was continued on his home aspirin, 81mg daily. | 535 | 289 |
11900173-DS-7 | 25,456,322 | 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 noted to
have elevated liver enzymes.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, your liver function tests were trended for
improvement. You had a right upper quadrant ultrasound that
identified possible hepatic steatosis, but no obvious
obstruction in your biliary tract.
- You had a procedure called an MRCP.
- You were evaluated by the liver team, who felt that you were
likely to have a condition called primary sclerosing
cholangitis. It is also possible that you had drug-induced
liver injury from Remicade in addition.
- You were started on a new medication called ursodiol.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- You will have follow-up with your primary care physician, your
hematologist, and an autoimmune liver disease specialist.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
The patient is a ___ with history of colitis (recently
on infliximab) due to transaminitis and hyperbilirubinemia,
asymptomatic and found on routine labs. Right upper quadrant
ultrasound found steatosis but ruled out gross obstruction of
the biliary tract. He had MRCP which revealed related findings
consistent with sclerosing cholangitis. Given the pattern of
transaminitis, it is thought he may also have had drug-induced
liver injury from Remicade. Transaminases and bilirubin down
trended throughout the admission. He remained a symptomatic
throughout the admission. He was started on ursodiol with plan
to follow-up as outpatient in the ___ clinic with Dr.
___ as well as with his primary hepatologist Dr. ___
PCP. | 174 | 111 |
19930907-DS-12 | 20,588,915 | Dear Mr. ___,
You were hospitalized due to symptoms of left-sided weakness
leading to a car accident resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we gave you the medication
for acute stroke (tPA) and took you for angiographic
intervention (with placement of right internal carotid artery
stents and clot retrieval).
We are changing your medications as follows:
- ADDING aspirin 81mg daily and Plavix 75mg daily which you
should remain on indefinitely.
YOU SHOULD REFRAIN FROM DRIVING until you are evaluated by the
___ DriveWise Team and are cleared to drive. We do not think
there is a serious contraindication for you traveling via plane
(you asked specifically about an upcoming trip to ___,
and we think this would be safe).
Your echocardiogram did not show any possible sources of stroke,
although there was one small unusual finding for which you
should receive a repeat echocardiogram in ___ years.
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
It was a pleasure taking care of you during this
hospitalization.
Sincerely,
Your ___ Neurology Team | This is a ___ year old man with chronic Hep B, splenic art
aneurysm who presented acutely after new left-sided weakness and
neglect leading to MVA on ___. On arrival to OSH he was found
to have NIHSS of 6 and CT showed hyperdense R MCA, was given iv
tPA at 22:00 and transferred to ___.
# Neuro
At ___ was 8 (LUE went to 2 and sensory deficit noted
in addition to tactile extinction) and CT/CTA showed R
extracranial carotid occlusion, right vert dissection and distal
R M1/M2 occlusion. He was taken urgently for endovacular
intervention around midnight and had 3 stents placed
extracranially (1 in the ECA, two in series in the ICA), he had
clot retreival, and carotid was successfully recanalized at
01:10 (~5h). He was admitted to the neurology ICU for post-tPA
care and monitoring. He had an unremarkable course and was
subsequently transferred to the floor, where his neurologic
examination continued to improve. Suspected etiology R-ICA
dissection with R-MCA (M-2) occlusion. Echo and telemetry did
not suggest alternative cardioembolic source, although he had
mildly dilated aortic arch on echo without any other associated
abnormalities for which he needs a follow up study in ___ years
as recommended by Cardiology guidelines. Evaluation of stroke
risk factors revealed A1c of 5.3 and LDL of 94. He was started
ASA 81mg/Plavix 75mg for indefinite secondary stroke prevention.
SBP goals 120-160 and plan for DriveWise driving clearance as
outpatient. | 371 | 238 |
10314252-DS-3 | 25,593,676 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had 10 days of abdominal
pain and diarrhea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, we did blood work and imaging to investigate
potential causes for your abdominal pain. The tests were
reassuring that there was not any underlying infection or
inflammation. It was also reassuring that improvement in pain
and diarrhea was noted.
- We also noted that your hyperactive bowel sounds were
increasing your anxiety so we optimized your medication.
- We also started a medication to help with your hyperactive
bowel which helped with your symptoms.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old female with history significant for
HTN, palpitations on digoxin, diverticulitis, IBS, GERD, anxiety
and depression who presents with 11 days of abdominal pain and
diarrhea, now largely resolved. Patient was also concerned of
her hyperactive bowel which she notes improvement after starting
Simethicone. | 167 | 51 |
19820565-DS-17 | 21,753,063 | Please call the Neurosurgery Office ___ on ___ for
your cerebral spinal fluid culture results now pending from
___.
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion, lethargy or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ New onset of the loss of function, or decrease of function
on one whole side of your body. | This is a ___ year old female with history of meningitis,
deafness and post
meningitic hydrocephalus s/p VP shunt at age ___ years old and
revision at ___ years old presents with headaches, nausea and
vomiting, and pain along VP shunt tract x 5 months. The patient
was evaluated by the neurosurgery service and admitted for
further evaluation and work up. On ___ there was a non
contrast head CT performed that was consistent with intact
right ventriculostomy catheter terminating in unchanged position
in the
right frontal horn. Stable ventricular size and configuration
without new
ventriculomegaly. No intracranial hemorrhage. The patient was
observed on the floor with every 4 hour neurological
assessments.
On ___, the patient was found to be neurologically stable.
After careful review of the Head CT. There was no indication
for urgent or emergent surgery. This was discussed with the
patient and decision as made to discharge the patient home with
follow up in the ___ clinic at a later date. | 168 | 172 |
12697000-DS-12 | 29,910,389 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for shortness of breath and abdominal distension,
caused by an exacerbation of your congestive heart failure. We
re-imaged your heart and did not find any evidence of active
bleeding. We gave you medications to help remove fluid from your
body and you improved.
Please weigh yourself every morning and call your PCP if weight
goes up more than 3 lbs, as this can be a sign of fluid
overload. You also experienced atrial fibrillation, but your
heart spontaneously converted back to sinus rhythm. | ___ with PMH presumed infarct related cardiomyopathy (EF
___, bicupsid aortic valve s/p bioprosthetic replacement
which degenerated and was replaced in ___ with a mechanical
valve, s/p Bentall procedure secondary to type A aortic
dissection (___), atrial fibrillation/flutter s/p ablation and
VT/Vfib arrest s/p ICD who was admitted on ___ for VT
ablation c/b a small LV perforation resulting in tamponade
presented with dyspnea and abdominal distension c/w an acute on
chronic CHF exacerbation.
.
# Dyspnea: Etiology likely acute on chronic congestive heart
failure with systolic dysfunction (worsened in setting of
pericardial effusion) in addition to atelectasis. LVEF ___ on
ECHO ___. There may be a component of diastolic
dysfunction as pt with paroxysmal a fib/flutter. Pt was
diuresed with lasix 40mg IV qd to BID to a dry weight of 81.8
kg. Home metoprolol was continued. Discharged pt on lasix 20mg
PO daily.
.
# abdominal distension: Abdominal CT was significant for small
ascites, likely due to ___ spacing in setting of CHF exacerbated
by pericardial effusion. LFTs not markedly elevated. Resolved
with diuresis.
.
#Pericardial effusion: Occurred s/p VT ablation procedure
___. ECHO ___ showed a very small pericardial effusion
with no echocardiographic signs of tamponade. ECHO ___
showed small to moderate sized loculated pericardial effusion
primarily posterolateral and apically, with no echocardiographic
signs of tamponade. Pulsus paradoxus stable between ___.
.
# leukocytosis: Prior to admission and during first 2 days of
admission pt endorsed chills with mild fever to 100.3. WBC on
___ was 15.3 with 80% neutrophils, no bands. He was started on
daptomycin and cefepime on ___ given leukocytosis, chills,
low grade fever. No localizing symptoms. U/A and CXR negative.
Blood cultures negative. Antibiotics were discontinued ___ and
patient remained afebrile with decreasing wbc count. WBC = 12.0
at time of discharge.
.
# acute kidney injury: Baseline creatinine 1.0-1.2. Etiology
likely poor perfusion in setting of CHF exacerbation. Urine
electrolytes suggest pre-renal etiology. Creatinine 1.5 on
discharge (___).
.
#HTN: Currently well controlled on metoprolol succinate 25mg qd.
Continued metoprolol during admission.
.
#atrial fibrillation and mechanical valve: Coumadin held
___ due to concern for pericardial hemorrhage with
resulting INR of 2.2. Restarted coumadin on ___ with doses
ranging from 1mg-7mg (pt manages his own coumadin and decides
what dose he will take). Continued home metoprolol as above. A
cardioversion was planned for ___, but the pt spontaneously
converted to sinus rhythm and remained in sinus rhythm through
discharge on ___.
.
## Transitional issues:
- coumadin held ___ with resulting INR of 2.2. Restarted
coumadin on ___ with doses ranging from 1mg-7mg. Please check
INR within ___ days of discharge.
- discharged pt on lasix 20mg PO daily. Please monitor volume
status, K + and creatinine. Recommend recheck of CHEM7 in ___
days.
- pt not on ACE inhibitor. LVEF 40%. Can consider starting ACE
in outpt setting. | 102 | 464 |
10692230-DS-20 | 24,373,486 | Dear Mr. ___,
You were seen at ___ due to difficulty breathing. We think
that your difficulty breathing was due to some food going down
the wrong pipe as well as some volume overload from your heart
failure. You were treated with a five-day course of antibiotics
and Lasix to get the water off your lungs and your breathing
improved.
You also had some high blood pressures so we started you on
amlodipine instead of your nifedipine.
You also had a stress test for your intermittent chest pain
which did not show any new damage to your heart.
There was also some discrepancy in your wishes in case of a
life-threatening or life-ending event. At this hospitalization,
you indicated that you would like to have chest compressions in
the event of your heart stopping and a breathing tube if you
cannot breath on your own. You have also requested to have fewer
hospitalizations. Please discuss these wishes with your family
and primary care provider and update the paperwork (MOLST) at
your facility accordingly.
Please continue to take your medications as prescribed.
We wish you all the best,
Your ___ team | ___ year old man who lives in a SNF with ___ CAD s/p PCI and CABG
___, Atrial fibrillation on coumadin, multiple episodes of
recurrent pneumonia, multiple CVAs with residual left sided
weakness, presented with fever and shortness of breath.
#Aspiration pneumonitis: Patient presented with SIRS (tachypnea,
leukocytosis, fever) and new oxygen requirement. Reports on
admission were significant for a presumed history of diastolic
CHF, although no ECHO in ___ system. Patient has a history of
recurrent pneumonia, including 3 previous admissions for
pneumonia in the last 6 months. CXR concerning for vascular
congestion and interstitial edema. Lactate 3.1 in the ED, given
1L NS, and had worsening oxygen requirement. Flu swab was
negative although he was MRSA screen positive. He received
vanc/cefepime in the ED. Sputum culture obtained but cancelled
for contamination. Lower extremity dopplers negative for DVT.
Per speech and swallow evaluation, patient has no evidence of
aspiration but postprandial reflux cannot be ruled out.
Differential includes viral PNA, aspiration PNA, or volume
overload. He completed a five-day course of levofloxacin 750mg
daily & flagyl (day 1 = ___ for atypical & anaerobic coverage
(through ___, which was given due to his history of recurrent
PNA and stroke. He was also diuresed with IV then PO Lasix. He
was treated with ranitidine for possible reflux.
# CHF: Patient has reported prior history of diastolic CHF but
no formal ECHO in ___ system. Overloaded on exam, suggesting
acute exacerbation. ECHO ___ showed LVEF = 35%. He was diuresed
with IV Lasix and then was switched to Lasix 40mg PO BID. His
spironolactone was held while inpatient. His home metoprolol was
continued.
# HTN: hypertensive to 180s intermittently in setting of held
nifedipine and spironolactone. He was diuresed with Lasix. He
was restarted on losartan and nifedipine was switched to
amlodipine. He was continued on metoprolol at higher dose. Home
isosorbide mononitrate ER 30mg daily was continued. Given
multiple medications, outpatient workup of refractory HTN should
be considered. Amlodipine should be given staggered from
simvastatin; baseline CK 148.
# Atrial fibrillation: in atrial fibrillation on Coumadin. INR
was initially therapeutic but uptrended so decreased Coumadin
from 5.5 mg PO 4X/WEEK (___), 4 mg PO 3X/WEEK (___)
to Warfarin 2mg qday. Patient was tachycardic in setting of
standing duonebs, nifedipine was held. Home metoprolol of 25mg
XL was increased to 50mg.
# Chest pain: Patient intermittently complained of chest pain.
On admission, EKG had some T wave inversions (but baseline is
unknown), Troponins negative x2. Pain is at rest, self limited,
no associated SOB, nausea, sweating, of vitals instability.
Patient described pain as pressure and may have had some
coughing afterwards, denies orthopnea but also describes PND
like symptoms. Nifedipine initially held for low blood pressures
then was switched to amlodipine for hypertension to 180s.
Cardiac perfusion scan showed mild fixed inferolateral wall
defect with hypokinesis. SBP on discharge was 150s.
# CAD s/p CABG: continued on ASA 81mg daily and Simvastatin 10
mg PO QPM.
# Left foot pain: Pt complained of severe L foot pain ___. No
evidence of infection, compartment syndrome, has painful PROM
only with pressure on plantar area otherwise WNL, afebrile, no
leukocytosis, no focal tenderness, suspect plantar fascitits vs
DTI vs fracture. Resolved ___.
# Incontinence: Has foley at ___. His oxybutynin was changed to
2.5mg BID while inpatient. His foley was continued.
# Anxiety/Insomnia: held Lorazepam 2 mg PO QHS:PRN anxiety due
to respiratory distress. He was given TraZODone 25 mg PO QHS:PRN
insomnia
# Depression: home Paroxetine 40 mg PO DAILY was held while
inpatient
# Constipation: continued Docusate Sodium 100 mg PO BID,
Polyethylene Glycol 17 g PO DAILY:PRN constipation, magnesium
hydroxide 473 oral DAILY:PRN constipation, Bisacodyl 10 mg PO
DAILY:PRN constipation
#Goals of care: Patient is now full code per wife. He has also
expressed wish for fewer hospitalizations. ___ benefit from
palliative care referral to manage chronic quality of life
problems
___ paperwork should be adjusted to reflect this.
=============================== | 188 | 649 |
17983472-DS-17 | 21,694,919 | Dear Mr. ___,
You were hospitalized after you suddenly developed droopiness on
the right side of your face as well as difficulty speaking and
slurring of your speech. Because of those symptoms, and because
they started suddenly, the possibility that you had a stroke was
investigated. An MRI of your brain showed that you did have a
stroke in frontal part of the left side of your brain, which
explains the symptoms that you were experiencing. Since you
have been in the hospital, your speech has improved. This is an
encouraging sign and suggests that your speech will continue to
improve.
In order to figure out what caused your stroke, more images of
your head and neck and some blood tests were done. One of the
images showed that there is some small degree narrowing in the
arteries that supply blood to your brain that could have led to
your stroke. Your previous history of high blood pressure, high
cholesterol, and high blood sugars (diabetes) could have
contributed to this narrowing and so blood tests were done to
check these things. Your cholesterol was normal and your blood
sugar was elevated while in the hospital.
We also did tests to check if your stroke could have been caused
by a problem in your heart. We did blood tests to help check if
your stroke could have been caused by a heart attack and those
tests were reassuring. We also did tests to see if your stroke
could have been caused by a blood clot that traveled from your
heart to blood vessels in your brain. One way that clots can
form in the heart is if you have any heart arrhythmias (abnormal
heart rhythm). In order to test this, we have started you on a
heart monitor that you will wear for at least 30 days. This
monitor will allow your doctors to ___ if you have any
arrhythmias and treat you with the proper medications if you do
have any arrhythmias. Please use this heart monitor as
instructed. We also did a cardiac echo (ultrasound of your
heart) in order to get images of your heart to see if there were
any visible clots in your heart. This test was also reassuring
(no obvious evidence of a clot in your heart at the time of the
study).
In order to help prevent another stroke, we have increased the
dose of the aspirin that you take. You were previously taking
81 mg daily of aspirin. At the time of your discharge from the
hospital, we increased the dose of your aspirin to 325 mg daily.
It will also be very important for you to continue to take your
blood pressure and cholesterol medications as prescribed. Please
continue to manage your diabetes and eat a healthy diet. At some
point you may need medication to help you control your diabetes.
It is also important that you continue not to smoke, as smoking
can increase the risk of strokes.
We have scheduled an appointment for you at your primary care
doctor's office for this ___ (the details of this
appointment are below). You should go to this appointment so
they can continue your care. We have also scheduled a follow-up
appointment for you with Dr. ___ neurologist that you
met while you were in the hospital (details below).
It was a pleasure caring for you in the hospital.
Sincerely,
Your ___ Neurology Team | Mr. ___ is an ___ old right-handed man with a past
medical history of DM, HTN and hypercholesterolemia who presents
with acute onset facial droop and aphasia characterized by
minimal verbal output, slurred speech, and intact comprehension.
=============
Active Issues
=============
#Neurology: Left frontal (precentral gyrus) infarct:
Mr. ___ symptoms and acuity of onset were concerning for
ischemic stroke. Noncontrast head CT showed no acute hemorrhage
but left frontal white matter
hypodensity suspicious for an age indeterminate infarction. CTA
head/neck demonstrated no evidence of dissection, luminal
occlusion or aneurysm greater than 3 mm in the principal
arteries of the head and neck. Subsequent MRI demonstrated acute
infarction in the left precentral gyrus without evidence of
hemorrhagic conversion as well as evidence of old L frontal
infarct. Complete carotid series suggested <40% stenosis in the
ICAs bilaterally. Carotid Doppler showed less than 40% stenosis
bilaterally. TTE demonstrated mild symmetric LV hypertrophy
with preserved EF, no evidence of ASD or gross evidence of
intracardiac thrombus.
Mr. ___ has chronic HTN, diet-controlled DM, and
hypercholesterolemia. HbA1c was 6.4. Lipid panel revealed
total cholesterol 129, LDL 77, HDL 28, triglycerides 121. TSH
was 1.2. Coagulation studies showed ___ 11.7, PTT 32.4, INR 1.1.
CK-MB was 4 and cTropnT was elevated to 0.02. Repeat cTropnT was
stable at 0.02.
The etiology of his infarct was felt to be cardioembolic vs
artery to artery embolism. While his carotid Dopplers did not
show severe stenosis, it was unclear the composition of the
atherosclerosis (soft vs hard plaque).
Patient presented with acute onset aphasia, saying that he knew
what he wanted to say but was unable to say it. He also stated
that he was slurring his words. Upon presentation to the ED,
his speech had improved. Language was fluent with intact
naming, repetition, and comprehension. He was able to read
without difficulty and was able to follow both midline and
appendicular commands. Likewise, prosody was normal.Speech was
moderately dysarthric and he did make multiple paraphasic
errors. On the day of discharge, patient felt like his speech
had improved considerably. His speech was still significantly
dysarthric. OT evaluated him and concluded that he was not in
need of any acute rehab.
Given the normal results of his lipid panel, home doses of
atorvastatin 20 nightly and fenofibrate 134 daily will be
continued.
On admission, Mr. ___ was on aspirin 81mg daily. Aspirin
increased to 325mg daily prior to discharge. Given no known
atrial fibrillation at this time and no gross evidence of
intracardiac thrombus, anti-coagulation is not indicated.
#CV:
On admission, patient's BP was 192/121. During admission, home
amplodipine 5mg daily was held and labetolol 100mg BID was
halved in order to allow for BP autoregulation. He will continue
his home antihypertensives on discharge.
#Endo: Patient is diet-controlled at home. HbA1c was pending at
the time of discharge, as above. He was maintained on SSI while
inpatient (some blood glucoses greater than 200). He may need
home glucose monitoring diabetes management at home in the
future to determine whether he might benefit from medication.
# Renal: ___.
On admission, patient's BUN/Cr were 32/1.7 but decreased to
___ prior to discharge. Patient's baseline creatinine was
unknown (last was 1.1 in ___ system in ___. Continued
monitoring of renal function is recommended, especially given
his history of chronic HTN as well as DM.
===================
Transitional Issues
===================
1. Cardiac Monitoring
Patient discharged with ___ of Hearts monitoring to assess for
underlying a-fib.
2. ___ on admission (unclear baseline). ___ consider renally
dosing medications and monitoring creatinine based on history of
HTN and DM.
3. Increase aspirin to 325 mg daily
4. Consider home blood glucose monitoring
5. Follow up with Neurology and PCP's office as scheduled
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =77) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A | 576 | 834 |
11601358-DS-7 | 21,397,343 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a motor vehicle crash sustaining multiple injuries
including: Thoracic spine compression fracture (T12),
nondisplaced coccyx fracture, sternal fracture, and right ___
rib fracture. You were closely monitored and given pain
medication to treat your pain. You were seen and evaluated by
physical therapy who recommended discharge to home to continue
your recovery.
You are now doing better, pain control is improved, and you are
ready to be discharge from the hospital to continue your
recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Rib Fractures:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Ms. ___ is a ___ yo F who was admitted to the Acute Care
Trauma Surgery service on ___ after sustaining a motor
vehicle crash car vs. wall. Patient was restrained passenger in
head on collision. Patient had chest, thoracic, and lumbar,
xrays which showed a T12 deformity. A CT torso was obtained and
showed a sternal fracture, right 2nd rib fracture, a T12
compression fracture, and a distal sacral/proximal coccyx
fracture. CT head and C-spine were negative for acute traumatic
injuries. Orthopedic spine surgery was consulted and recommended
non-operative management of her injuries with no need for
bracing. The patient was admitted to the Acute care Surgery
service for hemodynamic monitoring and pain control.
Pain was well controlled with oral oxycodone, Tylenol, iburpfen,
and topical lidocaine patches. She tolerated a regular diet
without difficulty. The patient voided without problem. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient was seen and evaluated by
physical therapy who recommended discharge to home.
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. | 555 | 246 |
12020348-DS-21 | 28,238,940 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted for mental status change. You were found to
have electrical activity in your brain consistent with seizure.
We started you on a medication to help treat this. There were
no signs of infection. Your workup for stroke was negative.
You do have periods of slow heart rate which has been present
since ___ and pauses which have been documented since last
year. We do not feel that your slow heart rate or pauses have
significantly contributed to your acute change in mental status,
particularly since you are still having these pauses but appear
well. However, to be more certain of this, we will be giving
you a ___ monitor to wear for the next ___ hours. The results
of this will be sent to your PCP, ___ will decide
whether to refer you to the electrophysiology doctors.
___ you had evidence of seizure activity on your EEG, it
will be important for you to follow up with neurology as below.
Medications started:
KEPPRA 125 mg BID for seizure
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | ___ F h/o CAD (s/p CABG), HTN, DM, CHF, CRI (bl Cr 1.4-1.8),
dementia, afib on coumadin p/w lethargy, aphasia and leaning to
right side, which resolved prior to presentation to ED.
.
# ? Left temporal lobe seizure: Pt presented with
Lethargy/leaning to right side/aphasia, which greatly improved
over course of yesterday and was back to baseline today. Pt
went for 20 minute EEG study which revealed intermittent sharp
left temporal spikes suggestive of possible seizure activity.
Per daughter, pt noted to be lethargic and often poorly
responsive at baseline and in decline, with episodes of sharp
decline before. Perhaps this is related to seizure activity and
in past has been related to UTI. Notably, pt recently completed
a course of ciprofloxacin for UTI and is also taking NSAIDs,
which could lower her seizure threshold. Daughter states that
pt has had no evidence of seizure before. Code stroke was called
in ED: Hemmorhagic stroke ruled out w/ unremarkable head CT and
unlikely to have ischemic stroke with therapuetic INR on
warfarin and also on aspirin.
Infectious w/u including CXR, UA were negative. Pt not febrile,
no leukocytosis, normal diff. Had UTI over ___ when
her mental status also decompensated, and has subsequently
gotten better until now. Noted in ED to have multiple episodes
of bradycardia which may be related to current episode of
lethargy although this has been noted in the past per daughter's
report and per last discharge summary in ___. Otherwise, rates
in high ___ and low ___ with ___ second pauses. No electrolyte
abnormalities. B12, TSH, LFTs normal. No suspicion of adrenal
insufficiency given good blood pressures, lack of abdominal
pain, stable appearance.
.
On discharge, pt with good strength in extremities, non-focal
exam, and alert and oriented x2-3, similar to how she's been
over past several weeks. Pt started on Keppra 125 mg BID.
Pt received ___ monitor after discharge. Should be monitored
for 48 hours with results sent to Dr. ___. If episodes of
bradycardia and pauses correlate with symptoms, then can refer
for EP study with consideration of pacemaker placement.
.
# Bradycardia: Has been noted before, during admission in ___
and per daughter while in assisted living. Pt was on metoprolol
prior to that admission which was discontinued due to
bradycardia which was asymptomatic. Pt again noted to have HRs
in ___ in the ED and on the floor which could potentially
contribute to lethargy, although pt has been responsive and
alert today. Pt also continues to have ___ s asympomatic
pauses. As above, the patient will have ___ monitoring for
48 hours.
.
# Elevated troponin: mildly elevated to 0.06 in setting of renal
failure and appears to be chornically elevated, no chest pain,
no EKG chagnes concerning for ACS
.
# ___: baseline Cr 1.2-1.6, near baseline today
.
# CHF: euvolemic on exam, cont lasix, spironolactone. ___
murmur of TR at LUSB/LLSB transmitted to left carotid.
.
# Afib: cont warfarin, monitor on tele, avoid beta blockers
given bradycardia.
.
# HTN: cont amlodipine
.
# tremor: continue carbidopa/levodopa
.
# Diabetes mellitus: not on treatment as outpt, diabetic diet
.
# COPD: continue symbicort, PRN albuterol
.
# CODE: DNR/DNI (form in chart)
# CONTACT: daughter/HCP ___ ___
.
Transitional: Left temporal sharps suggestive of seizure. Will
start on keppra and discharge with neurology follow up in 1
month with Dr. ___. Pt's family alerted to side effects of
medication. Pt also will have ___ monitor placed for 48
hours with follow up with Dr. ___. | 203 | 625 |
12365617-DS-9 | 23,246,691 | Mr. ___,
You were admitted to the ___ due to
penile bleeding. This was in the setting of a supratheraputic
INR and was likely the cause of your symptoms. You did not
experience any additional bleeding while in the hospital. We
held one dose of coumadin, which you should now resume taking.
You will need follow-up monitoring of your INR on ___.
Please continue to take your zytiga. If this does not improve
your symptoms you can discuss the role of radiation therapy with
Dr. ___ in four weeks. | Mr. ___ is a ___ ESRD on HD, CAD w/ MI & defibrillator,
NIDDM, metastatic prostate CA, known RLE DVT and worsening right
upper extremity pain and swelling who presented bloody discharge
per urethra in setting of supratherapeutic INR of 3.2 Patient is
anuric on HD who had several pin point spots of blood on
undergarments for ___ days prior to admission and then a large
drop of blood which prompted him to seek medical care. Due to
his metastatic prostate cancer with significant lymphadenopathy
and asymmetric right lower extremity edema he had a right lower
extremity ultrasound negative for DVT. CT A/P revealed
conglomerations of enlarged lymph nodes seen within the
bilateral inguinal regions and extending along the bilateral
iliac vessels causing local mass effect which is unchanged from
CT A/P on ___. He had started his Zytiga (Abiraterone)
the day prior to admission with plans to follow-up with
radiation in 4 weeks to consider additional radiation treatment
at that time.
His coumadin was held on ___ upon discharge his INR was
2.4 and his regular 5 mg dose of coumadin was given. He should
have an INR drawn on ___. | 88 | 191 |
12954759-DS-4 | 26,606,394 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
We recommend you discontinue your home Aspirin indefinitely
unless there is a strong indication. If your primary care
physician deems ___ is medically necessary, you may restart
it after ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | # TBI
___ is an ___ female with dementia who
presented ___ to ___ ED from an OSH with a mild TBI. Aspirin
was held on arrival and recommended to be held indefinitely,
unless medically necessary, due to the bleeding risk in a
patient with falls. She was admitted to the neurosurgery team
for monitoring and remained stable. No repeat imaging or further
neurosurgical evaluation was indicated. Patient remained stable
and was discharged back to her living facility on ___.
# UTI
Patient was found to have a UTI at the ___. She was
started on Ceftriaxone x3 doses to treat her UTI. At time of
discharge, she was transitioned to PO Bactrim for 3 days. Rehab
facility instructed to monitor potassium levels while patient
receiving Bactrim. Also instructed to follow up on urine culture
from OSH for ensure UTI is appropriately treated.
# Pneumonia
CXR on arrival was initially concerning for pneumonia. She
received one dose of Azithromycin while in the emergency room.
Patient remained afebrile without signs of respiratory distress.
She maintained O2 sats in the ___ on room air with normal
respiratory rate. Medicine was curb-side consulted and did not
recommend further treatment or workup of pneumonia unless the
patient should become symptomatic. | 385 | 202 |
12341486-DS-7 | 26,458,464 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- The amount of sodium in your blood was too low.
What did you receive in the hospital?
- Your blood pressure medication, hydroclorothiazide, was
stopped and the amount of water in your diet was decreased.
- You had imaging of your head, which showed a small mass in
your brain, most likely a meningioma. The neurosurgeons saw you
and have you set up for follow up.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
- Please do not drink too much water (drink to thirst)
We wish you all the best!
- Your ___ Care Team | Ms. ___ is a ___ with history significant for HTN and
HLD who presents with episodic nausea, vomiting, fatigue and
weakness for 3 weeks, found to be hyponatremic. The patient was
admitted from the ED for correction of her serum sodium. | 127 | 41 |
11002115-DS-3 | 28,466,341 | Dear Ms. ___,
You were admitted to ___ with shortness of breath. This was
due to new congestive heart failure secondary to an electrical
problem in your heart. Please weigh yourself daily and call your
new primary care doctor Dr. ___ your new cardiologist,
Dr. ___ you weight goes up by 3 pounds. You will need to
follow up with Dr. ___ electrical heart doctor) to discuss a
possible device to help you heart pump better.
We have set you up with a new Primary Care Doctor ___ Dr.
___. It is very important that you follow up with him on
___.
We started you on insulin called lantus that you will take every
night. Please continue to take metformin also.
Please take your medications as directed and follow up with your
doctors with the ___ that we have made for you.
It has been a pleasure taking care of you.
Best,
Your ___ Care Team | Ms. ___ is a ___ with a h/o breast cancer, DM (poorly
controlled with HgbA1c 10.6%), HTN and LBBB who presented with
SOB and pleural effusions. Found to be due to new systolic CHF
(EF 35%), likely due to ventricular dyssynchrony secondary to
LBBB. She was diuresed to good effect with 20mg IV lasix,
however diuresis was limited by ___. She was started on lantus
10U qPM. She will require close follow up for DM, CHF. She was
set up for EP evaluation for CRT. Oncology is following for
possible recurrence of malignancy.
# Acute systolic CHF: Patient had no signs of active ischemia on
presentation. Her symptoms ___ edema, orthopnea, and SOB were
consistent with CHF. EKG showed LBBB, consistent with prior.
Etiology of new-onset HCF was felt to be due to ventricular
dys-synchrony secondary to known LBBB. This was supported by TTE
performed on ___ which showed EF 35%. She was initially
digressed with 20mg IV lasix, to which she responded well.
However ongoing diuresis was limited due to ___ (see below).
Further diuresis was held and patient was discharged on home
HCTZ but not furosemide. She was discharged with follow up in
___ clinic and also in ___ clinic for evaluation and
consideration for cardiac resynchronization therapy.
___: Patient presented with Cr 0.8, which peaked to Cr 1.6
during hospitalization, most likely due to diuresis. Further
lasix was held. ___ and HCTZ were intermittently held before
being restarted on the day prior to discharge. Cr was
downtrending and was 1.4 on day of discharge.
# H/o Breast Ca: Patient notes 8 pound weight loss in last month
which was concerning for malignancy especially in setting of
gross volume overload on exam. Per conversation with Dr. ___
___ oncologist), CA125 level is concerning for
recurrence. As noted above, concern that pleural effusion is
related to a malignancy. Cytology as outpatient was negative,
but sensitivity is sub-optimal and may have been further lowered
secondary to superimposed process (CHF) causing transudative
pleural effusion as well as effusion secondary to malignancy.
# Pleural effusions: Appears similar to slightly worse than thte
pre-tap x-ray done on ___. The tap on ___ revealed negative
cytology, however chemistries were not sent. Also above,
negative cytology also has only moderate sensitivity, which may
be worsened further by CHF causing superimposed transudative
process. Given history of malignancy, concern remains for
possible malignant component. SOB symptomatically improved with
diuresis.
# HTN - On olmesartan 40 mg and HCTZ 25 mg at home daily.
Changed to losartan 100 mg Po daily while in house and
discharged on home regimen.
# HLD - on simvastatin 40mg at home. Switched to atorvastatin
80mg daily given HTN, DM.
# DM - Hgb A1c 10.6 during hospitalization. Patient met with DM
nurse educator, started on 10U qPM lantus. She was also on ISS
during hospitalization. Home metformin was held during
hospitalization and restarted on discharge. | 150 | 487 |
10060142-DS-15 | 22,559,711 | You were admitted with abdominal pain likely from your
pancreatitis. You had an MRCP to evaluation this. The final
results are pending, but the preliminary results are similar to
your prior imaging studies.
In addition, you were found to have anemia and iron deficiency.
You had an EGD and colonoscopy without finding evidence of
bleeding. You can consider a capsule study to evaluation for
bleed. Please discuss this with your outpatient physician. You
were started on iron supplementation and ascorbic acid (to help
your body absorb the iron). In addition, you were started on
stool softenters to prevent constipation.
You were able to eat and drink prior to discharge. You were
discharged with a few days of dilaudid to help with the pain. If
you have further pain, or are not able to tolerate food or
drink, you should contact your physician ___. | ___ with history of necrotizing gallstone pancreatitis, history
of opioid dependence, presents with abdominal pain secondary to
pancreatitis.
# Acute pancreatitis:
He presented from OSH with acute pancreatitis. He was managed
with bowel rest, IVF, analgesia. GI was consulted. MRCP was
done. Eventually he improved and his diet was advanced to
regular low fat diet. He was given a short course of dilaudid as
an outpatient. He will follow up with his PCP and GI.
# Anemia, iron deficiency:
The cause of the iron loss is not clear. He was guaiac negative
and EGD and colonoscopy did not show evidence of bleed. GI will
consider capsule study which they can arrange at follow up. He
was started on ferrous sulfate 325mg TID with ascorbic acid
___ with AM and ___ doses to improve absorption. His PPI
(indicated for ___ esophagus, dosing per outpatient
regimen) may inhibit some iron absorption. If he fails oral
repletion, he may need IV iron infusion. He was started on
colace and senna to prevent constipation.
# Opioid dependence:
He has some chronic pain. He has used heroin in past but has
been clean for 14 months (per his report). We discussed this and
prescribed a limited number of narcotics. He was in agreement
with this approach and was very reasonable.
# ___ esophagus:
On protonix. Biopsy pending. He will need to follow up with GI
for further evaluation and management. | 142 | 227 |
11074235-DS-8 | 27,952,464 | Dear Mr. ___,
You were ___ to ___ because of your leg
swelling and fever.
While you were here, you were given IV Lasix to help remove some
fluid. This improved your leg swelling. We have prescribed you
with a diuretic to take at home (torsemide) to help keep the
fluid off. You did not have any fevers while you were here. The
rheumatology doctors saw ___ and recommended some labs that you
will follow up on in clinic.
When you go home, please take your medications as prescribed.
Your medications and follow up appointments are below.
It was a pleasure to take care of you!
Sincerely,
Your ___ Cardiology Team | Mr. ___ is a ___ yo man with recent admission for pericarditis
c/b tamponade, bilateral pleural effusion, and fever, now
readmitted with recurrent fever and b/l leg swelling.
# Fever: Patient defervesced prior to discharge and with
recurrent fever to 100.3 on admission. No fever throughout
hospitalization. ___ have persistent fevers in setting of recent
pericarditis. Infectious workup negative during prior admission;
___ negative but etiology of pericarditis/pleural effusions
remains unclear. Leukocytosis was downtrending from prior
admission which is reassuring. Pericardial and pleural effusions
discussed below.
#Acute CHF exacerbation: Hypervolemic on admission exam. S/p
Lasix 40mg x1 and 20mg x1 during hospitalization. Started on
torsemide 5mg on discharge. No prior history of CHF and normal
EF on most recent echocardiogram. Most likely diastolic vs
constrictive physiology in setting of pericarditis/pericardial
effusion. TTE revealed no change from prior admission.
[ ] New medication: torsemide 5mg PO daily
#Recent pericarditis and pericardial effusion with tamponade:
Stable from prior admission. Rheumatology was consulted on this
admission and recommended additional studies, including
anti-CCP, RF, SSA/SSB, repeat ferritin, ESR and CRP and SPEP.
[ ] Pericardial fluid studies pending: viral culture - most
cultures negative so far.
[ ] Continue indomethacin bid x 1 week until ___, then daily
x 1 week
[ ] Continue colchicine x 6 months
[ ] Rheumatology follow up
[ ] Rheumatology labs to follow up: anti-CCP, RF, SSA/SSB,
repeat ferritin, ESR and CRP and SPEP
#Pleural effusions: Exudative last admission of unclear
etiology. Appear stable on most recent CXR.
[ ] Pleural fluid studies pending: viral culture, AFB culture,
fungal culture
#Afib: With RVR during prior admission in setting of
pericarditis/effusion, anticoagulation deferred. Remains in
sinus. Continue metop succinate 100 mg daily
#Groin rash: Does not appear typically candidal however itchy
and uncomfortable. Given trial of miconazole powder | 105 | 295 |
19480232-DS-10 | 25,323,395 | Dear Mr. ___, it was a pleaure taking care of you during
your hospital stay at ___. You were admitted because of
worsening confusion and found to have brain lesions concerning
for a tumor - there was one small area of bleeding, two areas of
leaky blood vessels and some swelling in the back of your brain.
This seemed possibly a 'metastasis' from another source, so we
performed a CAT scan of your chest which showed small nodules in
your lung. We offered brain biopsy for diagnosis, but you have
refused treatments for tumors. You have chosen instead to
return home and engage hospice services as needed. If you have
any concern or questions please contact us. We are also happy
to follow you in clinic. | ___ w/ CAD s/p CABG, COPD, ___ who was transferred from
___ for evaluation of likely metastatic hemorrhagic
brain lesion. | 132 | 20 |
15774211-DS-19 | 22,064,364 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
after a fall at home. You also reported depression.
You were seen by psychiatrists and by physical therapists. It
was recommended that you go to rehab upon discharge, but you
declined this option and chose instead to go home. We have made
every effort to maximize your home services. Please follow up at
your appointments as listed below.
It was a pleasure caring for you while you were at ___ and we
wish you all the best.
Sincerely,
The ___ Medicine Team | This is a ___ year old female with past medical history of
multiple sclerosis, neuropathic pain on opiate regimen, migraine
headaches, irritable bowel syndrome, depression with prior
psychiatric hospitalizations for ___, who was admitted ___
___nd worsening depression.
# Gait Instability. Patient presented reporting multiple falls
at home, with bruises over upper extremities. Trauma workup in
ED was negative for acute process. Patient was admitted and
evaluated by ___, who initially recommended rehab. Patient
declined this, and so ___ worked with her for several subsequent
days and continued to recommend rehab. Ultimately the patient
refused rehab, chose to be discharged home instead. Discussed
with her PCP, who agreed that it would be inappropriate and
counterproductive to attempt to send her to rehab against her
will (i.e. seeking HCP permission or guardianship). We made
every attempt to maximize her home services to facilitate her
continued improvement in gait. There seemed also to be a
psychiatric component to her gait instability, given she would
at times have a very stable gait for good distances, but other
times would suddenly say she couldn't walk and would wait until
help arrived before allowing her legs to "give out." The
patient insisted that stressful situations make her walking and
other issues worse, and that rehab would be a stressful
situation for her, and that home would be the best place for her
to recover. She was discharged to home with max services, and
ongoing self-pay home health aide (4 hours per day, 5 days per
week). She did not take home gabapentin while inpatient, saying
it was ineffective. Given that it also can cause falls, it was
discontinued and not included on discharge med rec.
# Depression with suicidal ideation -
On admission, patient reported having a plan for suicide if her
mother and cats should die. She was kept on a 1:1 observation,
and evaluated by psychiatry over 2 days. Patient subsequently
stated she did not intend to hurt herself. Psychiatry service
felt that her "earlier statements about contingent wish for
death appears to be an expression of her limited and
often-maladaptive coping and skills, rather than an indicator of
imminent risk of harm." Patient had an improved mood and
engaged in safety planning, and agreed to re-establish with
outpatient therapy. Inpatient psychiatric treatment was not
felt to be indicated. Continued fluoxetine, OXcarbazepine, and
lorazepam while inpatient and on discharge. She was set up with
appointment to resume home psychotherapy sessions (see
appointments below).
# Iron deficiency anemia: MCV is low, ferritin very low at 9.8,
she requires iron
repletion. This could also explain at least some component of
her restless
leg symptoms. Patient is on chronic PPI BID, so will not absorb
oral iron due
to acid suppresion, so gave first dose of IV ferric gluconate on
___. Patient should likely have weekly infusions until iron
stores are repleted, I have advised patient to follow-up with
Dr. ___ this on discharge.
# Dysphagia: intermittent, patient seems to be tolerating PO OK
during this hospitalization. SLP eval/recs: no clear persistent
issue, OK for
regular diet and thin liquids. Per review of prior records,
patient had an EGD done for dysphagia/odynophagia in ___
which did not reveal any
concerning intraluminal findings or pathologic features on
biopsy. No further inpatient work-up indicated at this time.
# Lower extremity pain
# Multiple sclerosis, progressive
# Restless leg syndrome
Continued fentanyl, PRN dilaudid, dronabinol, oxcarbazepine;
carisoprodol is nonformulary, so was held and restarted at
discharge. Gabapentin not used by patient during
hospitalization, DISCONTINUED on discharge.
# Migraine - Had typical migraine during admission, aborted with
her home prn imitrex. Intermittently complained of migraine
during hospitalization, treated with PRN meds.
# Chronic Abdominal Pain - Continued Hyoscyamine
# Asthma - Continued home montelukast, tiotropium
# GERD - Continued PPI
# Chronic constipation - Continued miralax, colace
=============================== | 95 | 640 |
10780669-DS-7 | 24,667,059 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ h/o of multiple myeloma, paroxysmal a. fib, CAD with recent
nstemi, CKD initially admitted with 10 days of cough, malaise
found to have influenza, ?superimposed pneumonia, ___ on CKD,
and ongoing RVR.
# Severe Sepsis
# Influenza A
# CAP: patient with known flu + status and interval worsening of
respiratory status c/f superimposed pna. He was started on
5-day course of oseltamivir with the addition of vanc/cefepime
for possible superimposed bacterial infection. He completed 6
days of IV abx and will be transitioned to levaquin for
completion of 10 day course given his prolonged respiratory
symptoms.
#Afib RVR: Pt with chronic afib. Developed RVR during this
admission likely ___ sepsis, ___, blood loss, and volume
depletion. He transferred to the FICU and started on metoprolol
which was uptitrated to 12.5mg q6H with good control of HR's. Pt
had been on beta-blockers in the past but per his wife, these
were d/c'ed d/t falls and hypotension. His BP's have remained
stable in the 120's-140's range on this regimen. He will be
discharged on metoprolol XL 50mg qDaily. He was also continued
on home amidoarone.
# ___ on CKD
Pt presented with Cr up to 3.0 from baseline of 1.1. ___ was
felt to possibly due to pre-renal volume depletion, ?component
of ATN ___ hypotension, and possibly progressive MM given
worsening SPEP. Cr improved slowly with IVF's and treatment of
infection per above and leveled off at 2.2 on discharge.
# Hematuria
Pt noted to have significant hematuria i/s/o traumatic foley
placement in context of BPH and asa use. Pt also noted to have
3mm stone at R UVJ on admission with associated hydronephrosis.
Urology was consulted and recommended bladder irrigation which
improved the hematuria. Repeat Renal US was done on ___
showed non-obstructing stones and resolved hydro so no
intervention was needed. Foley was removed on ___ and pt
voided well afterwards.
# MM
Unfortunately free light chains seem to be rising and could be
contributing to his renal failure. Outpatient team considering
ninlaro vs carfilzomib vs daratumumab. Deferred to OP Onc team
to discuss further treatment options. Continued acyclovir and
allopurinol, renally dosed
# Psych: Pt noted to be often agitated and likely depressed. He
was continued on home seroquel, duloxetine 30 daily. Plan for
pt to follow-up with ___ on ___.
# CAD, recent NSTEMI: Continued asa, statin initially held in
s/o sepsis but restarted on discharge.
# UC: cont mesalamine, no active diarrhea | 14 | 411 |
11460555-DS-18 | 24,696,580 | You were admitted to the inpatient colorectal surgery service
for treatment of diverticulitis. You have improved greatly. Dr.
___ will preform surgery at a later date. Our the woman who
makes the arrangements will call you at home with a date and
time. Please monitor your bowel function closely. If you are
taking narcotic pain medications there is a risk that you will
have some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms do not improve call
the office. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You will take Ciprofloxacin and Metrodiazole for two weeks until
the time of surgery.
Please call our clinic with any new abdominal pain, fever, or
any other questions. | Mr. ___ was admitted to the colorectal surgery service
for treatment of Diverticulitis. CT scan of the abdomen at the
time of admission showed no perforation or drainable fluid
collection. He was given intravenous antibiotics, Ciprofloxacin
and Flagyl. The patient's abdominal exam was monitored closely.
He was initially NPO and when symptoms improved, advanced to
clear liquids. He made dramatic improvements with bowel rest,
intravenous fluids, and intravenous antibiotics. On the day of
discharged he was advanced to a regular diet after examination
by Dr. ___. She discussed surgery with him which will be
arranged in the next few weeks as the schedule allows. He will
be contacted at home with a date and time. Please see Dr.
___ for further details. He was discharged home with
oral antibiotic therapy and contact information of our clinic. | 158 | 136 |
17220099-DS-19 | 22,994,819 | Discharge Instructions
Brain Tumor
Surgery
· *** You underwent a biopsy. A sample of tissue from the
lesion in your brain was sent to pathology for testing.
· 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.
· Please keep your incision dry until your sutures/staples
are removed.
· You may shower at this time but keep your incision dry.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the
neurosurgeon.
· ***You have been discharged on Keppra (Levetiracetam).
This medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may experience headaches and incisional pain.
· You may also experience some post-operative swelling
around your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Feeling more tired or restlessness is also common.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
When to Call Your Doctor at ___ for:
· 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 | Ms. ___ is a ___ year old female who presented to the ED
with complaints of worsening headache over the last three weeks.
A CT revealed a ___ ventricular lesion with obstructive
hydrocephalus. She was admitted to the ___ for close
observation.
#Hydrocephalus
The patient was taken to the operating room on ___ for
placement of a ventriculo-peritoneal shunt with Dr. ___
(___) and Dr. ___. A non-programmable shunt was
placed. Please see operative reports for further details. Postop
head CT was without acute complication.
#Brain Lesion
A MRI was completed and concerning for high grade glioma vs.
metastasis. She underwent metastatic work up including CT c/a/p
that was negative for metastasis.
The patient was taken to the OR with Dr. ___ stereotactic
biopsy. The procedure was without complication and the patient
will follow up with Brain Tumor Clinic on ___ for further
treatment planning. | 669 | 146 |
19460076-DS-13 | 21,425,804 | Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted because you had a heat stroke. We treated you with IV
fluids and cooling blankets. Please be advised to wear light
clothing in the summer, stay out of the sun for extended periods
of time, and drink plenty of water to stay well hydrated.
We did not make any changes to your medications. Please follow
up with Dr. ___ your medications. | ___ y/o M with ? h/o schizophrenia on multiple antipsychotics,
presents with syncope and hyperthermia at the Redsox game.
# Hyperthermia/Heat Stroke: Patient had confusion and syncope at
the baseball game on the day of admission after being
over-dressed, feeling dizzy and hot. In the ED, found to have
rectal temp of 103.9. Neurologic symptoms improved after
cooling in the ED. DDx includes heat stroke and neuroleptic
malignant syndrome given patient on typical and atypical
antipsychotics. Non-exertional heat stroke most likely in this
older gentleman who was out in the sun for an extended period of
time. NMS less likely given lack of rigidity on exam and normal
CK level. Patient treated with IV fluids and observed overnight
without recurrent fevers. Initially held haldol,
chlorpromazine, and risperidal, but restarted on discharge.
AAOx3 without focal neuro deficits at the time of discharge.
Patient to follow up with Dr. ___.
# Psychosis NOS: The patient and his family cannot provide
psychiatric diagnosis for which he is receiving antipsychotics.
Patient reports that he has been seeing Dr. ___ ___
months for ___ years. Attempted to reach Dr. ___
___ for his office, without success. Plan for patient to
follow up with Dr. ___ disease and medication management.
# ?PNA: Patient on NRB upon arrival to ED with report of
respiratory distress, likely related to heat stroke. CXR ? LLL
opacity but film was poor quality. Given CTX and azithromycin
in the ED. No cough or leukocytosis to suggest infection and
patient had no O2 requirement on arrival to the floor so
antibiotics were not continued.
# Transitional issues:
- code status: full code
- follow up: Dr. ___
- pending studies: final results from blood cultures from
___
- medication changes: none | 78 | 299 |
18400649-DS-22 | 28,851,077 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc).
8. ANTICOAGULATION: Please continue your Lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ___ (once at home): IV antibiotic infusions, Home ___,
dressing changes as instructed, wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. ROM as tolerated. No strenuous exercise or
heavy lifting until follow up appointment.
12. Midline access care: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CPK
- BUN/Cr
- LFTS
- ESR/CRP
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed
Physical Therapy:
WBAT LLE
L knee ROMAT
Mobilize frequently
Treatments Frequency:
Dressings may be changed as needed for drainage. No dressings
are needed if wound is clean and dry.
Staples will be removed in ___ weeks at Orthopaedic surgery
follow up appointment in clinic.
ice to operative knee
TEDs
Antibiotic Plan:
Daptomycin 350 mg IV daily for 2 weeks (patient will have
midline placed on day of discharge and will receive infusions at
the pheresis/infusion at ___ daily as scheduled and confirmed
by case management)
Ciprofloxacin 500 mg PO BID for 2 weeks | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an infected left prosthetic knee and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left knee washout and liner
exchange, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The Infectious
Diseases service was consulted and recommended Daptomycin IV and
Ciprofloxacin PO for total 2 week course with re-evaluation for
possible continuing antibiotics at the 2 week mark in clinic.
The patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity with range of motion as tolerated in the
left knee, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Patient will be discharged on total 2 week course of antibiotics
as determined by the ID team. She may subsequently require PO
antibiotics. Mid line access was placed and patient will present
daily to ___ infusion
Intraoperative cultures were NGTD. Universal PCR pending at
discharge
Patient was discharged to home with services in stable condition | 595 | 337 |
17236791-DS-4 | 20,700,316 | Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your
lightheadedness and because of your falls. We believe this
occurred because of your ___ Disease and possibly
because of some of the medications that you have been taking
caused "orthostatic hypotension" (decreased blood pressure when
standing for a long period of time or when standing from a
seated position).
We evaluated you with blood tests which were normal as well as
an ECG and an ultrasound of your heart which showed no changes.
Your ___ medication was adjusted as noted below. Please
discuss with your Neurologist these new medication adjustments.
You have an appointment on ___.
Your blood pressure medications including your atenolol and
isosorbide mononitrate were held as this was likely contributing
to your symptoms. Please call your Cardiologist to discuss
whether you should be off of these medications completely.
Your aspirin was adjusted from 325 mg daily to 81 mg daily.
Please discuss with your Cardiologist this medication
adjustment.
After discharge you should f/u with your neurologist for further
evaluation and management. You should continue to have your
regular screening tests for monitoring of your aortic valve
disease and the dilation of your aorta with an echocardiogram
(ultrasound of your heart).
To prevent further falls, please arise from a seated position
slowly. When attempting to get out of bed, please sit at the
edge of the bed until your lightheadedness resolves.
Also a CT of your abdomen and pelvis showed a Left renal
hypodensity measuring up to 2.9 cm with questionable mural
calcification. Please follow up with your primary care physician
to have this followed up with a renal ultrasound.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ with PMH of PD, bicuspid aortic valve, mild AS/AI,
ascending aortic aneurysm who presents with syncope and fall x2,
thought to be secondary to medication side effect.
# Syncope: The patient presented after sustaining 2 falls in the
past week prior to admission. Per his family, the patient had
been reporting "lightheadedness" intermittently since his
levodopa-carbidopa was increased on ___. The patient first
fall was unwitnessed and may have just been that he bumped his
head on a cabinet in his kitchen. The second fall occurred while
the patient was standing to shave in his bathroom and bent over,
reaching for something on the counter. He fell onto his buttock
and back without hitting his and without loss of consciousness.
His wife reported no slurred speech, facial droop, incontinence
or altered mental status. Given this history of ongoing
lightheadedness, with fall precipitated by positional change,
there was concern for orthostatic hypotension. The patient was
found to be orthostatic in the ED and again on the floor on the
second day of admission after receiving his home medications.
Cardiac etiologies were thought to be less likely cause of
syncope. Though the patient had a history of aortic stenosis,
this was noted to be mild per his outside records and he did not
appear to have severe stenosis by physical exam. The patient was
monitored on telemetry which was w/o evidence of arrhythmia.
Troponins were negative x2 and ECG showed no changes. Neurologic
and neurocardiogenic etiologies were thought to be less likely
given history. TSH and B12 were within normal limits. The
patient's outpatient neurologist was contacted, who agreed that
the most likely cause of the patient's symptoms was increased
dose of levodopa-carbidopa, as this is a known side effect and
seemed temporally related. The patient's dose was titrated to
carbidopa-levodopa 25 mg-100 mg 1 tablet four times per day
(previously 1.5 tablets 3x/day). The patient was maintained on
his home levodopa-carbidopa SR qHS. The patient's atenolol and
isosorbide mononitrate were also stopped. Pt should f/u wit his
neurologist and his PCP for further titration as needed.
# Fall: The patient was evaluated with extensive imaging,
including CT head, CT chest and CT abdomen/pelvis and CT spine
which showed no acute changes. The patient had a small abrasion
on his head which showed no evidence of infection. The patient
was evaluated by physical therapy who felt the patient was safe
to return home. He will continue his home ___ as outpatient.
# ___ Disease: In discussion with patient's outpatient
neurologist, the patient's home regimen was adjusted to
Carbidopa-Levodopa (___) 1 TAB PO QID and Carbidopa-Levodopa
CR (50-200) 1 TAB PO QHS. The patient will f/u with outpatient
neurologist for further management.
# Ascending aortic aneurysm: The patient has a history of
ascending aortic aneurysm, visualized on CT Chest and on TTE
___. Noted on CT chest to be 4.8cm. This is monitored every 6
months by the patient's outpatient physicians.
# Bicuspid aortic valve, mild AS, AI: The patient is followed by
a cardiologist as outpatient and gets TTEs every 6 months for
monitoring. As above, the patient's syncope was thought to be
related to orthostasis rather than progression of the patient's
AS. The patient will f/u with outpatient cardiologist and PCP
for further monitoring.
# CAD s/p stent: The patient was continued on his home
atorvastatin 10 mg PO QPM. The patient's atenolol 25mg PO daily,
and isosorbide mononitrate 30 mg PO daily were discontinued as
above. The patient's home aspirin was decreased to 325mg, as
81mg was thought to be more effective with less risk of bleeding
(particularly given the patient's recent falls). The patient
should f/u with PCP and cardiology for further management.
# Anemia: The patient's Hgb was ___ on admission with
macrocytosis, stable from his recent baseline. The patient has
previously been found to have this macrocytic anemia and B12
deficiency so was started on B12 supplementation. The patient's
B12 level was found to be within normal limits, but his
macrocytosis seems to have persisted. The patient should f/u
with his PCP for consideration of further work-up of other
underlying etiologies.
Transitional Issues:
- f/u with Dr. ___ further adjustment of sinemet.
- please adjust blood pressure medications as outpatient given
that the atenolol and isosorbide mononitrate were discontinued
at time of discharge to prevent orthostasis.
- f/u with PCP for consideration of using aspirin 81mg PO daily
instead of aspirin 325mg PO daily given increased risk of
bleeding
- Continue q 6 month evaluation of ascending aortic aneurysm and
valvular disease with cardiologist as outpatient, reportedly
scheduled for next set of imaging ___
- Consider further work up of macrocytic anemia. This appears to
be a chronic condition, pt H/H found to be at recent baseline.
He is currently receiving B12 supplementation and levels were
found to be WNL, but macrocytosis has persisted.
- Please re-assess minimal thrombocytopenia during
hospitalization. Platelet count of 141.
- CT Abd/Pelvis ___ showed: Left renal hypodensity measuring up
to 2.9 cm with questionable mural calcification. Consider
further evaluation with renal ultrasound as outpatient for
further characterization | 294 | 846 |
16758451-DS-4 | 21,066,112 | Dear Mr. ___,
It was a pleasure taking care of you while at the ___
___ after your fall. This was complicated
by left sided ___ rib fractures and a left sided
pneumothorax (air around your lung). To absorb the pneumothorax
a small catheter was placed in the space around your lung. You
have recovered well and are ready for discharge. Please follow
the below instructions:
* Your injury caused 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. ___ presented on ___ after sustaining a mechanical fall
where he was found to have left sided ___ rib fractures and
a left sided pneumothorax. A pigtail catheter was placed to
drain the left sided pneumothorax and was placed to suction. The
pneumothorax improved significantly with this approach, as
evidenced on chest x-rays. He did not have any desaturations and
was breathing normally on room air. His pain was well controlled
on oral pain medications and a bowel regimen was given. He
tolerated a regular diet. His pigtail was put to water seal on
___ and discontinued later that day after a 4 hour post-water
seal x-ray revealed only a trace left apical pneumothorax. He
was discharged home on room air in stable condition on ___ontrolled. Discharge instructions were given and the
patient voiced understanding of the discharge plan. | 306 | 141 |
13866798-DS-7 | 29,725,167 | You were admitted to the Acute Care Surgery service at ___
___ with perforated appendicitis. On
CT scan, there was a surrounding phlegmon and inflammation in
the bowel that the appendix attaches to. Thus, you were treated
conservatively with antibiotics, hydration, and bowel rest. Once
your pain improved your diet was advanced. You are now
tolerating a regular diet, on oral antibiotics, and your pain is
controlled with oral pain medication. You are ready to continue
your recovery at home. You will continue antibiotics for a total
of 2 weeks. You should talk to you PCP about having ___
colonoscopy versus having your appendix out in 6 weeks. Should
you opt to have your appendix out, follow up with us in ___
weeks.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Mr. ___ was admitted to the Acute Care Surgery service at ___
___ with a perforated appendicitis
with phlegmon and inflamed cecum.
He was treated conservatively with antibiotics, pain control, IV
fluids, and bowel rest. On hospital day three, the patient's
pain and abdominal exam were much improved and he was given
clear liquids. After tolerating clear liquids for much of the
day, his antibiotics were switched to po. On hospital day four,
the patient was advanced to a regular diet.
At discharge, the patient was tolerating a regular diet, on
oral antibiotics, and his pain was controlled with oral pain
medication. The patient will continue antibiotics for a total of
2 weeks. The patient was instructed to follow up with his PCP to
discuss having a colonoscopy versus an interval appendectomy
given the small chance that his appendicitis could have been
caused by a tumor. The patient was also instructed to follow up
in ___ clinic should he opt to have an appendectomy given the
___ chance of recurrent appendicitis. The patient expressed
understanding these instructions. | 308 | 179 |
18902344-DS-66 | 25,300,264 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted for
fluid retention and weight gain due to an exacerbation of your
heart failure. You were treated with IV Lasix and your symptoms
improved. You developed a slight kidney injury from getting too
much Lasix which improved with decreasing your dose. You will be
discharged taking torsemide 40mg twice a day until you see Dr.
___. It is very important that you see your PCP for further
adjustments to your Lasix.
You were also noted to have a urinary tract infection. You will
need to complete two additional days of antibiotics. We strongly
encourage you to consider removing your indwelling foley
catheter to reduce risk of recurrent infections.
Lastly, your blood sugars were very high while you were here. A
physician from ___ saw you in the hospital and adjusted your
insulin.
Please continue your medications as summarized below and keep
your follow-up visits. If you are able to find a scale that
accommodates you, please weigh yourself every morning and call
the cardiology clinic or your PCP if your weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ gentleman with morbid obesity,
poorly controlled type 2 diabetes, diastolic heart failure, and
recurrent UTIs (E. coli, Acinetobacter) in the setting of a
chronic indwelling Foley who presented with abdominal distension
and weight gain concerning for heart failure exacerbation.
# Acute on chronic heart failure: Patient presented with
abdominal distension and scrotal edema concerning for heart
failure exacerbation. BNP was 379, likely falsely low in the
setting of morbid obesity. TTE unchanged from prior with normal
EF. Volume exam was very difficult given body habitus but he did
appear slightly volume overloaded on admission. He was diuresed
with IV Lasix, which was discontinued when patient developed an
___ worsened despite holding Lasix, so Lasix was restarted
as ___ was thought to reflect cardiorenal etiology. ___ then
worsened (see below), so Lasix was discontinued. Patient
appeared hypovolemic and received IVF. Of note, patient was on
verapamil at home for unclear reasons (?hypertension), and this
was discontinued. Metoprolol was continued but then held due to
soft BPs but restarted the day of discharge with stable heart
rate. Lisinopril was held given ___. ASA and statin were
discontinued and restarted prior to discharge.
# Acute kidney injury: Baseline Cr 1.1-1.3. Cr on admission was
1.3 but rose with diuresis. Initially Lasix was held, but given
rising creatinine and weight gain, Lasix was resumed given
concern for cardiorenal etiology. Lasix was later discontinued
after creatinine continued to rise (max 3.3). Renal was
consulted. Urine was spun but there was no evidence for ATN.
Renal ultrasound was normal. Patient received gentle IVF and
creatinine improved, however fluids were stopped as sodium rose
quickly. Lisinopril on hold in setting of ___. After 1 day of
holding all intervention, his creatinine continued to fall
reaching 1.5. On discharge lower dose of torsemide was resumed.
He is instructed to follow up closely with PCP and get ___ blood
work and dose of torsemide wil/ need to be adjusted.
# Catheter-associated urinary tract infection: Patient has a
chronic indwelling Foley for preference given body habitus.
Urine culture on admission grew 10,000-100,000 Enterobacter,
thought to reflect colonization as patient was asymptomatic at
the time. Antibiotics were not given. Urinalysis was repeated on
___ in the setting of encephalopathy and showed positive
nitrites, >182 WBCs, and bacteria. Foley was exchanged and
patient was started on Zosyn pending urine culture given history
of multidrug-resistant bacteria. Patient declined Foley removal
but said he would consider a condom cath. The foley was
exchanged and he was switched to fosfomycin 3 total doses. He
was again counseled to stop using the foley.
# Toxic-metabolic encephalopathy:
# Uremia:
Patient became encephalopathic in the setting of uremia,
fluctuations in blood sugar, and multiple sedating medications.
Gabapentin dose was decreased in the setting of renal failure
and methadone was held. Infectious work-up on ___ revealed a
UTI, which was treated initially with Zosyn pending urine
culture given history of drug-resistant bacteria. He soon
cleared and methadone and gabapentin restarted prior to
discharge,
# Poorly-controlled type 2 diabetes:
Patient's blood sugars were elevated >500 on admission with
normal AG and mental status. A1c in ___ was 14%. ___ was
consulted and assisted with blood sugar management. Insulin then
had to be downtitrated in the setting of renal failure.
# Abdominal pain:
Patient reported generalized abdominal pain on admission,
possibly due to mild volume overload. Abdominal ultrasound
showed splenomegaly but was otherwise normal. LFTs and lipase
were normal. He developed lower abdominal pain again later
during the hospitalization, likely due to developing UTI. C.
diff was negative and KUB was normal. | 199 | 589 |
18371155-DS-41 | 28,947,846 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please test your blood sugars and call your insulin
provider if there are values that are consistently above 250.
You will need to come back in ___ weeks to have an endoscopic
ultrasound (EUS) to understand why your bile duct is larger than
expected | Ms. ___ is a ___ female with CAD s/p CABG, DM type II
c/b retinopathy, glaucoma, h/o CVA x2, dementia, CKD, h/o PE,
seizure disorder, anxiety, and depression who presented to the
ED
with a week of diarrhea and abdominal pain found to have C.diff
as well as some biliary ductal dilatation on RUQ US. Pts
diarrhea
has resolved at the time of discharge. | 60 | 61 |
16820602-DS-26 | 29,997,616 | Dear ___,
It was a pleasure looking after you. As you know, you were
admitted with shortness of breath consistent with severe asthma
exacerbation. You were treated with BiPAP initially and then
supplemental oxygen - along with steroids and nebulizer
treatments. Over the course of the hospitalization, your
breathing improved. Please continue with the steroid taper as
prescribed, along with your home asthma medications. You were
also given a prescription for Epi-pen in the event of an acute
asthma attack.
There are otherwise no other changes to your medication. We
wish you the best luck and good health.
Your ___ Team | ___ is a ___ year old man with a history of severe
persistent asthma, tobacco use, hypertension, who was admitted
to the ICU for an asthma exacerbation.
#Asthma Exacerbation:
Mr. ___ has severe persistent asthma with a recent PFT in ___: FVC 3.5 L, FEV1 predicted 80%, FEV1/FVC 47. In the ED, he
received Solumedrol 125 mg, magnesium, albuterol, ipratropium,
and placed on BiPAP. He was transferred to the ICU and quickly
weaned to nasal cannula. Steroids were switched to prednisone
60mg daily after 1 day of solumedrol in the ICU. He was
transferred to the floor on the hospital day 2.
He was observed for an additional day and appeared to do
well - weaned off O2 and able to ambulate without any
desaturations. This exacerbation occurred in the setting of
viral URI and recent emotional stressors (Mother in ___
with health problems). Other potential triggers include the use
of ACEI, GERD. There is low suspicion for
tracheobronchomalacia. He denies any environmental triggers.
He also cont to smoke ___ cigarettes/day - and understands the
importance of avoiding tob as best as possible.
He will continue with his duonebs, advair, Montelukast, at
home. He was discharged home with a slow prednisone taper
(decrease 10mg Q2D). He was also given a prescription for
Epipen in the event of a severe acute asthma exacerbation
requiring immediate treatment. He will follow up with his
pulmonologist and PCP at ___.
# Leukocytosis: Upon admission, patient's WBC was 16.1, most
likely from recent steroid use. CXR showed no acute
cardiopulmonary process, though patient did complain of
productive cough for 1 week prior to admission and had several
days of loose stool however this has resolved.
# Hypertension: Elevated in the setting of severe respiratory
distress up to 170s/100s. Improved with improved respiratory
status. Continued on home lisinopril.
# DMII: Last A1c was 6.5% in ___. Held metformin while
inpatient. Gave insulin sliding scale. Metformin to be
restarted at home.
#HLD: Last Lipid panel from ___ Chol 190, HDL 61, LDL 98, ___
155. Continued home atorvastatin.
#Alcohol use: Patient says he drinks 3 shots liquor daily last
drink was evening of ___. He has never had tremors or
seizure and never had an issue with symptomatic withdrawal.
#Tobacco use: Patient is current smoker. Tried bupropion without
success.
TRANSITIONAL ISSUES
========================
Code Status: FULL CODE
Communication: HCP ___ (Friend) ___ | 113 | 403 |
17218894-DS-20 | 27,789,570 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight Bearing as Tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
WBAT, posterior hip precautions
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining. | The patient was cosulted with the orthopedic surgery team and
was evaluated . The patient was found to have R femoral neck
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for R THA,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to Home with ___ services was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT and posterior hip precaution in the Right Lower extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 223 | 256 |
13042988-DS-5 | 28,760,770 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had severe abdominal pain, nausea and vomiting which were
concerning for a blockage in your intestines.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received fluids, medication for pain, and medication to
help your bowels move.
- A CT scan of your abdomen did not show an obstruction.
- Your diet was advanced gradually to regular foods as you were
able to tolerate it.
- You improved and were able to eat and drink.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
=========
This is a ___ with progressive, metastatic ovarian cancer on
gemcitabine who presents with 2 days of abdominal
pain/nausea/vomiting, most consistent with partial SBO vs ileus. | 112 | 26 |
12713435-DS-6 | 24,813,638 | Mrs. ___, you were transferred to the ___ with a spine
fracture. You were evaluated by Orthopedic Surgery and placed
in a special brace that you will need to wear for the next few
weeks until you follow-up with the Orthopedic Spine Specialists.
Your potassium was low therefore, one of your blood pressure
medications was discontinued. Your vitamin levels were also low
and you were started on several vitamin supplements.
Please see below for your follow-up appointments.
It was a pleasure caring for you and we wish you a speedy
recovery! | Ms. ___ is ___ with history of HTN, HLD, atrial fibrillation
on coumadin who is presenting s/p fall found to have L1
compression fracture.
# L1 fracture: Unclear what precipated the fall, if patient
slipped. She denies dizziness, lightheadedness, SOB or chest
pain prior to the event. She did report having her usual
Bourbon x 2 prior to the event, so perhaps she was just unsteady
on her feet from EtOH intoxicatin. Spine has already evaluated
the patient and recommends non operative treatment in the
setting of no neurologic compromise or retropulsion into canal.
Patient was placed on bed rest until TLSO brace was in place.
She was evaluated by ___ who recommended discharge to a
___ rehab for ___ and reconditioning. She was fitted with
her TLSO brace, which she should wear anytime she is ambuluting
or when the head of her bed is elevated to > 30 degrees. She was
started on standing tylenol and prn oxycodone for pain. She was
also started on calcium and vitamin D supplementation as her
levels were low in ___. Repeat Vitamin D level was 32 (ref
range ___, low normal, so she was continued on vitamin D
supplementation for now. She was discharged in good condition to
rehab, with Ortho Spine follow up in ___ weeks for further
management.
# Hyponatremia/hypokalmeia: likely ___ to medication affect as
pt was on low-dose HCTZ on admission which was stopped given
possible SE from electrolyte abnormalities in elderly pt who
does not need tight bloood pressure control. HCTZ was stopped
and hyponatremia and hypokalemia resolved. LDH, albumin and
LFTs unremarkable.
# Elevated HCT: Noted to have H/H 16.1/48.4 at OSH. Unclear
etiology, other cell lines are not elevated that could be c/w
hemoconcentration. Patient not chronically hypoxic at baseline.
Interestingly, recent crits have been elevated in the mid to
high ___, and she has also been developing a macrocytosis. B12
was low, likely ___ to EtOH, patient was started on folate,
thiamine and B12 supplementation.
# Memory deficitis: continued home donepezil 5 mg daily
# Atrial fibrillation s/p PPM: INR noted to be 1.2 at OSH; CHADS
2. Patient reports taking her medications daily, but appears per
OMR her INR is intermittently subtherapeutic. initially unclear
if patient was actually taking her meds as scheduled. She was
continued on home dose of coumadin and INR was monitored daily
pending a discussion with her PCP. Her PCP, ___,
was contacted by email and recommened holding warfarin for one
week. He also stated that the patient was receiving a minimal
dose of warfarin as she had experienced several abdominal
bleeds; the dose is intended to have some therapeutic effect but
is not expected to elevate the INR. Restart date, ___.
# HTN: Patient hypokalemic and BPs stable in 130s, she is on
low dose of HCTZ, would favor d/c HCTZ to prevent hypokalemia
causing muscle weakness and increased risk of fall, at her age
it is OK to not tightly control her BP. | 93 | 504 |
12294892-DS-48 | 24,332,367 | ================================================
Discharge Worksheet
================================================
Dear Mr. ___
WHY WERE YOU ADMITTED?
-You came to ___ because you were having fevers
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
-You had tests to look for a source of infection and were given
antibiotics
-Your foot was evaluated by the podiatry team to look for
infection. Thankfully, your heel was not thought to be infected.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please be sure to attend your follow up appointments (see
below)
- Please take all of your medications as prescribed (see below).
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ male with ___
chromosome-positive ALL ___ allo SCT (D0 = ___ with no
evidence of disease c/b severe chronic GVHD (skin, eyes, mouth,
and lungs on prednisone and ibrutinib), recurrent bacteremia
(Enterococcus, MSSA, Corynebacterium) in the setting of chronic
indwelling hardware (spinal stimulator, joint replacements),
non-obstructive CAD, non-ischemic cardiomyopathy with multiple
admissions for volume overload (status-post biventricular pacer
for cardiac resynchronization in ___, with subsequent
normalization of LVEF), stage III CKD, chronic pain, and severe
depression ___ ECT initiation ___ who presents with fever
and weakness. Patient was started on empiric vancomycin and
meropenem. Infectious work-up was largely unrevealing.
Infectious disease was consulted and podiatry consulted.
Podiatry evaluated both on patient's foot, felt not to be
infected. The patient was treated with a 10-day course of
vancomycin for cellulitis. Ultimately, he was discharged back
to rehab on his home medications. | 122 | 153 |
10015860-DS-13 | 28,236,161 | Please follow these guidelines unless your physician has
specifically instructed you otherwise. Please call our office
nurse if you have any questions. Dial 911 if you have any
medical emergency.
ACTIVITY:
There are restrictions on activity. On your right side you are
TOUCH DOWN WEIGHT BEARING TO THE HEEL IN A BIVALVE CAST AND
CRUTCHES/WALKER for ___ weeks. You should keep this site
elevated when ever possible (above the level of the heart!)
Physical therapy worked with you in the hospital and gave
instructions on weight bearing: please follow these accordingly.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
WOUND CARE:
You will be getting every other day dressing changes by a
visiting nurse with betadine paint to the ulceration and a dry
sterile dressing. You may cleanse the foot with peroxide. Once
the dressing is in place, avoid getting it wet.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for infection which will be taken every 6
hours.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | Mr. ___ presented to the Emergency Department at ___ after
missing a scheduled appointment with Dr. ___ concern that
his infection was worsening. He was admitted on ___ for a
right foot infection. During his stay, he received IV
antibiotics to fight the cellulitis and xrays were obtained and
showed no osteomyelitis. The wound was lightly debrided at the
bedside during his stay and he was fitted for a bivalve cast by
an orthotech. He was given strict instructions on touch down
weight bearing to the heel using a walker or crutches. Physical
therapy worked with him while in the hospital and cleared him
for home with such. Prior to discharge his vital signs were
stable and neurovascular status intact. He understood all of his
discharge instructions and is to follow up with Dr. ___ in
approximately 1 week. | 409 | 140 |
18395810-DS-13 | 20,341,119 | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You may wash your hair only after sutures have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101° F. | Patient was admitted to ___ with confusion, urinary
incontinence, and known brain lesion on ___. She was initially
made NPO incase surgery was moved up from ___ as prieviously
scheduled. On ___ it was determined that surgery would occur as
planned on ___ and as such she was given back a diet. Her UA
showed signs of infection so she was started on ciprofloxacin
while awaiting urine culture results. On ___ her exam was stable
while awaiting OR for biopsy of her corpus callosum lesion. She
complained of intermittent RUQ pain on ___ and an US was
performed that showed cholelithiasis but no cholecystitis.
Because her abdominal tenderness continued a gallbladder scan
was done and Gen Surg was curb sided. KUB was done in follow up
on ___. She went to the OR on ___ for a stereotactic brain
biospy for diagnosis of her tumor pathology. A repeat urine
culture on ___ was negative. She tolerated the procedure well
and was taken to the PACU. A post-op head CT was stable.
She was discharged to ___ Rehab on ___. | 192 | 181 |
15494663-DS-12 | 29,635,999 | 1. Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications/refills.
3. Resume your ___ hospital medications.
4. WB Status: WBAT
5. You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
6. No dressing is needed if wound continued to be non-draining.
7. You may not drive a car until cleared to do so by your
doctor.
8. Wound: You can get the wound wet/take a shower starting from
3 days post-op. No baths or swimming for at least 4 weeks. Any
stitches or staples that need to be removed will be taken out at
your 2-week follow up appointment.
9. Medication refills cannot be written after 12 noon on
___.
WBAT with no restrictions.
You can leave wound open to air if it's dry and intact. You can
shower. Leave steri strips in place until follow up. | The patient was admitted to the Orthopaedic Spine Service for
spinal stenosis with urinary incontinence. The patient was
taken to the OR and underwent an uncomplicated posterior spinal
decompression and fusion. The patient tolerated the procedure
without complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status: WBAT.
The patient received ___ antibiotics as well as
mechanical DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged home in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. | 225 | 146 |
14500691-DS-31 | 26,272,566 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You were admitted to the hospital with abdominal pain and a
partial small bowel obstruction. Your bowel obstruction has
resolved and you have resumed a regular diet, and should
continue to do so. There was some air on you CT scan which was
consistent with older CT scans that you have had and is likely
due to a sphincterotomy you have had in the past. You also had
CT scan findings that showed calcifications on your aortic valve
and it recommended that you have outpatient follow up with a
cardiologist for this. Please follow up with You are doing well
and are being discharged to rehab to continue your recovery from
this hospitalization.
If you have any questions regarding this recent hospitalization
you may contact the ___ Surgery Clinic by calling
___. | Ms. ___ was admitted under the Acute care service for
management of her partial small bowel obstruction. She was noted
to have pneumobilia on CT scan which was also present on prior
imaging and consistent with the patient having a prior ERCP with
sphincterotomy.
She was initially kept NPO on IV fluids. On the morning of HD#1
her abdominal pain and nausea had resolved and she was passing
flatus. Her diet was advanced as tolerated. On HD#2 she was
tolerating a regular diet and her home medications were
restarted. Her I&O's were monitored and she was voiding adequate
amounts of urine. She was placed on SC heparin for DVT
prophylaxis. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable.
Physical therapy was consulted to evaluate her mobility who
recommended rehab vs. home with 24 hour supervision. On ___ she
was discharged home with her son and home services for ___. She
was cared for by the acute care surgical services. | 146 | 163 |
13869750-DS-22 | 23,017,350 | Ms. ___
It was a pleasure taking care of you. As you know, you were
admitted with fever and were found to have a pneumonia which
took several days to resolve. Fortunately your symptoms resolved
with time. You completed your antibiotics during your
hospitalization. Please continue your home medications and
followup with Dr ___.
Given your normal BP during stay while off of your blood
pressure medications, you should hold these until your next
outpatient primary care appointment when your blood pressure
will be re-evaluated. | ___ PMH metastatic pancreatic cancer, recently progressed
through FOLFIRI, who presented with fever to 103.5F and CXR
showing diffuse b/l interstitial opacities c/w viral vs atypical
PNA, who had early resolution of fevers/leukocytosis but
prolonged hypoxia requiring twice daily diuresis prior to
discharge.
#Fever
#Atypcial vs Viral Pneumonia
#Acute Pulmonary Edema
Patient presented with report of self limited diarrhea, sore
throat, headache, myalgias which favored viral illness vs
atypical PNA given diffuse interstitial abnormality on CXR. Was
treated w/ CAP coverage but fevers persisted x2 days before
improving. Legionella/Flu/RVP/Strep/BGlucan/induced sputum all
negative so CTA ordered to help clarify causative disease
process and was consistent with infectious process. Per
discussion with pulmonary consult, they felt atypical pneumonia
was still highest on differential even though she had minimal
respiratory symptoms. They noted that it is hard to compare the
CXR to CT scan and noted that they don't make much of the
radiographic progression since her fever curve was downtrending.
Accordingly, pt was continued on CAP coverage and completed it
during stay. Despite all measures, patient had lingering hypoxia
with ambulation which required 2 days of BID diuresis prior to
discharge so likely had contribution from pulmonary edema.
Pulmonary consult recommended that patient have repeat CT Chest
prior to next cycle of chemotherapy to obtain baseline. While
they feel it is less likely, pneumonitis from chemotherapy was
considered, so having a baseline would be useful if she is
re-exposed to chemotherapy and has similar symptoms. In that
case there would be more supportive e/o chemotherapy induced
pneumonitis
# Progression of disease
# Failure to thrive
# Metastatic pancreatic adenocarcinoma
CT Torso ___ demonstrated increasing/new pulmonary nodules,
peripancreatic stranding, new 6 mm hypoattenuating liver lesion,
and new trace ascites. Per Dr ___ overall
progression has been slow. Has tolerated therapy poorly with
malaise/side effects. FOLFIRINOX de-escalated to FOLFIRI ___
and rec'd to continue while awaiting enrollment in Phase 1 study
of Anti-CTLA monoclonal ab. C13D1 ___ held ___ due to
malaise and above issues.
On this admission a new 6 mm hypoattentuating liver lesion
reported on CT scan, which was not surprising given slow
progression noted on prior scans. Dr ___ of
admission, will see patient in clinic shortly afterward.
#Chronic Neoplasm Related Pain
Pain seems to have resolved but patient remains on methadone due
to severe symptoms with attempted taper in the past. Pall care
visited patient during stay and rec'd downtitration to 2.5 BID
or 5mg once daily. However, patient noted that she would prefer
to delay taper until she has completely returned to baseline.
Has outpatient followup with her pall care provider ___
___ where taper will be discussed.
#?Pulmonary stenosis seen on CT.
Outpatient team to consider nonurgent TTE for better
visualization
# HTN:
Held home amlodipine, carvedilol in s/o low BPs from poor
intake, FTT as above. Patient was instructed to hold dosing of
both meds until next outpatient PCP appointment where BP will be
re-checked and meds restarted if needed
I personally spent 56 minutes preparing discharge paperwork,
educating patient/family, answering questions, and coordinating
care with outpatient providers
___ 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. | 84 | 564 |
17568660-DS-5 | 29,582,966 | Dear Mr. ___,
You presented to the ___ after
suffering facial trauma. You were admitted to the Trauma/Acute
Care Surgery service for further medical care.
The Oral Maxillofacial Surgery team evaluated your injuries and
you were taken to the Operating Room where you underwent repair
of your jaw and nasal fractures and had extraction of one tooth.
You tolerated these procedures well.
You are now tolerating a full liquid diet and your pain is
better controlled. Your nasal packing was removed and you are
now medically cleared to be discharged home to continue your
recovery. Please note the following discharge instructions:
-Apply ice to your face to help with the swelling and pain
-Swish and spit with Peridex mouth rinse twice daily
You will have a follow up appointment with Dr. ___
at the ___ ___ Maxillofacial surgery clinic at the
___ (please see appointment time below)
Postoperative instructions following jaw surgery:
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the
type that self dissolve. If you have any sutures on the skin of
your face or neck, your surgeon will remove them on the day of
your first follow up appointment. SMOKING is detrimental to
healing and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder
of your postoperative course should be gradual, steady
improvement. If you do not see continued improvement, please
call
our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice
bag or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to
decrease swelling and stiffness. Please use caution when
applying
ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous
brushing, but please make every effort to clean your teeth with
the bounds of comfort. Any toothpaste is acceptable. Please
remember that your gums may be numb after surgery. To avoid
injury to the gums during brushing, use a child size
toothbrush and brush in front of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking
5 min to use the entire glassful. Repeat as often as you like,
but you should do this at least 4 times each day. If your
surgeon
has prescribed a specific rinse, use as directed.
Showering: You may shower ___ days after surgery, but please ask
your surgeon about this. If you have any incisions on the
skin of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK
SURGICAL SITES. This will avoid getting the area excessively
wet.
As you may physically feel weak after surgery, initially
avoid extreme hot or cold showers, as these may cause some
patients to pass out. Also it is a good idea to make sure
someone
is available to assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop
the bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick
to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet
is allowed for the first 24 hours after surgery. After 48 hours,
you can increase to a full liquid diet, but please check with
your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with
a small amount of soft food. Taking pain pills with a large
glass
of water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better.
If your jaws are wired shut with elastics and you experience
nausea/vomiting, try tilting your head and neck to one side.
This
will allow the vomitus to drain out of your mouth. If you feel
that you cannot safely expel the vomitus in this manner, you
can cut elastics/wires and open your mouth. Inform our office
immediately if you elect to do this. If it is after normal
business hours, please come to the emergency room at once, and
have the oral surgery on call resident paged.
___ Instructions: If you have had a bone ___ or soft tissue
___ procedure, the site where the ___ was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the ___ harvest, your
surgeon will instruct you regarding specific instructions for
the
care of that area. If you had a bone ___ taken from your hip,
we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.
Elastics: Depending on the type of surgery, you may have
elastics
and/or wires placed on your braces. Before discharge from
the hospital, the doctor ___ instruct you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal
sprays and pain medications. Use them as directed. A daily
multivitamin pill for ___ weeks after surgery is recommended but
not essential.
If you have any questions about your progress, please call our
office at ___ (dental school) or ___
(hospital). After normal business hours or on weekends, call the
page operator at ___ ___ and
have them page the on call Oral & Maxillofacial Surgery
resident. | ___ year old male with history of depression/anxiety, EtOH use,
NIDDM, and Hep C admitted after assault with mandibular
fractures.
The patient presented to pre-op/Emergency Department on ACS. Pt
was evaluated by anaesthesia/ Upon arrival to ED on ___.
Given findings, the patient was taken to the operating room for
ORIF L mandible fracture, ORIF R body fracture. 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 ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was well controlled
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalisation.
GI/GU/FEN: 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 ___
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. | 1,389 | 267 |
18994767-DS-8 | 22,575,575 | Dear Mr. ___,
You were seen at ___ because of palpitations and shortness of
breath.
WHILE YOU WERE HERE
-You were found to have "atrial fibrillation," an abnormally
fast heart rate.
-You were given medications to slow down your heart.
-You had a "cardioversion" procedure to restore a regular heart
rhythm.
-You were started on a blood thinner "rivaroxaban" to decrease
your risk of blood clots and stroke. You are at risk because of
atrial fibrillation and your procedure.
WHAT YOU SHOULD DO NOW
-Take your new medications for atrial fibrillation: metoprolol
and rivaroxaban.
-Follow up with Cardiology on ___ as
soon as possible.
We wish you the very best!
Your ___ Care Team | Mr. ___ is a ___ with PMH rheumatic heart dz who presented
with palpitaions and dyspnea, found to have new atrial
fibrillation with RVR.
#Atrial Fibrillation: New diagnosis. Unclear date of onset.
Unclear cause; thought to be ___ RHD. Had HR 160s in ED,
received IV diltiazem and was started on PO diltiazem. Dilt
uptitrated on ___ to 60 mg Q6H, but rate control was not
achieved. Started on heparin gtt ___. Underwent TEE/DCCV on ___
and converted to NSR. Started on rivaroxaban ___, which he is
to continue for at least 4 weeks post procedure. CHADSVASC score
1. Was continued on metoprolol after DCCV, which was uptitrated
to 200 mg XL daily on day of discharge. HR in ___ at time of
discharge.
#Tachymyopathy:
#Acute heart failure with reduced EF
#Pulmonary Edema:
Likely ___ afib as above. Had TTE on ___ showing LVEF of ___
and mild to moderate mitral regurgitation. Mild pulmonary edema
on CXR ___ received 20 IV Lasix x1 on ___ and again 20 IV Lasix
on ___. Prior to discharge he was able to ambulate without
symptoms and did not meet criteria for orthostatic VS changes.
Started on aspirin 81 daily and atorvastatin 40 daily.
#NSTEMI: thought to be type 2 I/s/o AF with RVR. Troponin
0.23->0.15 with no MB elevation.
___: Cr elevated as high as 1.4. Last measured value 1.2 in
___. Unclear if new baseline or if had ___ in setting of acute
heart failure. Improved to 1.2 and was 1.3 on day of discharge.
TRANSITIONAL ISSUES
===================
-Started on metoprolol succinate XL 200 mg daily for rate
control. Please titrate PRN
-Started on rivaroxaban 20 mg nightly for anticoagulation in
setting of cardioversion. Should continue until at least ___
(4 weeks from procedure). CHADSVASC 1; please address
anticoagulation with patient going forward
-Please obtain repeat TTE to assess systolic function after
resolution of a fib. Had EF ___ during admission
-consider ACEi if ejection fraction remains reduced on repeat
TTE
-Recommend outpatient stress test to work up heart failure
# CODE: full
# CONTACT: HCP: wife ___, ___ | 103 | 337 |
15843413-DS-18 | 28,408,120 | Dear Miss ___,
You were admitted due to your blood count dropping and concern
for GI bleed.
You were treated and given 1 unit of blood. As we discussed, a
colonoscopy and EGD did not show any findings to explain the
blood drop.
Reassuringly, your blood count was stable prior to discharge
We recommend seeing a hematologist after discharge. Also note
that biopsies were taken from the EGD and you will be called
with the results from the GI team.
It was a pleasure being part of your care
Your ___ team | Ms. ___ is a ___ female with history of PVD s/p CEA
on Dual antiplatelet therapy and
hydradenitis suppurativa on methotrexate who presents with 3
weeks of dyspnea on exertion found to have new onset anemia on
outpatient labs.
#Acute Symptomatic Anemia
#Suspected GI bleed - new onset symptomatic anemia with normal
MCV but acute drop from 14 to 8.6 over 3 weeks (on admission
day). She received 1 unit of pRBCs on admission She is on DAPT
iso PVD and CEA most recently in ___. She denied
melena, coffee ground emesis or hematochezia. Hemolysis workup
was negative. ___ was reassuring except presence of
gastritis.
GI took biopsies with EGD on ___. Restarted ASA/Plavix for now
given stability of Hgb
Referred to heme as outpatient given stability in Hgb and no
abnormal findings (of note methotrexate felt to be playing a
role but atypical to cause such severe bone marrow suppression
in 3 weeks - while other lines are stable, given patient has
been on
it for years)
# H/o CEA: restarted ASA and Plavix given stability in Hgb and
no evidence of bleeding. Will need Hgb recheck soon after
discharge
# DOE
# Chest tightness - resolved; suspect some demand in the setting
of acute anemia. Troponin stable, transfuse as above and ___
with Lasix as needed. BNP not elevated and thus less likely
overt heart failure. Trops and EKG were reassuring | 86 | 228 |
11983559-DS-10 | 22,056,599 | Wound Care:
- Keep incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dressing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any staples that need to be removed will be taken out at your
2-week follow up appointment.
Activity:
- Continue to be weight-bearing as tolerated on both legs
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Weight-bearing as tolerated bilateral lower extremities
Treatments Frequency:
Please administer Vancomycin through PICC line as written. | Ms. ___ was admitted to the Orthopaedic Trauma service on
___ for further work-up of her recent-onset right groin pain
and fevers. She was taken to the Operating Room on ___ to
undergo removal of the pubic symphyseal plate as well as
irrigation and debridement. Intraoperative cultures were taken
and sent for analysis. Please see Operative Report for full
details. The patient tolerated the procedure well. She was
started empirically on Vancomycin and given Lovenox for DVT
prophylaxis. Post-operatively, she was taken to the recovery
room before being transferred back to the floor. Her fever
curve trended downward over the next few days.
The Infectious Diseases team was consulted, and the patient was
continued on Vancomycin and also started on oral Ciprofloxacin.
A PICC line was placed on ___ for administration of the
Vancomycin at home. Intraoperative cultures did not grow a
pathogen, but a PCR is currently pending.
The patient worked with the Physical Therapy service and was
able to ambulate independently. Her pain was well-controlled
with oral pain medications by the day of discharge.
Ms. ___ was discharged home on ___ in stable
condition. She was given detailed precautionary instructions as
well as instructions regarding follow-up care with the
Orthopaedic Surgery and Infectious Diseases services and her
primary care physician. | 266 | 223 |
12000071-DS-6 | 28,159,332 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Patient presented to ___ from home via ambulance for
evalaution after contacting us regarding a worsening headache.
She was evalauted in the ED and a noncontrast head CT was
obtained which showed stable to improving IVH with persistent
IPH/SAH and no signs of hydrocephalus. She was admitted to the
floor for pain control and further observation. On ___ she
remained stable and her pain regimen was titrated in order to
provide relief.
By the day of discharge on ___, the patient's symptoms were
well-controlled with a PO pain regimen. A repeat CTA was
performed which showed the hemorrhage to be stable. She was
discharged in improved condition with clear instructions for
follow-up. | 139 | 113 |
15194198-DS-6 | 27,305,796 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with a high fever and found to have a new infection in your
abdomen. You were given antibiotics and had a drain placed to
help remove the infection from your body. Your surgical wound
was closely monitored and a vac dressing was applied to help
prevent infection and promote healing. Your dialysis schedule
was maintained and your electrolytes were closely monitored. You
will follow up in the outpatient Transplant Surgery clinic to
discuss future venous access options for dialysis. You are now
doing better, tolerating a regular diet, and ready to be
discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Ms. ___ is a ___ yo F with complex abdominal surgery history
notable for RouenY Gastric bypass with revision, with a recent
exploratory laparotomy for a perforated gastric remnant
secondary to downstream obstruction of her Roux-en-Y gastric
bypass from a jejunojejunal intussusception. She was discharged
to rehab on ___ and then presented to the hospital on
___ with fever to 103 from rehab. CT scan was obtained and
was overall stable from prior with slight (expected) evolution
of posterior abdominal fluid collection. She was admitted to the
surgical service for fever work up, IV antibiotics, and ___
drainage.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with medications as
needed.
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 for ___ procedure.
After procedure, she was given a regular diet which she
tolerated without difficutly. Her PEG tube remains in place
despite her ability to achieve adequate nutrition via oral
means. Will consider removing PEG in the future as an
outpatient. On ___ while doing daily dressing changes on her
wound incision it was noted that tube feeds were coming out so a
drain study was ordered, tube feeds were discontinued and
patient continued on a regular diet with supplements. A wound
VAC was placed on wound incision in order to promote healing,
during the duration of her hospital stay drainage from the wound
VAC was serosanguineous in nature and scant ammount. She
underwent G-tube study that confirmed placement in the remnant
stomach but did not confirm a gastro cutaneous fistula. G-tube
was placed to gravity and the patient tolerated oral feedings
well. The patients electrolytes were monitored and she continued
to receive HD with nephology following. Patient's intake and
output were closely monitored. Blood glucose levels were
routinely monitored and treated with recommendations by the
___ Endocrine team. She initially presented with hypoglycemia
with blood glucose of 50 but otherwise asymptomatic. Basal
insulin was initially held and then titrated up as needed.
ID: The patient's fever curves were closely watched for signs of
infection. Infectious disease was consulted for assistance and
antimicrobial management given her persistent WBC count. Fluid
culture from ___ drain grew E coli and urine culture from ___
taken in the ER grew enterococcus and pseudomonas. She was
screen for clostridium difficile and negative for infection. She
was treated with broad spectrum Zosyn until ___ per ID recs. A
midline was placed on ___ for ongoing antibiotic therapy.
She was treated with a 2 week course of zosyn after drainage.
Her surgical wound was closely monitored for infection and
underwent bedside debridement and wound vac placement per
routine. 2 positive urine cultures for enterococcus were
confirmed so patient received a 7-day course of Linezolid per ID
recs (___).
HEME: The patient's blood counts were closely watched for signs
of bleeding.
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. | 375 | 577 |
14668686-DS-13 | 29,861,786 | Dear Ms. ___,
WHY DID YOU COME TO THE HOSPITAL?
You were admitted to ___ as you had a sacral decubitus ulcer
and concern for osteomyelitis.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an MRI scan which was concerning for infection of your
sacral bone
- You underwent debridement of the ulcer at the bedside and
subsequently in the OR with surgery
- You were given antibiotics based on the bacteria growing from
the ulcer
- Surgery recommended good nutrition and working with physical
therapy before proceeding with further surgeries
- You were seen by nutrition and given supplementation to help
your wound heal
- You were discharged to rehab to allow you to build up your
strength
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please follow-up with all of your outpatient providers as
advised
- It is important you take all of your medications as prescribed
It was a pleasure taking care of you!
Your ___ Healthcare Team | ___ with history of Crohn's disease status post colectomy with
ileostomy, chronic right heel non-healing ulcer attributed to
polyradiculopathy from chronic degenerative spine disease and
back surgery, chronic back pain, osteoporosis, HTN, pAF, and
recent humerus and femur fracture (___), who presented from
rehab with sacral decubitus ulcer with concern for
osteomyelitis.
==================== | 156 | 52 |
15537536-DS-12 | 23,624,122 | Dear Ms. ___,
It was a pleasure treating you at ___
___. You were admitted due to abdominal pain. We performed an
EGD to look for ulcers in your stomach and small intestine,
which was negative. We also performed an MRCP to evaluate your
pancreas and liver structures, which was also normal. We treated
your pain and nausea with medications.
You were also admitted because you passed out. We believe this
was due to vasovagal syncope, where a trigger causes a sudden
drop in your heart rate and blood pressure. This leads to
reduced blood flow to your brain, which results in a brief loss
of consciousness. This is usually harmless and requires no
treatment. | ___ yo F with no past medical history presented with 1 month
history of RUQ abdominal pain. Now worsening and associated with
nausea and vomiting. Patient also had a syncopal episode prior
to admission.
# Abdominal pain:
Our initial DDx included cholecystitis, peptic ulcer disease,
and chronic pancreatitis. Liver U/S was normal, making
gallstones less likely. Patient underwent EGD, which was normal.
Biopsies were taken from the antrum of the stomach, and the
results show now evidence of H. pylori. Patient underwent MRCP
which did not reveal any abnormalities. Her pain and nausea were
controlled during hospitalization. It was thought that her
abdominal pain was due to GERD. She was discharged on
Ranitidine.
# Vasovagal syncope:
Patient had a syncopal episode, lasting approximately ___
seconds prior to arriving at the ED. Patient also had an episode
of bradycardia in the ER. Patient stated she felt nauseous,
dizzy, diaphoretic, and clammy prior to these episodes. Patient
was monitored on telemetry, and there were no events.
TRANSITIONAL ISSUES:
None | 114 | 166 |
17415205-DS-8 | 27,766,096 | It was a pleasure taking care of you during your recent
admission.
You were admitted because of elevated blood pressure, muscle
cramps and a rash.
These symptoms were likely all related to your kidney failure,
as you had not had dialysis for over a year. Your electrolytes
were repleted, which helped your muscle cramps. You were
started on hemodialysis which helped your electrolytes, blood
counts, and mental status.
We also noted that you had increased level of a type of white
blood cell called eosinophils, which is likely reactive to
either taking ibuprofen, or from your exposure to the detergent
causing the rash.
The following changes were made to your medication regimen:
- STOP lisinopril
- START amlodipine 10mg once daily
- START furosemide 80mg twice a day
- START calcium acetate three times a day with meals
- START nephrocaps once a day
- START triamcinolone acetonide ointment twice daily
- START camphor menthol lotion four times daily
- START petrolatum ointment three times daily | ___ male with long-standing severe hypertension and ESRD for
which he was previously on hemodialysis who returns to care
after being lost to follow-up with severe muscle cramping and a
full-body rash.
# ESRD with Hypocalcemia- Off peritoneal dialysis and renal
replacement therapy for over ___ year, with grossly abnormal
creatinine and electrolytes on admission. Patient had no
evidence for urgent dialysis on admission. He was seen by
renal, who recommended starting calcium acetate TID for calcium
repletion and phosphate binding. In addition, patient required
large IV doses of calcium gluconate given symptomatic
hypocalcemia. He was also started on nephrocaps. PTH was
grossly elevated to 1091, but calcitriol was held in setting of
hyperphosphatemia.
On HD 2, patient had a tunneled HD line placed and began
hemodialysis. His electrolytes quickly improved. He will have
outpatient follow-up with transplant surgery for peritoneal
dialysis catheter placement, and will continue qMWF HD in the
meantime.
# Rash- Appeared to be chronic hyperpigmentation related to dry
skin, chronic itching. ___ have been due to uremic xerosis.
Dermatology recommended hydrocortisone cream for two weeks, in
addition to sarna lotion and aquaphor.
# Muscle cramps- Likely symptomatic hypocalcemia. Patient was
given large doses of IV calcium gluconate until calcium levels
normalized. Muscle cramps resolved as calcium normalized.
# Hypertension- Patient was hypertensive on admission, due to
not taking anti-hypertensives for a prolonged period of time.
Metoprolol was continued. Lisinopril was discontinued in case
there was some reversal acute kidney injury. Patient was
started on amlodipine, and titrated up to 10mg daily. He was
also started on lisinopril 80 mg BID
# Anemia- Related to ESRD without replacement therapy for
prolonged period of time. Normocytic in nature. Patient was
given epo during HD.
# Transitional issues-
- PPD placed during admission, negative
- patient will initiate HD with Davita of ___ starting at
5pm on ___
- Eosinophilia of unclear significance, recheck with PCP. Our
differential was possibly secondary to NSAID use versus possible
reaction on skin to detergent. We did not suspect other
systemic helminthic infection. | 159 | 363 |
13905222-DS-18 | 21,083,466 | Dear Mr. ___,
You were admitted to the hospital because your legs were weak.
This was due to a condition called rhabdomyolysis which is a
breakdown of your muscles. We think the simvastatin you were on
caused this.
This condition ended up damaging your kidneys and you will need
dialysis for the forseeable future. We took you off the
medications that caused this problem.
You will continue to see a kidney doctor to monitor how well
your kidneys are doing.
Please follow up with the appointments provided in order to be
evaluated for better dialysis access and for a potential kidney
transplant.
Please do not take your viagra while you are on Imdur. If this
is a problem, please speak with your doctor about switching to a
different blood pressure medication.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with a history of CKD (baseline
Cr 2.8), IDT2M, hepatitis C, HLD, and ___ transferred from
___ for bilateral leg weakness and pain. He presented to
___ on ___ after several weeks of leg cramping and
pain that had worsened in recent days. He was initially treated
with aggressive hydration and diuresis; however, given his
continued leg weakness and tenderness, in addition to worsening
lab values, dialysis was initiated on ___. He underwent 4
rounds of dialysis prior to discharge. His leg weakness improved
and he was discharged to rehab with a plan for transplant
surgery and renal transplant to follow up with him after
discharge to establish long-term dialysis access and care.
============
Acute issues
============
# Acute rhabdomyolysis:
On ___, he presented to ___ complaining of acute
worsening of bilateral leg weakness and pain that had been
ongoing for ___ weeks. He was found to have CK > 20k and
elevated LFTs and trops. He denied chest pain and EKG was wnl.
He was transferred to ___ for further management of presumed
rhabdomyolysis. On arrival to ___ ED, exam was notable for LEx
weakness and TTP at the quads. Labs demonstrated hyperkalemia
and acidosis, as well as elevated CK, BUN/Cr, trop-T and LFTs.
Uax +lg blood without RBCs. Renal was consulted and attributed
acute rhabdomyolysis to possible amlodipine/statin/fluconazole
interaction. His home amlodipin and statin were held. Is/Os were
closely monitored. Aggressive hydration and diuresis were
initially pursued, but his lab values remained elevated and he
developed uremic symptoms (nausea, vomiting). He underwent ___
placement of HD access (tunneled IJ) and 4 rounds of subsequent
dialysis (initiated ___. His lab values trended back down
to within normal limits and his clinical exam improved over his
stay.
# Acute on chronic kidney disease:
He has a baseline Cr of 2.8, thought to be due to diabetic and
hypertensive nephropathy, followed by nephrology here. Cr 6.6 on
admission and remained elevated despite aggressive hydration,
avoidance of nephrotoxic meds, and holding of home lisinopril.
He had decreased urine output, despite attempts at diuresis, and
his electrolyte abnormalities (hyperkalemia, hyperphosphatemia,
hypocalcemia, anion gap acidosis) persisted. Given these
findings, as well as nausea and vomiting suggestive of uremia,
he underwent dialysis as described above.
# Chest pain:
Mr. ___ had intermittent episodes of chest pain during his
stay. EKGs were wnl and troponins not interpretable due to
Rhabdomyolysis. Cardiology was consulted and followed during his
course. He was discharged on his home labetalol 200mg, and
started on aspirin 81mg, imdur ER 30mg, and fish oil 2g daily.
# Hyperkalemia:
He had a K of 6.3 on arrival to the ED, treated with calcium
gluconate and insulin with D50. On the floor, his potassium
levels were followed and he was managed with kayexalate and
lasix diuresis. He had daily EKG while hyperkalemic and was kept
on a low K diet. His K values stabilized with dialysis and were
closely monitored throughout the rest of his stay.
# Transaminitis:
On admission, LFTs were AST 1426/ ALT 758. These labs were
attributed to likely statin toxicity and trended over the course
of his stay. He also has a history of HCV, which may explain his
residual transaminitis. HCV VIRAL LOAD was checked and was
3,380,000 IU/mL. The patient will need outpatient follow up to
discuss treatment of HCV.
# Leukocytosis:
He had a WBC of 13 on admission, thought to be secondary to
rhabdo-related inflammation and/or sympathetic activation. These
values fluctuated between ___ during his stay. He remained
afebrile throughout his stay.
==============
Chronic issues
==============
# IDT2DM:
Mr. ___ is on 100u daily insulin at home. His glucose was 81
on arrival and his blood sugars were monitored during his stay.
He was placed on an insulin sliding scale to control his sugars
adequately. Glargine was discontinued.
# HLD:
His statin was held in the setting of rhabdomyolysis during his
stay.
# HTN:
His amlodipine and lisinopril were held in setting of
___. Labetalol was given for blood pressure control.
==============
Transitional issues
==============
-stopped statin, amlodipine on this admission and NOT restarted
on discharge as they were felt to contibute to rhabdomyolysis
-needs transplant surgery referral for access
-needs transplant nephrology follow up
-HCV viral load 3 million, will need referral to hepatology.
-standing lantus stopped on this admission due to low fasting
blood sugars; only on ISS while here with minimal requirement.
Please continue to evaluate for insulin requirement as appetite
continues to improve and renal function improves
-Dialysis should be conducted on an as needed basis based on
electrolytes and urinary output. If that is not possible,
dialysis should proceed on a ___ schedule. | 136 | 768 |
16003661-DS-26 | 27,210,748 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for shortness of breath. We
diagnosed you with a COPD(emphysema) exacerbation. We treated
you with Zithromax, nebulizer treatments and your regular
inhalers. We recommended steroids, however you refused. An x-ray
of your chest was performed in the emergency room and did not
show any evidence of pneumonia. If you have any further
questions regarding your hospitalization please feel free to
contact your ___ providers.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
None | ___ year old female with a history of COPD, diastolic HF and
paranoid schizophrenia who presented with shortness of breath.
She was diagnosed with a COPD flare in the emergency department
and treated with IV azithromycin and albuterol/ipratropium
nebulizers.
#SHORTNESS OF BREATH
The patient has a known history of what appears to be advanced
COPD. She responded well to treatments administered in the ED,
including ipratropium/albuterol nebulizers and IV azithromycin.
She refused IV and PO steroids in the emergency department, and
continued to do so on the floor. Her O2 saturations were in the
low to mid ___ throughout her entire hospital stay. She refused
nebulizer treatments and insisted on using handheld inhalers
instead. She occasionally used O2 for comfort. Her CXR did not
show any infiltrate suggestive of pneumonia. CXR also was
without evidence of pulmonary edema. Her JVP on admission was
approximately 8 cm. Her BNP was 1846. The patient likely has
pulmonary hypertension from her advanced lung disease. She
finished her course of azithromycin on ___.
#BACTEREMIA
Blood culture from ___ grew GPCs in pairs and clusters.
Speciation returned micrococcus/stomatococcus. This culture
likely represents a contaminant. Vancomycin was discontinued
after speciation return.
#CHEST PAIN
No acute changes on ECG (sinus,RBBB,<1mm ST depression V3).
Troponin <0.01 x2. Chest pain likely related to COPD flare. The
patient was given aspirin 325 in the ED. Aspirin 81mg daily was
continued during her hospitalization.
#HYPERTENSION
Blood pressure well controlled. HCTZ 25mg daily continued.
#PARANOID SCHIZOPHRENIA
Paranoia quite apparent on exam. The patient mostly expressed
concerns over a corrupt medical system. Not a danger to herself
or others at the present time.
TRANSITIONAL ISSUES
*******************
-follow up pending blood cultures | 101 | 266 |
15015163-DS-15 | 20,318,439 | Dear Mr. ___,
WHY DID YOU COME TO THE HOSPITAL?
- You were feeling overall unwell and went to urgent care where
they found your heart rate to be very slow.
WHAT HAPPENED WHILE YOU WERE HERE?
- We did an EKG that continued to show your heart rate was very
slow.
- We put a pacemaker inside your chest to stimulate your heart
to beat at a faster rate than it was beating on its own.
WHAT TO DO WHEN YOU LEAVE?
- Continue to take your regular medicines and go to all your
follow-up appointments.
- If you feel unwell again and are unsure if you should come
back to the hospital, you can call ___ to speak with a
nurse practitioner or doctor.
Best wishes,
Your ___ team | TRANSITIONAL ISSUES:
====================
[ ] He will require a device check with ___ cardiology in 1
week.
[ ] He needs to follow-up with Dr. ___ in ___ EP in ___
weeks.
[ ] Lyme titer is pending, this should be followed up by PCP in
case it contributed to heart block.
# CODE: full, presumed
# CONTACT/HCP: PEPP,ADRIA
Relationship: WIFE (HCP)
Phone: ___
Other Phone: ___ | 121 | 63 |
14471216-DS-5 | 25,894,747 | You were admitted to ___ on
___ with complaints of vague, diffuse abdominal pain since
___. On further examination, you were found to have an
internal hernia, as shown on CT scanning. You were taken to the
Operating Room on ___ where you had a laparotomy (open
abdomen) and reduction of the hernia. Your abdomen was then
closed, thereafter. You were recovered in PACU and transferred
back to the inpatient floor for further management.
Your care was complicated by a small bowel ileus ("sleeping of
your bowels") and hypertension. Because your intestines were
not moving well after surgery, you were given IV fluids and
medications. Your blood pressure was extremely high and you
were given IV blood pressure medications. Once you were
tolerating oral intake, you were slowly resumed on a regular
diet and oral medications were started.
You have now recovered well and are being discharged home with
the following discharge instructions:
Please follow up in ___ clinic at the appointment sdcheduled for
you below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
Your abdominal staples may be removed within 10 - 14 days after
your surgery. This is around ___. XXXXXXXXXXXXXXX
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon. Also call the doctor if there is expanding
redness around your staples or puss coming out of the wound.
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.
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 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 folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In 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 in drainage from the wound | Mr. ___ arrive to the emergency department complaining of
abdominal pain. On CT he was found to have a "swirrling
mesantery" that was suspicious for an internal hernia. The
risks and benifits of a surgery were explained to the patient
and he agreed to go to the OR that night.
In the operating room an internal hernia of the mid jejunum
through a defect in the transverse mesocolon was reduced with
repair of the defect. No bowel resection was necessary. For
more detailed information please see the op report.
The patient tolerated the procedure well. His recovery was
uncomplicated during the first three days post-operatively.
Pain control was sub-optimal with the patient complaining of
moderate pain the first few days but he was able to pass flatus
and was started on a clear diet. However, on post-op day 3 he
complained of nausea and was noted to have a distended abdomen
with 400cc emesis. A KUB showed constipation and non-specific
bowel-gas patter. He was made NPO and an NG tube was placed
with relief.
Also on post-op day 3 he had difficult to control blood pressure
with systolics >200 and complaints of chest pain. An EKG and
troponins were negative. IV hydralizine and metoprolol were
used in an attempt to better contol his pressures, but the
systolic could only be reduced to ~180.
On POD 4 the patient self-d/c'ed the NG tube. It was not
replaced as it had not put out a high volume over the prevous
several hours and he was passing flatus. His blood pressures
continued to be difficult to control with increasing doses of IV
medication, including lasix.
On POD 5 a clonadine patch was added for blood pressure control
and a medicine consult was obtained. Their recomendations of
starting HCTZ, PO hydralzaine, and increasing his valsartan and
amlodipine.
On POD 6 he developed another period of chest pain and EKG and
troponins were again negative. A supository was given and
patient had several large bowel movements.
On POD 7 pt was recovering well when pt was noted to have had a
change in mental status where he was difficult to arouse and was
generally somnolent. A head CT was negative and stat labs
showed no electrolyte abnormality. Upon re-evaluation 90
minutes later his mental status had returned to baseline.
Over the following three days his blood pressures were
adaquately controlled, he was no longer distended, and he was
advanced to a regular diet with improved pain control. He was
able to transition to all PO medication. He was discharged home
on POD 10 with instruction for close followup with his PCP for
management of his new blood pressure medication and to the ___
clinic. | 929 | 466 |
14518163-DS-12 | 28,346,890 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- low blood pressure
- abdominal pain & diarrhea
What was done for you in the hospital:
- we gave you fluids which returned your blood pressure to
normal
- you were monitored overnight to ensure that your symptoms
resolved and did not recur
- you completed a session of hemodialysis on ___
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ man with history of ESRD on HD, HTN, asthma, and
intellectual disability admitted for epigastric abdominal pain
and hypotension, etiology not entirely clear though most likely
due to hypovolemia from excess HD ultrafiltration, subsequently
resolved with fluid resuscitation.
# HYPOVOLEMIC SHOCK
Initially admitted to the MICU for hypotension in setting of
likely excess ultrafiltration at HD, acute on chronic diarrhea,
and vomiting. CT torso with evidence of mild colitis though no
other acute process to account for hypotension. Received empiric
antibiotics in the ED, subsequently weaned, with resolution of
hypotension following fluid resuscitation. Given rapid
improvement and absence of significant infectious signs/symptoms
a septic etiology was considered unlikely. Colitis suspected to
be viral gastroenteritis. No evidence of cardiogenic shock. He
remained stable on the floor and completed HD session on ___
without issue. Discharged with plan for close outpatient follow
up.
# ABDOMINAL PAIN / DIARRHEA
CT with evidence of colitis with stool studies negative to date.
C. diff negative. Abdominal pain rapidly improved and frequency
of stools returned to normal (of note does have some degree of
chronic diarrhea). Suspect possible viral gastroenteritis given
improvement without antibiotics and no other evidence of
significant infectious or inflammatory process.
# ESRD on HD
On ___ HD schedule. Electrolyte imbalances resolved while in
house. Last session HD ___ without issue.
CHRONIC / STABLE ISSUES
========================
# HYPERTENSION
Losartan and metoprolol held pending outpatient follow up.
# CHF W/ RECOVERED LVEF
LVEF 58% in ___. Suspected to be secondary to uncontrolled
hypertension. History
of EF 25%, diffusely hypokinetic, with pHTN and mildly dilated
LV. EF since has recovered to 58% in ___. Follows with
cardiologist ___.
# ASTHMA
Remained stable in house.
# GERD
Continued home famotidine.
TRANSITIONAL ISSUES
========================
[ ] Losartan and metoprolol held at discharge given admission
for hypotension. Will need to be resumed as outpatient as
tolerated given history of hypertension & CHF with recovered
LVEF.
[ ] Noted to have mild pan-cytopenia (WBC 3.1, Hgb 11, Plt 124)
on discharge labs. Overall similar to prior, stable, with likely
component of hemodilution. Recommend repeat CBC within ___ days
to ensure stable. Workup further as needed.
[ ] CTA Chest Finding: Right thyroid homogeneously hypodense
mass measuring 3.3 x 4.6 cm incompletely imaged along the
superior aspect, either a cyst or nodule. Recommend thyroid
ultrasound for further evaluation, particularly of the superior
aspect.
# CONTACT: ___ (guardian) ___
# CODE STATUS: Full (confirmed) | 188 | 384 |
13841714-DS-22 | 28,575,854 | Dear Ms. ___,
You were admitted to ___ for nausea and vomiting. You were
also found to be dehydrated. Your symptoms were mostly likely
caused by your chemotherapy treatment, which you started last
week. We gave you medications to treat your nausea and vomiting
and fluids through your IV. Please continue to take these
medications as prescribed.
In addition, you continued to receive your radiation treatments
while in the hospital. Please continue to come in for your
radiation treatments as scheduled.
You will also follow up with Dr. ___ Dr. ___ on
___ at 1:30pm.
We wish you the best,
Your ___ Care Team | Ms. ___ is a ___ female w/ stage IIIB NSCLC s/p resection,
on
cisplatin/pemetrexed (C1D1: ___ with concurrent radiation
and recent admission for dysphagia, now presenting with nausea
and vomiting and found to be hyponatremic to 127 and with an
acute kidney injury. Patient's symptoms were likely caused by
her recent chemotherapy treatment, given the emetogenic nature
of cisplatin. She was given zofran, Ativan, dexamethasone 2mg
daily and standing reglan to control the nausea. Given the
prolonged nature of his symptoms, abdominal and brain imaging
were recommended, though patient declined. Given her decreased
PO intake, the hyponatremia and ___ were thought to be ___
hypovolemia and resolved with IVF. During this admission, the
patient also continued to receive her radiation treatments as
previously scheduled.
#Nausea/Vomiting: most likely due to her recent chemotherapy
given the emetogenic nature of cisplatin and the start of
symptoms 2 days after chemotherapy. However, extended duration
of n/v concerning for other etiologies such as brain or
abdominal mets. The need for further imaging was discussed with
patient, but she continues to decline any imaging scans. Patient
was given zofran and ativan for symptom control. We discussed
with her the option of starting olanzapine for chemo-induced
emesis, but patient reported she experiences tachycardia and
palpitations on the medication. She was then started on
dexamethasone and reglan with some relief in symptoms.
#Dizziness: patient orthostatic in context of decreased PO
intake, likely due to hypovolemia. She was given several boluses
during admission for positive and borderline positive
orthostatics.
___: patient with creatinine 1.0 at admission, double her
baseline of 0.5-0.6. Initially thought ___ to hypovolemia and
improved with mIVF. At discharge, stable at 0.8-0.9.
#Hyponatremia: Patient presenting sodium is 127 in the setting
of nausea and vomiting. She was found to be 2 kg below her
recent discharge weight, supporting most likely cause of
hypovolemia. Now resolved with IVF.
#Anxiety: patient with marked anxiety about her cancer and
therapy. She was started on Ativan during last admission with
some mitigation of her symptoms. She was continued on the ativan
for both its anti-anxiety and anti-emetic properties.
#NSCLC: patient initiated radiation and chemotherapy on ___.
While an inpatient, she continued to receive her radiation
treatments as previously scheduled.
#Hypertension: patient with history of hypertension on
lisinopril at home. She had recently been on atenolol, which had
been discontinued by her PCP. During this admission her
lisinopril was held ___ ___. Her pressures remained stable with
SBPs in the 130s. She was restarted on her lisinopril prior to
discharge.
#GERD: patient had previously been switched from omeprazole to
lansoprazole ODT during last admission for ease of use with her
dysphagia. However, patient stated she did not like the
lansoprazole and had stopped taking it. She was switched back to
omeprazole this admission.
#Pain: patient was continued on her home pain regime of
oxycontin 30 mg BID and oxycodone 15 mg q4H PRN with adequate
pain control | 104 | 483 |
14927306-DS-21 | 21,589,348 | Dear Ms ___,
You were admitted to ___ after you fell and broke your
hip. Our orthopedic surgeons performed a hip repair surgery of
your left hip. Unfortunately, after your surgery we were
concerned as you had frequent periods where you were not acting
like yourself. We did an "EEG" which tests for seizures, which
showed that they were occurring, and we adjusted your
anti-seizure medications.
Finally, we did a procedure to remove a clot from your fistula,
which would allow you to get dialysis again. We also did a
procedure to stop a leak from one of your vessels that was
causing blood to collect in your arm and causing you pain.
Our surgeons have left some recommendations below for your after
your procedure.
It was a pleasure taking care of you!
Your ___ Team
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue to take your home anticoagulation regimen
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off. | Ms ___ is an ___ with a history of Type II DM, ESRD on HD
MWFSa, HTN, CAD s/p CABG in ___, seizures, chronic mesenteric
ischemia s/p SMA, PVD on aspirin/plavix, and dCHF s/p fall found
to have hip fx s/p hemiarthroplasty. Hospital course complicated
by transfer to medicine service for AMS (thought to be secondary
to opiate use and seizure) and thrombus, pseudoaneurysm and
hematoma of AVF s/p ___ thrombectomy and repair.
# Left femoral neck fracture s/p hemiarthroplasty: The patient
presented to the emergency department and was evaluated by the
orthopedic surgery team. The patient was found to have a left
femoral neck fracture and was admitted to the acute care surgery
service. The patient was taken to the operating room on ___
for a left hip hemiarthroplasty, 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.
She had continued left wrist pain, without fractures on imaging.
She had no acute fractures in her lumbar spine. In addition,
her tertiary exam did not reveal any additional injuries. Pain
was controlled in house with acetaminophen. Patient could not
tolerate opioids as she became very altered with this medication
(see below). Tramadol was avoided given seizure history. Patient
will follow up with orthopedic surgery for post-op staple
removal on approximately ___.
She was transferred to the medicine service from ___ on | 314 | 279 |
18394695-DS-31 | 21,815,720 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with confusion and
found to have a urinary tract infection. You were started on
antibiotics for this, and will be continuing antibiotics until
___. We also gave you lactulose to help improve your
thinking. You worked with the physical therapists here to help
you gain your strength, and it was determined that you will
still benefit from going to rehab.
While you were here, you were continued on dialysis. You also
underwent fluid removal from your abdomen on ___ with a
paracentesis.
The following changes were made to your home medication regimen:
1. START Ciprofloxacin 250 mg daily, take through ___
Please continue to take your medications, including lactulose
and rifaxamin. Please follow up with your primary care doctor,
and your liver specialist next week.
We wish you all the best,
Your ___ team | Mr. ___ is a ___ yo M with PMHx of alcoholic cirrhosis c/b
HE, diuretic refractory ascites requiring scheduled therapeutic
paracentesis, ESRD on HD (___) and type II DM who
presented with decline in his mental status secondary to hepatic
encephalopathy precipitated by UTI.
.
>> ACTIVE ISSUES:
# Hepatic Encephalopathy: Urinalysis with >182 WBC and postive
leukocyte esterase c/f UTI so he was started on ceftriaxone 1gm
q24hr ___. He did receive 2gm CTX on ___ ___eftriaxone was increased to 2gm q24hr for suspected SBP
treatment (day ___ d/t inability to obtain ascitic fluid.
He completed 5 days of SBP treatment and was transitioned to
oral ciprofloxacin to compelte a course of antbiotics for a UTI.
This course will be completed on ___.
.
# Alcoholic Cirrhosis: c/b recurrent HE, diuretic-refractory
ascites requiring weekly paracenteses, HRS, and grade I varices
noted on EGD ___. MELD remained in the ___, at his baseline.
He underwent paracentesis on ___ with 4L fluid removal, did
not show signs of SBP. Patient had treatment for UTI, and
paracentesis while on antibiotics, so therefore unable to
determine whether patient had SBP. Patient initially treated
empirically. Would consider patient to have diagnostic
paracenteis as outatient. Prognosis was discussed briefly with
patient, and to be continued int he otupatient setting with
primary hepatologist.
.
# ESRD: considered ___ hepatorenal syndrome in the setting of
pre-existing DM2/HTN. He was continued on nephrocaps and
Doxercalciferol 5 mcg qHD. Patient underwenet dialysis per
normal schedule without difficulty.
.
# Non-insulin-dependent Type II diabetes: not on insulin as
outpatient. Patient had elevated blood sugars while ___,
___ be contributing to dehydration etc. Patient was started on
low dose sliding scale, without strict glycemic control given
poor overall prognsois. Patient to continue slididng scale, and
may benefit a long-acting insulin in the future. This will be
titrated per outpatient primary care physician.
.
# Anemia: Patient's anemia was at baseline. Patient etiology is
chronic disease and end stage renal disease on dialysis.
Patient's EPO was initially held in the setting of a high
hemoglobin, and was continued on Venofer 50 mg ___.
Patient's iron was held in the setting of hepatic encephlopathy
and can be constipating (with lactulose treatment). Patient's
hemoglobin remained stable, and was hemodynmcially stable during
hospital stay.
.
# Hypertension: patient was continued on home labetolol
# Hyperlipidemia: Patient was continued on home atorvastatin. | 151 | 392 |
12246674-DS-21 | 25,230,157 | Dear Mr. ___,
You were admitted to the hospital to achieve better control of
your blood sugars prior to your foot surgery. You were given
increasing amounts of insulin with good control of your blood
sugars. You were also restarted on your home lisinopril to
control your blood pressure.
Please continue taking your medications, attached, as
prescribed. Please also follow-up with your appointments as
scheduled.
We wish you the best in the future!
Your ___ Care Team | Mr ___ is a ___ with DM, HTN, CKD, PVD and chronic foot
ulcer presenting for glycemic control prior to heel closure
surgery.
Most recent A1c 8.8, though per chart review appears pt has
difficulties with understanding his insulin regimen, need for
pre-prandial injections, and need for basal insulin. Patient's
diabetes is complicated by retinopathy, chronic foot ulceration,
and presumably CKD. The patient was started on lower doses than
his home insulin regimen, as he was likely not taking his
insulin as prescribed resulting in poor control of his blood
glucose levels. The ___ diabetes service was consulted for
uptitration of his insulin regimen, and he responded well. On
discharge his FSG ranged from 113 to 210. Pt was unable to
understand SSI, so he was discharged with Glargine and fixed
doses of prandial Humalog.
Patient's lisinopril was originally held in the setting of
presumed ___ on CKD. However, his Cr was felt to fluctuate
significantly with a high of 1.9. Cr was 1.5 at the time of
discharge. He was discharged with his home lisinopril.
Pt notably had chest pain during this hospitalization, which is
stable since prior surgery. Pain was reproducible with palpation
of the Left lateral chest wall and was felt to be
musculoskeletal. Chest x-ray did not reveal any fractures or
other obvious causes for pain. | 74 | 219 |
10674420-DS-15 | 23,203,507 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted to the hospital because of your pain and
because your oxygen level was low, and because you had thoughts
of wanting to hurt yourself
WHAT HAPPENED IN THE HOSPITAL?
- We treated your back pain and found that your oxygen level was
about where it normally is for you
WHAT SHOULD YOU DO AT HOME?
- Continue taking your pain medication as agreed upon with your
pain clinic
- If you have thoughts of wanting to hurt yourself, make sure
you follow the safety steps we discussed. Reach out to your
sister, call your doctor, or go to an emergency department.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | =================
SUMMARY STATEMENT
=================
___ y/o male with sig PMHx of COPD, chronic lower back pain s/p
L4-S1 fusion, spinal cord stimulator and chronic opioid therapy
p/w severe low back pain, fatigue admitted from ED for O2
saturation of 88% on room in ED.
====================
ACUTE MEDICAL ISSUES
====================
# Chronic low back pain:
S/p spinal cord stimulator. Presented to ED with hope of
removal. Concerned that his low oxygen saturation would end up
being a contraindication to removal, and therefore wanted to
have the date of this procedure advanced. Spoke with Dr.
___ indicated this hypoxia would not be a
contraindication to removal, and he plans to proceed with
removal on the previously scheduled date of ___. No
red flag symptoms, no pain on evaluation upon arrival to floor.
He was continued on his home oxycodone regimen while
hospitalized. Also treated with acetaminophen. The patient had
run out of all home percoset, and according to ___, he was
written for a 30d supply 13 days ago. Discussed with patient the
need to have these prescriptions managed by his pain clinic, but
we did write him for a 5 day supply to bridge him to his next
appointment.
#Hypoxemia and COPD:
Appears at baseline on review of OMR, goal would be 88-92% on RA
for COPD. He reports intermittent compliance with inhalers but
no increased dyspnea nor sputum production. A CTA was negative
for PE, but did detect a 4mm incidental nodule in the RLL. The
patient expressed a particular concern that his hypoxemia would
present a contraindication to his spinal cord stimulator
removal, but this does not appear to be the case after
discussion with his pain specialist, Dr. ___. He was
continued on his home inhalers with oxygen saturations in the
high 80's to low 90's on room air.
#Depression:
In the ED, the patient expressed a plan of putting his mouth on
a tailpipe. At that time, he was put on ___, but this
morning was re-evaluated and thought not to meet ___ criteria
by the consulting psychiatry team. His medical team spoke to him
at length regarding this comment, and he insisted he does not
have any thoughts of not wanting to be alive, or any plan or
intent to harm himself. He did express some frustration and
hopelessness as his long history of back pain, that he can no
longer play golf, and also that he has struggled greatly to care
for his adult son who had addiction problems. He suggested part
of the reason he made this comment was to increase his
likelihood of hospitalization so that his back pain could be
addressed. I reaffirmed the difficulty of dealing with these
challenging situations. He said that if he was ever going to
hurt himself "I would have done it a long time ago." His
greatest support continues to be his wife. He does not have any
weapons in his house.
# Systolic ejection murmur: Consistent with aortic stenosis, may
consider outpatient TTE.
# 4 mm right lower lobe pulmonary nodule. For incidentally
detected single solid pulmonary nodule smaller than 6 mm, no CT
follow-up is recommended in a low-risk patient, and an optional
CT in 12 months is recommend in a high-risk patient.
- this was reviewed with the patient in detail and he understand
that follow up CT in ___ year is recommended.
===================
TRANSITIONAL ISSUES
===================
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: 4 mm right lower lobe pulmonary nodule.
For incidentally detected single solid pulmonary nodule smaller
than 6 mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT in 12 months is recommend in a high-risk
patient.
- Discharge weight: 79.4kg
# CODE: full (presumed)
# CONTACT: wife ___ ___
[] Arrange close followup with psychiatrist
[] Consider TTE for systolic murmur
[] Consider f/u CT in 12 months for 4mm RLL nodule | 132 | 646 |
14070164-DS-14 | 27,232,893 | Ms ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain and diarrhea. A CT scan showed inflammation
of your descending colon and sigmoid colon (on the right). You
were treated with fluids, pain medications and bowel rest. You
improved and were able to tolerate a normal diet. You were seen
by GI specialists who recommended a new medication, but it was
too expensive--we decided to continue your current regimen, with
the plan for you to discuss further with your longitudinal
gastroenterologist regarding other possible medications.
Your CT scan also showed 2 other findings:
(1) It showed a new left upper quadrant mass - we discussed with
you about arranging for a biopsy to determine whether or not
this was cancer. You decided that you would like to do this as
an outpatient.
(2) There are a few cysts near your ovaries--radiology
recommended obtaining an outpatient ultrasound to better view
them.
All of this will be communicated to your primary care doctor and
outpatient gastroenterologist. | This is a ___ year old female with past medical history of
hypertension, longstanding diarrhea of unclear etiology on
empiric therapy for IBD with asacol, admitted ___ w 1 week
of worsening abdominal pain and diarrhea, imaging showing signs
of colitis, but with symptoms resolving with conservative
management, incidentally found to have LUQ mass for which
patient opted to ___ for outpatient biopsy, as well as
adnexal cysts for which outpatient ultrasound was recommended,
now able to be discharged home.
# Abdominal Pain / Diarrhea / Colitis NOS / Inflammatory Bowel
Disease - patient presented with several days of worsening
abdominal pain and diarrhea, similar to prior episodes; CT scan
showed descending and sigmoid colitis in addition to chronic
inflammation; no signs of infection on exam or labs; she was
seen by GI service; this was suspected to relate to her chronic
undifferentiated issues, IBD vs IBS; she was treated
conservatively with clinical resolution of symptoms; GI
initially recommended uceris ($671/month), but copay was too
high for patient; similar situation for generic budesonide
($400/month). Given patient improvement with only conservative
therapy, discussed with GI and patient regarding continuing her
current longitudinal therapy, with plan for outpatient ___
to further discuss whether
medication change is necessary. Continued home asacol and
Nortriptyline. Of note, IgA was found to be low--unclear if
this may be responsible for recurrent infections or decreased
sensitivity of celiac test. Communicated details of this
admission to PCP and primary gastroenterologist.
# Perisplenic mass - patient incidentally found to have
perisplenic mass on CT scan, concerning for neoplasm per
radiology; discussed with patient that this could be cancer and
that a biopsy would help us figure this out; she verbalized her
understanding, and reported that she wanted to go home to
recuperate before any
biopsies were attempted; notified PCP via email regarding
following up;
# Adnexal cyst - incidental finding on CT scan; recommended for
outpatient non-urgent ultrasound; notified PCP via email
regarding following up.
# Hypertension - continued amlodipine
# Anxiety - continued citalopram
# GERD - continued PPI
# Hypokalemia - has chronic hypokalemia thought to be due to GI
losses; repleted with IV in the setting of increased GI losses;
continued home potassium at discharge;
# Osteoporosis - continued home calcium, vitamin D, risedronate
Transitional Issues
- Discharged home; recommended outpatient PCP and GI ___
within 2 weeks
- Perisplenic mass as above, will likely require ___ guided
biopsy to be done a s outpatient
- Adnexal cyst as above, was recommended for pelvic ultrasound
to be done as outpatient | 176 | 420 |
12944501-DS-20 | 29,488,579 | Dear Mr. ___,
It was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because of cough, weight
gain, and shortness of breath with ambulation due to a heart
failure exacerbation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent diuresis with IV Lasix to get fluid out of the
body. You lost 20 pounds of water weight and you are now at your
baseline weight of 198.
- You had pneumonia that was treated with antibiotics. Your
symptoms improved and your lab values indicated successful
treatment of your pneumonia.
- You presented with abdominal pain and nausea managed with
anti-nausea medication. You also had trouble with swallowing for
which you were given medication and now has gotten better
without medication.
- You had high glucose levels when you arrived at the hospital
which was being managed with insulin during your
hospitalization.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- If you have new or worsening cough or your O2 saturation
remains in the high ___ on room air, please call your doctor.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 198 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | Mr. ___ is a ___ year old M w/ hx of type II DM, CKD stage
IV,
HFrEF (EF 38% in ___, and hypothyroidism who is presenting
as a
transfer from ___ with ___ lb weight gain, orthopnea,
and PND, found to have an acute heart failure exacerbation, DKA,
and NSTEMI. At ___ patient underwent aggressive diuresis down
to her dry weight of 198 lbs. His NSTEMI was likely demand in
the setting of known LAD lesion and heart failure exacerbation.
Cardiac catheterization was deferred given CKD ___, with plan to
consider catheterization once undergoing dialysis as an
outpatient. Patient also had CAP s/p CTX + Doxy with resolution
of symptoms but continued ___ O2 requirement at night and
during the day. Has been sating at high ___ on ambulation during
the day. | 287 | 133 |
13512647-DS-20 | 29,193,498 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because you were having
abdominal pain and rectal bleeding. We gave you IV fluids and
blood transfusions and attempted to determine the cause of your
symptoms. Unfortunately, there was not a clear answer, but we
believe this is related to your carcinoid tumor. In respecting
your wishes, we stopped aggressive tests and treatments in order
to focus on your comfort instead.
You developed thrush, for which you can take nystatin rinse for
up to ___s fluconazole for 2 more days (ending
___. | The patient is an ___ year-old female with history of
neuroendocrine tumor with hypothalamic suprasellar and liver
metastasis on ___ who presented with severe positional
abdominal pain and rectal bleeding (requiring transfusions but
hemodynamically stable), without clear source. The patient was
evaluated with EGD and partial flexible sigmoidoscopy and
colonoscopies (complicated by stool and/or blood), as well as
tagged RBC nuclear scan without localizing a source of bleeding.
She had intermittent positional abdominal pain and associated
elevation in her lactate, which may indicate transient ischemia
or bowel obstruction from tethering and bulky nodal involvement
of her carcinoid tumor. Rather than continue aggressive workup
and treatment of her symptoms, the patient opted for comfort
measures only and home hospice with her daughter in ___.
TRANSITIONAL ISSUES
# Metastatic carcinoid: Patient was on Octreotide LAR Depot 30
mg IM monthly for carcinoid symptoms. At time of discharge to
her daughter's house in ___, patient indicated she did not
want to continue.
# Foley Catheter - Per patient request, she wanted to keep her
Foley in until she made it home for comfort purposes. It can
likely be removed on arrival. | 97 | 186 |
15721475-DS-6 | 25,284,054 | Dear Ms. ___,
It was a pleasure to be part of your care.
You presented to the hospital with difficulty breathing when
walking. This is likely due to your anemia.
You received both treatment for a COPD exacerbation and a blood
transfusion for anemia.
You had an echocardiogram done to evaluate whether you had any
valvular heart disease that could have contributed to your
symptoms. Your echocardiogram showed that one of the valves in
your heart (the aortic valve) was moderately narrowed. This does
not require intervention but you should follow up with your
primary care doctor for instructions on ___ monitoring.
Please follow up with gastroenterology to schedule a colonoscopy
given your anemia; it is very important to figure out why you
were having low blood counts.
Please continue taking your prednisone/azithromycin for 5 days
total.
If your symptoms worsen then please seek medical attention.
We wish you the best,
your ___ team | ___ with past medical history notable for COPD, PAD, HLD,
hypothyroidism, who is presenting with exertional dyspnea and
new
anemia. | 151 | 19 |
15020369-DS-13 | 29,159,360 | Dear Ms ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
-You came to the hospital because he had a very bad cough
What happened while you were in the hospital?
-You had some tests done, and they showed that you had the flu,
an infection in your lungs, and a urinary tract infection
-You were given antibiotics to fight infection in your lungs and
the infection in your urinary tract
-You were given antiviral medication to help to fight the flu
-You were given some fluids through your IV, because you had not
been drinking very much water
-You had some loose stools, this is common after antibiotics.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
-If you get fever, or chills, or if you start to feel better,
but then began feeling worse again, new should call your doctor.
-___ you have ___ episodes of loose stools, abdominal pain,
fevers and chills, call your primary care doctor.
-___ sure that you are drinking plenty of fluids and eating
well.
We wish you all the best!
- Your ___ Care Team | PATIENT SUMMARY
===============
Ms. ___ is a ___ woman with AS, DMII, HTN, anemia, CKD,
recent L hip fracture (s/p closed reduction w/ percutaneous
pinning ___, who presented with five days of productive
cough and 3 days of fevers and worsening fatigue; found have
influenza, pneumonia, and UTI. | 197 | 46 |
17039362-DS-15 | 24,362,223 | Dear Mr. ___: You were admitted to the Orthopaedic Trauma
service at ___ for evaluation and treatment of your fibula
fracture. You are now in good condition and safe to return home
to complete your recovery.
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
You should keep your splint on at all times. Do not get the
splint wet. If you shower, please make sure to cover the splint
(you may use a plastic bag). 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
changes are needed.
******WEIGHT-BEARING*******
Non weight-bearing on your left leg.
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively. | The patient was admitted to the orthopaedic surgery service on
___ with a left distal fibula fracture. Patient was taken
to the operating room and underwent ORIF of left fibula
fracture. Patient tolerated the procedure without difficulty
and was transferred to the PACU, then the floor in stable
condition. Please see operative report for full details.
Musculoskeletal: prior to operation, patient was NWB. After
procedure, patient's weight-bearing status remained NWB.
Throughout the hospitalization, patient worked with physical
therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: No transfusions.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___ the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with crutches, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 232 | 284 |
12671770-DS-7 | 27,874,146 | Dear Ms. ___,
WHY WERE YOU ADMITTED?:
You were admitted to ___ for low potassium, elevated
Creatinine (a marker of kidney function), and low blood
pressure, findings consistent with dehydration and kidney injury
following your recent admission for gastroenteritis.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?:
-We did a number of blood tests, including looking at your
creatinine to evaluate your kidney function, monitoring your
electrolytes (potassium, magnesium, sodium, among others), and
looking at the acid/base status of your blood, which indicates
the severity of your kidney injury
-Given your physical symptoms, poor kidney function, and
abnormal laboratory test findings, we decided that your clinical
picture was most consistent with kidney injury due to
dehydration rather than kidney injury due to your lupus
-You were kept in the hospital for 4 days in order to be
re-hydrated and to regulate your electrolytes; over this time,
your kidney function, improved, and your electrolytes
normalized. We continued to treat your shortness of breath with
prednisone and your inhalers, and your symptoms improved
significantly
-You were discharged with a plan to follow-up closely with your
primary care doctor
WHAT TO DO WHEN YOU LEAVE THE HOSPITAL:
- Please continue to take your all your medications as
prescribed below.
- Please get your blood drawn at ___ on ___ to make sure
your kidney function and electrolytes are stable.
- Please take 2 packets of neutraphos (has potassium and
phosphorus) every day. You should call your PCP to ask if you
should continue these supplements after your blood is drawn on
___.
- Please follow-up closely with your primary care doctor ___.
___. We have been in touch with him during your
hospitalization.
We are happy to see you feeling better and wish you all the
best.
Sincerely,
Your ___ team | During the hospitalization, the patient's hypotension improved
with fluids, and her Cr downtrended with IVF, with continued
electrolyte fluctuations that were managed with repletion, and
chronic acidosis managed with bicarb. Hospitalization course by
problem below: | 286 | 35 |
11355855-DS-22 | 25,601,186 | Ms ___, you were admitted with abdominal pain on ___
in the setting of likely viral gasroenteritis.
You were continued on your home pain regimen as well as
administered IV pain medications to help control your pain. A CT
scan of your abdomen was negative for any acute process to
account for the pain. Your bowel movements slowed appreciably
and the concern for bacterial infection was low therefore you
were not started on antibiotics.
You opted to leave against medical advice on the evening of
___. Please be sure to follow-up with PCP regarding your
abdominal pain and pain medication management in the future. | Ms. ___ is a ___ female with of history of chronic
abdominal pain (history of 17 abdominal surgeries: gastric
bypass, insulinomas, obstructions, perforations), UE DVT/PE on
coumadin, admitted with recurrent abdominal pain, nausea and
loose stool consistent with gastroenteritis.
#. Acute on chronic abdominal pain:
Patient presented on ___ with complaints of general malaise,
low grade fevers, nausea/vomiting, loose stools as well as acute
on chronic abdominal pain. Acute pain described as cramping
(predominantly in right upper and lower quadrant) which is
different from her chronic epigastric/lower quadrant pain
secondary to surgeries and constipation. Admission abdominal
exam benign without palpable mass or HSM. Labs unremarkable. CT
without identifiable intra-abdominal pathology to explain flare
as there was no visualized obstruction, colitis, etc.
Constellation of symptoms (abdominal pain, nausea, vomiting,
loose stools) c/w viral gastroenteritis/GI infection. As patient
was recently hospitalized, C diff was ordered however never sent
as bowel movements slowed down appreciable on admission with
only one-two BM which unfortunately were not saved/sent. However
lack of leukocytosis, fever or e/o colonic inflammation on CT
made C diff infection less likely.
On arrival patient was made strict NPO (is at baseline but
occassionally eats for comfort). She received IVF and was
continued on TPN. She was started on IV dilaudid (hung in 50cc
of saline). IV pain medications were stopped on morning of
___ as pain was improved at a ___. Once loose stool resolved,
pr dilaudid was restarted. Patient reported increase in pain on
evening of ___ despite resolution of loose stools. IV dilaudid
was restarted. On evening of ___ Nightfloat was called as
patient complained of increasing pain. Patient received an
additional dose of IV pain medications however she felt that
pain was inadequately controlled and opted to leave against
medical advice.
OUTPATIENT ISSUES
[] Continue outpatient TPN via port
[] Continue home regimen of pr dilaudid and fentanyl patch with
plan to taper over time
[] Continue outpatient SW/consider psych follow-up for support
and establishment of coping mechanisms
[] Follow-up with ___ (followed patient on
earlier ___ admission)
[] Could consider EGD in future to work-up chronic complaint of
epigastric pain
# RUE DVT and PE. Per record, occurred in ___ with likely plan
for 3mths of anticoagulation. INR on admission 1.5. In setting
of subtherapeutic INR, patient received Lovenox on ___. INR on
___ was 2.5 and lovenox was stopped. Patient left without
coumadin counseling however likely would benefit from Coumadin
7.5mg daily rather than alternating doses of 7.5mg daily and 5mg
daily. | 103 | 410 |
16909817-DS-40 | 25,581,679 | Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with a urinary tract infection. You
were seen by the infectious disease doctors who recommended
treating you with Zosyn for 2 weeks. You had a midline placed in
interventional radiology to administer the antibiotics. Please
discuss with your infectious disease doctor if you should resume
your Fosfomycin once your antibiotics are completed.
You were also noted to have a low potassium and low bicarbonate.
You were seen by the renal team who recommended that you start
bicarbonate supplements. Your electrolyte abnormalities are
likely due to something called renal tubular acidosis (RTA)
which is from your underlying kidney problems. Your potassium
was very low on the day of discharge- you prefer to follow up as
an outpatient. You should continue your potassium supplements
and have your labs checked next week.
It is important that you continue a balanced diet and follow up
with your primary care doctor, ___ and with Dr.
___.
We wish you the best,
Your ___ care team | ___ year old woman with a history of recurrent UTI/pyelonephritis
in the setting of bl medullary sponge kidney, b/l AKA ___ b/l
iliac artery thrombosis in setting of sepsis, anorexia nervosa,
presenting with recurrent UTI and ___ after recently completing
2-week course of Zosyn for MDR pseudomonal UTI.
# Recurrent UTI
Pt presenting with dysuria, urinary frequency similar to prior
symptoms of UTI. UA on admission grossly dirty. Recently
completed 2 week course of Zosyn for pseudomonal UTI. She has
also had history of multiple MDR pseudomonal UTI's in the past,
though has been less frequent lately. Was on fosfomycin at home
for suppression as well. Urine culture from admission was
positive for pseudomonas. She was seen by ID who recommended 2
weeks of IV Zosyn. The patient had a midline placed in ___ and
will complete 2 weeks of Zosyn through ___. Fosfomycin
sensitivities were added on to urine culture and to determine if
patient should continue on prophylaxis as an outpatient.
Consider adding vaginal estrogen.
# Acute renal failure on CKD
# Hyponatremia/hypochloremia/hypokalemia/acidosis
# Likely RTA
Pt admitted with Cr of 2.8 from baseline <1.0 and
hyponatremia/hypochloremia. This is likely prerenal/volume
depletion in setting of poor PO intake and UTI. She was given IV
fluids with improvement in her Creatinine to 1.0 on discharge.
Given her body weight her GFR is likely in the low ___. The
patient subsequently developed acidosis/academia and
hypokalemia. She was seen by nephrology who felt she likely has
an RTA due to her underlying medullary sponge kidney. She was
started on bicarbonate supplementation with improvement in her
bicarbonate. Her potassium was low on the day of discharge and
this was aggressively repleted. The patient preferred to follow
up as an outpatient and not remain hospitalized for repeat labs.
She understood the risks of leaving with a low potassium, which
was also communicated to the patient's husband.
# Chronic Severe Malnutrition
# History of Anorexia
Patient with remote history of an eating disorder, and last
admission was noted to have 10lb weight loss since prior.
___ MD discussed with patient and husband who report that
that weight was all lost during an 8 week admission at an OSH;
no changes in eating habits at home and no acutely concerning
behavior; she was seen by nutrition and understands benefit of
improving protein intake and supplementation; On discussion with
the patient's husband, he declined evaluation by psychiatry and
feels that it is detrimental in the hospital. It was
recommended that the patient follow up with her PCP for ongoing
management of malnutrition.
#IV access
The patient has difficult IV access. The patient had an ___
guided midline placed. This should be removed at completion of
antibiotics. | 174 | 452 |
18642116-DS-16 | 29,270,262 | You were admitted to the hospital after presenting with nausea,
heartburn and decreased ostomy output for 24hours. An x-ray was
notable for distended bowels concerning for a small bowel
obstruction of your para-mucous fistula hernia. You were managed
conservatively and briefly needed a placement of an nasogastric
tube for an episode of vomiting. The nasogastric tube was
removed, with improvements in your nausea and abdominal pain.
Your ostomy output has improved and you have been able to
tolerate a regular diet. You are now deemed stable for
discharge. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension,increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
Please resume all regular home medications, unless specifically
advised not to take a particular medication and take any new
medications as prescribed. A list of medications that you were
on in the hospital will be provided. Please continue your
steroid taper (20 pred x 2 days, then 10 pred x 3 more days).
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
Thank you for allowing us to participate in your care! | The patient is ___ year old female with history of Crohn's
disease, end ileostomy, mucous fistula ___, with a known
para-mucous fistula hernia, who presented with a pSBO from
para-MF hernia. The hernia was reduced in the ED. The patient
was admitted to the inpatient surgical unit for further
observation. She was made NPO with IVF and bowel rest. She had
one episode of emesis HD1 overnight and a nasogastric tube was
place. The nasogastric tube was subsequently removed when it had
minimal output with no further episodes of nausea or vomiting.
Serial abdominal exams were performed and her abdomen was soft,
and the muscous fistula hernia was reduced with good output
through her ostomy with both gas and stool at the time of
discharge. Once her nasogastric tube was removed, her diet was
advanced and she was transitioned back on her oral medications.
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 without the need for pain medications. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 212 | 199 |
12010947-DS-7 | 23,980,240 | Dear Ms. ___,
You were admitted to ___ with severely elevated blood sugars
(diabetic ketoacidosis) and an upper respiratory tract infection
with RSV. You were treated in the ICU and then transferred to
the floor. You blood sugars were controlled with insulin. You
were evaluated by the ___ Diabetes team who helped to manage
your blood sugars.
Please check your blood sugars at least four times daily (before
meals and at bedtime) and record these readings. Bring these
readings with you when you see your primary endocrinologist.
You have agreed to call to make an appointment with Dr. ___
primary endocrinologist) for ___.
It was a pleasure caring for you while you were in the hospital.
Sincerely,
The ___ Medicine Team | BRIEF ICU SUMMARY STATEMENT:
===========================
Ms ___ is a ___ woman with a history of T1DM with previous
DKA, who presented with DKA in the setting of medication
non-compliance and 1 week of cough, sore throat, and malaise and
was found to be RSV + on viral respiratory panel. She was
admitted to the ICU for insulin gtt & close monitoring of her
sugars. Within 24 hours, her gap closed, she was transitioned to
insulin injections, and she was tolerating a diabetic diet. No
antibiotics were given, and RSV was positive, likely explaining
her URI infectious symptoms. | 122 | 95 |
19821558-DS-18 | 25,558,499 | Mr. ___
You were admitted due to fever when your blood counts were low.
You were found to have pneumonia with improved with antibiotics
time and count improvement. You were also found to have an
effusion (fluid in your lungs) which was drained. You will
follow up with the pulmonary team outpatient for sleep study and
repeat imaging. You will be discharged home and follow up with
Dr. ___ as stated below. It was a pleasure taking care of
you. | ___ yo M with AML t(8;21) s/p 7+3 induction
followed by two cycles of MIDAC consolidation, T1DM, CAD and ICM
(EF 40%), adrenal insufficiency, who presents with febrile
neutropenia with imaging c/f LLL PNA with persistent hypoxia.
ACUTE ISSUES
---------------
#Neutropenic Fever:
#LLL consolidation c/f PNA:
#Hypoxia:
#Pleural Effusions:
On admission, patient was noted for complaint of L sided
pleuritic chest pain, dry cough, and consolidation on CTA.
Neutropenic fever source most c/f PNA. No PE or aortic
abnormality. His pleuritic chest pain resolved. Initiated
vancomycin ___ (D1: ___, added
posaconazole for fungal coverage (D1: ___ but
discontinued
posaconazole ___ as was no longer neutrapenic and negative
fungal markers. Albeit w/ symptomatic improvement and aggressive
diuresis, he remained hypoxic (requiring ~ ___ of supplemental
02), prompting pulmonary consultation on ___. Repeat imaging
with CT chest ___ showed radiographic progression of LLL
consolidation despite antibacterial (since admission) and fungal
therapy (5D prior to repeat imaging). Pulmonary thinks his lung
findings are likely fungal in etiology given nodular opacity vs.
likely some component of aspiration though would not expect to
see such progression on CT with antibiotics. Given this,
bronchoscopy with BAL was performed on ___ for further
evaluation. Additionally, patient was noted to have
parapneumonic
effusions on CT; therefore, IP was consulted per pulmonology
recommendations and placed a Left CT, sent fluid for pleural
analysis on ___. Patient drained ~450ml and tube was removed
on ___ per IP. In the context of neutropenia resolution, low
suspicion for aspiration pneumonia and prolonged anti-bacterial
therapy, changes were made to his regimen as below. He has been
requiring 02 supplementation overnight while asleep but on RA
during the day. Recent CXR ___ did not show worsening PTX or
re-accumulation of pleural effusion
-Cefepime(D1: ___ Vancomycin ___ restarted
Posaconazole ___ post BAL but d/c per ID recs on ___
-Flagyl (D1: ___ was added ___ per pulmonary recs due
to aspiration PNA concern; however, patient developed
significant
GI effects and given low aspiration PNA suspicion, medication
was
discontinued on ___.
-Repeat fungal markers ___ negative
-Barium swallow evaluation ___ did not show clear evidence
of
aspiration
-Appreciate PULM recs: regarding hypoxia at night, thinks likely
due to atelectasis or ? sleep apnea. scheduled sleep study
outpatient ___ along with PFTs. He will be d/c with 02
supplementation
which can be weaned off outpatient with improvement. Needs
repeat
CT chest in 4 weeks, requested ___ before ___ appointment
-IP signed off
-Consulted ID ___: guidance on course of antifungal therapy;
thinks no indication for antibacterial or antifungal therapy
given substantial improvement since admission therefore off all
empiric ABX at discharge
#Heart failure with reduced ejection fraction:
#Left Sided Chest Pain and DOE:
#Hypoxia
#Coronary artery disease, triple vessel disease:
Patient complained of new intermittent left sided chest pain on
___ which differed from his initial presentation on this
admission (see below). EKG notable for sinus tachycardia at 100
BPM. LAD. Widened QRS in RBBB pattern (not new). QTc calculated
at 407. Cardiac enzymes showing flat CK-MB and normal trops. Of
note, he had a type II NSTEMI attributed to severe anemia during
his initial AML diagnosis. CXR ___ imaging suggested
pulmonary congestion as well as small pleural effusions. Weight
was up ~7lbs from admission and patient was noted to be hypoxic
requiring ___ of supplemental 02. His BNP was also elevated.
Given this, we were concerned about volume overload likely
related to frequent transfusions which likely exacerbated known
HFrEF. Patient was actively diuresed throughout admission
-Received 40mg IV Lasix ___ and below baseline weight (118lb
from 123lb baseline) so held off since ___. He remains
intermittently hypoxic as above but suspect less likely from
volume overload.
___ between MD ___ patient agree to home O2"
Pt has CHF and is in a chronic and stable state, not
experiencing acute illness/exacerbation. Alternative treatments
have been tried and failed in improving hypoxia (weaning off O2,
drainage of pleural effusion, bronchoscopy with no infectious
source found) Pt requires long term home and portable oxygen
therapy to improve hypoxia related symptoms.
#AML (___):
#Pancytopenia in s/o MIDAC:
He is s/p 7+3 and 2C MIDAC consolidation and currently D+32
presenting with neutropenic fever. Previous course of MIDAC c/b
neutropenic fever also c/f pulmonary source. He has signs of
counts recovery.
-Transfuse hgb <7 and/or Plt <10
-Continue acyclovir ppx
-Active T&S
-Received pepfilgrastim on ___, counts recovered as of ___
#Hyperglycemia in s/o acute stress/neutropenic fever:
#Pseudohyponatremia in s/o hyperglycemia:
#T1DM with labile blood sugars:
Improved. Requiring ___ consults over last couple
hospitalizations when receiving dexamethasone. Resistant
hyperglycemia on this admission needing far more than usual
insulin without any steroids on board which may be likely driven
by stress of underlying pulmonary infection. Consulted ___
for
recommendation given recent hypoglycemia ___.
-Continue lantus and sliding scale w/ Humalog per ___
modifications
-Diabetic diet
#Lip lesion: Significantly improved. R upper lip of unclear
etiology originally thought secondary to folliculitis although
consider HSV as potential cause. Initiated higher dose acyclovir
5x daily (d1 ___ and monitor for improvement continue x5d
course (___) now back to prophylactic dosing.
#Neuropathic Ulcer: On R heel. Wound nurse consulted. Continue
with daily dressing changes as recommended. Does not appear
acutely infected. Monitor closely.
#Hypomagnesaemia/Hypophosphatemia: Normalized. Was likely
exacerbated in the setting of diuresis. Monitoring lytes
CHRONIC/RESOLVED/STABLE CONDITIONS
#Acute Chest Pain, chest-tube site: Resolved, associated with
chest tube placement. Improved with opioids. Continue to assess
for re-occurrence.
#Pneumothorax: Resolved, trace left apical pneumothorax noted
per
imaging following chest tube removal on ___. Patient without
worsening chest discomfort and/or increasing 02 supplementation.
CXR on ___ showed resolution of PTX.
#Nausea/Vomiting: Resolved, attributed to medication effect
(flagyl?). Continues with zofran as needed.
#Constipation: continues on bowel regimen, adjust as needed
#Adrenal Insufficiency:
#Autonomic Dysfunction:
-Continue daily 5mg of prednisone
-Consider escalating to stress dose steroids as above
-Home midodrine has been weaned off but consider adding back if
persistently orthostatic
-___ following
#CAD w/ triple vessel disease, history of type 2 NSTEMI, CHF (EF
40%). Holding lisinopril given soft BPs on admission.
#GERD: Continue home pantoprazole | 79 | 889 |
17860497-DS-27 | 26,541,609 | You were admitted to ___ after a fall and were found to have a
fractured rib and a urinary tract infection. You are being
treated with antibiotics and have been evaluated by Physical
Therapy who are recommending you be discharged to rehab to
continue your recovery. Please note the following instructions:
* Your injury caused a rib fracture 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). | ___ female with multiple medical comorbidities including
___ disease (type I) on Cerezyme infusions since ___,
vertigo and Meniere's disease with motor tics/dystonic limb
movements (followed by ___ Neurology), ___ disease,
and recurrent UTIs, who is s/p mechanical fall with imaging
revealing a right ___ nondisplaced rib fracture and lab work
notable for a urinary tract infection. the patient was admitted
for pain control, pulmonary toileting, ___ evaluation, and
treatment of her UTI. The patient was hemodynamically stable.
The Medicine team was consulted for recommendations of the
patient's vertigo, which seemed to be associated with starting
HCTZ. Therefore, HCTZ was stopped and the patient's nebivolol
was restarted. Most recent urine culture grew klebsiella
sensitive to NF, so Medicine team felt it was reasonable to
continue NF despite long history of intermittent resistance
pattern to NF.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient was evaluated by ___ who
felt the patient would benefit from rehab once medically clear
for discharge. The patient 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, out of bed with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 293 | 255 |
15591198-DS-22 | 24,095,835 | Dear Ms. ___,
You were admitted to the hospital with pneumonia. We treated you
initially with IV antibiotics and you improved, so we were able
to transition you to oral antibiotics. Please continue to finish
your course of antibiotics as prescribed.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | ___ year-old woman with stage IVB carcinosarcoma of the ovary,
S/P exploratory laparotomy w/ TAH-BSO, partial transverse
colectomy w/ side to side anastomosis, adjuvant chemotherapy,
now with platinumresistant recurrence C5D2 of doxorubicin
admitted with septic shock likely in the setting of community
acquired pneumonia.
#Septic shock
#Community acquired pneumonia
Presented with five days of cough and SOB with CXR demonstrating
LLL infiltrate. Hypotensive on arrival to the ED s/p 3L of fluid
with continued vasopressor requirement. She was continued on
vanc/cefepime/azithro with cultures pending. Levophed was weaned
off and pressures remained stable. She transferred to the floor
and was clinically improved. She was able to transition to oral
levofloxacin on ___ and remained stable for the next ___ hours.
She will be discharged on levofloxacin to continue her course
for a total of 7 days. She will also be given cough medications.
#ovarian carcinoma
S/p extensive surgical resection in ___ with adjuvant
chemotherapy. Unfortunately has had complicated postoperative
course with SBO x2 now with platinum resistant reocurrance.
Continues to undergo chemo with Doxorubicin now C5D2.
=============== | 49 | 173 |
14539176-DS-14 | 23,980,443 | You were admitted with right arm and hand weakness. You were
found to have numerous metastatic cancer lesions throughout your
body. You were started on steroids to help with the swelling
these are causing. You also had a biopsy done.
You were advised to stay longer in the hospital to make sure you
had no complications from the biopsy and to arrange for
appropriate discharge planning but refused this.
You MUST get your prescriptions filled tonight and take the
dexamethasone as prescribed. | ___ y/o male with history of Melanoma s/p lymphadenectomy in
___, and Eccrine porocarcinoma in ___, s/p surgical resection,
referred to Medical Oncology clinic for an initial consultation
for likely metastatic cancer of unknown etiology in the setting
of RUE weakness who was subsequently admitted for further
workup.
Metastatic Cancer of Unknown Primary
- The patient was admitted with right upper extremity weakness.
He had a CT done in the ED which showed a previously known
cervical spine lesion. He then had an MRI brain, thoracic and
lumbar spine which showed metastatic lesions in brain, cervical
and thoracic vertebral bodies, sacrum, and soft tissue masses
causing spinal cord narrowing and encasing nerve roots in
cervical and thoracic spine. He also had a CT torso which showed
metastatic lesions in lungs, lymph nodes, adrenals, liver,
duodenum, and bone. He was started on steroids with improvement
in the weakness of his right upper extremity. A biopsy was done
by ___ of the mass near the pelvic bone. The biopsy results were
pending at the time of discharge. Neurosurgery was consulted in
the ED and did not feel a surgical intervention was needed. It
was recommended that the patient stay the night after his biopsy
was done to monitor for pain or complications and to further
arrange discharge planning however after the patient spoke with
his primary oncologist he insisted on leaving. He was therefore
discharged by the night oncology hospitalist. He was given
prescriptions for dexamethasone and oxycodone. When he follows
up with his primary oncologist for biopsy results it needs to be
confirmed that he is taking these properly as he was unable to
be appropriately counseled on them given his premature
discharge. The dexamethasone dose can likely be decreased if he
is doing well. Radiation oncology was consulted but they were
unable to see the patient prior to his unplanned discharged so
follow up with them will need to be arranged as an outpatient.
Social work was consulted and would have followed up the
following day but this was not possible due to the discharge. He
would likely benefit from social work follow up to be arranged
as an outpatient. Occupational therapy was consulted but also
was not able to see the patient prior to his premature
discharge. Outpatient consultation needs to be arranged as he
was having difficulty with fine motor movements of his right
hand including writing and would likely benefit from therapy.
His outpatient oncologist needs to call him with a follow up
appointment because this was not arranged and able to be
included in his discharge paperwork given the unplanned
discharge.
History of Stroke
- The patient's home Aggrenox needs to be stopped acutely in the
setting of possible hemorrhagic brain metastasis seen on the
brain MRI. This was noted on his discharge paperwork but due to
leaving the hospital prematurely he was unable to be counseled
on this so this needs to be followed up as an outpatient. | 80 | 490 |
17216454-DS-8 | 27,717,481 | 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 of pain and weakness
in several of your joints.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you had imaging of several of your joints
with x-rays and MRIs. It was determined your pain was likely
due to a disease called ankylosing spondylitis. He will
___ as an outpatient with the rheumatology team for
further evaluation. You were started on a medication called
naproxen to help with your pain.
- You had some discomfort in your bladder, and you were found to
have microscopic amounts of blood in your urine. I study called
a CT urogram was performed to try to image the bladder, which
identified a lesion that should be looked at by a urologist.
You will have ___ scheduled with urology for a procedure
called a cystoscopy.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your ___ appointments listed below.
- You should ___ with rheumatology for further evaluation
of your joint pains. This appointment has already been
scheduled for you.
- You should ___ with urology for procedure called a
cystoscopy and further evaluation of your bladder discomfort.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
====================
The patient is a ___ man with a history of latent TB
status post treatment presenting with joint pain (right
shoulder, right wrist), weakness, fatigue, and suprapubic pain
with urination, and significant weight loss. Workup revealed a
CRP of over 100. Imaging of the shoulder was normal; imaging of
wrist revealed a small fluid collection, which was better
characterized with MRI which found synovitis involving multiple
joint spaces consistent with inflammatory process such as
arthritis. X-ray of the lumbar spine and SI joints noted
bilaterally symmetric sacroiliitis, likely indicating ankylosing
spondylitis. He was initiated on naproxen 500 mg twice daily for
pain control. He was incidentally noted to have a sclerotic,
expansile lesion in the left proximal femur which was determined
by MRI to be likely chronic changes of past infection or
fracture. He had microscopic hematuria on admission on UA which
was gathered due to some suprapubic tenderness, and CT urogram
showed a possible lesion in the dome of the bladder. Pt was
feeling much better and was eager to return home to complete the
remaining work up as an outpt. We spoke at length with patient
and daughter on the day of discharge regarding the indications
and importance of follow up with rheumatology, urology for
cystoscopy given bladder lesion/hematuria, and verbal handoff
was provided to his PCP. | 231 | 223 |
19073526-DS-5 | 20,095,837 | Mr ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted for worsening of your chronic cough. This was
initially thought to be due to congestive heart failure. You
were given medication to help remove extra fluid from your lungs
but you still required oxygen. There was initially concern you
may have a pneumonia however a chest xray did not show a
pneumonia. You had a CT of your lungs to rule out a blood clot
which was negative. You were seen by the lung doctors who ___
this was likely due to worsening lung disease. You were
discharged with home oxygen. You will need to ___ with the
lung doctors as ___ outpatient.
We made the following changes to your medications
1. START guaifenesin with codeine. You may take this medicine at
night to help with your cough. Please do not drive if you have
taken this medication, as it will make you drowsy.
You should continue to take all other medications as instructed.
Feel free to call with any questions or concerns | PRIMARY REASON FOR ADMISSION
___ with history of CAD, chronic cough, presenting today with
continued dry cough, worsening over last week
.
ACUTE ISSUES
.
# Cough/hypoxia- Ultimately is was felt that the patients
hypoxia was likely multifactorial in nature. As above the
patient was started on levofloxacin in the emergency department
given concern for pneumonia. Given the lack of fever, elevated
WBC and sputum production presentation was not completely
consistent with PNA. Therefore antibiotics were discontinued on
admission. Patient has a known history of systolic congestive
heart failure and was mildly volume overloaded on exam. He was
diuresed a total of 5 L with bolus doses of lasix (20 mg). Labs
were reflective of a contraction alkalosis and patients weight
was below dry weight of 192 lbs. Though cough improved the
patient remained hypoxic on ambulation despite aggressive
diuresis. Oxygen saturation on room air was 95% at rest, 88%
with ambulation and 79% with stairs. Further workup included a
CT chest unchanged from prior with evidence of significant ILD.
LENIs were negative for DVT. CTA which negative for PE. Despite
CKD CTA was done with prehydration in place of a V/Q scan
because it was felt that V/Q scan was unlikely to have utility
in the setting of underlying lung disease. Intracardiac shunt
was considered however given relatively normal pulmonary artery
pressures on his last echo it was felt that this was an unlikely
etiology of his hypoxia and a bubble study was not done. Patient
has a history of restrictive lung disease, pulmonary function
tests showed worsening restrictive lung disease which likely
have resulted in his new oxygen requirement. He was discharged
with 2L of home oxygen and will ___ with pulmonary as an
outpatient.
.
# acute on chronic congestive heart failure- Patient has a known
history of sCHF with an ejection fraction of < 25% on last echo.
As above patient appears mildly volume overloaded on exam and
was diuresed. He was continued on his home carvedilol, aspirin,
and atorvastatin. Irbesartan was replaced with losartan for
formulary reasons.
.
# ? atrial fibrillation- Per OMR patient has a history of atrial
fibrillation. However per his outpatient cardiologist Dr.
___ has not had true atrial fibrillation documented on
EKG. Therefore he is not ___ with warfarin. He was
noted to have a irregular ___ rhythm that was concerning for
a malfunctioning atrial lead. EP interrogated the pacemaker and
found that it was functioning correctly. He was continued on
his home aspirin and beta blocker.
.
STABLE ISSUES
.
#Chronic Renal Failure- The patient has a known history of
chronic renal failure with a baseline creatinine of ___.
Creatinine remained stable throughout admission. As above a CTA
was done to rule out PE. Pre and hydration were done for renal
protection. The patient was discharged with instructions to
have his creatinine checked 2 days after discharge.
.
# CAD- Patient has a significant cardiac history including CABG
and MI c/b vfib arrest he is now s/p ICD placement. He was
continued on his home aspirin and antihypertensive regimen.
.
# ___ was continued on his home antihypertensive regimen
(replace irbesartan with losartan given formulary issues).
.
# DM: Continued on home insulin regimen
.
# HL- continued on atorvastatin
.
TRANSITIONAL ISSUES
- As above patient will have electrolytes checked as an
outpatient to monitor creatinine in the setting of recent CTA.
- Patient will ___ with a pulmonologist, his outpatient
cardiologist and his PCP
- blood cultures were pending throughout this admission
- Patient was DNR/DNI throughout this admission | 187 | 594 |
10439484-DS-29 | 26,824,494 | You were admitted to the inpatient Colorectal Surgery Service
after a Laparoscopic Extended Right Colectomy for surgical
management of your Transverse Colon Cancer. You have recovered
from this procedure well and you are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you regarding these
results they will contact you before this time. You have
tolerated a regular diet, are passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by your surgical team.
You will be prescribed narcotic pain medication Oxycodone. This
medication should be taken when you have pain and as needed as
written on the bottle. This is not a standing medication. You
should continue to take Tylenol for pain around the clock and
you can also take Advil. Please do not take more than 3000mg of
Tylenol in 24 hours. Do not drink alcohol while taking narcotic
pain medication or Tylenol. Please do not drive a car while
taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck! | ASSESSMENT AND PLAN:
___ man with PMHx of severe PVD (on plavix) s/p multiple recent
vascular interventions, stenting, and toe amputation, NSTEMI in
___ s/p cath and angioplasty, on Pradaxa, IDDM type 2 poorly
controlled and complicated by PVD and neuropathy, history of
CVA, multiple prior TIAs and recent diagnosis of colon cancer
found after admission for acute blood loss anemia presented to
the ED with presyncopal event at home, found to have acute
pulmonary embolism.
# Pre-syncope: Patient never lost consciousness, never fell but
felt lightheaded and was found to be hypotensive. Potentially
related to overdiuresis from Torsemide as evidenced by
hypotension and pre-renal pattern of acute renal failure.
- Hold Torsemide
- IVFs
- Orthostatic vital signs
- ___
# Acute renal failure:
While Cr is within normal range Cr has increased by 50%
suggesting 50% drop in GFR. BUN:Cr ratio >20. Seems pre-renal
given clinical scenario.
- IVFs
- Monitor Cr
- Hold Torsemide
# Thoracic pain: Potentially related to pleuritic pain due to PE
though worsening pain with standing position and after he was
lifted by his sons suggests ___ pain. He is currently
asymptomatic and CT chest did not reveal fractures
- Pain control for now
- ___ consult
# Acute pulmonary embolism:
Right subsegmental, low risk, patient is not tachycardic, has
normal troponins and BNP lower than previous. Aspirin and
Dabigatran held in the outpatient setting in preparation for
surgical intervention this ___
- Continue Heparin drip
- Enoxaparin likely superior given underlying malignancy but
since patient is already therapeutic on Heparin, has not shown
evidence of bleeding and can be discontinued if needed, will
continue heparin pending surgical intervention ___
- Monitor Hct
# Transverse colon adenocarcinoma:
No evidence of metastases on imaging. 4 cm transverse colon mass
seen on colonoscopy ___ s/p biopsy revealing
adenocarcinoma, CEA 7.9. Colorectal surgery, oncology, and
vascular surgery were all involved. Per documentation family
meeting last week decided to pursue surgical intervention,
understanding significant surgical risk given past medical
history. Colorectal surgery already consulted in the ED, plan
for elective surgical transverse colonic resection this ___.
- Colorectal surgery consultation
# Coronary artery disease
# Peripheral Vascular Disease:
Recent POBA (___) for CAD and grafting for PVD
(___). Maintained as an outpatient with ASA, Clopidogrel
and Dabigatran. Per vascular surgery risk of graft failure is
at least 20% without pradaxa and next step would be amputation
of limb. Cardiology recommended minimizing time off of
anticoagulation. Discharged on
Plavix and off of ASA and pradaxa until after his surgery, per
documentation.
- Continue Metoprolol, Isosorbide, Clopidogrel
- Continue to hold aspirin and dabigatran
# DM type II:
Chronic, poorly controlled, insulin dependent, complicated by
neuropathy and peripheral vascular disease. A1c 7.5% in ___.
- Continue Humalog and glargine in place of aspart and glargine
# Constipation:
- Bowel reg
# HTN:
- Holding home BP meds given PE
# Anemia:
Chronic, iron deficiency from chronic GI blood loss and recent
acute blood loss anemia from acute lower GI bleed.
- Monitor hct
#DVT PROPHYLAXIS: [ ] Heparin sc [] Mechanical [X] Therapeutic
anticoagulation
#CODE STATUS: [X] Full Code []DNR/DNI
#DISPOSITION: Inpatient pending surgical intervention ___ and
bridging back to oral anticoagulation
I have discussed this case with [X]patient [X]family
[]housestaff [X]RN []Case Management []Social Work [X]PCP
[]consultants .
Attending Physician ___: ______________________________
___, MD
___ ___
Date: ___
Time: 2300
Colorectal Surgery Hospital Course
Mr. ___ was transferred to the inpatient colorectal surgery
service after a laparoscopic Colectomy for Transverse colon
cancer. On ___ his vitals stable, pain controlled, no
events overnight, and he was transferred to floor. On ___
he tolerated sips without issue, peripheral pulses were viable.
The Central Venous Line was in use. The heparin drip had been
restarted and On ___ PTT was 51 our goal was ___. He was
given clear liquids. PTT 67 and the heparin drip was changed to
1150uniuts. The Foley and Dilaudid PCA was discontinued. On
___ the heparin gtt to 1050. The patient was found to be
orthostatic hypotension and given the patient's cardiac history
a cardiology consult was called. We decreased glargine to 30.
The patients hematocrit was low and cardiology requested
transfusion to hgb above 8. He was given 2 units. On ___
the patient's hematocrit was 28.5, PTT 59.1. The tolerated clear
liquids. Given continued orthostasis all blood pressure
medications and diuretics were held. The patient was to hold
these medications until follow-up with his cardiologist. He was
euvolemic and blood pressure were stable. He was evaluated by
physical therapy who recommended discharge to rehab. ___
the regland was stopped for QTc. He was tolerating a regular
diet, was passing flatus, surgical site was intact. The central
line was removed without issue. Therapeutic Lovenox was started
as anticoagulation for cardiac stents as well as for recent
vascular surgery at the recommendation of Dr. ___. He
will continue Lovenox for 6 months at least until this can be
reevaluated for anticoagulation given recent pulmonary embolism.
___ he was stable for discharge to rehab. | 608 | 858 |
11045286-DS-15 | 23,961,634 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for lower extremity edema and
acute renal failure. While you were here, we gave you lasix to
take fluid off of you while watching your kidney function to
make sure it remains stable. We initially took fluid off too
quickly, so we gave some back to you, and then took some more
off gently. When we felt you were close to your dry weight,
your leg edema had improved, and your renal failure had
resolved, we felt you were safe to go to rehab. Before you were
discharged, you were diagnosed with a urinary tract infection.
Your rehab center can continue to treat you for this infection.
Please note that the following changes have been made to your
medications:
- Please START using miconazole powder to area of rash in your
groin
- Please START using glipide 5mg every morning
- Please START using lantus 8U every night
- Please START using humalog according to a sliding scale:
check finger sticks before meals and at night, and give 2U for
201-250; 3U for 251-300; 4U for 301-350; 5U for 351-400.
- Please START taking Lasix 40mg every day
- Please STOP taking bumetanide and metolazone | PRIMARY REASON FOR ADMISSION:
Ms. ___ is a ___ with h/o CAD, HTN, PAD s/p R AKA, Aflutter on
coumadin who has had gradual worsening of LLE edema over the
past ___ months, found to be hypotensive in clinic, admitted for
LLE edema and hypotension, found to be in acute renal failure. | 212 | 55 |
13422599-DS-20 | 23,180,771 | Dear Ms. ___,
As you know, you were hospitalized at ___
___ because of ingesting three razor blades. Luckily,
this did not cause any significant harm. You had daily xrays and
you passed the foreign bodies on your own. You also had a CT
scan that showed no evidence of remaining foreign bodies. We
treated your symptoms with medications and they resolved after
you passed the foreign bodies.
We wish you all the best.
-Your ___ Team | ___ year old woman, currently incarcerated, with history of
polysubstance abuse, anxiety/depression (multiple
hospitalizations and suicide attempts), PTSD and morbid obesity
(s/p lap RnYGB) presenting after acute ingestion of foreign body
-- 2 razor blades (broke 1 in half and one full razor, total 3
items).
# Foreign body ingestion: Patient has a history of multiple
foreign body ingestions in the past. Evaluated by general
surgery, bariatric surgery and gastroenterology. The patient had
serial abdominal xrays that showed progression of the foreign
bodies. Two of the three items were retrieved from bowel
movements. Review of ___ imaging with ___ radiologists
confirmed the presence of 3 foreign bodies at initial
presentation. Prior to discharge, the patient underwent a CT
scan that showed no evidence of retained foreign body,
suggesting passage of ___ object ___ razor) was complete,
although not retrieved. Her abdominal pain improved with passing
of foreign bodies.She did have modest amount of BRBPR associated
with passage of BMs and razors, with stable H/H (13.7/38.3 on
day of discharge) and improving at the time of discharge. She
was tolerating regular diet on discharge. Patient was evaluated
by the psychiatry service and was thought not to be suicidal.
# Gastritis/intestinal erosion secondary to prior razor
ingestion: Patient received EGD on ___ and ___ with
removal of razor and plastic knife, respectively. Patient was
continued on protonix and given sucralfate.
#Depression/Anxiety: Patient had razor ingestion leading to last
admission. currently not suicidal. Patient was evaluated by
psychiatry and deemed not to have suicidal ideation. Patient had
a 1:1 sitter w/officers from prison. She was continued on home
hydrOXYzine 50 mg PO QHS, Mirtazapine 15 mg PO HS, RISperidone 1
mg PO HS and haldol 5mg PO BID PRN
# Asthma: continued on home xopenex.
# Code: Full | 76 | 298 |
15941554-DS-12 | 24,488,182 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. Here you were admitted
after concerns of an infection in your right leg. You underwent
imaging to ensure there was no clot in your right leg, and then
were given intravenous antibiotics to help fight this infection.
You were doing very well with these antibiotics, and were
switched to two antibiotics to take while at home for the next 7
days. You will finish these anbitiotics on ___.
1. START Cephalexin 500 mg every 6 hours (four times/day) until
___
2. START Sulfameth/Trimethoprim DS 1 tab twice/day until
___
Please continue to take your other home medications as
prescribed. Please follow-up with your primary care doctor upon
discharge from the hospital.
Take Care,
Your ___ Team. | Mr. ___ is a ___ yo male with h/o of morbid obesity, HTN, OSA,
presenting to clinic with fever, right lower extremity erythema
and pain, concerning for right lower extremity cellulitis.
.
>> ACTIVE ISSUES:
# Sepsis ___ to ___ Cellulitis: Upon admission, patient's right
lower extremity was found to be warm, erythematous, and
presented with fever and leukocytosis concerning for sepsis ___
to extremity cellulitis. Patient underwent ___ and was found to
have no DVT in right lower extremity, and lactate drawn as 1.8,
and blood cultures were drawn as well. Upon admission, patient
was placed on IV Vancomycin and Unasyn for empiric coverage, and
this was transitioned to more frequent IV Vancomycin dosing
monotherapy of 1 gram q 8 hours given his morbid obesity with
improvement in his symptoms. He was transitioned to a 7 day
course (ending ___ total 10 days with IV Abx) of both
Cephalexin 500 mg q 6 hours and Bactrim DS BID. This would
hopefully ensure both coverage of MRSA, since patient may be at
an increased risk given morbid obesity. Patient tolerated oral
regimen well, and was transitioned out hospital with close
follow-up at the end of antibiotic course.
.
# ___: Upon admission, patient found to have elevated
creatinine, and thought to be secondary to decreased PO intake
in the setting of his cellulitis. He received IVF with
resolution back to baseline.
.
# INR: Patient initially admitted with an increased INR (no
prior labs to compare), and this was unclear reason. Patient did
not seem to have systemic infection causing coagulopathy, did
not seem to have vitamin deficiency, and LFTs checked during
hospital stay were within normal limits. However, during
hospital stay his INR trended back to normal prior to discharge.
.
# Hypertension: Patient's home anti-HTN were initially held in
concerns for systemic infection and sepsis. However, during
hospital stay no episodes of hypertensive urgency or
hypotension. Antihypertensives were resumed on discharge.
.
# Obstructive Sleep Apnea: Patient currently only intermittently
using CPAP at home, and per PCP note referred to CPAP titration
as outpatient. Respiratory therapy was consulted and patient was
placed on CPAP overnight.
.
# Anemia: Patient found to have chronic anemia, and per PCP note
most likely ___ to hemorrhoids. Patient has undergone prior
colonoscopy in ___ with normal appearing colon, and denied any
lower GI bleeding symptoms during hospital stay. Further workup
per outpatient. No lightheadedness or dizziness or fatigue
during hospital stay.
.
>> TRANSITIONAL ISSUES:
# Cellulitis: Patient will continue antibiotics as above until
___. Discussed with patient warning signs, including
worsening pain, redness, fevers, that he should be evaluated
urgently.
# Morbid Obesity: Patient may fit criteria to implement
metformin in regimen to help with weight loss.
# OSA: Patient received CPAP, will need outpatient titration of
CPAP and discussion regarding continued use as outpatient. | 129 | 467 |
14506968-DS-9 | 20,830,493 | Dear ___,
___ was a pleasure taking part in your admission to ___
___. As you know, you were admitted to ___
___ for a soft tissue infection in
your neck. A CT scan of your neck showed no abscess or drainable
fluid collection in your neck, and the ear, nose, and throat
doctors who ___ did not feel that you needed surgery.
Your pain and swallowing improved with IV antibiotics, and you
were transitioned to oral antibiotics at discharge.
While here your INR level was checked and found to be quite
high, suggesting your blood was very thin from warfarin. We
gave you vitamin K to thicken your blood and adjusted your
warfarin dosing accordingly to bring the INR to between ___. It
is important that you take warfarin 0.5mg daily (less than your
previous dose) unless directed otherwise by your primary care
doctor.
Please continue with your ___ services after discharge and
follow up with your doctors as detailed below. Thank you for
allowing us to participate in your care. | ___ with multiple sclerosis, neurogenic bladder, history of DVT
on warfarin, type 2 diabetes mellitus, and recent C. difficile
infection who presented with tooth and neck pain for 1 week and
was admitted for a soft tissue infection of the left
retropharyngeal space. | 170 | 44 |
19505901-DS-5 | 29,837,328 | You were admitted with fever and mild sepsis from a urinary
tract infection. You were treated with antibiotics and IV
fluids and improved. You will need to complete the course of
antibiotics as prescribed. | ___ with autonomic insufficiency, DM, neurogenic bladder
requiring self-catheterization admitted with fever, HA, dysuria
and sepsis from urinary infection.
# sepsis from urinary source
# DM2
# autonomic insufficiency
# neurogenic bladder | 36 | 30 |
11453452-DS-10 | 24,334,293 | Please follow the recommendations below to ensure a speedy and
uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as 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. | The patient presented to pre-op on ___. Pt was
evaluated by anaesthesia and taken to the operating room for
ventral hernia repair with mesh overlay. 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 ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral oxycodone, tramadol,
and acetominophen and the patient was discharged with a
prescription for tramadol.
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 and slowly
advanced to regular diet which she tolerated well. Patient's
intake and output were closely monitored. JP output remained
serosanguinous throughout admission; the drain was removed prior
to discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
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.
She will go home with physical therapy and visiting nurse
assistance as well as a walker supplied by physical therapy for
assistance with ambulation. | 745 | 291 |
14010581-DS-17 | 23,845,877 | Discharge Instructions - ___ Tumor
Surgery
You underwent a biopsy. A sample of tissue from the lesion in
your ___ was sent to pathology for testing.
Please keep your incision dry until your suture is removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
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 | ___ yo female presented ___ with progressive confusion, memory
loss, and shuffling gait. She was found to have large ___
lesion crossing the corpus callosum.
___ lesion
Neuro and Radiation Oncology were consulted. Patient was
admitted and brought to the OR for stereotactic ___ biopsy
___. Please see separate operative report by Dr. ___.
Frozen pathology was consistent with high grade glioma.
Post-operatively patient was monitored on the floor and was
neurologically stable.
#Fever
Patient was febrile in the emergency department to 102.3. Chest
xray was negative. Blood cultures were negative. Urine cultures
grew gram + cocci. She was started on a three day course of
Cipro, for her UTI, which ended ___. Patient remained afebrile
throughout the rest of her hospital stay.
#Discharge
Physical and Occupational therapy were consulted and initially
recommended discharge to rehab. Patient and family requested
discharge to home. Patient improved physically and cognitively
over the course of her hospital stay and patient was
re-evaluated by ___ who ultimately recommended discharge to
home with 24 hours supervision and services. | 453 | 170 |
18976887-DS-5 | 24,126,072 | Brain Hemorrhage with Surgery
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.
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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | # ___
___ yo female pat who underwent an outpatient Head CT from
continued headaches and dizziness since falling while skiing 1
month ago. Following results of the scan, she was referred to
the ED for evaluation of a large right mixed density SDH. The
patient was admitted on ___ and added to the add-on schedule
for surgery. She was taken for a mini-craniotomy for subdural
evacuation on ___. Surgery was uncomplicated and she was
transferred with a subdural drain in place to the step down
unit. The post operative scan demonstrated pneumocephalus for
which she was started on a non-rebreather. A repeat scan on
___ showed a persistent fluid collection, but stable subdural
evacuation. Output from the subdural drain decreased and the
drain was removed on ___. Post-pull CT was stable. She remained
neurologically stable and was transferred to the floor. On ___
the patient continued to do well and ambulated with nursing.
She was nervous about going home and has roughly 12 steps and so
a ___ evaluation was placed. She did well ambulating with both
nursing and ___ and was cleared for home without services. | 565 | 192 |
19501460-DS-17 | 26,808,552 | Dear Ms. ___,
You were hospitalized due to symptoms of left-sided vision loss
resulting from a TIA (transient ischemic attack), a condition
where a blood vessel providing oxygen and nutrients to the brain
is temporarily blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so being deprived of its blood supply temporarily can result in
a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Elevated LDL cholesterol
We are changing your medications as follows:
- Please take a baby aspirin (81mg) daily
- Please take atorvastatin 20 mg by mouth each evening
Please take your other medications as prescribed.
Please follow up with your neurologist Dr. ___ your
primary care physician as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
Ms. ___ is a ___ year old right-handed woman with a history
of two prior complex migraines who presented for evaluation of
transient left-sided vision loss that occurred 6 days ago.
She reports that she was in her usual state of health until last
___. She was in ___ for a funeral and was driving
to put gas in her car when suddenly she realized that half of
the car in front of her was missing. She initially thought there
was something wrong with the car, but then she realized the cars
on the other side of the street were also missing on the left
side. She denies any other symptoms such as headache, weakness,
tingling, numbness, speech changes (although she did not try to
speak for some time later), double vision, dizziness. She pulled
over to the side of the road but briefly but decided to get back
on the road and go to her destination, which was around the
corner. Within ___ minutes the vision changes completely
subsided.
The day after that she did not feel well, but she had no
headache. She felt exhausted and weak all over, and just did not
feel like "herself". She just attributed this to the stress of
the funeral and decided not to seek medical attention. Then on
___ she saw her PCP ___. Her D-dimer was 0.84
(reference range 0.0-0.49) and her BP was not elevated at this
visit. She was referred to Dr. ___ in neurology, who sent
her to the ED for TIA work-up. The morning of this appointment
she had a very slight headache, but notes that she neglected to
eat that morning and attributes the headache to that. She had
no photo/phonophobia, nausea or vomiting. No positional
features. She took ibuprofen for this and the headache went
away.
She does note that about 6 months ago she started waking up in
the morning with "racing heart", breathing heavily and thought
she was having panic attacks. This has occurred nearly everyday
since ___, and rarely occurs at night. She denies any
stress in her life that may have triggered these events and she
does not snore as far as she is aware. She did have an episode
in ___ in which she was at work and all of the sudden couldn't
figure out how to write. This resolved within a few minutes but
she went to the ED and had TIA work-up at ___ with negative
MRI. She had no headache at any point, but she was diagnosed
with complex migraine at this time. She endorses one other
migraine in her life, in addition to this episode.
Upon arrival to the floor, she was asymptomatic and her
neurological exam was within normal limits. Her BP was elevated
to 169/74 on admission but was subsequently 120s-130s/70s. Her
MR head without contrast showed no acute intracranial findings.
She had a TTE that showed no structural cardiac source of
embolism (e.g.patent foramen ovale/atrial septal defect,
intracardiac thrombus, or vegetation) seen. She had no
significant arrhythmic events on telemetry during her admission.
Given absence of head pain and absence of positive symptoms
associated with vision loss, her transient vision loss is more
likely consistent with TIA versus migraine. MRI is reassuring
for lack of stroke. She will be discharged with a Ziopatch
monitor to assess for occult atrial fibrillation, given history
of palpitations and suspected family history of arrhythmia
(father on coumadin for reasons unknown to patient). | 286 | 589 |
15015389-DS-4 | 23,380,538 | You were admitted with severe dehydration, kidney failure,
electrolyte abnormalities, and confusion. You were very
malnourished. You were found to have pneumonia and low oxygen
levels, likely due to ongoing aspiration with swallowing. Your
breathing severely worsened and your required a breathing tube.
You ended up going into shock and had signs of bleeding. There
were not options for treating your cancer due to your other
medical problems causing you to be too sick to tolerate
treatment. Your family decided to focus on keeping you
comfortable rather than pursue aggressive treatment. | ___ man with past medical history of left facial basal
cell carcinoma (6.5 x 3.1 cm), and recent diagnosis of
metastatic lung adenocarcinoma (multiple bilateral pulmonary
nodules, no lesions outside the chest), admitted with
significant dehydration, hypotension, ___, and hypernatremia,
leading to encephalopathy, as well as severe cachexia.
# Acute encephalopathy: This is most likely due to initial
dehydration, pain, chronic illness. 4mm lesion seen on CT of
the head could be metastasis versus small hemorrhage, but
unlikely to
account for mental status. Mental status seems improved, alert,
but less oriented today. His mental status waxed and waned prior
to ICU transfer.
# Acute hypoxic respiratory failure: He required up to 6L NC on
the floor and CXR showed right mid-lower lung opacity. Given
his history of dysphagia, there was high concern for possible
aspiration, even though he was afebrile with only slight
leukocytosis. He was started on Unasyn 3g Q12H (renal dosing)
___ for suspected aspiration pneumonia. Ultimately he likely
had another aspiration event leading to worsening respiratory
failure requiring intubation.
# Severe dehydration with hypotension
# Acute renal failure: This was likely somewhat chronic, with
prerenal component as well as possible intrarenal (acute tubular
necrosis). Post-renal was less likely, with initial bladder
scan was only 223 cc. Renal function was improving prior to ICU
transfer.
# Metastatic lung adenocarcinoma: On ___, PET-CT showed
multiple pulmonary nodules consistent with metastatic lung
adenocarcinoma. He was seen by Thoracic Surgery and Radiation
Oncology who referred him to Medical Oncology. Outpatient
oncologists are Dr. ___, Dr. ___. He was
planning to get chemotherapy but when arriving to clinic
for his initial medical oncology appointment, and the discussion
about chemotherapy, he was found to have all the issues that led
to this admission. Due to his declining functional status and
severe medical problems, ultimately he was not a candidate for
therapy for his cancer.
# Advanced left face basal cell carcinoma: He had a very large
tumor on left side of face.
# Dysphagia with high risk of aspiration: SLP evaluated and
recommended strict NPO and he was given IV fluids.
# Severe protein calorie malnutrition: He weighed 35 kg (78
pounds), and had a BMI of 12, so nutrition was consulted, but
ultimately due to changing goals of care, he was not started on
parenteral or enteral nutrition.
ICU COURSE
On ___ the patient became hypoxemic and was placed on 4 L mask.
He was also mildly disoriented with chest x-ray showing new
bilateral effusions and right lower lobe lung infiltrate. He
was evaluated by anesthesia due to his complex airway given his
large left maxillary basal cell carcinoma. On ___ at 0100
patient had bradycardia down to ___ with O2 sats of ___ and was
nonresponsive. A code was called, he was bag masked and
intubated and brought to the FICU for management of acute
hypoxemic respiratory failure. Bedside echo was performed which
showed a pericardial effusion so there is concern for
obstructive shock. Pulses was normal and TTE was unremarkable
for cardiogenic shock and showed a very small pericardial
effusion, cardiology signed off at that point. While in the
ICU, the team attempted to wean sedation however the patient did
not tolerate this well. Goals of care discussion was held with
the niece, niece's husband, and sister (via phone)/healthcare
proxy on ___, at which point the patient was DNR/DNI but not
yet made comfort measures only due to healthcare proxy wanting
to settle some affairs. He had a hemoglobin drop to 5.8 from
8.3 concerning for acute bleeding into his stomach from his
facial/oral mass with possible additional upper GI bleed. He
responds appropriately to transfusions of red blood cells. On
___ the patient was made comfort measures only so lab draws
were stopped and transferred to the floor for further
management.
He was comfort measures only upon transfer to the floor on ___.
He passed away on ___ at 8:58 am. | 96 | 657 |
14254598-DS-12 | 27,714,128 | Ms ___, you were admitted because of dehydration
with low blood pressure and low white blood cell count as well
as a history of lower GI bleed. You received IV fluids and IV
antibiotics.Blood and urine cultures obtained and these are
negative.Your red blood cell count was monitored closely and you
had no evidence of active bleeding. The gastrointestinal service
was consulted because of your epigastric pain and recommended an
endoscopy once your white blood cell count stabilizes. Your
white blood cell count is still low , so please stay away from
big crowds or sick contacts.If you have fever, please contact Dr
___.
Changes in medications:
oxycontin 10 mg po BID
vitamin B12 1000mcg shots daily x 4 days to complte 1 week
treatment and then weekly x 4 doses.
protonix 40 mg po daily
.
pending results:
final blood culture results | ___ yo woman with met NSCLC s/p cycle #1 pemetrexed /___ on
___ admitted with neutropenia and hypotension.
.
#Hypotension: Ethiology likely dehydration. BP improved and was
back to baseline after IVFs. AM cortisol level was borderlione
low, but a cosyntropin stim test negative.
.
#Neutropenia:With hypotension and chills at home.Treated as
febrile neutropenia with empiric cefepime started ___. Blood
cxs adn urine cxs remained sterile and CXR w/o evidecne of an
infiltrate.Pt did receive neupogen . On d/c pt afebrile and npt
neutropenic. Low vitamin B12 level could explain early
neutropenia -started and pt started on SC /IM viatmin B12 which
she is to complete at home.
.
#Epigastric pain: Question if esophageal or due to known lung
mass.Cardiac source less likely.Started protonix and increased
to BID. ecg with inf lead T wave abnormalities, seen on ___.
cardiac enzymes and telemetry were negative. GI was consulted
and recommended an EGD, however, pt deferred at this time and
will be referred as and outpt as needed.RUQ did show evidence of
gallstones, but did show adenomyomatosis of the gallbladder,
which may explian symptoms, however, without an EGD cannot
exclude other possible etiologies. Pt had no evidence of active
GI bleed during hospital stay.
.
#GI bleed/BRBPR: On admission no significant drop in hct ( drop
in all counts likely due to chemotherapy). However, during
hospital stay h/h remained stable and as above, there was no
evidence of gI bleed.
.
#Depression: Off antidepress. meds. Cont. prn clonazepam.
. | 137 | 236 |
19739825-DS-21 | 24,742,053 | Mr. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted after feeling
light-headed at home. You were found to have the flu and an
irregular rapid heart rhythm, called "atrial fibrillation." This
resolved after you were treated with IV fluids.
You had an echocardiogram of your heart during your
hospitalization. We will contact you with the final results. You
should follow-up with your PCP and your new heart doctor as
listed below.
Take care,
Your ___ Team | Mr. ___ is a ___ man with h/o OSA and post-operative
paroxysmal afib who p/w 5 days of ILI and episode of
pre-syncope, found to have rapid AF and influenza A infection.
# Paroxysmal atrial fibrillation: Patient presented in AF with
rates into the 140s, which resolved with IVF and IV diltiazem.
He had 1 prior episode of AF in the post-op setting after his
bilateral knee replacements. He denies ever having had a holter
monitor to evaluate for AF burden. This episode is likely
precipitated by acute infectious process and hypovolemia. He may
have underlying paroxysmal AF, perhaps due to his OSA, which is
currently untreated. TTE did not show any valvular disorders or
structural heart disease. TSH was mildly elevated but T3/free T4
were within normal limits. CHADS2-vasc score of 1 for age and
thus, anticoagulation discussion was initiated, but patient
preferred to defer decision until he could read more information
and consider his options. He was monitored on telemetry without
any further episodes of AF. He was arranged for outpatient
cardiology follow-up.
# influenza A: Patient presented on day 4 of symptoms once
fevers and cough had resolved and he remained afebrile during
hospitalization. He declined Tamiflu as he was feeling better
and without fevers.
# elevated blood pressures: Patient's blood pressures were
initially low-normal in setting of rapid AF and hypovolemia,
which normalized after IVF. The day of discharge, he was noted
to have blood pressures in the 150-170 range, though he admitted
he was stressed from pressures at home and his current illness.
# OSA: Patient declined CPAP. TTE did show borderline elevated
PASP, which may be due to untreated OSA. Please continue to
encourage CPAP use. | 82 | 282 |
16320691-DS-27 | 21,929,641 | You were admitted for an episode of syncope (fainting). It was
felt that this was most likely due to infection. You had
evidence of infection in the bloodstream. The most likely source
of the infection was your urinary tract, though your CT abdomen
and renal ultrasound showed no evidence of abscess. You will
complete one week of antibiotics through a PICC line. You will
follow-up with the infectious disease doctors as ___ outpatient
and they will decide if your antibiotics need to be continued. | ___ yo M w/ h/o prostate cancer s/p TURP, COPD, DM, HTN, NHL
(___), Afib (not on coumadin ___ frequent falls) recent
admission for fall and tx for UTI and pna p/w hematuria after
foley trauma and syncopal episode.
#Hematuria: Based on history, this was suspected to be secondary
to foley trauma (balloon noted to be ruptured in the ED). His
hematocrit remained stable and his foley was left in place.
#Syncope: Felt to be vasovagal vs. related to UTI. There were no
reports of seizure activity and no focal neurologic defecits on
exam. Telemetry remained remarkable only for patient's known a
fib. He had no further episodes during the admission.
#UTI/bacteremia: The patient was initially placed on ceftriaxone
for a UTI. However, his blood grew out pseudomonas and GPCs.
Renal ultrasound and CT abdomen were negative. Regardless, the
source of the patient's bactermia was felt to probably be
urinary. He will continue on one week of ceftazidiem/vancomycin
per the ID team. He will follow-up with ID on ___ and it
will be determined at that time if the course needs to be
continued.
#SIADH: The patient's salt tabs were initially held but then
restarted. The patient's sodium largely remained normal but
occasionally dipped as low as 132. He will need close sodium
monitoring at his rehab.
#HTN: The patient was continued on lisinopril with good control
#Afib: The patient is not on coumadin. This was discussed with
the PCP on last admission, who was holding coumadin due to
frequent falls. He was continued on aspirin and remained rate
controlled during the admission.
#BPH: The patient's flomax was initially held but restarted.
#DM: The patient was followed on an ISS. | 84 | 275 |
17333919-DS-25 | 22,887,386 | Dear Ms. ___,
You came to the hospital because you were having trouble
breathing. This difficulty breathing is due to your known lung
disease (ILD) which is becoming worse. We offered you certain
medications to try to improve your breathing (diuretics and
antibiotics), some of which you were willing to take and others
which you did not want to take. We discussed that we cannot cure
your lung disease and you decided that you would prefer to be at
home than in the hospital receiving invasive treatments, many of
which you do not agree with. You went home with hospice services
to make you comfortable at home.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team | ___ is a ___ with history of ILD, OSA, and pHTN on home
O2 and nonadherent to CPAP and home medications who presented
with acute hypoxic respiratory failure.
# Acute hypoxic respiratory failure
# Intersitial lung disease
Patient with diagnosis of non-IPF ILD for ___ year, on 4L NC at
home, on chronic prednisone but taking lower dose than
prescribed by pulmonologist (10 mg instead of 20 mg), also
prescribed AZA but not taking it. Nonadherence related to
distrust of medical system and lack of belief in efficacy of
medications/treatments.
She was initially admitted to the MICU from the ED on ___ after
presenting with acute worsening of her chronic dyspnea and
cough. She had been hypoxic requiring BiPAP in the ED but was
weaned off BiPAP overnight and treated with a dose of 20 mg IV
Lasix with thought that some pulmonary edema may have been
contributing to her respiratory failure. Her prednisone was
increased to 20 mg daily prednisone. She was not treated with
antibiotics and azathioprine was not started given her decision
that she did not want to take this medication and therefore
would not continue it even if she took it in the hospital.
She was weaned to her home O2 overnight and called out to the
floor the next day. On the floor she has had intermittent
episodes of desaturation, often with movement. The floor team
started her on a 5 day course of levofloxacin and tried to start
her on PO diuresis however she often refused these medications
as well as sometimes refusing the prednisone. She also refused
BiPAP at night.
On ___ she became acutely hypoxic and dyspneic with clear
respiratory distress (diaphoresis, increased WOB, tachycardia to
the 130s). She was placed on NRB with improvement in saturations
to 88-90% but had ongoing respiratory distress, prompting
transition to the MICU. She was placed on HFNC with rapid
improvement and was soon weaned back to ___. She refused Lasix.
Exacerbations were thought to be due to acute derecruitment as
she promptly improved on BiPAP or even HiFlow.
# Goals of care
# Hospice
Given the patient's reluctance to accept many medical therapies,
multiple discussions were had with her and her family with the
assistance of a ___ interpreter regarding what she
hoped to gain from hospitalization/medical treatment and what
her goals were. She was clear that her priority was to be at
home. She understood that she had progressive, terminal lung
disease. She wanted to avoid taking medications or treatments
that she viewed as ineffective or likely to harm her. She and
her family agreed with involving hospice to maximize her quality
of life and to allow her to stay at home. She did not want
interventions not directed at getting her home since they could
not cure her disease. She understood this meant that we would
not do CPR or intubation. However, she was reluctant to sign a
MOLST prior to transfer. She understood this meant she might
receive treatments she did not want but was uncomfortable
signing a document as she felt that doctors "have studied all of
this, you should decide" and did not want to be the person
signing the document. She appeared mistrustful of the motive
behind the MOLST. | 126 | 534 |
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