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19982541-DS-12 | 20,860,014 | Dear Mr. ___,
You were transferred to ___ on
___ for evaluation of abdominal pain and were found to have
acute cholecystitis (inflammation of your gallbladder) with an
abscess in your liver. You were evaluated by the acute care
surgery team and interventional radiology. You subsequently
underwent placement of a percutaneous cholecystostomy tube. You
tolerated this procedure well. You have since been tolerating a
regular diet, ambulating, and your pain has resolved. You are
now ready for discharge home with ___ services. Please follow
the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Mr. ___ is a ___ year old male with a PMH significant for
HTN, HLD, MI, and stroke (___), who presented to OSH and had CT
imaging which showed acute cholecystitis and a hepatic abscess.
He was transferred to ___ on ___ for further management.
He was admitted to the Acute Care Surgery service and made NPO
and started on IV fluids and IV antibiotics. The Interventional
Radiology service was consulted for a percutaneous
cholecystostomy, which was done on ___. Upon return to the
floor, the patient was started on a clear liquid diet. The next
day on HD1, he was advanced to a regular diet, which he was
tolerating well. He was transitioned from IV antibiotics to PO
antibiotics (Augmentin) on HD1 to finish a 10 day course. His
abdominal pain had resolved. He was having bilious drainage from
the percutaneous cholecystostomy tube.
During this hospitalization, the patient voided without
difficulty and was ambulating. The patient received subcutaneous
heparin and venodyne boots were used during this stay. Nursing
performed teaching with the patient on drain care and the
patient verbalized understanding. At the time of discharge on
___, the patient was doing well. He was afebrile and vital
signs were stable. The patient was discharged home with ___
services set up. Discharge teaching was completed and follow-up
instructions were reviewed with reported understanding and
agreement. He will follow up in the Acute Care Surgery clinic
and with his PCP. | 422 | 242 |
14731346-DS-11 | 24,239,388 | Dear ___,
___ was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
were short of breath. We think this is due to mucous caught in
your airways. You had a breathing tube placed in your neck and a
feeding tube put into your stomach. Your procedures were
uncomplicated, and we now feel it is safe for you to leave the
hospital. | ___ hx HepC/EtOH cirrhosis, DM, chronic decubitus ulcer, chronic
foley, recent admission for rectus sheath hematoma presents with
respiratory distress.
# POST-HYPOXIC RESPIRATORY ARREST: The patient had PEA arrest
while in the ED, thought to be due to preceding hypoxia. The
patient was intubated and was bronched while in the ED; bronch
was notable for copious secretions. She was ultimately treated
for PNA. She was initially started on Vanc/Zosyn and
azithromycin on arrival to the ICU. Respiratory cultures grew
back Moraxella and the patient completed a course of Cefepime.
While in the ICU, the patient was extubated, but then needed to
be reintubated in the setting of likely aspiration. She also had
multiple mucous plugging episodes and required multiple
bronchoscopies during this admission. Given her issues with
mucous plugging and desaturating, the decision was made to go
ahead with tracheostomy. The patient is now s/p trach and PEG.
Her current vent settings are pressure support ___, FIO2 40%.
The patient will need to be suctioned every ___ hours, pending
amount of secretions.
# RUL Collapse: As noted above, the patient has had issues with
mucous plugging which is the likely etiology of her RUL
collapse. She has had multiple bronchoscopies this admission
with suctioning. The patient has been doing well since getting
her trach, and has been getting suctioning about ___ hours.
# SEPSIS: The patient was on pressors initially while in the
unit, thought to be secondary to sedation and underlying
pneumonia. With weaning of sedation, and treatment of her
pneumonia, the patient's pressors were weaned.
# HCV/EtOH Cirrhosis: Previously decompensated by hepatic
encephalopathy, but was stable during this admission. Her LFTs
were monitored. She was continued on her home lactulose and
rifaxamin regimen.
# T2DM: The patient was continued on Lantus and HISS.
# hypertension: Upon discharge, the patient's home labetolol was
increased to 100 mg BID.
# Hypothyroid: The patient was continued on home levothyroxine.
# volume overload: The patient developed volume overload while
in the unit, and was ultimately net positive about 8L. She
responds well to IV Lasix 10 mg, and was given PRN boluses for
aim net negative 500-1000cc daily. This can be continued in
rehab.
# s/p PEG: The patient had PEG tube placed. She was continued on
tube feeds. | 69 | 386 |
14120635-DS-26 | 26,463,456 | Dear Mr. ___,
You were admitted to the hospital because you were reporting
increased chest pain and difficulty breathing. Because this is
a recurrent problem for you, you were admitted for further work
up. Lab tests showed that you did not have a heart attack, and
the scan we did showed no signs of poor blood flow or a heart
attack. We started a new medication to help prevent chest pain,
and to prevent strokes because of your atrial fibrillation.
Please follow-up with your doctors for further ___. Your
Primary care doctors / ___ will help you monitor
this.
It was also noted that your Tacrolimus level was low the day you
went home. We increased the dose to 2mg every 12 hours. You will
need to have a repeat blood draw on ___ to check the level.
On the morning of ___, you should not take
your Tacrolimus as usual. You should first go to the lab you
always get your liver checks at and get your blood drawn. After
the lab draw, take your usual morning tacrolimus.
When you are home, you should also continue taking your usual
insulin doses.
It has been a pleasure taking care of you. We wish you all the
best.
Sincerely,
- Your ___ Care Team | Mr. ___ is a ___ with history of HBV cirrhosis status post
orthotopic liver transplant in ___, chronic kidney injury
(stage III), and insulin-dependent diabetes mellitus (HA1c 6.9
in ___ who presented with acute on chronic chest pain. On
___ he experienced increasing CP dyspnea. In the ED he was
noted to be in AFib and was started on a dilt drip. His CP
improved with 325mg ASA. With new Afib and a worry for angina he
was admitted for further workup. CXR ___ was negative. When
he arrived on the floor he was in sinus rhythm and remained in
sinus throughout the rest of his stay. His vital remained stable
and his Chest pain and shortness of breath resolved. A nuclear
stress test ___ showed no ischemic changes. Medications were
adjusted as below.
He was also noted to have a low tacrolinus level, and the dose
was increased. His WBC also dropped from 2.5 to 1.8 with
absolute nuetrophil count of 1114 making him neutropenic the day
of discharge. He remained without fevers or objective signs of
infection. CBC with diff were added to his follow-up labs. His
blood sugar was followed, and he was kept on equivalents of his
home insulin regimen without incident. He reported feeling great
starting hospital day 1.
# Hyperkalemia - noted to have hyperkalemia on admission,
treated with Ca Gluconate and Kayexylate, resolved.
Atrial fibrillation - AFib on initial EKG, pt reverted to
sinus rhythm upon arrival on floor with dilt drip. dilt drip
d/ced. pt remained in sinus rhythm. Started on warfarin 2mg qd
(after initial dose 5mg ___ and Metoprolol Succinate XL 25
mg daily. INR f/up on ___ with PCP. Confirmed with office and
new ___ clinic.
Vitals on discharge were: Temp 97.8, HR 67-75; BP 136-160 /
___ ; RR 16, 100% RA
================ | 214 | 307 |
15914008-DS-8 | 27,591,050 | You were readmitted to ___ for
a small bowel obstruction due to a metastasized pancreatic
carcinoma that required an ileocectomy (resection of bowel) with
primary anastomosis.
Your incisions have absorbable sutures that do not need to be
removed. They are covered in dermabond which will naturally go
away over time.
You are being discharged on pain medications post-operatively.
Please take these medications as prescribed. Do not drink
alcohol ro drive while taking narcotic pain medications such as
Oxycodone. Do not take greater than 4,000mg Tylenol per day for
risk of liver damage.
You may shower after arriving home. Please do not bathe in a tub
or submerge your body underwater for at least two weeks to
ensure that an appropriate amount of time has passed for your
wounds to heal.
You are encouraged to walk and stay active. Do not lift heavy
items or strain yourself until your follow-up appointment
though. | Mrs. ___ was admitted to the inpatient colorectal surgery
service on ___ for surgical management of small bowel
obstruction related to a metastatic pancreatic adenocarcinoma in
the region of the terminal ileum and contiguous with the
peritoneum of the RLQ. She was recently discharged from ___
___ for an SBO with work-up revealing the above mentioned
diagnosis. Due to the fact that she had metastatic disease, the
decision was to perform a palliative surgery to resect the
obstructing mass. Hematology/Oncology had been following the
patient and planned to follow-up with possible palliative
Gemcitabine treatment. The medical hospitalist team cleared the
patient for surgery and an ostomy nurse marked the patient for a
likely ostomy. On ___, the patient underwent an ileocectomy
which included resection of the peritoneal and abdominal
components of the metastatic mass. The decision was made to
anastomose the ileum and ascending colon instead of creating an
ostomy. Please see the operative report for further details. She
had an uneventful stay in the PACU and was then transferred to
the floor for further operative management.
Neuro: The patient was initially given IV pain medications for
pain control and was transitioned to PO medications when
tolerating PO. At discharged her pain was well controlled with
tylenol.
CV: The patient was tachycardic to the 150s on the evening of
POD1. EKG showed sinus tachycardia. The patient was making
appropriate urine, was not in pain, and had a normal hematocrit.
She was given 5mg of IV lopressor and her heart remained between
100 and 120 on POD2. The decision was made to give the patient
12.5mg PO lopressor BID post-operatively to prevent demand
ischemia. She will follow up in the clinic for possible
discontinuation of this regimen.
Pulm: The patient had no respiratory issues throughout her
hospitalization.
GI: The patient was NPO pre-op and was given sips
post-operatively. She was advanced to clears and then regular
once passing flatus. At discharge the patient was tolerating a
regular diet, passing flatus, and passing stool regularly.
GU: The patient had a Foley post-operatively which was
discontinued on the evening of post-operative day 1. She voided
without difficulty and continued to void without difficulty for
the remainder of her hospitalization.
ID: The patient's fever curves were monitored for signs of
infection of which there were none. Incisions were monitored for
infection during hospital stay and remained free of erythema or
cellulitis.
Heme: The patient's hematocrit was stable post-operatively.
On ___, post-operative day 4, the patient was discharged to
home with her supportive family. At discharge she was ambulating
independently, tolerating a diet, voiding and stooling
appropriately, and with well controlled pain. She will follow up
in our ___ clinic and with oncology for further
management of her metastatic pancreatic adenocarcinoma. | 150 | 457 |
19442637-DS-15 | 23,280,898 | Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You presented to the ___
Medcial ___ after sustaining a fall which caused you to
develop a small bleed in your brain. Images were taken of you
body and had to determine if you had broken any bones. No broken
bones were notable. You were intially seen by the Neurosurgery
Team who felt you did not need an operation. You were then
transferred to the Medicine Team.
While in the hospital you were additionally dialyzed per your
home schedule of ___. You had no other
complications from your fall.
Again it was a pleasure taking care of you. Please remember to
weigh yourself every morning. Call a doctor if your weight goes
up more than 3 lbs. Because of the small bleed in your head,
you should not take aspirin until ___. Also you have
a follow up appointment scheduled with Dr. ___
neurosurgery on ___. You will need a CT of your head
done on the same day as your appointment with Dr. ___
has been scheduled for you.
Best,
Your ___ Medicine Team | Ms. ___ is an ___ woman with a history of HTN, HLD,
CAD, CHF, DM2 c/b neuropathy, CKD (stage 4), anemia of CKD, OA,
GERD and hyperparathyroidism, who reportedly had a mechanical
fall suffering a left small SAH hemorrhage, deemed
non-operative, stable on repeat imaging. | 190 | 46 |
11277253-DS-7 | 24,635,300 | Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital for alcohol withdrawal. Because your
body is used to high levels of alcohol, cutting it off suddenly
can lead to withdrawal, which means your body becomes
hyperactive without the alcohol and have a fast heart rate, high
blood pressure and shaking.
WHAT HAPPENED IN THE HOSPITAL?
- In the hospital, we gave you Valium to treat the withdrawal.
This works by mimicking alcohol so that your body is not
suddenly cut off; then you are gradually weaned off. However,
the valium was not enough, so you were transferred to the
Intensive Care Unity for phenobarbital, which works by the same
process. Once you were more stable, you were moved to the
medicine floor to continue phenobarbital treatment.
- You had bleeding from your rectum. Thankfully it resolved. You
saw the gastroenterology team who suggested you follow up with
your primary care doctor and potentially get a colonoscopy as an
outpatient.
WHAT SHOULD I DO WHEN I GO HOME?
-Take all your medications as prescribed.
-Follow up with your appointment with Arbour for intensive
outpatient program ___ at 9:00 as directed.
-Follow up with Primary care doctor and cardiologist. Call
Healthcare Associates to make an appointment within the next
week.
-Your primary care doctor ___ refer you to gastroenterology to
get a colonoscopy and get further imaging of your liver as
necessary
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Discharge weight: 110.22 kg (242.99 lb)
We wish you the best!
-Your Care Team at ___ | Mr. ___ is a ___ y/o man with history of ETOH abuse, dilated
cardiomyopathy (LVEF 25%) likely ___ etoh, paroxysmal atrial
fibrillation, PTSD and depression, who presented acutely
intoxicated complaining of left chest pain and left arm pain,
withdrawal treated with phenobarbital, course complicated by
melena and ___.
============= | 280 | 48 |
18772912-DS-16 | 28,049,243 | Dear ___,
___ was a pleasure taking care of you.
Why were you here:
-You had an obstruction in your small intestine
What was done:
-You rested your bowels by not eating
-We gave you intravenous fluids and pain medications as needed
-Your bowel obstruction resolved, and you were started on reglan
for indigestion
We wish you all the best,
Your ___ team | ___ year-old woman with PMH of metastatic breast cancer with
peritoneal carcinomatosis, malignant ascites s/p Pleurx
abdominal catheter, new bone/liver mets on doxil (___) who
presents from home with recurrent abdominal pain, nausea, emesis
concerning for SBO. Abdominal CT showed SBO with transition
point, however, at the time of imaging was performed she had
already started to pas gas. She declined NGT. Pain on admission
was managed with IV morphine, but she only needed this for ~1
day. On hospital day 3, after resolution of SBO, she had
increased dyspepsia and decreased bowel sounds. KUB showed
non-specific bowel gas pattern. Reglan was added with symptom
relief and return of bowel sounds. She was slowly advanced to a
regular diet, which she was tolerating on day of discharge.
#Abdominal pain:
#Indigestion: Admission CT A/P showed transition point, however
on night of admission, she had a bowel movement and emesis
resolved. She had minimal bowel sounds and persistent
indigestion, and was started on reglan for this. Indigestion
improved, bowel sounds returned, and she tolerated soft solids
on day of discharge. She was discharged with a new rx for
reglan, with plan for possible weaning and/or discontinuation as
an outpatient.
#Metastatic breast cancer, with peritoneal carcinomatosis and
ascites and new bone and liver mets: C4d1 doxil ___
(palliative). Has pleurX in place, which is drained TIW. CA
___ was checked and was pending at time of discharge.
# HCP/Contact: Husband ___ ___
# Code: Full, confirmed | 55 | 245 |
17392550-DS-11 | 29,592,084 | Dear. Ms. ___, it was a pleasure to care for you at ___.
You were admitted to the hospital because you fell and fractured
your left hip (iliac crest). While you were here you developed
shortness of breath and a fast heart rate. You were started on a
medication called diltiazem to control your heart rate and to
help with your shortness of breath. Your blood work did not
show any evidence of a heart attack, and your heart ultrasound
did not show any problems with the heart valves. We stopped your
theophylline as it may have been contributing to your rapid
heart rate, and switched your albuterol to levalbuterol to avoid
a rapid heart rate.
You were seen by the orthopedic surgeons and they did not
recommend surgery. They recommend that you follow up with them
as an outpatient. On a CT scan there was an incidental nodule
found in your lung and you should follow up for this with
another CT scan in 6 months. There was also an adnexal cyst
found incidentally; you can follow up with your primary care
doctor for this and consider an ultrasound to further evaluate
it. | Summary:
Ms. ___ is a ___ year old female with past medical history
of COPD on 2LNC at home, aortic stenosis s/p bioprosthetic AVR
and rheumatoid arthritis who was admitted for a fall and L iliac
wing fracture and SOB | 198 | 40 |
11043567-DS-5 | 21,731,004 | Dear Ms. ___,
You were admitted for knee pain. You did well with crutches. You
should follow up with your PCP. We wish you all the best. | ___ yo F with PMH GERD presenting with left knee pain. Pt has had
chronic left knee pain for 1.5 months and then developed acute
pain today in the back of her knee and felt a sensation like a
"pulling."
ACUTE CARE
# Knee pain: DDx includes medial collateral ligamentous tear vs
medial meniscal tear vs bursitis vs ruptured ___ cyst. Exam is
limited by pain but there is no joint laxity to suggest full
thickness/ruptured ligament, so likely there is a small
ligamentous tear or strain. Pain at rest is concerning for
bursitis or ruptured ___ cyst, acute onset makes bursitis less
likely; ruptured cyst is possible given the history of joint
pain chronically for 1.5 months that suddenly worsened, but she
has no other signs of this on exam. Pt admitted for ___ consult
who cleared her with crutches. She was discharged on tylenol and
ibuprofen, RICE and PCP ___ follow up.
CHRONIC CARE
# GERD: cont omeprazole
# Depression: cont venlafaxine | 26 | 167 |
14661372-DS-21 | 25,492,083 | You were admitted to the hospital because of unsteadiness on
your feet. We did not find a cause for this, but while you were
here we monitored your heart and did not find any unusual
events.
Please stop by room 316 after discharge today to get a 24 hour
holter (heart) monitor. Dr. ___ will followup the results
with you. You should also follow up in ___ this week for a
post-discharge appointment. | ___ with PMH significant for CAD, HTN, HLD and peripheral
neuropathy who presents following an episode of dizziness and
nausea concerning for presyncope/syncope.
#Presyncope. No clear etiology identified. Suspect vasovagal and
dehydration (elev BUN:CR ratio, nausea). HR stable on tele
arouind 60. One epiode of hypotension to 88/52 around midnight
while sleeping; asymptomatic. Head/neck CT unrevealing and exam
not consistent with TIA. He was wearing a tight collar during
one episode of presyncope which suggests carotid
hypersensitivity. Will discharge with 24h holter monitor, Dr.
___ will followup results. Would consider ECHO (systolic
murmur on exam) although critical AS seems unlikely given
symptoms at rest and not on exertion. Orthostatics have been
negative after receiving IVF.
#HTN: Blood pressure currently 155/83 on admission, continued
home meds.
#Peripheral neuropathy: Likely secondary vitamin b12 deficiency.
Patient denies history of diabetes. Last A1c was 5.6 in ___. Continued home gabapentin, B12.
#HLD: Stable, cont home atorvastatin 80mg daily.
#Insomnia: Continue on home oxazepam 15mg qhs.
Transitional Issues
#Presyncope: F/u holter, consider ECHO. F/u final read head/neck
CT (addendum: this was unremarkable for significant stenosis).
F/u ___ ___ clinic within 1 week, then at scheduled
visit with Dr. ___
#Peripheral Neurology f/u in ___ in the ___
___ | 75 | 201 |
18539987-DS-17 | 29,362,322 | You were admitted to the hospital due to a very low sodium level
in the blood. This improved with stopping a medication called
hydrochlorothiazide. You were noted to have a small nodule on a
chest xray. A CT scan of the chest was done to have a better
look at this area. There is no sign of a tumor there. Yuo do
have signs that at times you do not clear out secretions in the
lungs very well. You also had an ultrasound looking at the
blood vessels in the abdomen-- there is good blood flow through
them to the stomach.
Dr ___ recommends that you see a GI doctor in the
future to evaluate further the pain that you have in the upper
abdomen/chest region. | ___ with hx of HTN presenting with weakness found to be
hyponatremic and anemic.
#hyponatremia: Most likely hypovolemic hyponatremia in setting
of decreased PO intake. Patient also has been on a HCTZ which
could also contribute to hypoNa. Pt improved initially with the
use of IVF, and after fluids were stopped she continued to have
improvement in her sodium level.
#normocytic anemia: Hb 8.6 from 10.2 in ___. Per discussion
with PCP, has been gradually declined over last year with poor
appetite, had esophageal stenosis for which she has had dilation
procedures with last one ___ months ago, checked stool guaiac
several times which were neg, normal EGD a year ago, no
colonoscopy.
#UTI: patient with large ___, WBCs and moderate bacteria on U/A
suggesting UTI, however patient denied any urinary frequency,
dysuria, or hematuria. Outpatient labs showed similar U/A back
in ___. Was given CTX x 1 in ED however was d/c due to lack of
symptoms.
#lung nodule: seen on CXR-- followed up with CT that showed no
nodule. Possible findings consistent was MAC, but as pt is
asymptomatic would not pursue treatment at this time.
Pt came out of the ICU to the regular floor. She did well, but
described via translater terrible intermittent chest/epigastric
pain. She reports that she is able to easily walk for extended
periods without CP. She is not sure if the pain is food related.
She was scheduled to have mesenteric duplex and was quite
distressed about missing the appt. This was therefore performed
here-- no sign of significant stenosis.
___ was d/w pt's pcp and she was set up with GI follow up. | 130 | 272 |
10774619-DS-8 | 22,990,451 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
and weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- High cholesterol
- Heart disease
We also started on a new medication, Fluoxetine, to treat
symptoms of depression. Depression is very common after a
stroke, and you should follow up with your PCP about how best to
manage this moving forward.
We are changing your medications as follows:
- Start taking Apixaban (Eliquis) 5mg twice daily on ___.
- When you start Apixaban
(1) DECREASE your dose of Aspirin from 325mg daily to
81mg daily.
(2) STOP taking Clopidogrel (Plavix)
- Continue taking Fluoxetine 10mg daily. Increase your dose to
20mg daily on ___.
- We reduced your blood pressure medications while you were
admitted. Your doctor ___ increase/resume your doses as
indicated to keep your blood pressure under good control.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ year old with history of HTN, HLD, CAD s/p
CABG and bare metal stent, and prior CVA with acute monocular
vision loss (suspected CRAO) who was admitted to the Neurology
stroke service with aphasia and right-sided weakness and found
to have multifocal ischemic infarcts in posterior circulation
territories (R cerebellum, L occipital and L thalamus). Given
its location in multiple posterior circulation territories, we
feel his stroke was mostly due to a proximal source e.g. cardiac
embolism from apical ventricular akinesis as visualized on echo.
For that reason, we will start him on Apixaban for
anticoagulation. His deficits improved greatly prior to
discharge. He still had significant R-sided motor dyscordination
with minimal speech impairment at time of discharge. He will
continue rehab at a rehab center.
His stroke risk factors include the following:
1) Intracranial atherosclerosis of both anterior and posterior
circulation.
2) Hyperlipidemia: well controlled on Atorvastatin 80mg with
LDL 50
3) Hypertension
4) Cardiac disease - CAD, abnormal cardiac wall motion.
An echocardiogram showed apical areas of hypokinesis and
akinesis. No thrombus was visualized, though the study was
limited.
During his stay, he also had urine and blood cultures sent
after developing a self-limiting acute episode of confusion.
Urine culture was negative and final blood culture results
pending at time of discharge. He remained afebrile without other
changes in mental status and further infectious workup was not
pursued. He also exhibit symptoms of depression, for which he
was started on Fluoxetine 10mg daily.
Transitional issues:
- Anticoagulation: He is being discharged on both Aspirin 325mg
daily and Plavix 75mg daily. On ___ (2 weeks after stroke),
he should START Apixaban 5mg PO BID, REDUCE his Aspirin dose to
81mg daily, and STOP Plavix. Apixaban prior authorization was
initiated on ___ and should be processed within 24 hours.
- HTN: His anti-hypertensive regimen was reduced during his
admission. He was maintained on Metoprolol 25mg BID and
Valsartan 160mg BID prior to discharge. His Valsartan-HCTZ is to
be resumed on discharge, and his Metoprolol dose may be
increased as indicated with BP monitoring.
- Depression: He exhibited symptoms of depression after his
stroke. He was started on Fluoxetine 10mg PO daily on ___.
Please INCREASE his dose to 20mg PO daily on ___. | 405 | 385 |
11794057-DS-12 | 27,262,368 | Dear Ms. ___,
You were admitted to the hospital to monitor you after your
cardioversion.
WHAT HAPPENED IN THE HOSPITAL?
Your heart rhythm was monitored and there was no signs of atrial
fibrillation. You were started on a medication to control your
heart rate called metoprolol, and a blood thinner called
heparin.
WHAT ARE THE NEXT STEPS?
- Please continue taking your medications as below
- Please follow up with your doctors as below
It was a pleasure taking care of you!
Your ___ Care Team | ___ year old woman with a history of MVP/MR, osteopenia, reported
hx of cdiff, IBS, who presented as a transfer w/ Afib/RVR and
hypotension now s/p cardioversion.
TRANSITIONAL ISSUES
=====================
[] She was found to have a small to moderate pericardial
effusion, without tamponade physiology. A follow up TTE is
recommended.
[] The patient expressed concern for being able to pay for
apixaban moving forward. Please reassess the most appropriate
anticoagulation strategy.
[] Patient was adamant about being DNR/DNI. Her code status
should be further explored and documented as an outpatient.
NEW MEDICATIONS: Apixaban, metoprolol
ACUTE ISSUES
==============
#AFib with RVR
Patient transferred after developing hypotension with new onset
AFib. She was cardioverted in the ED, reverting back to sinus.
She was admitted to the CCU for monitoring. She was started on a
heparin drip overnight. She had no arrhythmia on telemetry. In
the morning, she was started on metoprolol for rate control, and
switched to apixaban for anticoagulation. She'll continue both
these medications as an outpatient.
#NSTEMI
Patient had a type II NSTEMI iso arrhythmia and cardioversion.
Her EKG showed no signs of ischemia. A TTE showed normal left
ventricular wall thickness, cavity size, and regional/global
systolic
function. Mild posterior mitral valve prolapse. Mild mitral
regurgitation. Mild tricuspid regurgitation. Normal estimated
pulmonary artery systolic pressure. Small to moderate
predominantly anterior, loculated pericardial effusion without
echocardiographic evidence of tamponade.
CHRONIC ISSUES
===============
#Osteoporosis
Patient on alendronate, however not consistently taking. | 78 | 225 |
16990734-DS-21 | 29,300,094 | Ms. ___, it was a pleasure to take part in your care at ___.
You were admitted to the hospital for shortness of breath. You
were given nebulizers and a steroid medication to help you
breath easier, and over the course of the past day, you have
improved significantly. You are now able to walk without needing
oxygen and keeping your oxygen levels high. | ___ chronic heavy smoker with a h/o Rheumatic heart disease w/
mitral stenosis, A-fib on Warfarin, pleural effusions, and
pericardial effusions who presents with dyspnea consistent with
possible COPD exacerbation.
ACTIVE ISSUES BY PROBLEM:
# COPD exacerbation: dyspnea attributed to likely exacerbation
of COPD. Major DDx is small mucous plug vs. CHF exacerbation. No
JVD or pitting edema on exam, no pleural effusions on CXR (if
anything improved from baseline). Pericardial and pleural
effusions seen in ED is small so unlikely contributing. PE also
a possibility, however is on coumadin and work up for PE would
not change management. Improved symptomatically after getting
nebs, steroids and azithro. Discharged the following day with
plan to complete a total 5 day course of prednisone 40mg and
azithromycin. She was also given a rx for albuterol PRN and
daily spiriva. | 64 | 139 |
16334516-DS-35 | 24,546,405 | Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted due to a very severe urinary tract infection that
caused your blood sugar to be dangerously high and cause you to
need mechanical ventilation. Fortunately, with treatment you
improved markedly, and eventually returned to your baseline.
You will need to continue following up closely with the renal
transplant doctors and ___ once you are
discharged. You will also need to continue antibiotics
(Linezolid) to complete a total 14day course (___). | BRIEF HOSPITAL COURSE:
=============================
___ with h/o CAD s/p CABG and PCI, dHF, ESRD s/p cadaveric renal
transplant ___ ___, IDDM1, extensive PVD with chronic venous
ulcers, h/o DVTs s/p IVC filter on warfarin, and new onset AFib,
who was transferred from ___ ___ for further
management of uroseptic shock ___ VRE UTI (briefly requiring
pressors), hypoxemic respiratory failure (s/p extubation), now
w/ stable/improved clinical status upon discharge. | 90 | 66 |
12672809-DS-8 | 22,190,249 | You were evaluated at ___ for
your three day history of headache, nausea, and vomiting which
started on waking and fortunately has improved. We evaluated
you with a CT scan of the head which revealed no abnormalities,
including no bleed. An Angiogram of the head was also performed
which demonstrated no aneurysm or areas of malformation. It is
likely that you suffered from a viral illness which caused your
symptoms. It is less likely that these symptoms are due to any
complications with any demyelinating illness such as multiple
sclerosis (MS).
We also found that you had a urinary tract infection which we
are treating with a short course of antibiotics. | Mrs. ___ is a ___ year old right-handed woman with past
medical history of anxiety and possible multiple sclerosis
(currently undergoing diagnostic work-up) who presented with 3
days of dizziness, nausea and vomiting and 1 day of headache
that started upon waking. She was admitted to the general
neurology service for work-up and treatment of a possible
multiple slerosis flare. As pt had presented with a headache
that was severe and located in the occipital area, there was
also a concern for a sentinel headache.
While in the hospital, lumbar puncture was attempted but
unsuccessful due to pt's back anatomy. A CTA was checked which
was negative for an aneurysm or hemorrhage. Pt's symptoms
resolved with intravenous fluid repletion. Neurologic exam also
remained normal apart from a mildly positive impulse test.
Orthostatics were also normal. As pt's symptoms had resolved,
there was low suspicion for subarachnoid hemorrhage so further
attempts at lumbar puncture were deferred. Pt's symptoms were
attributed to a viral infection due to their rapid resolution
with intravenous fluids.
Additionally, pt had a urinalysis with few bacteria and 7 white
blood cells. She was started on a 3 day course of ciprofloxacin
to treat a possible urinary tract infection.
Otherwise, pt's chronic medical conditions were controlled while
in the hospital. She was continued on sertraline for depression
and lorazepam as needed for anxiety. She was also placed on
heparin SQ for DVT prophylaxis.
On day of discharge, pt was advised to return promptly to the
emergency department if symptoms were to recur.
==================================
TRANSITION OF CARE
==================================
Mrs. ___ was admitted for symptoms concerning for a
possible multiple sclerosis flare (headache, nausea, vomiting,
dizziness). Work-up for these etiologies was negative. Her
symptoms resolved with intravenous fluid repletion and were
attributed to a viral infection. She will follow-up at her
previously scheduled appointment with Dr. ___. | 116 | 305 |
17987285-DS-20 | 23,471,297 | You went to the emergency room after being hit by a motor
vehilcle.You suffered a concussion. In the emergency room you
had scanning done which showed a left temporal fracture. You
have a wound which is closed with staples in the back of your
head and a laceration on your forehead and an abrasian on the
right cheek. You were then admitted to the hospital to be
observed. You were seen by neurology and plastic surgery. You
have been stable, tolerating a regular diet and are ready to go
home. Here are discharge instructions for you to follow:
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 is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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
doctor.
Avoid driving or operating heavy machinery for a couple of
weeks.
Wound Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the wound
sites.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash wounds with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
- You will be finishing the Keflex which you have already
started- 5 day course in total
- Bacitracin twice daily to right malar (cheek)abrasion
- Keep your head elevated on two-three pillows, cold pack to
forehead as needed for 48 hours
- Follow-up in plastic surgery clinic on ___, for suture
removal
-rest for two weeks after concussion. No physical or exertional
activity. quiet environment for 2 weeks is preferable. | The patient presented to Emergency Department on ___. Upon
admission, the patient was evaluated and found to have a
subgaleal hematoma as well as a left temporal fracture. The
patient was also noted to have a laceration on the back of the
head which required staples and a laceration on the forehead
which is now intact with steri-strips. She had suffered a
concussion at the time of the accident but had normal findings
on her neuro exam in the hospital. The patient was admitted to
the hospital for observation.
REVEIW OF SYSTEMS:
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 but shortly
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.
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. | 455 | 246 |
11271475-DS-20 | 21,740,275 | Dear Mr. ___,
You were admitted for episodes of room spinning. You had an MRI
of the brain, which was normal. There was no strokes. These
episodes can be related to your inner ear. These episodes have
also been associated with diarrhea, for which we would recommend
you seek workup with your primary care provider.
Your imaging did show an incidental finding of narrowing of your
right carotid artery. This is not related to your symptoms.
Vascular Surgery reviewed your case and they recommended you
follow up with Dr. ___ further management.
There were no medication changes. Please follow up with your
primary care provider, vascular surgery and neurology.
Sincerely,
Your ___ Neurology Team | ___ is a ___ year old gentleman who presents with
distinct episodes of vertigo lasting 20 minutes for the past 3
weeks, occasionally with associated vomiting and diarrhea,
referred by his PCP to the ___ for evaluation.
#Hospital Course
Patient initially presented to ___, where a CT angiogram
revealed bilateral carotid artery atherosclerosis with
significant right-sided stenosis, prompting transfer to ___
for vascular surgery evaluation. His symptoms, if they were
central in origin, would be secondary to posterior circulation
disease. However, there was no issues with the posterior
circulation on CTA and patient does not have fetal PCAs
connecting the anterior to the posterior circulation. Therefore,
we believe that the carotid artery stenosis is not the cause of
his symptoms. We think that his symptoms are a separate problem
from his carotid artery atherosclerosis, so he therefore did not
have a symptomatic carotid artery. We did an MRI which was
negative for acute stroke, so his vertiginous symptoms were
thought thought to be likely peripheral in origin. We did an
ultrasound of the carotids, which showed Right ICA 80-99%
stenosis and Left ICA <40% stenosis. Vascular surgery was
consulted, who recommended outpatient follow up with Dr. ___
___ consideration of elective CEA.
Patient's hemoglobin A1c was 8.4, and LDL was 58. We continued
his home medications, including aspirin 81mg and atorvastatin
for stroke prophylaxis.
#Transitional Issues
- Follow up with vascular surgery as an outpatient
- Follow up with PCP for improved blood sugar control, lifestyle
intervention
- Follow up with neurology as scheduled | 114 | 250 |
12272035-DS-19 | 21,504,791 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having arm
and neck pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We checked cardiac labs, which were all normal.
- We did a stress test, which was reassuring against any cardiac
etiologies.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team | Ms. ___ is a ___ year-old woman with MS, thalassemia, HTN who
presented with L arm pain which began suddenly and associated
with radiation to L chest and jaw as well as L hand
paresthesias. Similar symptoms had happened in ___. Symptoms
resolved after getting nitroglycerin, but unclear correlation.
Troponins negative x2. EKG with lateral ST depressions similar
to prior in ___, but slightly worse. Pharmacologic stress
test with normal perfusion. Additionally noted to have anion-gap
metabolic acidosis on initial labs, which resolved on repeat. No
clear etiology for acidosis; no ingestions.
TRANSITIONAL ISSUES
=================
[ ] PCP ___ scheduled in 1 week.
[ ] Reports volatile BPs for quite some time, however BPs
reasonably controlled this admission. Continued on
prior-to-admission meds.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 93 | 181 |
17148940-DS-6 | 28,791,253 | Dear ___,
You were admitted to ___
because you had a headache and a stomach ache after hitting your
head.
What happened while I was here?
- You had a head CT which was normal
- You had a CT of your abdomen and pelvis which did not show a
reason for your abdominal pain
- An eye doctor looked at your eye and scheduled you for a
follow up appointment
What should I do when I go home?
- Please go to all of your appointments. You should be going to
the eye doctor either ___ ___ or ___.
- If you develop any new symptoms such as headache, nausea,
vomiting or anything else that concerns you, please call your
doctor or return to the emergency room.
Sincerely,
The team at ___ | ___ was in her usual state of health at home and hit her right
cheek/eye on the coffee table while sleeping during a dream. The
following day, she developed headache, abdominal pain and nausea
and had one episode of diarrhea, prompting her to go to urgent
care. There, she did not have any focal neurological findings
but did report slurred speech. CT head was unrevealing for acute
hemorrhage though did show a well circumscribed hemorrhagic
collection in the vitreous cavity of the right eye. This could
represent a choroidal hemorrhage, choroidal melanoma +/-
hemorrhage. There was also significant scleral thinning superior
with ectasia and uveal prolapse. She was seen by ophthalmology
who will schedule an appointment with her for either ___
___ or ___.
In the setting of concern for altered mental status, an
infectious work up was pursued. Chest XR showed a possible
opacity and she was given one day of antibiotics; however, given
that she had no clinical symptoms of pneumonia (i.e. fever,
white count, or respiratory symptoms), the antibiotics were
discontinued.
Additionally, the patient had a CT scan of her abdomen and
pelvis given her above symptoms. There was no acute pathology
though two incidental findings were shown:
1. The cervix has a slightly heterogeneous appearance, which is
nonspecific. This may be further evaluated with direct
inspection.
2. Indeterminate 8 mm soft tissue density in the left breast.
Recommend correlation with mammography
The patient's symptoms resolved and she was discharged after
less than 24 hours of hospitalization.
====================== | 123 | 250 |
19166723-DS-27 | 25,616,875 | Ms ___,
It was a pleasure participating in your care while you were
admitted to ___ as you know you were
admitted because you were having chest pain. This was most
likely due to your use of cocaine leading to damage in your
heart. It is extremely important that you stop using drugs as
this could lead to futher damage to your heart and possibly even
death. You reported not regularily taking your HIV medications
so they were stopped. It is extremely important that you
follow-up with your ID doctor as below to discuss restarting
these medications. | []BRIEF CLINICAL COURSE: ___ yo female HIV (CD4 of 24 in ___
and recent hx of cocaine and heroin use who presents with chest
pain. Cardiac enzymes negative X 3, EKG stable compared to
priors. Infectious disease did not feel it necessary to restart
HAART therapy given the patient's poor compliance; she will
follow up with her outpatient infectious disease physician. The
patient received information from social work regarding
outpatient detox programs.
.
# Coronary Vasospasm: Presentation most consistent with
vasospasm in the setting of recent cocaine use. DDX includes MI
from coronary disease (HIV is a risk factor) however this seems
less likely given the stable changes on her ECG when compared to
recent prior ECGs. Troponins negative x 3. CXR was without
evidence of PNA. No hx to suggest risk for PE. The patient was
placed on ASA, pravastatin. We monitored the patient on tele
with no events. Had TTE, grossly non-pathologic with LVEF of
60-65%. At discharge, the patient had no recurrence of chest
pain.
.
# HIV/AIDS: Patient has a history of non-compliance with HAART.
Patient states that for the past 2 weeks she has been
sporadically taking her medications. Per ID will not restart
HAART and will defer management to outpatient ID doctor at the
___ due to concerns of non compliance; f/u has been set up.
We continued the patient on her bactrim and fluconazole
prophylaxis, CD4 count on this admission 198. Lipid panel WNL
except for HDL low at 35. LFTs WNL.
.
# Substance abuse: Patient has a long history of active abuse of
alcohol, cocaine and heroin. Social work saw patient along with
the BEST service to facilitate transfer to a specialized ___
facility. At discharge, the patient was not scoring on CIWA but
was having mild s/s of heroin withdrawl that, while
uncomfortable, is not dangerous.
.
# Depression: Patient not currently on medication.
.
# Asthma: Patient not current on medication. PRN albuterol
.
[]TRANSITIONAL ISSUES
-pt to f/u with her infectious disease doctor regarding
restarting HAART therapy.
-pt was seen by social work and was provided with outpatient
information regarding detox programs. | 98 | 381 |
10621477-DS-16 | 24,139,105 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized to work up potential neurological
conditions which may have caused you to lose voluntary control
and consciousness when using the toilet.
What was done while I was in the hospital?
- Pictures were taken that showed you did not have a sudden
bleed in your brain which may have caused a stroke or did not
have a fracture in your spinal cord in your neck.
- A brain wave recorder was used to determine if you are
actively having seizure like brain activity, which did not
return such tracings.
- You were regulated on your home medications to help you
avoid potential doses which may cause delirium or changes in the
consciousness of patients, especially the elderly.
- You had a urine test done that was concerning for a urinary
tract infection so you were started on an antibiotic called
bactrim.
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 seizures or further loss of voluntary motor
function, please tell your primary doctor or go to the emergency
room.
Best wishes,
Your ___ team | ___ w/ CVA (L-sided weakness), ___, HTN, arthritis p/w
recurrent vasovagal syncope and unresponsive episode. | 229 | 15 |
11615166-DS-14 | 28,776,639 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I ___ THE HOSPITAL?
==========================
- You were admitted for severe low back pain, and were found to
have an infectious collection ___ your spinal cord.
WHAT HAPPENED ___ THE HOSPITAL?
==============================
- You underwent surgery to drain the infection ___ your spine,
and to stabilize your spine.
- You were treated with antibiotics through an IV with plan to
continue the antibiotics for 6 weeks for the infection.
- You improved each day and are ready to go to a rehab facility
to work to improve your strength.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved ___ your care, we wish
you all the best!
Your ___ Healthcare Team
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs for
2 weeks.You will be more comfortable if you do not sit or stand
more than~45 minutes without getting up and walking around.
Rehabilitation/ Physical ___ times a day you should go
for a walk for ___ minutes as part of your recovery.You can
walk as much as you can tolerate.Limit any kind of lifting.
Diet: Eat a normal healthy diet.You may have some constipation
after surgery.You have been given medication to help with this
issue.
Brace: You may have been given a brace.If you have been given
a brace,this brace is to be worn when you are walking.You may
take it off when sitting ___ a chair or while lying ___ bed.
Wound Care: Remove the dressing ___ 2 days.If the incision is
draining cover it with a new sterile dressing.If it is dry then
you can leave the incision open to the air.Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower.Do not soak the incision ___ a bath or pool.If the
incision starts draining at anytime after surgery, do not get
the incision wet.Cover it with a sterile dressing.Call the
office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control
your pain.Please allow 72 hours for refill of narcotic
prescriptions,so please plan ahead.You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call ___ or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your ___
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision,take baseline
X-rays and answer any questions.We may at that time start
physical therapy
We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound. | TRANSITIONAL ISSUES
===================
[ ] Follow up with PCP for general visit and the concerns below:
[ ] Discharged with Foley and will need follow up outpatient
with urology for trial of voiding
[ ] Ensure up to date with colonoscopy and any recent findings
on colonoscopies have been addressed due to anemia this
admission; consider outpatient EGD for Anemia workup
[ ] Pt previously was on 70/30 48 Units Breakfast on admission.
This was changed to Glargine 24U qHS, Humalog 8U qACHS. This has
provided better glycemic control. However, there were some
concerns regarding his ability to be adherent to this regimen as
outpatient. This should be re-addressed post-discharge.
[ ] Follow up for ID below:
OPAT Diagnosis: L2-L3 discitis/ostemyelitis with associated
epidural abscess and left paraspinal myositis | 539 | 125 |
12727378-DS-17 | 24,852,171 | Dear Mr. ___,
You were admitted to ___ with abdominal pain and found to have
evidence of a mass on imaging of your abdomen which was
concerning for cancer. You had a biopsy on ___ which showed
evidence of lymphoma. Oncology was consulted and recommended
transfer to the bone marrow transplant service. You were
transferred on ___ and while on the service were officially
diagnosed with Burkitt's Lymphoma. You were started on a
chemotherapy regimen for this type of cancer. You are to follow
up with your outpatient oncologist Dr. ___ later this
week.
In order to prevent future infections, we recommend you take new
medications including trimethoprim-sulfamethoxazole (bactrim)
and acyclovir. Please also take neupogen (filgrastim) to keep
your white blood cell counts high.
It was a pleasure taking care of you during your
hospitalization. We wish you all the best!
Sincerely,
Your ___ Care Team | ___ year old male PHMx HTN, obesity s/p sleeve gastrectomy in ___ presents with a 2 week history of abdominal pain and
fatigue, with newly diagnosed lymphoma.
# ___'S LYMPHOMA - Patient presented with 2 week history of
RUQ abdominal mass, abd pain and fatigue. A CT of the
abdomen/pelvis showed evidence of questionable internal hernia
versus mass causing small bowel obstruction with adjacent bowel
wall edema with concern for ischemia, as well as peritoneal
carcinomatosis. Given these findings, surgery was consulted but
they did not feel that there was evidence of SBO or active
ischemia. His abdominal exam was unconcerning with soft,
distended abdomen without rebound or guarding. His pain remained
well controlled initially with IV Morphine and then subsequently
with oral. His lactate trended upwards with peak of 5.3 but his
serial abdominal exams remained stable. Surgery was following
and were not concerned for bowel ischemia. The thought was that
the tumor burden was causing the elevated lactate rather than
ischemia. Patient had tumor markers including: AFP, ___ and
CEA which were negative. He had an ___ guided omental biopsy on
___ which preliminarily shows evidence of lymphoma. Oncology
was consult who recommended trending tumor lysis labs and
transfer to ___. On the ___ Service he underwent a bone marrow
biopsy which showed Burkitt's Lymphoma. He was treated with
DA-EPOCH and tolerated the chemotherapy regimen well. He
underwent lumbar puncture on ___ and ___ with IT cytarabine.
On ___ he also underwent an infusion of rituximab without any
difficulties. CT of the neck was performed which showed multiple
small neck nodes with the largest approximately 1.7 cm in
dimension. At the time of discharge he was on acyclovir and
sulfamethoxazole-trimethoprim for prophylaxis.
# SPINAL HEADACHE: Mr. ___ experienced a spinal headache
(with headache worse when he sat up and improved when he would
lay down) after the LP on ___. Headache persisted for four
days leading to nausea, vomiting and generalized discomfort. To
treat the spinal headache he was re-hydrated with IVF, given
caffeine, and put on fioricet. These interventions did not
resolve the headache. Due to ongoing headache, neurology was
consulted who also believed this was secondary to a spinal
headache. They recommended Mr. ___ lay on his belly to
decrease the CSF leak causing the headache. These intervention
significantly improved his headache. At the time of discharge
the headache was nearly absent. He was discharged on baclofen to
relax muscles in the cervical region of neck.
# HYPERURICEMIA: The patient's uric acid levels were elevated to
peak of 14.7 in the setting of high cell turnover from likely
malignancy. He was started on Allopurinol ___ PO daily and
maintained with aggressive IVFs with decrease in uric acid
levels. He also received rasburicase to decrease the uric acid
level. Renal function remained intact throughout
hospitalization. He did undergo some evidence of tumor lysis but
was maintained on allopurinol. Kidney function remained intact
with creatinine at the time of discharge of 0.9. Uric acid level
was 4.4 at the time of discharge.
# BRADYCARDIA: Patient was noted to have bradycardia during
hospitalization with heart rates ranging from the mid ___ to mid
___. On admission heart rate was in ___. The bradycardia
developed after receiving his cycle of chemotherapy. When heart
rates were in the ___, he was completely asymptomatic. These
heart rates usually occurred when he was laying in bed. Heart
rates increased to normal when he was moving and walking the
halls. An EKG was obtained which showed sinus bradycardia with
first degree AV block. Due to the prolonged PR interval
medications that could have affected AV node conduction such as
metaclopramide, and ondansetron were discontinued. Etiology was
thought to be secondary to increased vagal tone while resting
versus effect from the chemotherapy regimen.
# ___ VIRUS POSITIVE: Patient's EBV came back positive
at 1,181 copies/mL. Consistent with Burk___'s Lymphoma. Patient
received rituxin on ___. EBV <200 copies/mL on ___.
# HYPERTENSION: Blood pressure was well controlled on
lisinopril. At the time of discharge he was continued on
lisinopril.
# GASTROESOPHAGEAL REFLUX DISEASE: Previously was on famotidine
at home. Famotidine was discontinued. Instead he was placed on
pantoprazole at the time of discharge.
TRANSITIONAL ISSUES
===================
#CT NECK: Multiple small neck nodes, some of which are mildly
prominent with the largest located at level 2 on the right,
1.7cm in CC dimension as noted above. Correlate clinically and
if needed with PET to assess the significance and followup as
needed given the findings on CT Torso.
#BRADYCARDIA: Patient was noted to be bradycardic during
hospitalization. Please evaluate chemotherapy regimen and
consider medication choices given the bradycardia.
#HEPATITIS VACCINATION: Patient is hepatitis B surface antibody
negative. Please consider vaccination for Hepatitis B.
#CONTACT: ___ (wife): Home: ___, Cell: ___.
#CODE STATUS: FULL CODE | 144 | 801 |
10931979-DS-4 | 29,868,588 | Please wear your c-collar at all times until told otherwise by
neurosurgery (Dr. ___ team).
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. | Mr. ___ was transferred to ___ by ambulance on ___ after he
was found to have an unstable C5/C6 vertebral fracture s/p MVC.
He was stable upon arrival to ___, with stable vitals, A&O x
3, and GCS 15. The orthopedic spine team was consulted, who
evaluated him and determined his injury to be operative. He was
taken to the OR on ___ for closed reduction with halo traction,
anterior cervical diskectomy with fusion, C5-6, using allograft
(structural), plate, and screws, and open reduction using ___
distraction pins. 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 once
tolerating a diet. He was maintained on a prednisone taper.
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 kept on 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. | 232 | 310 |
11137177-DS-17 | 26,133,494 | Dear Mr. ___,
You were admitted to ___ on
___ with acute pancreatitis. You were found to have
gallstones as well, which may have caused your pancreatitis. You
recovered well, and are now ready for discharge.
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. | Mr. ___ was admitted to ___
___ on ___ for management of pancreatitis. He did well
overnight, his pain was well controlled, and he was kept NPO in
IV fluid resuscitation. The morning of ___, he was transferred
to the ICU for tachycardia and increased O2 requirement
ICU course:
Patient was transferred to the SICU for tachycardia and
increasing O2 requirement. He was transferred to the unit,
placed on nasal cannula, and started on aggressive fluid
resuscitation. His ICU course by systems is as follows:
Neuro: pain was controlled with intermittent dilaudid
CV: His tachycardia resolved with resuscitation.
Resp: A CTA was obtained which was negative for a PE. He had a
persistent O2 requirement and some tachypnea, initially
attributed to splinting and then due to some volume overload. He
was diuresed and his O2 requirement continued to trend downward.
GI: Patient being treated for severe acute pancreatitis. A HIDA
was obtained which was negative for acute cholecystitis. An UGI
was obtained for concern of duodenal perforation on CT scan, but
this was negative for any extrvaastaion and signs of
perforation. He was made NPO and his pan slowly resolved. Once
his pain was gone, he was advanced to a regular diet and
tolerating well. He was having bowel movement, then began to
have diarrhea. Cdiff was negative and he was started on lomotil.
GU: He was started on aggressive fluid resuscitation and bloused
as needed for urine output. Once his pancretaitis had resolved,
he was fluid overloaded and was diuresed with intermittent IV
Lasix doses.
Heme: NAI
ID: NAI
He was stable for transfer to the floor on ___
He did well on the regular nursing floor; however, he had a
persistent and rising lqeukocytosis to 20 on ___. A CT
abdomen/pelvis showed increased peripancreatic stranding, but
was otherwise unchanged. His oxygen requirement was weaned to
room air by ___, and he was ambulating without issue. His pain
was well controlled and he was tolerating a regular diet. On
___, his WBC remained persistently high at 20.6. An infectious
work-up including a CXR, UA/culture, and stool sample (for
diarrhea) were sent, which were all negative. On ___, his
white blood cell count decreased to 17.8. continued to decrease,
however, remained elevated. Due to the facvt that it was
decreasing and no infectious source could be ascertained, and
due to the fact that he clinically looked well for several days,
he was discharged in stable condition with a plan to follow-up
in ___ clinic in 2 weeks. | 196 | 414 |
18973855-DS-22 | 20,045,198 | Mr. ___,
You were admitted due to cough and found to have influenza A.
You were started on medicines for this with improvement in your
cough. You will follow up with Dr. ___ as stated below. It
was a pleasure taking care of you. | Mr. ___ is a ___ y/o male with IgA multiple myeloma s/p
auto ___ currently day 15 of carfilzomib/revlimid who presents
with cough and was found to have influenza and pneumonia.
# Influenza:
- oseltamivir 75mg BID touched base with ID will treat for 5 d
course (___)
- respiratory precautions
- cough medication prn
# Pneumonia, community acquired: CXR with RML opacification.
Most
likely superimposed pneumonia in the setting of influenza.
- azithromycin day 1: ___, to complete 7d course due to
immunocompromised state until ___
- f/u BCx NTD
# Multiple myeloma: currently receiving carfilzomib/revlimid
- hold revlimid/carfilozmib
- back to Valtrex at discharge
- will set up f/u to resume chemotherapy once improved from
respiratory/infectious standpoint
# DM:
- on levemir as an outpatient, will administer lantus while
inpatient
- Humalog sliding scale
- resume home metformin and victoza
# Postherpetic neuralgia
- continue home duloxetine, lyrica
- Valtrex resumed
# Chronic pain:
- continue morphine ER 15 mg BID | 43 | 141 |
14726886-DS-11 | 22,238,483 | Dear ___
___ were admitted to ___, after
___ were hit by a car and were found to have rib and spine
fractures, left ribs ___ and L2-4 transverse process fracture.
___ are now stable and ready for discharge. Please following
structures to aid in a speedy recovery
Rib Fractures:
* Your injury caused left ___ rib fractures which can cause
severe pain and subsequently cause ___ to take shallow breaths
because of the pain.
* ___ should take your pain medication as directed to stay ahead
of the pain otherwise ___ 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 ___ 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.
* ___ will be more comfortable if ___ 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 ___
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Best Wishes,
Your ___ Surgery Team | Ms ___ is a ___ year old female with a PMH of
hypothyroidism and hypercholesterolemia who was transferred from
an outside hospital after being struck by a car, found to have
left ribs ___ fracture, L2-L4 transverse process fractures, who
was admitted to the trauma service for further management. She
was initially admitted to the ICU for close respiratory
monitoring due to her rib fractures. However, she was breathing
comfortably on room air, using her incentive spirometer, and she
was deemed stable for the floor. She was transferred to the
surgical floor where she remained throughout her hospitalization
She was advanced to a regular diet which was well tolerated. She
continued to breath comfortably on room air, saturating well,
using incentive spirometer. Her pain was well controlled on oral
pain medication alone. She was evaluated by physical therapy who
deemed her stable for discharge home. She was out of bed and
ambulating without assistance
At the time of discharge, she was afebrile and hemodynamically
stable, tolerating a regular diet, voiding adequately and
spontaneously, pain well controlled on oral medication alone,
ambulating without assistance, and she was deemed stable for
discharge home with services, with appropriate outpatient follow
up. She verbalized understanding and agreement with the plan. | 495 | 205 |
14964616-DS-16 | 20,670,043 | Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted because you were having
gastrointestinal bleeding. The GI team performed an upper and a
lower endoscopy, and found some redness and ulcers near the site
of you prior surgical anastamosis. They also gave you a capsule
study to evaluate the rest of your bowels to ensure there were
not any other sites of bleeding. Your blood counts have
stabilized, so you can follow up the results as an outpatient.
You may resume your home medications as usually prescribed. | REASON FOR ADMISSION: ___ with history of GI bleed, ___
disease s/p ileocolonic anastomosis, reflux esophagtitis
presents with bright red blood per rectum.
# GI Bleed: Patient admitted to ___ for close monitoring after
having two large bloody bowel movements in ED. Patient was
given two liters of IV fluids and two units of packed red blood
cells and started on IV PPI. CTA of pelvis and abdomen did not
show any source of the bleeding. Gastroenterology was consulted
for GI bleed. Upper GI bleed very unlikely given negative NG
lavage and EGD. Colonoscopy performed and showed ulceration at
ileo-colonic anastamosis site, which may account for bleeding.
To rule out other cause of bleeding a capsule endoscopy was
started and will be followed up as outpatient. Hemoglobin and
hematocrit stablized and there was not further bleeding.
# Chron's- Patient has history of Chron's requiring partial
colectomy with ileocolonic anastamosis. Colonoscopy showed
ulceration at the site of anastamosis, which may account for GI
bleed. Pentasa was initially held and then restarted following
colonoscopy. A PPD was negative in preparation for starting
Humira. Patient will follow up with GI as outpatient. | 97 | 200 |
10065656-DS-14 | 27,129,771 | Dear ___,
You were admitted to ___ on
___ for evaluation of seizure like activity. We monitored
you with EEG to determine if these were epileptic or
nonepileptic seizures. We found that these seizures did not have
a correlation to epileptic seizures. For this reason no changes
were made to your medications at this time.
We made the following changes to your medications:
1) Per your request we stopped your DEPAKOTE.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay. | Neuro: ___ was admitted to the Neurology- Epilepsy service
under Dr. ___. He was monitored by EEG for multiple events.
The EEG was found to have no epileptic events. As these events
appear non-epileptic and were not found to have an EEG
correlate, no changes were made to ___ medications.
Psychiatry: consulted during admission and recommended the
following:
-Though these seizure activity likely do not have electrical
origins, would suggest minimizing stigma by by not using phrases
suggesting pt can stop these on his own - these episodes are
unlikely consciously manufactured
-Analogy of IBS is helpful to family for understanding of how
stress/anxiety/depression can cause physical symptoms.
-Attending, Dr. ___ will attempt to make referral to
psychiatrist specializes in nonelectrical seizures
-pt should continue with his current therapist
-would not initiate psychotropics at this time.
-pls page ___ during the day with concerns/questions. Page
___ nights/weekends.
Cardio/Pulm: as ___ was found to have some increased heart
rate and decreased O2 saturations during these events, he
continued on telemetry. While there was variation in his vitals
during these seizures these changes were self-limited and did
not require treatment.
FENGI: Initially ___ was kept NPO as he was not at baseline.
As he became more alert, his diet was advanced as tolerated
ID: There were no signs of infection during this hospitalization
and no antibiotics were started
Social: mom was present throughout the course of his
hospitalization and both mom and the pt understood the plan. | 100 | 238 |
13701550-DS-2 | 29,764,408 | ******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 can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
weight bearing as tolerated in left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not drive, operate heavy machinery or drink alcohol when
taking this medication. As your pain improves please decrease
the amount of pain medication. This medication can cause
constipation, so you should drink ___ glasses of water daily
and take a stool softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please have your staples removed at your rehabilitation
facility at post-operative day 14.
Please follow up with ___ in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
weight bearing as tolerated left lower extremity
Treatments Frequency:
physical therapy
nursing
wound care | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left femur intertrochanteric fracture. The patient
was taken to the OR and underwent an uncomplicated left TFN.
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: weight bearing as tolerated in left lower
extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incisions were clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 235 | 177 |
18128150-DS-10 | 22,654,216 | You were admitted to the hospital with diffuse abdominal
discomfort and decreased appetite. On Cat scan imaging you were
noted to have a small bowel obstruction. You were taken to the
operating room to have an exploratory laparotomy and small bowel
resection. You are slowly recovering from your surgery. You
have resumed a regular diet. You are preparing for discharge
home with the following instructions:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing 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 fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the 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.
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 | ___ year old male admitted to the hospital with abdominal pain
and decreased appetite. Upon admission, the patient was made
NPO, given intravenous fluids, and underwent imaging. CT scan
imaging showed a small bowel obstruction. The patient was also
resported to have an elevated white blood cell count to 25.
Given these findings, he was taken to the operating room on HD
#1 where he underwent an exploratory laparotomy and small bowel
resection. Intra-operative findings were notable for a
micro-perforation at the prior anastomosis site. Operative
course was stable with minimal blood loss. The patient was
extubated after the procedure and monitored in the recovery
room.
The post-operative course was stable. After return of bowel
function, the ___ tube was removed and the patient was
started on clear liquids and advanced to a regular diet. The
patient's incisional pain was controlled with oral analgesia.
The foley catheter was removed on POD #3 and the patient voided.
Flomax was added to his medical regimen to assist with
urination. The patient was ambulatory. At the time of
discharge, his white blood cell count had normalized. The
patient was discharged home on POD #5 in stable condition: he
was tolerating a diet, voiding, ambulating, and denied pain.
Discharge instructions were reviewed and questions answered. A
follow-up appointment was made in the Acute care clinic. | 870 | 236 |
12990690-DS-15 | 28,979,292 | 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) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox 40 mg daily
with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots).
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days 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 after aqaucel is removed 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.
Your retention suture will be removed at one week post-op. Your
nylon sutures will be removed approximately 2 weeks after
surgery.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity using knee immobilizer at all times. Two crutches or
walker. Wean assistive device as able. Mobilize. ROM as
tolerated. No strenuous exercise or heavy lifting until follow
up appointment.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
Physical Therapy:
WBAT LLE in knee immobilizer at all times
ROMAT
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
***Retention suture to be removed one week post-op***
Nylon sutures to be removed two weeks post-op | The patient presented to the emergency department and was
evaluated by the Orthopedic surgery team. The patient was found
to have a left TKA PJI and was admitted to the Orthopedic
surgery service. The patient was taken to the operating room
initially on ___ for I&D, ex-plant of femoral component, and
placement of an antibiotic spacer (___), 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 ___
anticoagulation per routine. The Infectious Disease team was
consulted postoperatively and the patient was initially placed
on Vancomycin and Cefepime. When intraoperative cultures began
growing Citrobacter, the patient was converted to Cefepime
alone.
On the night of ___, the patient was transferred from the
Orthopaedic Trauma service to the Orthopaedic Joints service to
facilitate further care per the patient's joint surgeon, Dr.
___. The patient was taken back to the operating room on
___ for I&D, patellar explant, non-articulating antibiotic
spacer placement ___, ___. The surgery was uncomplicated
and the patient tolerated the procedure well. Patient continued
on Cefepime postoperatively. | 550 | 227 |
17784168-DS-24 | 22,706,155 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because you were having a
hard time breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You had imaging done to determine the cause of your difficulty
breathing.
-You were given antibiotics to treat your infection.
-You were given steroids and breathing treatments to help with
your breathing.
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 | ___ with history Stage 3C intrahepatic cholangiocarcinoma and
recent admission for bilateral pulmonary embolism complicated by
pulmonary infarction (on apixaban) who presented with acute
hypoxic respiratory failure requiring admission to intensive
care, possibly secondary to bacterial vs. viral pneumonia.
TRANSITIONAL ISSUES
===================
[ ] Continue two more days of PO prednisone after discharge.
[ ] Consider repeat PFTs after resolution, given emphysema on
imaging, apparent low pulmonary reserves and good response to
steroid treatment.
[ ] Consider outpatient iron repletion given lab evidence of
iron deficiency.
[ ] Continue follow up with outpatient oncology.
[ ] Continue home ___ plan per physical therapy evaluation.
[ ] Monitor respiratory status and continued requirement for
rescue inhalers.
ACTIVE ISSUES
=============
#Fever, rigors
#Leukocytosis
He presented initially with fever and rigors starting a few
hours after port placement. Most likely source was deemed to be
respiratory in the setting of cough, fever and sputum
production. Blood cultures remained negative. He was treated
with antibiotics per below.
#Hypoxic respiratory failure
Presented with significant oxygen requirement to 6L NC. CT
concerning for multifocal pneumonia or aspiration in the setting
of vomiting; possibly volume overload in the setting of BNP 462
but TTE with EF=65%. While in the ICU, oxygen saturation
decreased and required oxygen by oxymizer up to 20L which was
quickly weaned. When deemed stable was transferred to care on
the floor on the Hematology/Oncology service with 4L oxygen by
oxymizer on arrival to floor. Repeat CTA with resolving clot
burden and no new emboli. With escalating O2 requirements, he
was started on duonebs and a single IV Lasix dose with good
response. An echocardiogram demonstrated EF=55% with no
significant findings. Discontinued Vancomycin after MRSA swab
negative and completed course of cefepime and azithromycin for
presumed community acquired pneumonia with atypical coverage for
5 day course. SLP evaluation without evidence of aspiration.
Given history of long term smoking and evidence of emphysema on
imaging, despite negative outpatient PFTs, he was started on a
prednisone burst with improvement in his respiratory status. He
was weaned to room air at rest and on ambulation. Of note,
negative studies include Flu (A&B), Respiratory Panel, Urine
Legionella, Strep Pneumo, MRSA Swab, Blood cultures. Will
continue rescue inhaler for two weeks and complete five days of
steroids as outpatient, with follow up in clinic set up for the
week following discharge.
# Bilateral pulmonary embolic c/b pulmonary infarction
Diagnosed incidentally on ___ CT chest done for staging.
Started on enoxaparin then transitioned to apixaban, which was
held ___ for port placement. In ___, apixaban held and
patient started on heparin gtt while awaiting CTA to ensure
hypoxic respiratory failure was not secondary to recurrent PE
iso treatment failure with apixaban. Reassuringly, CTA negative
and patient re-started on apixaban ___. Of note, cardiac enzyme
studies were also negative. Patient will continue home regimen
of 5mg BID apixaban on discharge.
# Stage 3C Intrahepatic Cholangiocarcinoma
CT abdomen/pelvis ___ with several perihepatic lymph nodes
concerning for metastatic disease. ___ has been rising
rapidly despite chemotherapy. Dr. ___ outpatient
oncologist, has been updated through this admission. Planned to
start gemcitabine/cisplatin after discharge with resolution of
respiratory symptoms. Home regimen for analgesia and
anti-emetics was continued, including Compazine, ondansetron,
and lorazepam. | 111 | 518 |
19150427-DS-29 | 21,382,475 | Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted because you felt fevers with
a cough, and an X-ray of your chest showed you have pneumonia.
We treated you with IV fluids and antibiotics. You should finish
these antibiotics at home.
.
Please note the changes to your medications:
You should START levofloxacin every other day until you finish
the antibiotics. | The patient is a ___ y/o male with CAD s/p CABG, systolic CHF,
DMII hypothyroidism, chronic renal insufficiency and multiple
episodes of PNA who presented with subjective fevers, cough and
was diagnosed with community acquire pneumonia.
# Community Acquired Pneumonia - The patient presented with a
lobar pnuemonia seen on chest x-ray. The patient was admitted
with a PORT score of 137 at presentation (based on age, CHF, and
elevated BUN). He was treated with levofloxacin, renally dosed
at 750mg Q48H for a 7 day course. His elevated BUN improved
after receiving 500mL NS, and he was asymptomatic and wholly
well appearing. He was stable during his stay and had strong
family support at home, so it was determined that the patient
could finish his treatment at home. We arranged an appointment
for close PCP ___. Blood cultures were negative. | 67 | 141 |
16015778-DS-10 | 21,750,343 | Dear Ms ___ it was a pleasure taking care of you.
You were admitted to ___ for evaluation of abdominal pain and
diarrhea. CT scan was without evidence of Crohns flare,
infectious colitis, or diverticulitis. You were put on bowel
rest and hydrated with IV fluids. You were seen by GI who
recommended conservative management without need for
endoscopy/colonscopy in house.
.
At time of discharge you were tolerating limited PO without
further episodes of diarrhea.
.
CHANGES TO YOUR MEDICATIONS:
START taking ATOVOQUONE 1500mg daily to prevent pulmonary
infection while taking steriods
START taking calcium-vitamin D supplementation to
protect/strength bones while taking steriods
Continue oxycontin with breathru oxycodone for pain control. | Ms. ___ is a ___ year old female with history of connective
tissue disease on methylprednisone 4mg daily and Crohns disease
who was admitted with 2 week history of bloody diarrhea, nausea
and left lower quadrant (LLQ) pain but whose diarrhea resolved
upon admission and a cause was not found. | 105 | 50 |
16007214-DS-50 | 21,429,769 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You were admitted following ___ to ___ with
reports of chest pain. There were no elevations in your cardiac
enzymes and your electrocardiogram remained unchanged over
priors. Given your extensive cardiac history and risk profile, a
cardiac catheterization was deemed prudent to ensure there was
no further coronary artery disease or stenosis of your grafts
and stents. After consultation with two different
interventionalists, it was felt that your medical management
should be optimized before further consideration of a
catheterization. Your Isosorbide was increased to 60 mg daily
but your blood pressure dropped (felt to be secondary more to
poor hydration rather than the dose itself) and was subsequently
decreased back to your home dose of 30 mg. Because you have a
guardian who must consent for and assist you with your health
care and legal needs, attempts were made to obtain this informed
consent. This consent was ultimately obtained on ___
however catheterization was not performed. During the outreach
to your current guardian (___) he indicated that he
wished to have a new guardian established. Social Work and Case
Management were involved in these issues, along with the Legal
Department and coordination of obtaining a new guardian for the
longer term is being worked on. ___ will remain your
guardian until a new one can be obtained. Prior to discharge,
your guardian was working on changing your insurance to CCA so
that you could receive continued care at ___ for better health
management. Follow up appointments with Dr. ___ a
cardiologist are currently in progress. It is important for you
to keep your medical appointments to ensure better health
maintenance.
You were maintained on medications to help prevent DVT while
hospitalized as you have a history of DVT and pulmonary embolism
in ___ but are no longer anticoagulated due to supratherapeutic
INRs and compliance with therapy. There has been no evidence of
blood clot and you will continue with your chronic daily Aspirin
for your cardiac history but no additional anticoagulants to
prevent DVT or PE.
You should follow up with Dr. ___ as your prior
Cardiologist is no longer with ___. You should also follow up
with your PCP as scheduled below. Additionally during your last
admission in ___, old records were reviewed which revealed
you have a history of positive sickle cell, requiring ongoing
workup, monitoring and care by your PCP.
It is important to keep these appointments and to take all of
your medications as prescribed. As preadmission, you will
continue with your current ___ Services to help with your
medication management.
Additionally, you were seen to have platelet clumping and given
you were on medication to reduce the risk of a blood clot, were
seen by Hematology and additional tests were performed to look
at your platelets more closely under a microscope and to assess
them a different way. You had a low platelet count that
stabilized to normal on ___. It is very important for you
to ensure you follow up with a PCP and see your PCP when
scheduled to help manage you many medical issues and to prevent
hospital readmission. | The patient had an unremarkable hospital course. He
inconsistently reported chest pain to the physicians, but when
seen by the NP ___ on a daily basis denied any chest pain,
palpitations, shortness of breath. He was ambulatory in the
unit and encouraged to be up and out of bed more often. He was
pleasant and cooperative. His current guardian was ultimately
contacted after much difficulty and consented to the
catheterization procedure on ___ with a plan to proceed to the
catheterization lab on ___. His guardian expressed a
desire to be replaced and ___ Case Management, Social Work and
Legal were heavily involved in these issues and is working
towards assignment of a new guardian at the time of this
discharge summary. However for the time being guardian remains
unchanged. His insurance was changed to ___
___ so that his care can be continued with Dr. ___
___.
___, his vital signs remained stable, and he complained
of chest pain, pointing to his abdomen early in his course. A
KUB was ordered which revealed no pathology but with mild
dilated loops of bowel and significant stool throughout the
colon. He was maintained on a laxative regime and has reported
two bowel movements this stay. His abdomen remains distended
but ___ and he has as noted been counseled to be out of
bed and ambulating the unit to enhance bowel motility to prevent
ileus and other GI complications. He was maintained on his
chronic pain medication (Percocet) while hospitalized for his
low back pain. His telemetry remained stable with minimal
ectopy and occasional pauses. His creatinine has been noted to
be increased ranging from 1.6 to 1.9 from 1.3 in early ___.
He had been recently hospitalized at ___ in mid ___ and
managed by the ___ team and his creatinine averaged ___
during that time. His medications were carefully reviewed but
no further adjustments were made. During this hospitalization,
he was maintained initially on SC Heparin TID for DVT
prophylaxis given his history of DVT/PE in ___ ___
with Coumadin therapy and supratherapeutic INRs) and converted
to once daily Lovenox on ___. Of note, while hospitalized at
___ in mid ___ review of old records indicated he had had
prior blood tests with positive result for sickle cell for which
he has not sought care and further workup. This should be done
post discharge with his PCP. He has remained afebrile and his
white count remains normal, however his platelets have continued
to clump and as mentioned previously, he requires outpatient
workup for his sickle cell, and preferably a peripheral smear.
Differential was ordered while here and results are included in
this discharge summary. He was seen by Hematology who felt that
his drop in platelets to 105 and 110 respectively on ___ and ___
were likely pseudothrombocytopenia. His platelet count was
obtained using a yellow top tube and has since improved to 184
on ___. Of note, he was started on Lovenox on ___.
With regards to his catheterization, this was ultimately
cancelled after discussion with two interventionalists who felt
that his atypical chest pain was best managed medically. Should
he develop positive signs for NSTEMI or STEMI, then an
intervention would be performed. His Toprol was increased to 50
mg Daily. | 537 | 568 |
17176505-DS-13 | 21,589,129 | Mr. ___,
You were admitted due to food getting stuck in your esophagus.
You had an EGD whereby food was seen at the far end of your
oesophagus and pushed into your stomach. The GI team also did a
balloon dilation of your esophagus. They took a sample of tissue
and will follow up with you about the result. We recommend
chewing smaller pieces of food from henceforth.
You also had a fever and a chest x-ray showed you have a
pneumonia for which you are being treated with levofloxacin.
Take this every other day (or every 48 hours, next dose is
___ and last dose is ___ for a total of 5 doses.
Your omeprazole was switched to pantoprazole 40mg twice a day
for 8 weeks, and then you can return to your old omeprazole
dosing.
It was a pleasure being part of your care
Your ___ team | ___ year old man history of GERD, HTN, HLD, abdominal hernia
repair, who presented with nausea, diarrhea and abdominal pain
as well as getting a piece of chicken stuck in his throat
# Food impaction: Patient had a chicken thigh stuck in his
throat, which has currently resolved prior to discharge. Scope
did not show any abnormalities upto his cord. Further scoping
showed food in distal oesophagus which was pushed into stomach
and a balloon dilation was done. Will encourage patient to eat
smaller pieces of food given he has had similar episodes of
impaction before (~5 in lifetime, most recent ___ years early).
On pantoprazole 40mg Q12H for 8 weeks and then can go back on
home dose of daily omeprazole 20mg.
# Pneumonia: Had fevers on night of admission to 102. Cxray,
urine cultures, blood cultures were obtained. Cxray was
concerning for a left lower lobe pneumonia. WBC was 11.4.
patient was asymptomatic with no cough but treated for concern
of pneumonia with levofloxacin Q48H for 5 doses. CAP was most
likely given had been in hospital for just 12 hours. Aspiration
was less likely given consolidation is more left sided than
right lung side.
# Nausea/Diarrhea/Abdominal pain: This resolved prior to arrival
to the ED and had been going for 4 days. Stool studies were
ordered in the ED but patient had no more diarrhea to be sent.
Patient had recent history of nausea, vomiting and diarrhea
which had self resolved. No exposure to any sick contacts
(except his partner who is still having chronic diarrhea) and
infectious workup being done with stools sent on this admission
from ED. Of note patient had a history of chronic diarrhea for
which he was followed by GI and resolved in ___. At that time,
it was thought to be due to a viral gastroenteritis or bacterial
infection missed on stool studies and resolved incidentally when
he was treated with azithromycin for respiratory infection.
# Acute on Chronic kidney disease: Improving prior to discharge.
Improved with fluids as was thought to be pre-renal due to poor
PO intake and loss of fluids from diarrhea in days prior to
admission. Creatinine elevated on admission to 1.7 from baseline
of 1.1. As stated, most likely pre-renal in the setting of
diarrhea and poor PO intake as above. Lisinopril was briefly
held on day of admission and restarted on discharge
# HTN: Continued home metoprolol and lisinopri on day after
admission and improvement of ___
# Hypothyroidism: Continued levothyroxine
## TRANSITIONAL ISSUES
=============================
- Chem 10 check on presentation to clinic to ensure creatinine
keeps improving
- GI will contact patient about EGD biopsy result | 145 | 433 |
11158326-DS-14 | 27,495,195 | Dear Ms. ___,
You were hospitalized for a severe necrotizing soft tissue
infection that required surgery to remove infected tissues. You
have recovered well from the surgery and have been discharged to
rehab for continued care of your wounds. Please follow up with
us in surgery clinic. | Ms ___ was admitted to the acute care surgery service and was
taken from the ED urgently to the operating room for treatment
of her necrotizing fasciitis. Please see operative note for full
details of this and all other procedures that she underwent.
Postoperatively, she was brought to the trauma SICU. Her course
during that time by systems is as follows.
Neuro: She was initially on fentanyl and propofol for pain
control and sedation, respectively, while intubated. Her mental
status was often poor. Once she was extubated, her pain
medications were switched to an oral regimen. She was delirious
in the ICU but her mental status improved.
CV: She was initially on pressors and also required
resuscitation in the form of crystalloid boluss, albumin
boluses, and blood. She was weaned off pressors and then was
stable after that. In addition, she had an irregular heart rate
at times that was most likely atrial bigeminy.
Pulm: She was intubated for over a week then successfully
extubated. Her oxygen was weaned.
GI: She remained NPO with IVF while intubated. An OGT was placed
and she received tube feeds. Once extubated, she was evaluated
by speech and swallow, who initially recomended NPO except for
crushed meds given aspiration risk. After her VAC was placed, a
flexiseal was also placed for hygeine. This, since the VAC was
so close to the anus, was discontinued.
GU: Urine output was monitored closely. She received some lasix
PRN for diuresis given her overall hypervolemia.
Heme: She was started and continued on heparin SQ and SCDs for
DVT prophylaxis.
Endo: Initially she required an insulin drip that was on and off
until a stable regimen of insulin sliding scale was working for
her elevated FSBG.
ID: She was empirically started on vanc/zosyn/clinda. Her OR
cultures were followed and her antibiotics were narrowed to
zosyn only on ___. She was monitored for signs and symptoms of
infection and her WBC count was monitored.
MSK: She was activity as tolerated and physical therapy
evaluated her.
As her oxygen was weaned down and delirium improved, she was
transferred to the floor, where the rest of her course is
detailed below.
Pt was transferred to the general surgery floor on ___ where
she underwent a series of OR/bedside wound VAC changes every 3
days. She passed a speech/swallow eval and her diet was advanced
to regular which she is tolerating well. Her tube feed was
turned off. She was started on Cefazolin transitioned to Keflex
for concern of superficial cellulitis around the margins of her
posterior wound. Antibitotics were discontinued on ___ however
given that the mild erythema around the wound was likely related
to pressure and she otherwise showed no signs of ongoing
infection. Discussions were held with the pt's siblings,
including the health care proxy, and it was decided that no
diverting ostomy would be attempted during this admission. Pt
has been able to pass stool rectally and the posterior wound can
be kept clean with good nursing care while avoiding the risks of
further surgery. Pt was transferred to rehab for continued care. | 46 | 514 |
13285779-DS-18 | 21,211,219 | You were admitted with worsening abdominal pain and were found
to have a severe infection in your gallbladder and liver. A
drain was placed to drain a pocket of infection (abscess). You
should continue taking antibiotics and follow-up with surgery
and infectious disease as scheduled. | ___ with history of gastritis (diagnosed in ___ who
presents with abdominal pain and is found to have cholecystitis.
He was started on cipro/flagyl at that time
(___), and surgery consult was obtained. Further workup per
surgical team revealed complicated gangrenous cholecystitis with
hepatic abscess, and he is now s/p ___ abscess drain placement.
This is thought to communicate directly with gallbladder, so is
also a functional perc-chole tube.
# Gangrenous cholecystitis
# Cholelithiasis
# Perforated gallbladder with dropped stone
# Hepatic abscess:
Stable, overall BP improved, afebrile. Repeat RUQ US showing
tube in proper
position and abscess smaller. ID was consulted and he was kept
on PO cipro and flagyl to continue for at least two weeks.
Cultures remained no growth.
- F/u with ACS and ID in 2 weeks
- Patient and family taught drain care.
# GERD/gastritis: H. pylori stool antigen negative
- Cont PPI
# Weight loss: Patient complaining of weight loss over months,
given severe gallbladder disease this may have caused the weight
loss.
- Recommend routine outpatient colonoscopy
# PPX: Ambulation
# Disposition: home
# Code status: Full code | 47 | 174 |
17863031-DS-2 | 28,202,470 | Dear Ms. ___,
You were admitted to the hospital with acute liver failure
caused by acetaminophen (Tylenol) toxicity. You were taken to
the ICU and given a medication to treat the Tylenol overdose.
Your liver tests were very high when you came in but they slowly
improved during your hospital stay.
Your platelets were found to be VERY low when you were in the
ICU. We believe you developed a condition called ITP (idiopathic
thrombocytopenic purpura) where your platelets become low. We
are not certain of what causes this. You were given 2
medications to treat the low platelets, IVIg and steroids. Your
platelet counts improved.
Due to this, we recommend you AVOID ANY MEDICATIONS THAT CONTAIN
TYLENOL or ACETAMINOPHEN.
You had a fall during your stay. CT scan of the head and spine
showed no fracture. However, you were found to have bacteria in
the blood. We gave you antibiotics to treat this infection. You
will continue to take ciprofloxacin 500mg every 12 hours with
the last day on ___.
If you develop worsening abdominal pain, fevers, chills,
yellowing of the skin or eyes, painful urination, dizziness or
lightheadedness please call your doctor or return to the
emergency room.
Please follow up with OBGYN and consider taking out the IUD
given it was causing you pain and led to you taking the high
doses of Tylenol.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Liver Team | ___ year old woman with no significant PMH who presents with
nausea, vomiting, and abdominal pain for several months, found
to have markedly elevated transaminitis and acute liver failure
secondary to APAP overdose now improving on NAC and ITP that is
improving s/p IVIG and prednisone found to have Kelbsiella
oxytoca bacteremia.
# ACETAMINOPHEN-TOXICITY INDUCED HEPATITIS, with concern for
# ACUTE LIVER FAILURE: Extensive work-up performed and
ultimately thought to be due to acetaminophen toxicity. No
evidence Budd-Chiari on ultrasound. Serologies negative for
autoimmune and viral hepatitis, though ___ slightly positive (at
1:40). She was continued on n-acetylcysteine drip, per
transplant surgery/hepatology recommendations, until INR <2 that
was stopped ___. She was also initiated on lactulose for
encephalopathy (see below). LFTs downtrended, and on discharge
were improved with ALT 309 AST 48 Alk Phos 156 Bili 3.1. INR
0.9. No encephalopathy on presentation but developed asterixis
and had difficulty with concentration thought to be due to liver
failure - grade II encephalopathy, on HD #3. Given lactulose
with improvement in encephalopathic symptoms. Lactulose was
discontinued on HD #9.
# THROMBOCYTOPENIA: no prior on record, though extremely low (5)
on admission. She had had recent heavy vaginal bleeding and
bleeding from the gums. Currently no active bleed. No
splenomegaly. Smear reviewed by hematology without schistocytes.
Hematology recommended initiating prednisone for likely ITP
thought to be drug effect. She was treated with prednisone 60 mg
initially and then transitioned to dexamethasone and IV Ig (x2
doses), with improvement in platelet count. This was complicated
by leukopenia after IVIg treatment that self-resolved. On
discharge, platelets improved to 196. Avoid acetaminophen in the
future (placed on allergy list)
# COAGULOPATHY: mild elevation of INR on admission which peaked
at 6.3. Normal fibrinogen and no schistocytes on smear. She was
given vitamin K IV x3 days. INR began normalizing, without any
bleeding. On discharge, INR normalized to 0.9.
# BACTEREMIA: GNR bacteremia detected with labs taken s/p fall
on ___ with ___ bottles positive speciated to Klebsiella
oxytoca. Source possibly related to UTI but with minimal urinary
symptoms. She had abdominal discomfort for weeks leading up to
her admission. Leukocytosis, hypotension and elevated lactate to
2.9 improved with IVF, empiric Zosyn (D1 = ___. ID consulted
and getting surveillance cultures that were negative at the time
of discharge. OB-GYN consulted for evaluation for endometritis
as source. Exam not consistent and given limited contraceptive
options recommend to leave IUD in place, low suspicion for
source of bacteremia. When GNR speciated to Klebsiella on ___,
zosyn narrowed to ceftriaxone 2G Q 24H. She remained non-septic
appearing. The most likely source was a urinary source and she
was transitioned to oral ciprofloxacin on ___ for a planned two
week total course of antibiotics to complete on ___.
She will also follow up with OBGYN as outpatientfor
consideration of taking out the IUD
# FALL: Fall ___ likely related to vasovagal episode after
using toilet. She had positive orthostatics after the fall. Fall
was unwitnessed. CT head, C-spine, T-spine, L-spine WNL. She was
given 1.5L of IVF with improvement in symptoms. She was found to
be bacteremic as above.
TRANSITIONAL ISSUES:
====================
#NEW MEDICATIONS:
- Ciprofloxacin 500mg BID (course completed ___
[]Given drug-induced ITP likely related to acetaminophen,
hematology recommends that she avoid acetaminophen going
forward. Placed on allergy list.
[]Liver follow up at 2 weeks post discharge for one time
appointment to ensure labs and symptoms resolved
[]GYN Follow up to discuss birth control. Paraguard left in
place on discharge.
[]Consider further investigation of abdominal pain if not
resolved after ciprofloxacin course. Consider paraguard removal
in discussion with OBGYN.
[]Repeat Thyroid function tests. Abnormal in setting of acute
liver failure. Question of sick euthyroid vs. hypothyroidism.
#Code: full, confirmed
#Communication: ___ (father) ___ | 239 | 613 |
18934666-DS-7 | 25,062,733 | WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a kidney infection (called pyelonephritis) and were
very dehydrated.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an ultrasound of your kidney, which showed a small
stone in your right kidney (likely unrelated to your kidney
infection, which is on the left).
- You were given IV fluid.
- You were started on antibiotics to treat your kidney
infection.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take your antibiotic, called ciprofloxacin,
through the end of the day on ___ - this will complete your
treatment for pyelonephritis.
- Continue to eat and drink plenty of fluids.
- You may take acetaminophen (two 500mg (extra strength) pills
three times a day) and ibuprofen (two 200mg pills three times a
day) over the next few days to help the pain; the pain should go
away as your infection resolves. | Ms. ___ is a ___ year old F w/ type I DM, psoriasis, and hx of
pyelonephritis presenting with L-sided flank pain for two days,
found to have findings concerning for sepsis ___ pyelonephritis.
ACUTE/ACTIVE PROBLEMS:
======================
# Sepsis ___ pyelonephritis
Patient with bilateral flank pain and grossly inflammatory UA on
presentation. Febrile to 102.3 with HR in 120s-130s on arrival
to ED - responsive to IVF and acetaminophen. Required several
doses of narcotic pain medication to achieve adequate pain
control. Started on IV ceftriaxone on ___ with rapid
improvement in symptoms and vital signs. Transitioned to
ciprofloxacin 500mg q12h with plan to complete ___nding ___. Continue outpatient pain control with
acetaminophen and ibuprofen. She is at risk for recurrent
infections give type I DM and nephrolithiasis, unfortunately.
CHRONIC/STABLE PROBLEMS:
========================
# Type I DM
Continued home insulin regimen.
# ADD
Home Vyvanse is non-formulary at ___ - can resume following
discharge.
TRANSITIONAL ISSUES
===================
[ ] Discharged with ciprofloxacin 500mg q12h to complete 7-day
course of antibiotics (last day ___.
[ ] Has 6mm R renal stone, non-obstructing.
[ ] Consider urology follow-up as this is second episode of
pyelonephritis (in otherwise healthy ___ year-old). | 145 | 183 |
14538096-DS-17 | 29,795,189 | You were admitted to the hospital after you were struck in the
face with a pole and sustained a fracture of the mandible. You
were taken to the operating room to have the fracture repaired.
Your vital signs have been stable. You had a drain place in the
surgical area. You have been cleared for discharge with the
following instructions:
Bulb Drain Home Care
A bulb drain consists of a thin rubber tube and a soft, round
bulb that creates a gentle suction. The rubber tube is placed in
the area where you had surgery. A bulb is attached to the end of
the tube that is outside the body. The bulb drain removes excess
fluid that normally builds up in a surgical wound after surgery.
The color and amount of fluid will vary. Immediately after
surgery, the fluid is bright red and is a little thicker than
water. It may gradually change to a yellow or pink color and
become more thin and water-like. When the amount decreases to
about 1 or 2 tbsp in 24 hours, your health care provider ___
usually remove it.
DAILY CARE
Keep the bulb flat (compressed) at all times, except while
emptying it. The flatness creates suction. You can flatten the
bulb by squeezing it firmly in the middle and then closing the
cap.
Keep sites where the tube enters the skin dry and covered with a
bandage (dressing).
Secure the tube ___ in (2.5-5.1 cm) below the insertion sites to
keep it from pulling on your stitches. The tube is stitched in
place and will not slip out.
Secure the bulb as directed by your health care provider.
For the first 3 days after surgery, there usually is more fluid
in the bulb. Empty the bulb whenever it becomes half full
because
the bulb does not create enough suction if it is too full. The
bulb could also overflow. Write down how much fluid you remove
each time you empty your drain. Add up the amount removed in 24
hours.
Empty the bulb at the same time every day once the amount of
fluid decreases and you only need to empty it once a day. Write
down the amounts and the 24-hour totals to give to your health
care provider. This helps your health care provider know when
the
tubes can be removed.
EMPTYING THE BULB DRAIN
Before emptying the bulb, get a measuring cup, a piece of paper
and a pen, and wash your hands.
Gently run your fingers down the tube (stripping) to empty any
drainage from the tubing into the bulb. This may need to be done
several times a day to clear the tubing of clots and tissue.
Open the bulb cap to release suction, which causes it to
inflate.
Do not touch the inside of the cap.
Gently run your fingers down the tube (stripping) to empty any
drainage from the tubing into the bulb.
Hold the cap out of the way, and pour fluid into the measuring
cup.
Squeeze the bulb to provide suction.
Replace the cap.
Check the tape that holds the tube to your skin. If it is
becoming loose, you can remove the loose piece of tape and apply
a new one. Then, pin the bulb to your shirt.
Write down the amount of fluid you emptied out. Write down the
date and each time you emptied your bulb drain. (If there are 2
bulbs, note the amount of drainage from each bulb and keep the
totals separate. Your health care provider ___ want to know the
total amounts for each drain and which tube is draining more.)
Flush the fluid down the toilet and wash your hands.
Call your health care provider once you have less than 2 tbsp of
fluid collecting in the bulb drain every 24 hours.
If there is drainage around the tube site, change dressings and
keep the area dry. Cleanse around tube with sterile saline and
place dry gauze around site. This gauze should be changed when
it
is soiled. If it stays clean and unsoiled, it should still be
changed daily.
SEEK MEDICAL CARE IF:
Your drainage has a bad smell or is cloudy.
You have a fever.
Your drainage is increasing instead of decreasing.
Your tube fell out.
You have redness or swelling around the tube site.
You have drainage from a surgical wound.
Your bulb drain will not stay flat after you empty it.
MAKE SURE YOU:
Understand these instructions.
Will watch your condition.
Will get help right away if you are not doing well or get worse.
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved. | ___ year old gentleman who presented from an OSH after being
struck on the
left side of his head and face with a large metal pole at the
construction site where he worked. He sustained loss of
consciousness for several seconds following the incident. Upon
admission, the patient reported bilateral jaw pain with
radiating pain to his face. Cat scan imaging of the face showed
bilateral mandibular fractures. The patient was transferred
here for surgical repair.
In addition to the cat scan imaging of the head, the patient
underwent imaging of his chest and neck. A CT scan of the
cervical spine was completed and revealed a thyroid nodule as
well as multilevel degenerative disc disease most prominent at
C5-6. Neurosurgery was consulted for further evaluation of the
cervical spine. No immediate surgical intervention was
indicated. The patient was taken to the operating room on HD #2
where he underwent an ORIF of the right body fracture via
intraoral approach and an ORIF of the left angle fracture via
trans-cervical approach. The operative course was stable with a
200cc blood loss. At the close of the procedure a JP drain was
placed in the left neck. During the post-operative course, the
patient was placed on sinus precautions and his pain was
controlled with oral and intravenous analgesia. The patient was
started on peridex mouthwash and placed on sinus precautions.
On POD #1, the patient reported new onset of left eye pain. The
Ophthalmology service was consulted and determined that the eye
pain was related to a small post-operative corneal abrasion. Eye
ointment was ordered and the eye pain decreased in severity in
48 hours.
In preparation for discharge, the patient was evaluated by
occupational therapy and cleared for discharge home with the
assistance of ___ for drain management. The patient was
discharged home on POD #3. His vital signs were stable and he
was afebrile. He was tolerating a full liquid diet and voiding
without difficulty and he was ambulatory. He was evaluated by
the ___ service and the decision was made to leave the left neck
drain place with anticipated removal at follow-up. Drain care
instructions were reviewed and sinus precautions outlined. A
follow-up appointment was made with the OMF and spine service.
Discharge instructions were reviewd and questions answered.
+++++++++++++++++++++++++++
The patient was informed of the need for MRI imaging at
follow-up with Spine to evaluate degenerative changes in the
cervical spine and new finding of a thyroid nodule. | 916 | 424 |
10257475-DS-18 | 27,692,166 | Dear Mr. ___,
You presented to the hospital with abdominal pain. On imaging,
you were found to have appendicitis (inflammation of your
appendix). You underwent laparoscopic surgery for removal of
your appendix. You have recovered, your pain is controlled, you
are tolerating a regular diet, and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told
you otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the endoscopy.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
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:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- 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.
WOUND CARE:
- Dressing removal: You may remove the top layer of dressing in
2 days. Keep the steri-strips (white small strips) in place.
- You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off.
- Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
It was a pleasure taking care of you,
--Your ___ Care Team | The patient re-presented on ___ with with clinical and
radiographic evidence of acute appendicitis. He was taken
urgently to the operating room and underwent a laparoscopic
appendectomy on ___. There were no adverse events in the
operating room; please see the operative note for details.
Post-operatively the patient was taken to the PACU until stable
and then transferred to the wards until stable to go home.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medications and transitioned to PO pain medications. Pain was
very well controlled with PO Tylenol and PO Oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Orthostatic
vitals were normal prior to discharge.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation was encouraged throughout hospitalization.
GI/GU/FEN: The patient was tolerating a regular diet prior to
discharge.
ID: Patient was previously sent home for medical treatment of
appendicitis on Amoxicillin-Clavulanic Acid ___ mg PO Q12H.
Post-surgery, antibiotics were discontinued as adequate source
control was achieved through surgery. The patient's fever curves
were closely watched for signs of infection, of which there were
none. | 535 | 202 |
12239968-DS-4 | 23,965,075 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You felt short of breath and overall unwell.
-You were found to have a type of leukemia.
What did you receive in the hospital?
-Your leukemia went into remission after receiving high dose
vitamin A and arsenic
-You received a blood thinner for a clot on a heart valve
-You were having heart palpitations that may have been secondary
to therapy or to your PICC line. We started you on Metoprolol to
help control those symptoms.
-We found blood clots in your lungs. We are thinning your blood
to help them resolve and prevent further clotting
What should you do once you leave the hospital?
-Please follow-up with your primary oncologist, Dr. ___
___, and the cardioncologist, ophthalmologist, and
neurologist, all listed below
-Give yourself a Lovenox (blood thinner) injection twice per
day, as demonstrated (squirt out 0.1 ml to get to 70 mg dose)
-Please take your medicines as directed below
-Note you will take one final dose ATRA tonight at 10 pm. Hold
taking further doses until seen by Dr. ___.
-You will be going home with a PICC. The infusion company will
teach you how to use it.
-You will initially have regular follow up in the ___ clinic to
check your blood levels.
-If you develop confusion, slurred speech, or weakness please go
to the emergency room.
-If you develop acute shortness of breath please report to the
emergency room.
We wish you the best!
Your ___ Care Team | ___ female with history of recent normal spontaneous
vaginal delivery complicated by gestational hypertension versus
preeclampsia, post-partum hemorrhage for retained placenta and
superficial thrombophlebitis status-post 45-day course of
rivaroxaban who presents with fatigue and dyspnea found to be
profoundly pancytopenic. Peripheral blood cytogenetics were
positive for t(15;17) indicating APL. Now in remission after
ATRA/ATO induction though complicated by ventricular
tachyarrhythmia/ectopy and nonbacterial thrombotic mitral
endocarditis.
#) Pancytopenia
#) Acute promyelocytic leukemia: ANC 50, hemoglobin 4.9,
platelet 25 at presentation s/p 3U pRBC, 2U platlets,
respectively. Circulating atypical myeloid precursors on
peripheral smear, prompting empiric ATRA while awaiting formal
hematopathologic diagnosis. Peripheral blood cytogenetics later
indicative of APL/RARA gene rearrangement, t(15;17).
ATRA/aresenic trioxide implemented with reduced blast burden and
appropriate maturation on peripheral smear. Day 26 bone marrow
biopsy confirmed remission, protocol continued for full 28 days
prior to discharge. Hydroxyurea given for WBC >20. She received
prednisone prophylaxis and was monitored closely for
differentiation syndrome. Also received acyclovir, TMP/SMX, and
micafungin prophylaxis. While transfusion-dependent, patient
otherwise without febrile neutropenia, DIC, or TLS. Upon
discharge micafungin was discontinued. Her prednisone taper
began (5 days per 10 mg). At cessation of prednisone, patient's
PJP and HSV prophylaxis can be discontinued.
#) Multifocal PVCs, symptomatic
#) Non-sustained VT, monomorphic
#) Mitral regurgitation, severe (3+)
#) Endocarditis, nonbacterial thrombotic
Patient described palpitations, which were initially thought to
be related to her PICC placement. Palpitation, however,
continued despite PICC repositioning, but continued to be the
worst when she was laying on her left side. She was found to
have multifocal PVCs and monomorphic non-sustained VT on
telemetry. TTE was obtained, which suggested nonbacterial
thrombotic endocarditis (Marantic) likely secondary to her APL.
Blood cultures negative. ___ weakly positive. APLA negative and
reportedly factor V Leiden negative on prior thrombosis work-up.
MRI head obtained prior to anticoagulation, which demonstrated
subacute to chronic punctate cerebellar lesion versus artifact
though to have low propensity for hemorrhage. Lovenox 0.5 mg/kg
Q12H was therefore initiated (full dose on discharge see below).
Platelet transfusion threshold increased to 50. With regard to
mitral regurgitation, volume status and afterload monitored
closely. Uncertain if ventricular ectopy was related to arsenic,
endocarditis, or PICC. ATO nevertheless held for 48 hours, given
concern for cardiotoxicity/arrhythmogenicity despite normal QTC.
No meaningful change, thus it was restarted. Ectopy frequency,
however, later improved with beta blockade. Electrolytes
repleted appropriately. Patient discharged on 50 mg Metoprolol
XL.
#) Vaginal bleeding: presumably second postpartum menses, given
28-day interval since prior, though minor amount. Ultimately
favored blood product support rather than hormonal
menstruation/ovulation suppression given tenuous
hemorrhage-thrombosis diathesis. GnRH agonist reportedly causes
QTC prolongation too.
#)Left ___ toe abscess
Small pustule with defined head on top. Some mild
darkening/erythema surrounding the site, but no evolution with
time. Non-tender to palpation. Deferred treatment.
#Pulmonary Emboli:
Waxing and waning pleuritic pain shoulder/back pain. Concern for
PE as patient missed 2x doses Lovenox while platelets were < 40.
Could also represent muscle strain, PNA, or effusion. No DVT on
LUE US. CXR with no effusion or PNA. CTA completed for
definitive diagnosis which showed bilateral pleural effusions
without evidence of RHS on CT. Patient also with an area of RT
lower lobe infarct. Due to high clot risk, after discussion with
neurology, the decision was made to initiate full
anticoagulation at 1 mg/kg.
#Malaise
Patient with generalized malaise and sore throat during
admission. Most likely represented a viral infection, but could
not exclude a bacterial phenomenon. She was treated with 5 days
of ceftriaxone. As patient is immunocompromised and on
prednisone she may not be able to mount a fever. Respiratory
viral panels and flu were negative. Resolved by the time of
discharge
#) Photopsia: without blurriness, decreased visual acuity,
diplopia, or scotomata. Scattered retinal microhemorrhages on
dilated eye exam consistent with leukemic effect. No occlusive
thrombi. Platelet transfusion threshold, as above. | 270 | 626 |
12206591-DS-9 | 21,531,569 | Dear Ms ___,
You were admitted with vision changes from optic neuritis that
was most likely consistent with a new diagnosis of Multiple
Sclerosis. However, other causes of recurrent optic neuritis
were also sent and many of these labs are pending. These tests
will be followed by your outpatient neurologist and you will
receive a call if one of these tests is positive and requires
treatment/intervention.
Treatment with a 5 day course of steroids was started in the
hospital. You will need 1g Solumedrol for three more daily doses
through a peripheral IV. A visiting nurse ___ come administer
the medication at your home. | Ms. ___ is a ___ yo woman with prior L optic neuritis who
presented with several days of worsening right eye blurry
vision. On admission exam she had a right RAPD and decreased
visual acuity intranasally in R eye.
Initial differential diagnosis was strongly suspicious for
multiple sclerosis based on the history of prior optic neuritis,
prior MRI with orthogonal periventricular white matter lesions,
and prior oligoclonal bands in CSF as well as prior negative ___
and ___.
Other possibilities on admission were NMO, syphilis related,
thyroid related optic neuritis. Pseudotumor cerebri as a cause
for her headache and possibly her vision changes was thought to
be less likely but still possible.
The patient had an MRI that showed R optic nerve enhancement
consistent with optic neuritis. There were also two new areas of
white matter FLAIR (nonenhancing) intensities in right frontal
and left external capsule. MRI cervical and thoracic spine did
not show any demyelinating lesions. TSH returned normal and CRP
was within normal limits. RPR, ESR, and repeat ___ Ab were
still pending at the time of discharge.
With the findings above, Ms ___ has presumptive multiple
sclerosis. However, repeat ___ ab and RPR were still pending -
while these infectious etiologies are unlikely, they are still
possible until these labs return.
She was treated with Solumedrol 1g daily IV to continue to five
days of treatment that she will continue as an outpatient.
She will follow up with neurology as an outpatient for continued
counseling and workup/treatment. | 103 | 250 |
14162496-DS-14 | 29,457,694 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after you likely had a platelet transfusion reaction.
You had no fevers while in the hospital. Due to your low white
blood count (neutropenia), you have a higher risk of infection.
Please monitor for fevers and if you have a temperature above
100.4 please come back to the Emergency Room. If you have any
other concerns please call the on-call Oncology team.
You will follow-up with your outpatient Oncology team.
All the best,
Your ___ Team | Mr. ___ is a ___ yo M with PMH of esophageal cancer on
___ chemo with concurrent RT who presents today after
having chills during a platelet transfusion.
# Platelet Transfusion Reaction:
# Neutropenia:
# Thrombocytopenia:
# Anemia in Malignancy: Patient with chills/rigors during
platelet transfusion reaction which quickly resolved after
Tylenol, Benadryl and Demerol. No fevers during hospitalization.
Patient otherwise asymptomatic without any localizing infectious
symptoms. He will follow-up with outpatient team for further
work-up and management of pancytopenia. Defer starting
filgrastim to outpatient team. Provided strict instruction to
return to hospital for fever.
# Esophageal Cancer: He will continue tube feeds. He will
follow-up with outpatient team.
# BILLING: 35 minutes were spent in preparation of discharge
summary and coordination with outpatient providers.
==================== | 92 | 119 |
10610191-DS-19 | 22,670,679 | You were admitted with bizarre behavior. We did tests to look
for neurologic causes of this, and all the tests that came back
during your admission were normal. There were some tests sent on
your spinal fluid which won't be back for another several weeks.
We will see you in clinic to follow up these results. If all of
this testing is normal, it is most likely that these changes are
due to either substance induced psychosis or primary psychiatric
disorder. Please avoid any and all intoxicating substances. You
will follow up with Neurology and Psychiatry as listed below. | Ms. ___ was admitted to the Neurology service for workup of
possible neurologic etiologies of her abnormal behavior,
hallucinations and disorganized thinking. Initial differential
diagnosis included autoimmune encephalitis, post-ictal psychosis
is possible however highly unlikely given the lack of any ictal
events. Substance induced psychosis is also very possible given
recent substance use. These changes (including from marijuana)
can last for weeks to months. Primary psychiatric diagnosis is
also a strong possibility.
She also had jerking movements which were thought possibly
myoclonus on examination, and for evaluation of this she was
placed on continuous video EEG monitoring, which showed that
these movements had no electrographic correlate, also showing
normal background and no epileptiform discharges. Other workup
including serologies were normal, MRI brain normal, systemic
infectious workup normal, CSF basic studies normal, and at the
time of discharge, CSF paraneoplastic and autoimmune
encephalitis panels are still pending.
Psychiatry was consulted from the ED, and followed throughout
her admission. They recommended ___ and inpatient
psychiatric placement, as well as starting scheduled olanzapine,
with prn PO or IM olanzapine. IM olanzapine was never required.
She also began to voice numerous somatic complants, of which she
was not able to give any chronicity or detailed history, and the
complaints changed over the span of seconds.
Throughout her admission, her myoclonus resolved, and her
hallucinations and disorganized thinking resolved. On the day of
discharge her thinking was linear and logical and she denied
hallucinations. In consultation with Psychiatry, given her
marked improvement, it was determined that she was safe for
discharge with close outpatient psychiatric follow up, which was
subsequently arranged for 5 days post-discharge.
===============================================
Transitional Issues
[ ] Neurology to follow up CSF paraneoplastic and autoimmune
encephalitis panels in clinic.
[ ] f/u need for continued zyprexa at outpatient psychiatric
follow-up.
[ ] if substance abuse is not problematic in the future,
recommend reevaluating whether or not thiamine and folate
supplementation are required. | 99 | 319 |
16113521-DS-16 | 22,021,631 | Mr. ___,
You were admitted with bleeding per rectum. Your bleeding
stopped and your hemoglobin stabilized. You had a colonoscopy
___ that showed ischemic colitis, which is inflammation of the
colon. Although this can be caused by a blood clot in your
arteries the CT scan did not show this. Please continue to
monitor for bleeding or abdominal pain and discuss with your PCP
or go to the ED with any concerns.
You should follow up with your PCP with repeat CBC in ___ weeks
to ensure that your labs are improving. If your blood counts
remain low you will need to follow up with your
hematologist-oncologist.
It was a pleasure taking care of you.
-Your ___ team | ___ h/o CAD s/p CABG w/ AVR, DM II, HTN, and pancreatic cancer
stage IIB (T3 N1 M0) s/p primary resection and adjuvant
chemoradiotherapy now in remission presents with bright red
blood per rectum.
1. Acute on chronic normocytic anemia due to bright right red
blood per rectum h/o diverticulosis
-Drop in hemoglobin from 10.4/31 ___ --> 8.7/28.1 ___.
Although last bloody bowel movement ___ with
hemodynamic/clinical stability he underwent colonoscopy ___
that showed ischemic colitis. CT abdomen/pelvis w/ contrast did
not reveal thrombus as cause of ischemic colitis. Patient
tolerated diet with stable hemoglobin and discharged home.
2. Pancytopenia
-Unclear etiology of leukocopenia (neutropenia w/ ANC 0.92) and
thrombocytopenia. Patient with leukopenia and thrombocytopenia
in ___ in our system reporting that he has been told his WBC
have been low lately upon outpatient follow up. Question
whether patient could have degree of marrow suppression.
Discussed counts w/ Dr. ___ recommended monitoring.
Recommend repeat CBC in ___ weeks and continued outpatient
follow up with heme-onc if counts remain low.
CHRONIC MEDICAL PROBLEMS
1. CAD s/p CABR & AVR: Hold asprin, statin, and metoprolol.
2. pancreatic cancer stage IIB (T3 N1 M0): s/p resection and
adjuvant chemoradiation now in remission. Discussed with his
oncologist Dr. ___ does not have any further
recommendations at this time.
3. DM II: SSI. Resume metformin at discharge.
4. BPH: continue finasteride and tamsulosin
>30 minutes spent on discharge planning | 121 | 239 |
12745743-DS-9 | 28,663,863 | It was a pleasure caring for you at ___. You were admitted to
the ___ service because we believe you suffered a mild heart
attack. We gave you medications that help prevent any
progression of your heart attack, and you were closely
monitored. You did not have any recurrent symptoms of nausea and
vomiting or chest pain while you were here.
You were transferred to ___ for further
management because all of your records and your cardiologist is
based at this facility. They will decide whether or not to
proceed with a cardiac catheterization to look at your coronary
arteries for worsening of diseae.
There were no medcations changes made on this admission | ___ yo F with recent h/o N/V resulting in ED visit to ___
___. Subsequently found to have elevated troponins and ST
depressions in anterolateral leads of EKG. Treating for NSTEMI
at ___. Pt remained asymptomatic in-house,and plan was to cath
after the weekend for evaluation of coronary anatomy. As patient
received majority of care and previous POBA x2 at ___, she was
transferred to this facility for further management.
.
Active Issues:
# NSTEMI: Presentation with N/V to OSH likely anginal
equivalent. Several week h/o chest pain with activity and
relieved by SL nitro classic for angina. Symptoms at rest
concerning for UA. At ___, trops were elevated and
EKG showed ST-depressions in anterolateral leads. Transfered to
___ and treating for NSTEMI with heparin gtt, ASA, plavix, and
BB. Held statin in light of prior statin assctd transaminitis.
Troponin at ___ were 0.41 and on admission were
0.26->0.24->0.27. MB peaked to 11 and on transfer was 10.
Patient remained entirely asymptomatic while in-house. Planned
for catheterization on ___, however trasferred patient to ___
for further work-up, as she is known to them and followed by ___
cardiologist.
. | 112 | 186 |
12552022-DS-5 | 26,259,429 | Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted with abdominal pain and poor
appetite. We did many blood and imaging tests and saw no serious
cause of your pain. You had some nausea, and your CT scan showed
an area of intestines that could be due to a stomach bug. You
improved slowly and on discharge your pain was manageable and
your appetite improved. We hope you continue to get better.
Your lasix was stopped while you are having your illness and
because we were concered about an allergy. Please follow up with
your PCP and liver team this week to discuss restarting this
medication.
The cause of your rash is unclear. Some medications including
antibiotics and Lasix can cause a rash like this. In addition,
some viral infections (GI bugs) can cause a rash like this.
Almost every time the rash will clear on it's own. | Mr. ___ is a ___ with history of newly diagnosed alcoholic
cirrhosis, alcoholic hepatitis (discharged on ___ treated with
steroids, and pneumonia presenting with diffuse abdominal pain
and anorexia x ___ontrolled with improving
appetite.
# Alcoholic Hepatitis: Discriminant function of 37. Patient left
with PICC line and there could be some concern for acute drug
use and exposure to hepatitis virus. T. Bili continues to
improve, patient not vomiting in 24 hours. Hep B viral load
negative. It was decided that given his continued improvement he
did not need steroids.
# Abdominal pain: Mmost likely due to both gastroenteritis and
alcholic hepatitis. Has evidence of liquid filled bowels on CT
which could be GI virus or also lactulose. Abdominal exam,
downtrending lab values, and imaging are reassuring for other
processes on DDx. Lipase ok. UA clean and UCx negative. Para
showed few polys not consistent with SBP, with culture negative.
Pain responded well to oxycodone. He was eating and drinking
with no vomiting and having bowel movements for two days on day
of discharge.
# Rash: His exam notable for a maculopapular rash in the UE and
trunk. No mucosal involvment. Most likely viral exanthem vs.
drug rash. Viral exanthem supported by gastroenteritis which is
most often a viral process. Drug rash is also supported by the
fact that patient has been on vancomycin, cefepime, lasix and
azithromycin (all of which may cause rash) and mild eosinophilia
on labs now resolved. Rash was resolving on discharge. He was
not on antibiotics during this admission and his lasix was held.
# Tachycardia: Developed in the setting of vomiting and poor
appetite. Regular. Likely secondary to hypovolemia. He improved
with 5% albumin.
# Hepatic Encephalopathy: History in the past but none on this
admission. His lactulose was initially held and then restarted
on discharge.
# Ascites: mild on exam and US but CT scan showed increased
ascites compared to the CT during last admission. He was on
lasix 20mg daily. Bedside US with no good fluid pocket for
paracentesis. Lasix was stopped given concern for rash with
recommendation to follow up with ___ further
evaluation.
# Nutrition: Pt reports anorexia, weight loss, fatigue, and poor
muscle strength. Nutrition was consulted who recommended
continued nutritional encouragement. He did not need enteral
access nor tube feeds.
# Cirrhosis: Due to alcohol. Pt presented with alcoholic
hepatitis on previous admission and was treated with steroid
which had to be weaned off quickly due to pneumonia and
encephalopathy. MELD score 20, which was 19 on discharge.
# Coagulopathy: INR 1.7 (downtrending) which was downtrending
from last admission and with normal platelets. Pt reports
intermittent black stool but rectal exam with brown stool and
H&H overall stable. He was monitored and his INR remained
stable.
Transitional
------------
- follow up on nutritional status, he is concerned about weight
loss
- consider restarting diuresis with Lasix to challenge if this
caused rash, or with ethacrynic acid if need other diuresis | 151 | 485 |
19603912-DS-23 | 23,317,228 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty with
word-finding for one week and one episode of blurry vision
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) Coronary Artery Disease
2) High Cholesterol
3) Atrial Fibrillation
4) High Blood Pressure
Please take your other medications as prescribed.
Please call your primary care physician for referral to
Neurology.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is ___ year old right-handed man with AF on
warfarin, HTN, CAD and MI s/p cardiac arrest (___), CABG and
multiple stents, recent cholelithiasis and cholecystitis s/p
stenting and cholecystectomy off AC ~15 days who is admitted to
the Neurology stroke service with word-finging difficulties
secondary to an acute ischemic stroke. His stroke was most
likely secondary to being off anticoagulation for 15 days with
subtherapeutic INR 1.6 at time of admission. Patient had CT
head without contrast (___) which showed no evidence of
hemorrhage or infarction. CTA of head and neck (___) was
signficant for 70% stenosis of right and left ICA. Carotid US
(___) confirmed 40-50% right carotid artery stenosis. Patient
did not receive an MRI due to incompatible pacemaker. He was
treated with a heparin drip until his INR became therapeutic, as
it was later that day. His speech deficits improved throughout
this hospital stay. At the time of discharge, the only notable
deficit was subtly effortful with a few pauses but otherwise
fluent with full sentences. NIHSS = 0. Patient was continued on
his home medications. | 243 | 184 |
12473155-DS-14 | 23,753,152 | ******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********
- 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.
******WEIGHT-BEARING*******
touch down weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Treatments Frequency:
splint - keep clean, dry and intact until follow up | The patient was admitted to the orthopaedic surgery service on
___ with R ankle fracture. Patient was taken to the
operating room and underwent ORIF R ankle. 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 RLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB RLE. 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: The patient was hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
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 HD#3, POD #2, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. 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. | 191 | 293 |
14361616-DS-3 | 26,597,514 | Dear ___,
It was a pleasure caring for you at ___. You were admitted in
diabetic ketoacidosis. This means your blood sugar levels were
high, there were ketones in your blood and urine, and your blood
had more acid in it than normal. You were on an insulin drip
while we controlled your sugars. You improved, were able to eat
and were transitioned to subcutaneous insulin. We consulted
___ to help us manage your home insulin regimen. Their final
recommendations is included in your discharge summary.
Take all your insulin as scheduled. Please attend all your
follow up appointments.
Take care,
Your ICU Team | Impression: ___ man with h/o type I DM who presents with DKA in
the setting of likely viral gastroenteritis.
DKA: Patient presented with signs and symptoms of DKA with a pH
of 7.08 and an anion gap of 30. He was admitted to the ICU on
insulin gtt and was managed with aggressive fluid rescuscitation
and insulin gtt until his anion gap closed. Precipitating factor
is most likely viral gastroenteritis as patient denies any
medication non-compliance and other infectious workup was
negative. He was then transitioned to subcutaneous insulin and
sliding scale, which was managed with the aid ___
consultants. | 105 | 102 |
10121316-DS-9 | 20,600,733 | Dear Ms. ___,
It was a pleasure taking care of you.
Why you were here?
-You were admitted because of a skin infection of your left leg
called cellulitis.
What we did for you?
-We started you on antibiotics and gave you antibodies to boost
your immune system to help fight the infection
-You had a painful rash on your left shoulder that may be
shingles so we treated you with an antiviral medication called
valacyclovir
What should you do when you leave the hospital?
-Please take all your medications as prescribed.
-Follow up with your outpatient oncologist
We wish you the best,
Your ___ team | Ms. ___ is a ___ ___ woman with a past
medical history significant for PVD, HTN, DM, and CLL who
transferred from ___ for evaluation of LLE
edema and pain concerning for cellulitis complicated by DM, PVD,
and CLL.
# Cellulitis
Painful, erythematous, edematous LLE consistent with soft tissue
infection. CT scan w/o e/o nec fasc. ___ ED, initially treated
with Vanc/Zosyn, switched to Vanc/Cefepime the following day.
Clindamycin was added to empirically cover for toxin-elaborating
organisms. Clindamycin and vancomycin was d/ced during hospital
course due to less concern for MRSA and toxin forming microbes
as patient's cellulitis improved. Cefepime was switched to
meropenem on day 12 due to concern for seizure risk and
ultimately patient's abx course was finished after a 14 day
course with resolution of cellulitis. Of note, pt continued to
have LLE pain while hospitalized, and CTA showed
"Mild-to-moderate narrowing of the branching of the femoral
profunda at distal end of the external iliac to profunda bypass
graft. Complete occlusion of the left superficial femoral artery
with reconstitution of the popliteal artery as well as several
collaterals from the level of the profunda." Of note, pt's
ibrutinib was initially held on admission, given concern for
immunosuppression and restarted on ___. Pt was also found to be
hypogammaglobulinemic, and she was given weekly IVIG x3 doses
per heme-onc.
# Left shoulder rash and pain: Shoulder pain began on day 11
(___) and an erythematous patch was noted at the inferior
border of the scapula extending past the axilla along the
inferolateral breast ___ a T4 dermatomal distribution. There were
no vesicles. Given history of shingles on her left hip/back,
acyclovir was started empirically for VZV. Patient's rash
improved after 1 day of acyclovir, which lowered index of
suspicion for VZV. However, given that patient had started on
acyclovir and improved, we decided to continue treatment with 7
day course of valacyclovir 1g q8h per ID. Shoulder pain and rash
had resolved at discharge
# Fever: Pt developed fevers on ___ and ___, with
TMax 102.4. Blood and urine cultures were unremarkable and CXR
was also unremarkable. No obvious localizing symptoms. Pt was
otherwise well and hemodynamically stable. Fevers were not felt
to be infectious ___ nature. Instead, they were felt to be more
likely ___ CLL vs delayed inflammatory reaction to IVIG (given
that fevers occurred ___ days after IVIG infusion each day).
# Altered mental status: On ___, patient had RUE shaking, oral
automatisms, and unresponsiveness which was concerning for
seizure with post ictal state ___ the setting of infection and
cefepime vs delirium. 48 hour cvEEG did not show seizure
activity, but slow wide wave spikes may be sign of decreased
seizure threshold. Cefepime was switched to meropenem due to
concern of seizure. Patient may also had superimposed delirium
___ the setting of older age, infection, and superinfection of
her left shoulder concerning for VZV shingles. Patient's mental
status returned to baseline the following day. On ___ nurse
noted patient was slumped to the left with a left facial droop
and was not responding to verbal commands, a code stroke was
called with negative head CT and CTA head/neck. MRI negative for
acute stroke, patient quickly returned to baseline and remained
so at hospital discharge. Pt was not felt to have had a seizure.
# CLL: Home ibrutinib was held on admission due to concern of
immunomodulatory effects but was restarted on ___ after consult
with hemotology/oncology. They were also consulted for the
presence of atypical lymphocytes on WBC differential on hospital
day 6. As per their note, no indications of Richter
transformation. Also found to have hypogammaglobunemia, which
may have been prolonging her infection recovery. Subsequently,
IVIG 25 g was administered on hospital days ___, ___, ___.
Outpatient hematologist is Dr. ___ (___) at
___ follow up on discharge.
# Normocytic anemia: Patient initially admitted with H/H ~7 and
was transfused 1uPRBC. Unclear etiology, but may be related at
least ___ part to CLL or Ibrutinib with reduced bone marrow
production consistent with her low reticulocyte count. However,
H/H dropped and brown guaiac positive stool on day 6 ___ the
setting of supratherapeutic INR, which was concerning for
bleeding and patient was given another unit PRBC. Also, CT
abd/pelvis was obtained which did not show any hematomas. There
was initial concern for upper GI bleed, so PPI was started.
Patient's H/H notably decreased from 7.6/24.6 -> 6.9/22.7 on the
day of discharge, felt to be more likely stochastic variation vs
mild hemolysis ___ the setting of IVIG the day prior.
# Peripheral vascular disease: History of PVD s/p multiple
surgeries for revision ___ LLE may be complicating clinical
picture of infection. Vascular surgery determined patent
vasculature and graft on admission. They have advised
anticoagulation with INR goal ___ while inpatient. Aspirin was
continued during this admission. Patient will follow up
outpatient.
# Labile INR: INR on admission was 4.8 likely elevated ___
setting of infection. INR elevated to 6.7, suspect due to
cefepime as it increases INR and possibly CLL on ibrutinib and
broad spectrum antibiotics w/ reduced dietary intake may be
contributing. Patient lost IV access on ___ and to obtain
R-IJ CVC placement, patient was given 2.5mg phytonadione and
FFP. INR dropped to 1.3 and was restarted on heparin drip with
bridge to warfarin. Pt's warfarin was titrated on admission, but
was downtrending at the time of discharge.
# Bilateral crackles: On admission CXR show bibasilar lung
opacities, follow up CXR/CT chest showed ground glass opacities
concerning for pneumonia. Because of rising WBC, Azithromycin
was started to cover for additional atypicals on top of the
cefepime/vancomycin pt was already receiving. However, given
patient was not coughing or dyspneic, there was low suspicion of
pneumonia and azithromycin was discontinued. Patient discharged
stable on room air.
# T2NSTEMI/CAD: On admission, ECG showed dynamic TWI ___
inferolateral leads and mild troponinemia, likely due to
increased demand ___ the setting of infection. Patient with known
inferior perfusion defect from prior MIBI. Statin was originally
discontinued due to increased CK levels, but was restarted once
CK levels normalized. Patient did not experience chest pain and
was discharged stable on atorvastatin, atenolol, ASA.
# Right ocular subconjunctival hemorrhage: Developed ___
hospital, seen by ophthalmology, who believe it is a benign
subconjunctival hemorrhage. Likely to take up to 2 weeks to self
resolve. Artificial tears administered, stable on discharge.
# LLQ skin ulcer: Underneath pannus, a small 1cm ulcer with no
purulence, erythema, or bleeding. Likely a sore from excess
moisture and friction from skin fold above. Miconazole powder
and dry dressings were started due to concern for fungal
infection, stable during hospital course and on discharge.
# HTN: high ___ the 180's but given clinical picture of
infection, initially held home medications. After patient's
infection was improving and blood pressures continued to remain
high, home hydrochlorothiazide was restarted. Patient discharged
with HCTZ and amlodipine.
# DM: A1C 6.6 ___ ___. Patient on home metformin, which was
held. Patient was on insulin sliding scale, but did not require
any insulin while hospitalized.
# Glaucoma: Stable. Continued home latanoprost and
brimonidine/timolol
# Depression: Home amitriptyline was continued.
# Facial Droop/UE weakness: Pt was thought to potentially a
Right facial droop on ___ when seen by ___ covering MD. CTA
head/neck and MRI head did not show e/o acute CVA. Neuro exam
was stable at the time of discharge. | 96 | 1,221 |
12745171-DS-7 | 28,708,076 | Dear Ms. ___,
It was a pleasure caring for you here at ___. You were
admitted with weakness and black stools and found to have very
low blood counts. This was probably due to bleeding from your GI
system. You received two units of blood cells as a transfusion.
Your bleeding stopped and your blood counts were stable.
You had a camera placed into your stomach which unfortunately
did not show a source of bleeding. It did show some irritation,
for which you should take some antacid medication (please see
attached for new medication list).
Your bleeding may have been caused by the medication you were on
for your atrial fibrillation (Pradaxa). We stopped this
medication. You should discuss whether or not to restart it with
your Primary Care Physician. We also are holding several of your
blood pressure medications (please see the attached list).
Please discuss these medications with your primary care doctor.
We wish you all the ___.
- Your ___ Team | PRIMARY REASON FOR HOSPITALIZATION:
=================================================
___ y/o female with PMHx of atrial fibrillation (on Pradaxa),
HTN, chronic lower extremity edema. She presented on ___ with
about 1 week of reported black stools, with associated Hct drop
from 1 month prior. | 159 | 38 |
18008568-DS-9 | 21,273,425 | 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. | Ms. ___ presented to ___ on ___ complaining of
wretching, and epigastric pain. The patient was otherwise
hemodynamically stable, and labs were WNL. She was admitted to
the ACS service, was made NPO, placed on IV fluids, and an NG
tube was subsequently placed. Imaging showed a significant
hiatal hernia.
___: the ___ Surgery service was consulted for
evaluation and possible surgical repair. NG tube was to deemed
necessary to stay, and a UGI swallow study was performed.
___: patient's nausea was managed, serial abdominal
exams, outpatient follow-up coordinated. NGT removed
___: Patient's diet advanced, DC home
___ NGT clamp trial. spoke w/ PCP to coordinate EGD and pH
study.
___ NGT to ___
___ lytes repleated, awaiting final OR plan
___ admitted to ACS, NPO, IVF | 176 | 129 |
14245358-DS-20 | 20,252,262 | Dear Ms. ___:
You were admitted to ___
because your heart was not beating regularly and it was beating
very fast. This condition is called atrial fibrillation with
rapid ventricular rate. We gave you some medicines to help slow
down your heart rate.
-We increased you Diltiazem dose
-We added a new medication called Metoprolol
We think that your heart rate has been controlled enough and
that it is safe for you to go back and continue your
rehabilitation plan.
Please take all medications as prescribed, and please make sure
that you attend your follow-up appointments.
-You will have an appointment with Dr. ___, please
make sure you attend this appointment.
Thank you for allowing us to participate in your care. | Transitional issues:
- Was started on Metoprolol during this hospital admission, will
need daily monitoring of her heart rate and blood pressure for
the next few days.
- Home diltiazem dose increased to 360mg extended release,
please continue to monitor blood pressure and heart rate as
above.
- patient continued on apixaban 5mg twice daily without
incident.
- We did not start Amiodarone because the patient did not
accept. Additionally she was not comfortable with the idea of
electrical cardioversion so medical management was focused on
rate control. Will require ongoing discussions if heart rate not
adequately controlled on Metoprolol and diltazem.
- Follow up scheduled with Dr. ___ to facilitate ongoing
discussions. Please ensure appointment adherence.
- Discharge weight: 93.7 kg (206.5 lbs)
HOSPITAL SUMMARY
Ms. ___ is a ___ with a PMHx of AF/flutter and recent
CVA on apixaban who presented from rehab in AF with RVR.
#AF with RVR, recent CVA:
Pt p/w AF/flutter with RVR from rehab. Based on history, not
clear what inciting event was. During her hospital stay she was
treated with PO diltiazem and PO metoprolol, managing to obtain
adequate HR control. We suggested starting Amiodarone and
possible electrical cardioversion if this was not successful.
However, patient refused this treatment plan.
-Continue apixaban 5mg BID for AC
-Continue PO diltiazem
-Continue PO Metoprolol
#UTI(resolved): pt with RVR and UA with neg nitrites,
contaminated, asymptomatic
-U Cx w/mixed bacterial flora, so we held off on antibiotics
(she received 2 doses of ceftriaxone while in-house, was
discontinued for negative culture)
#IDDM:
Continued home insulin regimen of 40U of glargine daily and was
put on insulin sliding scale, and 5U Humalog TID with meals
#HLD:
-Continued statin | 117 | 269 |
10035780-DS-18 | 23,172,477 | ======================
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 needed your fistula
fixed.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had your fistula fixed so you could get dialysis.
- You had low red blood cell counts and platelets. You were
given one unit of red blood cells with improvement in your blood
counts.
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 ___ y/o ___ speaking patient with PMH
significant for Alzheimer's dementia, ESRD, and HTN, who
presented for thrombectomy, but was determined to not have
capacity to consent to procedure, and ___ was unable to get
consent, thus admitted for ___ procedure and dialysis. On ___,
Ms. ___ received a temp. line and recieved HD given worsening of
her condition. Eventually, HCP was contacted and She had a AVF
thrombectomy on ___. Her course was complicated by pancytopenia
requiring 1u pRBCs with improvement in cell counts prior to
discharge. | 101 | 94 |
10285455-DS-9 | 22,472,652 | 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 30mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
Physical Therapy:
Weight bearing as tolerated left lower extremity
Treatments Frequency:
Staples will be removed at follow up appointment. No need to
redress unless for comfort. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for CRPP L hip, 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
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient 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, 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. | 148 | 239 |
12381874-DS-6 | 28,748,781 | Dear Ms. ___,
You were admitted to the hospital with an episode of loss of
consciousness at work. It is unclear whether you had a seizure.
You were monitored on the video EEG while you were in the
hospital and it did not show seizure activities.
EKG was done and showed prolonged QT interval, likely related to
your zofran use. Your zofran was decreased again. Please follow
up with Dr. ___ 1 week for a repeat EKG.
Your right hip pain was thought to be due to trochanteric
bursitis, which can be treated with non-steroidal
anti-inflammatory medications such as advil or aleve. You should
also use heat packs to the area and gently stretch the leg. If
the pain continues, please discuss with Dr. ___
possible MRI of the hip and/or injection. There were no
fractures to the bone, and your muscle enzyme and inflammatory
markers were all within normal.
Please note that ___ law prohibits you from driving
for 6 months after a seizure or an episode of sudden loss of
consciousness. Please also avoid doing any activities that could
be dangerous if you were to have a sudden loss of consciousness,
such as swimming or bathing alone, climbing, using sharp objects
unsupervised or exposure to heat sources (open fires, stoves). | Ms. ___ is a ___ year-old right-handed woman with a history
of epilepsy with nocturnal events (followed by Dr. ___.
___ who presents with a seizure at work. Patient's typical
events are nocturnal and she states that she rarely has seizures
during the day. Also complaining of R hip pain x2 days prior to
admission.
# NEURO: given the atypical seizure during the day, she was
admitted for EEG monitoring. As her valproate level was
subtherapeutic on admission, she was given extra dose of
valproate and continued on her home dose. She did have some of
her typical nocturnal events characterized by arousal,
nausea/vomiting and headaches but it was not associated with EEG
changes.
She complained of constant headache in the hospital, not much
different from her chronic daily headaches. Multiple medications
including tylenol, toradol, morphine and oxycodone were tried
without much effect.
Her gabapentin was increased for her numbness/tingling/burning
pain in her right ___ thigh, most likely due to
meralgia paresthetica.
# GI: patient with chronic nausea/vomiting, taking zofran daily
at home for headaches/nausea. Her LFTs and amylase/lipase were
checked and were wnl.
# MSK: R hip pain, appears to be muscle tenderness. ESR/CRP, CK
were checked and they were all wnl. Ultrasound of RLE did not
show any DVT. Patient was placed on standing toradol for both
headaches and her R hip pain, as it was thought to due more MSK
pain.
# PSYCH: depression, continued on home fluoxetine MWF. | 210 | 241 |
18833676-DS-22 | 28,833,869 | You were admitted and treated for alcohol withdrawal. Your
symptoms improved. You also reported some bloody vomit and a
episode of dark stools. This may be due to gastritis or
irritation in your stomach from alcohol use. You must be sure to
avoid any alcohol in the future as this will lead to more bodily
damage and/or death. You were seen by social work to help you
with sobriety and with discussion for more resources to help
you. Your elected to follow up with your outpatient providers at
___. Please be sure to follow up there. | ___ hx EtOH abuse and depression who presented with alcohol
intoxication and was admitted for withdrawal.
# Alcohol Intoxication with Signs of Withdrawal: Patient with
long alcohol abuse history, with recent binge for the past week.
Denied other ingestions; serum and urine tox negative. She had
evidence of withdrawal on admission, with visual hallucinations,
tachycardia, tremors. She was started on the phenobarbital
protocol in the ICU and did well, with improving withdrawal
symptoms. She completed the phenobarbital protocol while
inpatient. She was started on thiamine/Folate/MVI. Social work
consulted, and helped the patient with outpatient resources for
ongoing treatment. She declined an inpatient admission.
Her naltrexone was restarted at discharge.
# Falls: Patient reports several falls in the past week during
her alcohol use; denied any falls prior to alcohol ingestion. CT
head/neck negative for fractures or dislocations. B12 was
checked and was normal. She was able to ambulate without issue.
# Hematemesis: Patient with several episodes of vomiting over
prior to admission, with small amounts of blood in the emesis.
Did not start out bloody; only became bloody after recurrent
emesis. She had no further episodes of vomiting after admission.
Her blood counts were at baseline and the patient was
hemodynamically intact. Most likely due to ___ tear,
but gastritis or PUD could be contributing given alcohol use.
She was initially started on an IV PPI BID, which was switched
to an oral PPI daily once she had no more episodes of vomiting.
# Depression/bipolar disorder: Continued topiramate/sertraline.
She reports that she will be resuming care with her outpatient
providers and she reports a good report with them. She declined
any inpatient treatment at this time.
.
#reports of purging behavior/?eating disorder NOS -pt reported
that she partakes in purging behavior. She reports that she has
outpt treaters for this and that she has a good rapport with
them. She denied this during admission and denied further
assistance with this. She is aware of the need to stop and is
trying to stop. .
.
#QTC prolongation-pt noted to have prolonged QTC on EKG's around
500. Would continue to monitor this in the outpatient setting
and consider when prescribing medication for pt. | 96 | 359 |
16430675-DS-29 | 27,182,775 | You were admitted to the hospital for small skin infection after
shaving and pain from lymph node swelling in your neck and head.
A CT scan of your neck and head did not show any deep infection
or concerning features. You improved with antibiotics and pain
medications. Your lymph node swelling and pain should improve
over the next couple days. Please follow-up with your PCP if
your symptoms do not fully resolve within 7 days.
The following changes were made to your medications:
1. Started clindamycin, an antibiotic, to treat the skin
infection.
2. Started oxycodone, a narcotic pain medication, to treat your
pain. You should not drink alcohol or drive while on this
sedating medicine. | Mr. ___ is a ___ M with history of insulin dependent type 2
DM who presented facial abscess and was monitored overnight.
# Facial abscess with surrounding LAD: This likely developed
after innoculation of bacteria when he cut himself shaving.
Given his DM, he is at risk for more severe infection, however,
it appears area was localized to this area and self-expressed
pus prior to arrival to ED. There was no evidence of
surrounding cellulitis or systemic illness. Blood cultures were
negative. He was treated with vancomycin and unasyn overnight
and transitioned to clindamycin at discharge. He was in
significant pain from his lymphadenopathy and was given short
course of low dose oxycodone for this as needed.
# Anemia: He previously had history of anemia but recent hct
have been within normal limits. He was continued on his iron
supplementation.
# Diabetes: Insulin dependent type 2. He was treated with his
home lantus and an insulin sliding scale while inpatient. His
home metformin was restarted at discharge.
# HTN: His home lisinopril was continued.
# HL: He was continued on his home statin and his fenofibrate
was restarted at discharge.
# Dyspepsia: His home protonix and sucralfate were continued.
# Depression/anxiety: His home buproprion and diazepam were
continued. | 117 | 212 |
12047822-DS-20 | 22,974,815 | Dear Ms. ___,
You were admitted to ___ after falling and being found
unresponsive at home. We think you were dehydrated as a result
of the recent urinary tract infection you had. We gave you
fluids through the IV and your symptoms improved. There was
some damage to your heart as a result of being dehydrated, for
which our cardiologists evaluated you and felt that this would
be best managed with medicines.
We completed your antibiotic course for urinary tract infeciton
with two more days of IV antibiotics. Unfortunately, during
your stay you fell from a chair and hit your head, resulting in
a bruise. A CT scan of your head was performed and showed no
signs of brain bleeding. You were discharged home on your
regular medications with plan for close follow up with your
primary care physician, ___.
It was a pleasure taking care of you at ___. If you have any
questions about the care you recieved, please do not hestiate to
task.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with history of HTN, CHF,
likely Afib and other issues s/p recent admission for S. Bovis
UTI, discharged home on amoxicillin, who was re-admitted with a
fall concerning for syncope.
#Syncope and Encephalopathy: Patient found unresponsive on the
floor per care takers. There was no ictal activity noted, and
she was slumped over forward, no immediate complaints before
episode. On EMS arrival patient was pale, (+) pulses, moved to
floor, at that point gradually began regaining consciousness.
FSBG 170s, VSS and WNL, sinus on monitor. Patient was then
brought to ___ ED for further evaluation. Imaging non con
head CT showed acute intracranial process, CXR showed no acute
cardiopulmonary process. Given recent history of infection she
was given IV ceftriaxone for UTI, 1L NS, 600mg ASA. Patient was
initially delerious but demonstrated significant improvement
with gentle fluid, frequent re-orientaiton, avoidance of
deleriogenic medications and antibiotics. Of note, the patient
fell out of her chair during the night while admitted and
developed a hematoma, but no acute intracranial process on CT.
Suspect multifactorial with contributing etiologies including
infection (UTI), volume depletion (with acute kidney injury),
and potential cardiac etiology given elevated troponin 0.55
which downtrended to .48.
She was discharged with improved mentation, near baseline per
care taker.
#UTI: Patient had no urinary symptoms, but given history of
recent UTI, she treated with IV Ceftriaxone until discharge.
#Hypertension: With altered mental status, the patient was
unable to take home PO medications. IV labetalol was used prn
until she could tolerate home meds. Remained normotensive.
#Hyponatremia: Na 128 on admission, improved from previous
admission. Thought to be related to SIADH during admission due
to high urine OSMS and sodium (see admission labs) despite low
urine Na. TSH and cortisol where found to be within normal
limits. She was kept on a 1.5L fluid restriction and had a
discharge Na of 131.
___: Admission creatinine 1.3 from baseline 0.8, concerning for
pre-renal azotemia, likely related to UTI and syncopal episode.
Improved to 1.1 with IVF.
She was altered and had a troponinemia that peaked at 0.55.
Cardiology evaluated her and felt this was most likely due to
demand ischemia. She received IVF and improved symptomatically.
No etiology for syncope was ultimately found. She was treated
with 2d of IV ceftriaxone to complete her treatment course for
her S. bovis UTI. She sustained a fall while in the hospital
with head strike, resulting in a scalp hematoma but no
intracranial bleed. When she was symptomatically improved she
was discharged home. | 176 | 435 |
19306047-DS-7 | 22,920,611 | You were admitted to the hospital with abdominal pain, nausea
and vomiting. Intravenous pantoprazole, oral carafate and pain
medication were administered with improvement in your symptoms.
You are now preparing for discharge to home with the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Ms. ___ presented to the Emergency Department on ___ with complaints of abdominal pain and associated nausea/
vomiting. The patient was subsequently made NPO, placed on IVF
and intravenous protonix/hydromorphone. Radiographic imaging
including an abd CT and chest x-ray were obtained and
unrevealing as a source of pain. The patient was subsequently
admitted to the general surgical ward for ongoing observation
and intravenous protonix administration.
Neurological: The patient remained alert and oriented throughout
her hospitalization. Pain was initially managed with
intravenous hydromorphone and transitioned to tramadol and
acetaminophen once taking a diet
Cardiovascular/ Respiratory: The patient remained stable from a
cardiopulmonary standpoint; vital signs were routinely monitored
throughout the admission.
Gastrotintestinal: The patient was initally NPO x meds with
administration of intravenous pantoprazole and oral carafate for
a presumed marginal ulcer. On HD1, her diet was advanced to
Stage 4, however, the patient developed nausea and abdominal
discomfort, therefore, her diet was changed to stage 2. On HD2,
the patient's symptoms improved and a stage 4 diet was trialed
with and tolerated well.
Genitourinary: The patient was voiding adequately throughout her
hospitalization
Psychiatric: A social work consult was obtained due to concerns
of multiple social stressors; please see note for details. The
patient was referred to the ___ Domestic Abuse who met
with the patient prior to discharge.
Prophylaxis: The patient received subcutaneous heparin
throughout her hospitalization. | 333 | 230 |
15573937-DS-18 | 20,512,687 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why was I admitted to the hospital?
-You were admitted because of numbness and tingling in your chin
and lip.
What did we do for you in the hospital?
-We did a CT scan and MRI of your head, which showed no bleeding
or mass to explain your symptoms. It is likely that multiple
myeloma in your jaw bone is causing some compression of the
nerve in your face, which is causing numbness.
-You received platelets.
What should I do at home?
-You should follow up with your oncologist Dr. ___ week
to continue with your treatment.
-You should call your doctor or return the ___ Department
immediately if your symptoms worsen.
We wish you all the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with IgA lambda-secreting
multiple myeloma on Darutumumab (C1D3) who presented to ED with
suddent onset of lip and jaw numbness, concerning for mental
neuropathy.
#Mental neuropathy: patient presented with sudden onset
numbness/tingling in distribution of mental nerve. Base on
literature review, this is an uncommon manifestation of
malignancy that has typically metastasized to the mandible with
invasion or compression of the inferior alveolar or mental
nerve. It typically confers poor prognosis. Neurology consulted
in ED. CT head showed no intracranial abnormality. MRI head was
obtained per neurology recs and showed no masses, infarct or
osseous lesion. Neuropathy may be secondary to local immune
response to recent therapy with Darutumumab. Patient's symptoms
stable over course of hospitalization and she was discharged
with close oncology follow up.
#Elevated transaminases/tbili: in setting of likely drug induced
liver injury. Aminotransferases continued to downtrend from
prior admission.
#ANEMIA:
#THROMBOCYTOPENIA:
#MULTIPLE MYELOMA: Patient with multiple myeloma diagnosed in
___ which did not respond to single Cytoxan/Velcade. Patient
subsequently unable to tolerate carfilzomib and lenalodomide ___
acute liver injury. On admission she was C1D3 of daratumumab
___ dose) with plan to possibly start pomalidomide in future.
Due for next Daratumumab infusion on ___. Patient received
platelets for thrombocytopenia prior to discharge.
#HYPOTHYROIDISM: continued levothyroxine 100mcg daily
Transitional Issues
====================
[ ] patient to follow up with outpatient oncologist for
continued treatment of MM.
[ ] HCP/Contact:Husband ___ ___
[ ] Code: Full | 129 | 238 |
16526136-DS-21 | 21,810,979 | It was a pleasure taking care of you here at ___
___. You are now ready to be discharged
home. Please follow the recommendations below:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may feel weak or "washed out". You might want to nap
often. Simple tasks may exhaust you.
- 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.
- Constipation is a common side effect of narcotic medicine. If
needed, you were given prescriptions for an over the counter
stool softener (such as Colace, one capsule) or gentle laxative
(such as milk of magnesia, 1 tbs) - you may take this twice a
day if needed. You can get both of these medicines without a
prescription if you need more.
- 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
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
- It is normal to feel some discomfort/pain. This pain is often
described as "soreness".
- 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.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- You have been prescribed 1 week's amount. Please don't take
any other 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.
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 | ___ h/o gastric bypass in ___, recent gastric ulcer perforation
requiring surgical repair p/f OSH c/o epigastric tenderness,
n/v, diarrhea. She presented to ___ with these symptoms on
___. CT at that time was c/f gastro-gastric fistula.Based on
how far out she is from surgery, there was a concerned for G-G
fistula. We therefore admitted her to bariatric surgery for
further work up with upper GI study - the results is: "No focal
lesion is identified. No evidence of gastric outlet obstruction,
and barium passes freely into the duodenum. There was no
opacification of the excluded portion of the stomach".
Another cause of pain related to RNY is attributable marginal
ulcer. This is managed with PPI, which she is on. We proceeded
to manage her conservatively there after. Patient was put on
PPI, carafate, and nutrition and routine labs were drawn. They
were unrevealing and we continued with supportive care. Her
hospital course consisted mainly of c/o abdominal pain, without
an obvious cause with regards to her history. She was notable
for having pain that is uncontrolled. She takes narcotics at
home. It also appears that she has been prescribed narcotics by
several MDs and over multiple pharmacies. The decision, was
therefore, brought up to the patient to be been given 1 weeks
worth of oxycodone liquid to manage her pain in the interim so
that she can be referred to a chronic pain center. Additionally,
an outpatient EGD was also scheduled for her on ___ with GI.
She was agreeable to this plan and was discharged accordingly.
Her exam remains unchanged and benign upon discharge. She
tolerated a diet and was essentially normalized. | 395 | 274 |
15623806-DS-22 | 27,708,020 | Dear Mr. ___,
You were seen in the hospital for an MRI showing multiple small
strokes that were likely a complication of your cardiac
catheterization. Your repeat MRI here showed no new strokes.
We made the following changes to your medications:
1) We STARTED you on ATORAVASTATIN 80mg once a day.
2) We STARTED you on CEFPODOXIME 400mg every 12 hours to finish
on ___
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization. | Mr ___ is a ___ year old right handed man who was recently
admitted at ___ in ___ for an NSTEMI/ respiratory distress
with a complicated course of delerium and pneumonia who returned
on this admission after MRI findings of multiple areas of
restricted diffusion concerning for strokes.
.
# Neuro: patient's repeat MRI showed no new infarcts and the
multiple small embolic infarcts were felt to be related to his
cath he had 1 month previously. He was continued on ASA/plavix
given his drug eluting stents, and he had vasculitis labs sent,
which are still pending currently.
# Cardiovascular: we continued pt's home BP/CHF med as he was at
least 3 days out from his strokes on admission. He was unable
to get an echo during his stay here, so we recommend that he
receive one as an outpatient.
# Urinary: pt had foley left in at ___ for extended
amount of time, so we decided to straight cath him every 6 hours
here.
# Infectious disease: U/A showed a UTI so he was started on
ceftriaxone. His UCx showed GNR's, with speciation pending, so
at discharge he was sent out on cefpodoxime 400mg Q12H to stop
___ for a planned 7 day course.
# FEN: he came in with a bridled NGT, but here our speech and
swallow team cleared him for thin liquids and soft solids. We
left the NGT in until calorie counts could be completed. He
will need further calorie evaluations at rehab as we weren't
able to fully determine his intake here. | 101 | 261 |
12456824-DS-18 | 23,522,619 | Dear Mr. ___,
You were admitted to the hospital for a new atypical heart
rhythm, exacerbation of your congestive heart failure, and
pneumonia. You underwent a procedure called an ablation to stop
the irregular heart rhythm, and we gave you medications to
decrease the extra fluid (diuretics), and antibiotics for your
pneumonia. You improved throughout your stay with us.
All of your medications with any changes are detailed in your
discharge medication list. You should review this carefully and
take it with you to any follow up appointments. Please have your
electrolyte labs checked in one week.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ year old male with PMH significant for COPD, HTN,
Schizophrenia, h/o DVT who presented to the ED from ___
with shortness of breath, found to be tachycardic with new
atrial flutter, now s/p successful aflutter ablation, treatment
of HCAP, and euvolemic from CHF exacerbation.
# Leukocytosis without SIRS
WBC dropped from 19 to 10. Patient non-toxic appearing, HDS,
softer pressures likely ___ diltiazem. Covered with CTX, would
cover strep, UTI, pyelo, some respiratory flora. Patient's OP
secretions not typical of strep pharyngitis, would be treated.
Patient treated for HCAP, has remained afebrile, HDS. Patient
with chronic foley. Initial U/A with pyuria and bacteria, ___ +
Nit neg. UCx sent
- CeftriaXONE 1 gm IV Q24H ___.
- Foley removed on discharge
- new U/A and UCx - UA dirty, UCx pending
- Blood Cx x 2 pending
# Atrial Flutter: s/p successful ablation. Patient previously
difficult to rate control and was symptomatic with shortness of
breath, worsening pulmonary edema. Patient in SR.
- home Diltiazem to 180 mg XR
- patient will need to be on ASA 81mg for one month
- continue Apixaban 5mg BID indefinetly
- discontinued Metoprolol
*********
# HCAP: Patient initially treated with Vanc/Cefepime, narrowed
to Ceftriaxone. First full day of antibiotics ___. Patient
was additionally given steroids up front for possible COPD
exacerbation. No positive culture data this admission. S/p 5
days of Azithromycin for atypical coverage/ COPD exacerbation.
- final day of Ceftriaxone 1gram course was ___
# ___: Patient presented with evidence of volume overload.
Rapid ventricular respnose likely contributing factor. He was
diursed previously with boluses of Lasix 40mg IV, last given on
___. Diuresis held in the setting of ? infection.
# COPD: baseline COPD on Symbicort, Albuterol, Tiotropium.
Patient did receive steroids this admission for component of
COPD exacerbation. Now with no ongoing evidence of exacerbation.
He is s/p 5 days of Azithro.
- continue standing ipratropium
- Albuterol as needed
- Tessalon perles for cough
- continued Montelukast 10mg daily
# Schizophrenia: not on any antispsychotics normally.
- Continued Mirtazapine 30mg qhs
# GERD: Omeprazole 20mg daily
# BPH: home Flomax
#CODE: DNR/DNI
#CONTACT: Patient, Legal guardian ___ ___
___ | 116 | 348 |
14363579-DS-9 | 27,486,573 | You were admitted with shortness of breath. You were having some
reactive airway disease and an influenza infection.
You were started on Tamiflu and an albuterol inhaler with
improvement in your symptoms. You were also started on codeine
for your cough.
You were discharged home. Please know that you are still
infectious for a few more days. Please avoid anyone who is
immunocompromised. | ___ with influenza.
# Influenza:
She presents with cough and shortness of breath. This was
improved with inhalers. She was found to be influenza type A
positive. She was started on Tamiflu and continued on nebs. Her
fever resolved and respiratory status returned to near baseline.
She had some coughing which was symptomatically treated with
codeine. At the time of discharge she felt improved. She was
warned that she was still infectious for another few days and
that codeine will cause sedation.
# Headache:
She had a headache in the setting of not drinking as much coffee
as she usually does. She was treated with fioricet with
improvement. She was discharge with a limited prescription of
fioricet.
# Asthma:
Normally well controlled. However, she did have some evidence of
mild reactive airway disease likely from the influenza. She was
treated with 1 dose of steroids which were discontinued after
rapid improvement with inhalers. She was prescribed an albuterol
inhaler at discharge.
# Hypothyroidism:
Stable. Continued home regimen.
# Anemia:
Mild, no evidence of bleeding. Will need follow up as
outpatient. | 61 | 172 |
13809466-DS-21 | 26,555,613 | Dear Mr. ___,
You were admitted to ___ and
underwent an endovascular AAA repair with coiling of your right
hypogastric artery on ___. You have now recovered from
surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
PLEASE NOTE: After endovascular aortic repair (EVAR), it is very
important to have regular appointments (every ___ months) for
the rest of your life. These appointments will include a CT
(CAT) scan and/or ultrasound of your graft. If you miss an
appointment, please call to reschedule.
WHAT TO EXPECT:
Bruising, tenderness, and a sensation of fullness at the groin
puncture sites (or incisions) is normal and will go away in
one-two weeks
CARE OF THE GROIN PUNCTURE SITES:
It is normal to have mild swelling, a small bruise, or small
amounts of drainage at the groin puncture sites. In two weeks,
you may feel a small, painless, pea sized knot at the puncture
sites. This too is normal. Male patients may notice swelling in
the scrotum. The swelling will get better over one-two weeks.
Look at the area daily to see if there are any changes. Be
sure to report signs of infection. These include: increasing
redness; worsening pain; new or increasing drainage, or drainage
that is white, yellow, or green; or fever of 101.5 or more. (If
you have taken aspirin, Tylenol, or other fever reducing
medicine, wait at least ___ hours after taking it before you
check your temperature in order to get an accurate reading.)
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
If you have sudden, severe bleeding or swelling at either of
the groin puncture sites:
-Lie down, keep leg straight and apply (or have someone apply)
firm pressure to area for ___ minutes with a gauze pad or
clean cloth.
-Once bleeding has stopped, call your surgeon to report what
happened.
-If bleeding does not stop, call ___ for transfer to closest
Emergency Room.
You may shower 48 hours after surgery. Let the soapy water run
over the puncture sites, then rinse and pat dry. Do not rub
these sites and do not apply cream, lotion, ointment or powder.
Wear loose-fitting pants and clothing as this will be less
irritating to the groin puncture sites.
MEDICATIONS
Take aspirin daily. Aspirin helps prevent blood clots that
could form in your repaired artery.
It is very important that you never stop taking aspirin or
other blood thinning medicines-even for a short while- unless
the surgeon who repaired your aneurysm tells you it is okay to
stop. Do not stop taking them, even if another doctor or nurse
tells you to, without getting an okay from the surgeon who first
prescribed them.
You will be given prescriptions for any new medication started
during your hospital stay.
Before you go home, your nurse ___ give you information about
new medication and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
PAIN MANAGEMENT
Most patients do not have much pain following this procedure.
Your puncture sites may be a little sore. This will improve
daily. If it is getting worse, please let us know.
You will be given instructions about taking pain medicine if
you need it.
ACTIVITY
You must limit activity to protect the puncture sites in your
groin. For ONE WEEK:
-Do not drive
-Do not swim, take a tub bath or go in a Jacuzzi or hot tub
-Do not lift, push, pull or carry anything heavier than five
pounds
-Do not do any exercise or activity that causes you to hold your
breath or bear down with your abdominal muscles.
-Do not resume sexual activity
Discuss with your surgeon when you may return to other regular
activities, including work. If needed, we will give you a letter
for your workplace.
It is normal to feel weak and tired. This can last six-eight
weeks, but should get better day by day. You may want to have
help around the house during this time.
___ push yourself too hard during your recovery. Rest when
you feel tired. Gradually return to normal activities over the
next month.
We encourage you to walk regularly. Walking, especially
outdoors in good weather is the best exercise for circulation.
Walk short distances at first, even in the house, then do a
little more each day.
It is okay to climb stairs. You may need to climb them slowly
and pause after every few steps.
DIET
It is normal to have a decreased appetite. Your appetite will
return over time.
Follow a well balance, heart-healthy diet, with moderate
restriction of salt and fat.
Eat small, frequent meals with nutritious food options (high
fiber, lean meats, fruits, and vegetables) to maintain your
strength and to help with wound healing.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to your
pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your primary
care physician about ways to quit smoking. | Mr. ___ is a ___ yo M who was admitted to the ___
___ on ___ with evidence of
expanding AAA and concern for imminent rupture.The patient was
taken to the endovascular suite and underwent EVAR w/ coil embo
of R hypogastric. For details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. He was then sent
to the cardiovascular ICU for further monitoring. He did well
overnight, but required a nicardipine drip temporarily for blood
pressure control. On POD1 he was transitioned to oral blood
pressure agents. He also had poor pain control overnight which
was managed with a PCA. When appropriate in the morning he was
transitioned to oral pain regimen. His foley was dced on POD1
and he was voiding spontaneously. On POD 1 he was transferred to
the vascular ICU (step-down unit) for further monitoring.
Post-operatively,he did well without any groin swelling. He was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. Patient confirmed that he has
adequate supply of Eliquis for now, and will discuss transition
to Coumadin with PCP as this ___ be a more financially viable
option.
On POD 2, he was deemed ready for discharge, and was given the
appropriate discharge and follow-up instructions. | 966 | 244 |
12817683-DS-25 | 27,500,563 | ___
Phone: ___
Please call the transplant clinic at ___ for fever of
101 or higher, chills, nausea, vomiting, diarrhea, constipation,
inability to tolerate food, fluids or medications, yellowing of
skin or eyes, increased abdominal pain, incision redness,
drainage or bleeding, dizziness or weakness, decreased urine
output or dark, cloudy urine, swelling of abdomen or ankles, or
any other concerning symptoms.
Bring your list of current medications to every clinic visit.
You will need to have labs drawn on ___ then twice
weekly on ___ and ___
Please measure and record your urine output in the urinal
provided until you are instructed by the transplant clinic that
you can stop. Bring the record with you to your transplant
clinic follow up visits
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotion or powder near the incision.
You may leave the incision open to the air. The staples are
removed approximately 3 weeks following your transplant.
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Check your blood sugars four times daily and treat with insulin
as directed.
Check blood pressure daily. Report consistently elevated values
to the transplant clinic of greater than 160 or less than 110
systolic.
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant.
Refer to the transplant binder provided, and remember that there
is always someone on call at the transplant clinic with any
questions that may arise | ___ with ESRD ___ DM s/p failed renal transplant in ___ ( HD
via LUE AVF) s/p Deceased donor renal transplant (in L iliac
fossa) who presented with po intolerance, hyperkalemia, refusal
to take medications over several days who was found to have
___ esophagitis on EGD on ___. He was started on
fluconazole with plan for 2 weeks treatment. PO tolerance and
dysphagia symptoms improved.
UTI-c/o dysuria. UCX positive on ___ for Klebsiella sensitive
to Meropenem. He completed a ___ midline.
Midline was removed on ___. Ureteral stent still in place
that will by removed by urology on ___
Nausea/gi intolerance-mycophenolate was held on ___.
Azathiprine was started and prednisone was continued.Tacrolimus
was continued and dosed per trough levels as follows:
FK =tacrolimus/prograf
mg trough
___ FK ___ (15)
___ FK ___ (4.9);
___ FK ___ (3.7)
___ FK ___ (3.2)
___ FK ___ (3.4)
___ FK ___ (6.9)
___ FK ___ FK ___ (8.6)
___ FK ___
___ FK ___
___ FK ___
___ FK ___ (5.6)
___ FK ___
___ FK ___ FK ___
___ FK ___ (13.3)
___ FK ___ 14.5)
Hyperkalemia-likely secondary to bactrim. Bactrim was switched
to Atovaquone for PCP ___. Hyperkalemia occurred on
several days. In addition to switching bactrim, he received IV
lasix/IV fluid and kayexalate. Hyperkalemia continued with
treatment directed daily to bringing potassium down. Florinef
was added and potassium now better controlled.
He was also started on sodium bicarbonate for non-anion gap
acidosis with improvement.
Chronic
DM-Lantus and Humalog insulin was adjusted.
HTN-nifedipine was changed to amlodipine.
HLD-atorvastatin held secondary to interaction with azathiprine
Transitional issues:
Continue to assure patient is taking and swallowing all
medications as ordered. If issues arise please contact the
transplant clinic.
Discussion has started to convert patient to Belatacept for
immunosuppression. A port will need to be placed and this will
be arranged pending approval of Belatacept conversion. ___
___ contacted for right sided port for future. | 270 | 340 |
18320467-DS-16 | 21,122,661 | Dear Ms. ___,
You were admitted to our hospital for abdominal pain and
diarrhea. You had a CT-scan of the abdomen that showed large
colonic fecal load, but no evidence of ischemia or colitis. We
think your symptoms are due to gastroenteritis. We recommend a
___ diet (bread, rice, apple sauce, tea and toast). You can
avoid dairy and fatty foods until you feel better.
We also did a Chest X-Ray that showed on the apical lung
scarring but raised concern for possible apical lung mass.
Please follow up with your primary care physician regarding this
as well. You can call ___ and ask for medical records
to have a copy of the CD of your Chest X-Ray be sent to his
office. We have informed your doctor regarding this.
Your digoxin level was 1.4, with some changes in your ECG that
may be related to digoxin. Your primary care physician is aware
of this and will follow up with you regarding this.
We also did an ultrasound of your left leg because of the
swelling that did not show clot. | ___ y/o woman with atrial fibrillation and CHF, transferred from
OSH for evaluation of abdominal pain and diarrhea.
1. Abdominal pain/diarrhea: Her symptoms were thought to be
secondary to viral gastroenteritis. CTA was neg for colitis,
ischemia, or diverticulitis but showed large fecal load.
Overnight patient had several large BMs/diarrhea. Her
leukocytosis resolved. Her pain resolved by the following
morning by time of discharge.
2. Afib: Her dig was held given elevated serum level and ECG
changes. Her PCP was contacted and recommended that Digoxin be
resumed at its usual dose and to follow up with him later that
week for further mgmt. Home Diltiazam and ASA were continued. It
was confirmed that patient is NOT on Coumadin.
3. Chronic left leg edema: LLE Dopplers negative for DVT.
4. CXR findings: CXR concern for scar vs apical lung mass. PCP
was notified by phone, who stated that this has been noted on
prior CXRs and has been stable on serial CXRs. Further follow-up
deferred to PCP. | 177 | 163 |
15871138-DS-5 | 21,441,230 | Dear Ms. ___,
It was a pleasure caring for you at ___!
What happened while I was in the hospital?
==========================================
You were admitted to the hospital after falling at home. You
were found to have a lung mass that spread to your liver, spine
and ribs. Biopsy of your liver lesion showed metastatic lung
cancer.
What happens now that I am going home?
======================================
You will see an outpatient oncologist (Dr. ___ on ___ who
will follow-up the genetic testing of your cancer. Please see
your paperwork for further information regarding your follow-up
appointments. Now that you are leaving the hospital, you will
have 24 hour care at home through your family and a visiting
nurse.
We Wish You The Best,
Your ___ Care Team | This is an ___ year old female with past medical history of
hypertension, hypothyroidism, vascular dementia admitted
___ after being found down secondary to suspected syncopal
episode, with workup revealing new metastatic
malignancy and acute pulmonary embolism, status post liver
biopsy showing metastatic non-small cell lung cancer, course
complicated by delirium, now improved, able to be discharged
home with family and outpatient oncology follow-up
# Metastatic Lung Adenocarcinoma of L Lower Lobe: Patient is a
life-long non-smoker found during this admission to have new L
lower lobe lung mass with hypodensities in ribs, liver, and
spine. Course notable for ultrasound guided biopsy of liver
revealing metastatic lung adenocarcinoma. Advanced testing for
targetable mutations were sent. She was scheduled for follow-up
with ___ as an outpatient at ___ for discussion of
treatment options once advanced testing results return. Staging
with CT A/P was completed. MRI of brain was severely motion
limited and was deemed to be not ___ conclusive to rule out CNS
metastasis.
# Status post unwitnessed fall: Thought to be mechanical fall,
although could not rule out syncope given that patient is not a
reliable reporter. Workup of syncope was unremarkable, except
for incidental finding of pulmonary embolism as part of fall
workup (as below). Given that patient often forgot to use
walker when working with ___ and was significantly unsteady on
feet, she was recommended for 24 hour care. Discharged home
with sister.
# Right segmental and sub-segmental pulmonary embolus: CT
abdomen and pelvis incidentally revealed RLL segmental and
subsegmental emboli. Patient asymptomatic without findings on
EKG, telemetry, or vital signs. It was felt to be unlikely that
this contributed to her initial presentation, and she
subsequently developed no sequellae of consequences. Felt to be
caused due to immobilization in combination with malignant
hypercoagulable state. She was started on therapeutic dosed
lovenox.
# Dementia with behavioral disturbance - She has a recent
diagnosis of vascular dementia. Noted to be slowly declining as
an outpatient and her course was complicated by frequent sun
downing and OT evaluation recommending need for 24 hour care.
This was confirmed by reevaluation. She required intermittent
doses of Haldol for agitation, but never required scheduled
Haldol.
# Leukocytosis: Her white blood cell count was elevated at
admission at 14, and continued to remain in low teens throughout
admission. Infectious w/u was negative. Thought to be a reaction
from her cancer.
# Goals of Care:
Based on discussions with patient and family, she was enrolled
in hospice, given her newly diagnosed diseases, chronic disease
burden, and need for enhanced support at home. Family/patient
were open to additional goals of care discussions once results
of genetic tumor testing result.
# Hypertension: held metoprolol initially, but then resumed.
Ultimately started amlodipine 5 mg daily to improved BP control.
# Hypothyroidism: Continued levothyroxine
# HLD: Continued Atorvastatin
TRANSITIONAL ISSUES
====================
# NEW MEDICATIONS: Lovenox, amlodipine
# STOPPED MEDICATIONS: Aspirin
- Discharged home, with care to be provided by family and ___,
with outpatient oncology follow up; patient was enrolled in
hospice on discharge. Goals of care to be determined pending
conversation with oncologist after results of genetic tumor
testing result.
- Follow up advanced molecular and genetic testing
- MRI brain did not show CNA metastases but was limited by
motion
- Blood pressure was elevated during hospitalization, started on
amlodipine
- Patient has baseline mild-moderate dementia and became
confused and agitated while in the hospital at times overnight.
It was recommended that she have 24 hour care at home
- Leukocytosis without evidence of infection. Continue to follow
as an outpatient, deemed likely reactive from large tumor
burden.
- Consider zometa for bone metastases as outpatient
- Incidental thyroid mass and renal mass seen on imaging
# CODE STATUS: DNR/DNI
# CONTACT: ___ (daughter HCP) ___ | 119 | 631 |
11145811-DS-2 | 28,172,197 | Dear Mr. ___,
It has been our pleasure to take care of you. You were admitted
for a kidney biopsy as well as a thyroid biopsy. We have also
started you on steroid during the course of this hospitalization
to treat your vasculitis. We have given you a script for
prednisone; please take it daily and your rheumatologist or
kidney doctors ___ further adjust the dosage in the future to
taper you off the steroid. While you are taking steroids, we
have provided you medications to protect your bones (Ca/Vit D);
you should also be checking your sugars daily to ensure that
they are within a reasonable range. | ___ y/o male with history of HTN, carotid artery stenosis, mildly
reduced kidney function (baseline Cr low-mid 1s), now with
___ suspected secondary to vasculitis with + ANCA-MPO, admitted
for IV steroid as well as renal biopsy
# hydralazine induced ANCA+ vasculitis: pt p/w fatigue,
migratory rash as well as worsening kidney function. Pt was
admitted for IV steroid initiation as well as kidney biopsy per
discussion with his rheumatologist and nephrologists. Pt
received IV solumedrol 1g for 3 days, then transitioned to
prednisone 100mg every other day. Based on the skin and
preliminary kidney biopsy results, pt was given the diagnosis of
hydralazine induced ANCA+ vasculitis. Based on the degree of
activity from skin biopsy, pt was initiated on rituximab - he
recieved first dose in the hospital, with planned 2 additional
doses the following 2 weeks. Pt's hepatitis B panel was
determined to be negative prior to treatmet initiation. Quant
Gold was indeterminate, PPD was placed prior to discharge.
Bactrim DS daily every other day for PCP ___. Pt was
also started on calcium, vit D for bone protection while on
steroid; alendronate was considered but held until CrCl
improves, to be started as an outpatient. Pt has close follow
up with nephrology and rheumatology within 4 days post
discharge.
# ___ on CRF - baseline Cr of ___ until ___. 2.0 on
admission, likely ___ underlying intrinsic renal dz (namely
vasculitis). during this hospitalization, further elevated,
though likely pre-renal ___ NPO status for procedure, improved
to 1.8 after fluid and resumption of PO. Hydralazine was held
given hydralzine-induced ANCA+ vasculitis. Valsartan was also
held given worsening renal function from baseline.
# Thyroid mass - found on recent CT, pt reports recent weight
loss but otherwise asymptomatic. TSH was found to be 0.86 on
this admission. FNA of thyroid mass showed atypia of
undetermined sig. MRI of neck w/o contrast showed
"Enlargement of left lobe of the thyroid gland without apparent
invasion
into the tracheal lumen with mass effect on the
sternocleidomastoid muscle." Endocrine follow up within 4 days
post discharge was arranged for patient.
# HTN - valsartan was held due to worsening kidney function.
hydralazine was held given hydralazine induced ANCA+ vasculitis,
pt was switched from atenolol to labetalol 200mg BID. Pt has PCP
appointment within 1 week to further adjust hypertension regimen
as needed.
# Anemia: pt asx, no known baseline, microcyitic, but recent H/H
8.___.6, admission H/H appears stable may be ___ chronic kidney
disease or vasculitis (iron studies from ___ normal). Daily
CBC was checked and remained stable throughout the hospital
stay.
# Hyperglycemia: in setting of high dose steriods. insulin
teaching was performed by ___ team. mealtime and
bedtime sugar was checked with insulin sliding scale.
# GERD stable on Prilosec 20mg
# Anxiety: stable onparoxetine 30 mg daily. | 110 | 473 |
19542790-DS-3 | 22,419,472 | Ms. ___, you were admitted to ___
___ on ___ for chest pain. While you were here, we
performed man tests including a CT scan, Endoscopy, and blood
work. We believe you pain is from a condition called gastritis.
We started a medication called omeprazole. It is important that
you try to avoid ibuprofen (Advil) and acidic foods as we
discussed. | Ms. ___ is a ___ F with PMH reactive airway disease who
presented with slowly worsening pleuritic chest pain x ___
months with significant chest wall tenderness.
.
# Chest pain: Most consistent with esophagitis/gastritis due to
ongoing use of NSAIDs. EGD on ___ demonstrated erythema in the
antrum that could be consistent with gastritis, but was
otherwise normal. Gastric biopsy is pending at the time of
discharge. Ms. ___ was instructed regarding gastritis and
its precipitants and palliating factors (eg lifestyle
modifications). She received GI cocktail
(Maalox/lidocaine/diphenhydramine) as well as omeprazole during
her hospitalization. Lipase & LFTs were wnl. No RUQ pain or
tenderness. Musculoskeletal etiology (eg costochondritis) also
possible given tenderness to light palpation. Repeat read of CTA
for evidence of soft tissue, chest wall, or skeletal pathology
reveals no findings on ___. History is atypical for anginal
pain. No ischemic changes on EKG. Pleuritic nature is concerning
for PE, PNA or pleural process, but CTA final read is negative
for PE or parenchymal process. Aortic dissection is possible,
but no large dissection seen on CTA. Pericarditis is possible,
although no sx on EKG. No large hernia seen on CTA ___.
.
# Psychosocial history. The patient has a history of domestic
physical and emotional abuse, with possible trauma to her
sternum. Though she denies hypervigilance, avoidance, or
nightmares, she does note that the pain makes her think of past
traumatic relationships, which worsen the pain, which is
suggestive of PTSD. We recommend close outpatient follow-up with
her PCP as well as a psychiatry referral.
.
# Ambulatory Hypoxemia: Likely from splinting due to chest wall
pain with breathing. Patient was noted to desat to the ___
with ambulation in her PCPs office and again in the ED.
Ambulatory sat 98% once on floor ___ AM; repeat ambulatory
sats 98-100% on ___. Orthostatics were positive due to increase
in HR of >20 from supine to standing (increase in 48 BPM),
likely due to dehydration and immobility. RA sats at rest 100%.
CTA final read ___ neg for PE or lung process.
. | 61 | 338 |
14480817-DS-9 | 29,331,231 | Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization at ___. You came to our hospital very sick,
with a blood stream infection. Over the course of time, you
improved, and are now doing much better. You will need to be on
IV antibiotics for several days for this infection.
You have been started on several new medications for a heart
attack that you suffered when you came to the hospital. Please
remember to take all of these medications.
You have also started a medication called warfarin for the blood
clots found in your legs. You will be taking this medication
indefinitely, and will follow up at ___ for management of this
medication.
It is important that you continue to take all medications as
prescribed and follow up with the appointments listed below.
Good luck! | ___ year old male with a history of HIV (on HAART, no detectable
viral low), chronic low back pain (on opiates), depression,
anxiety, and hypertension who presented with syncope, and was
found to have sepsis with a likely aspiration pneumonia, acute
kidney injury with elevated CK, and elevated troponin found to
have bilateral DVT.
# Syncope: Patient presented initially with syncope of unclear
cause likely in the setting of overdose. Was in the setting of
lots of sedating medications, which likely contributed.
Immediately after, he had SVT to the 180s and BP in ___, so
it is possible that he had a cardiac event contributing to his
syncope. No history of seizures, nonfocal neurologic exam, and
normal head CT in ED. He was monitored on telemetry and
evaluated for cardiac etiology, none of which showed significant
findings. He was treated for infection as noted below. ___ of
Hearts monitor will be set up for him following discharge.
# Sepsis
# Multifocal community-acquired pneumonia
# Strep pneumoniae bacteremia: On admission, patient had no
fever, but he had tachycardia, leukocytosis, and an elevated
lactate to 4 with a CXR concerning for multifocal pneumonia.
Blood culture with GPC speciated to strep pneumoniae. He was
initially started on vancomycin and zosyn. Infectious disease
was consulted and recommended Vancomycin and Ceftriaxone
(antibiotic course started ___ and vancomycin was
discontinued ___. Influenza PCR was negative. TTE and TEE
showed no clear vegetations. He will complete a total 14 day
course, last day ___. A midline was placed for antibiotic
administration. After talking with his psychiatrist, there was
no concern for intravenous drug use.
# Tachycardia: Tachycardic to 180s when assessed by EMS that
responded to adenosine and diltiazem. Episode of SVT to 190s on
day 1 of admission that returned to sinus rhythm with adenosine
12mg. Metoprolol PO started and titrated up for effective rate
control. Cardiology was consulted and recommended ___ of
Hearts monitor, which will be arranged upon follow-up with his
PCP.
# Bilateral deep venous thromboses: ___ with bilateral proximal
lower extremity DVT, nonocclusive, in R common femoral then goes
down through pop. L superficial femoral vein involved. Heparin
gtt that had been initially started for elevated troponin was
converted to dosing for acute DVT. PTT was subtherapeutic on
heparin gtt and patient was changed to lovenox on ___. The
patient was started on warfarin for anticoagulation on ___,
was therapeutic on discharge, and will be followed by the ___
___ clinic going forward. INR will be checked next
on ___. He should likely be on anticoagulation indefinitely
given that this was likely an unprovoked clot.
# NSTEMI: On admission, troponin was elevated to 0.14. ECG with
no ischemic changes now with troponin elevated to peak of 0.2.
This was likely type 2 presentation. He received aspirin 324mg
in the ED and Aspirin 81mg daily was started. Atorvastatin 80mg
was started. Heparin gtt was started in the ED and continued for
acute DVT treatment, switched to lovenox as above. TTE performed
with LVEF 55% without focal wall motion abnormality. Cardiology
was consulted and recommended outpatient stress test, as well as
adding lisinopril and metoprolol to his medication regimen. He
should follow up with Cardiology as an outpatient for further
care and planning, including likely stress test.
# Respiratory acidosis: On arrival to ED, pH was 7.28 with PCO2
57. Likely in the setting of hypoventilation while being down.
Had taken lots of sedating medications. Lactate trended to
normal. Duonebs and incentive spirometry were given.
# Acute kidney injury: On admission, creatinine elevated to 2.0,
from baseline of 1.0. Likely pre-renal in setting of
hypotension. Good urine output was noted, with no evidence of
obstruction. Improved to baseline.
# Elevated creatine kinase: On admission, CK was elevated to
3384. This was in the setting of being found down for an unknown
time. Does not quite meet diagnostic criteria for
rhabdomyolysis and CK trending down with fluid resuscitation.
# Toxic-metabolic encephalopathy: Patient came in very
somnolent. He is on many sedating medications at home, and it is
not clear if he took anything prior to coming in. Head CT was
normal. Encephalopathy improved over the course of his
admission to normal baseline mental status.
# Anemia: No obvious acute process at present. Hemolysis labs
normal with low iron and low transferrin saturation suggesting
iron deficiency anemia. He remained anemic at a stable level
during his hospital course, which likely also reflects anemia of
chronic inflammation.
# HIV: Continued home LaMIVudine-Zidovudine (Combivir) 1 TAB
PO/NG BID and Nevirapine 200 mg PO BID. CD4 87, difficulty to
interpret in setting of acute infection and was repeated CD4 up
to 390. VL not detected. Patient will follow up with Dr.
___ as an outpatient for further HIV care.
# Chronic pain: unlikely to represent acute process. Pain
medications that are sedating should be limited in the
outpatient setting, given patient's clinical presentation and
encephalopathy.
# Depression/anxiety: diazepam dosing was decreased during
___ hospital stay, and patient was discharged on a lesser
dose than he had been taking at home. In talking with patient's
outpatient psychiatrist, there have been numerous efforts to cut
back on diazepam as an outpatient. He will follow up with his
psychiatrist soon after discharge.
# B12 deficiency: continued Cyanocobalamin 1000 mcg PO/NG DAILY
ALLERGIES
- Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN congestion | 140 | 891 |
13520806-DS-4 | 24,625,640 | You were admitted for treatment of a pericardial effusion or a
collection of fluid in the sac that surrounds the heart muscle.
We placed a drain to empty the fluid and sent it to be examined.
The drain was pulled and the fluid did not reaccumulate around
the heart. Because of the stress placed on the heart with the
effusion you went into a rapid rhythm called atrial
fibrillation. We placed you on medications to slow the heart
rate down and you converted to a regular rhythm on your own. You
are doing well and are now ready for discharge home. We have
included an updated list of medications. You will have follow up
with Dr. ___ as well as your primary care doctor. | ___ with h/o arthritis and HTN, presented with fatigue and
shoulder pain and was found to have a pericardial effusion with
tamponade physiology, requiring pericardiocentesis. | 124 | 25 |
13247300-DS-3 | 22,470,517 | Dear Ms. ___,
You were admitted to ___ from clinic with unintentional weight
loss due to your pancreatitis and peripancreatic fluid
collections. A feeding tube (dobhoff) was placed and advanced
post-pyloric so that you can receive tube feeding and not
aggravate your pancreatitis. You are now tolerating tube feeds
at goal. You are ready to be discharged back to your rehab to
continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of anorexia and weigh loss
in the setting of pancreatitis. Admission abdominal/pelvic CT
revealed extensive rim enhancing peripancreatic fluid
collections consistent with walled-off necrosis, overall
decreased in size compared with the prior CT scan from ___.
The patient underwent a dobhoff placement and went to ___ for
post-pyloric advancement, which went well without complication.
The patient was hemodynamically stable.
Tube feeds were started on ___ and slowly advanced. The
patient had some nausea at first and the tube feeds were backed
down and advanced at a slower rate until she was tolerating them
at goal. During this hospitalization, 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, tube feeds, 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. | 221 | 204 |
19238806-DS-17 | 25,697,238 | You were admitted with leg weakness and worse confusion. Tests
showed that you had a large stroke that has caused these
problems. The recommended treatment is aspirin. Tests showed
mild increase in the size of your brain tumor. After discussion
with you and your family, you will go home with hospice and
follow up with Dr. ___. | Assessment/Plan:ASSESSMENT/PLAN: ___ yo female ___ metastatic
breast cancer, presenting with worsening cognitive problems and
acute onset of lower extremity weakness. Found to have large
embolic stroke and several smaller strokes in addition to
progression of brain metastases though stroke likely accounted
for her presentation.
.
# Evolving Embolic stroke: Dr. ___ onc) recommends
ASA only. Advised that the risk of hemorrhage was too great for
more intensive anticoagulation. Started ASA 325 daily after
discussion with her family, primary oncologist, and neuro
oncology. Discontinued megace given its prothrombotic side
effects. Informal consult with endocrine regarding steroid
replacement in setting of stopping her megace who recommended to
start prednisone with a taper to avoid addisonian symptoms.
.
# Goals of Care: Reviewed MRI findings ___ in detail with Drs
___ with the concensus to offer treatment with ASA.
Dr. ___ NOT recommend anticoagulation due to high risk
of hemorrhage into the infarct. Meeting with the pt's husband
and her son from ___ regarding MRI findings and
recommendation for ASA only due to risk for hemhorrage. MRI
findings were discussed with the patient with her family
present. She had difficulty understanding the findings and their
implications given her cognitive deficits from stroke and white
matter disease post radiation. However, the family decided to
take her home with hospice care and the patient was agreeable to
returning home. The patient remained DNR/DNI no FICU transfer.
Continued foley catheter at discharge. continued trazadone and
ativan prn. continued oxycodone for pain. discharged to home
with hospice.
.
# Met breast cancer: MRI with contrast confirmed disease
progression of dominant cerebellar met as well as large infarct.
Care will be supportive as the family wished to proceed with
hospice.
.
# Metabolic encephalopathy/ leukoencephalopathy due to brain XRT
and new stroke: Decompensation due long term effect of two full
courses of whole brain radiation in an elderly woman with
contribution from embolic stroke and minimal disease
progression. We will not pursue further work up of embolic
sources given goals of care. ASA 325 mg one daily. DC megace.
.
#. Lower extremity weakness: Likely due to severe apraxia per
neuro oncology. Prior to definitive MRI, Received Thiamine IV x
2 days. B12, folate and TSH were all WNL. no further work up per
goals of care. Treated UTI.
.
#. UTI: Treated with bactrim. Foley placed per goals of care.
#. HTN: continued home amlodipine and metoprolol
# anxiety: continued alprazolam prn and ativan
.
CODE: DNR/DNI after discussion with husband (HCP) son and
daughter on ___ .
. | 57 | 417 |
17692947-DS-10 | 23,680,445 | Ms. ___, you were admitted for treatment of endometritis.
You were given IV antibiotics. You will need to continue taking
an oral antibiotic (Doxycycline) for the next ___ days.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex)for 2
weeks
* You may eat a regular diet | Given fundal tenderness and elevated WBC, Ms. ___ was
admitted to the GYN service for treatment of endometritis. She
remained afebrile throughout her stay. A pelvic ultrasound was
negative for retained products. She received 24 hours of IV
gentamicin, ampicillin, and clindamycin. She reported ___
episodes of emesis which improved with IV zofran. She was
tolerating PO prior to discharge, and reported improvement in
pain after receiving Percocet. She was discharged home on
hospital day #2 in stable condition and was prescribed a 10 day
course of doxycycline. | 90 | 90 |
16982643-DS-12 | 23,900,735 | You were admitted to ___ on ___ with a left thigh abscess,
which required an incision and drainage, followed by wound
exploration in the operating room. You will be discharged home
with a wound vac in place. Visiting nursing assistance will be
provided, and will change your wound vac every three (3) days.
If you have any signs on wound infection, fever, chills, redness
surrounding the wound, discharge from the wound, or other
symptoms, please call your doctor, or go to the ER.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
PAIN MANAGEMENT:
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently. Do not
take Plavix; this medicine was stopped during your hospital stay
and you do not need to resume it as an outpatient. You should
follow up with your primary care doctor for further management
of your regular medicines.
If you have any specific questions about what medicine to take
or not to take, please call your surgeon. | Mr. ___ was admitted to ___ on ___ for a left anterior
thigh abscess, reporting ___ pain. He states that this occurred
while he was gardening, and struck his leg on a fence post 1
week prior. He was taken to the operating room on the afternoon
of ___. An incision and drainage of the abscess was
performed, along with exploration of the abscess. wound cultures
were sent at that time as well. He was transferred to the floor
at that time, and was doing well. The following day Mr. ___
was taken back to the operating room for re exploration of the
abscess, with a washout, debridement, and wound vac placement.
Again he continued to do well on the floor. However, wound
cultures returned positive for multiple bacteria. He was started
on IV linezolid and meropenem and changed to oral linezolid. On
the afternoon of ___, he began to have diffuse swelling and
pain from his left knee to his scrotum. The entirety of his left
leg was erythematous, but not warm. Hr was taken back to the
operating room, and the wound was explored and the wound vac
discontinued. Throughout the rest of his hospital stay he
continued to improve. On ___ Mr. ___ had improved to the
point where he could be discharged. He was afebrile, his pain
was well controlled, and was able to ambulate with independence.
He was given oral pain medications, which he tolerated well, and
was discharged following 5 days of antibiotics. | 495 | 250 |
16151061-DS-13 | 25,687,585 | Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had acute diarrhea with blood in the stool.
====================================
What happened at the hospital? What needs to happen when you
leave the hospital?
====================================
-You underwent imaging scan of the abdomen which showed colitis
in the descending colon, which is inflammation in the lining of
the intestine.
-We cannot easily determine the exact cause of this
inflammation, but it is usually because of an infection (usually
a virus or bacteria) or an overactive immune system (such as an
inflammatory bowel disease like ulcerative colitis or Crohn's
disease). What we recommend is treatment for a presumed
infection with antibiotics for 7 days, and then if the symptoms
never persist or come back, it is probably a self limited
infectious cause. However, if your symptoms continue for many
days after this acute episode, you will need to see the
gastroenterologist (a specialized stomach doctor) in the office
for further testing for possible inflammatory bowel disease. You
have an appointment with your primary care physician's office
next week to follow this up.
-We also saw on the CT scan of the abdomen a possible blood clot
in a vein that travels in the liver area. We checked the same
area with an ultrasound test that can look to see if the blood
is flowing normally there (it would not, if a significant blood
clot is present). The radiologist informed us that this
ultrasound test shows the blood is actually flowing normally, so
it seems unlikely that there is a real blood clot there.
HOWEVER, if you experience sudden worsening of abdominal pain,
or new nausea or vomiting, this can mean you actually have a
blood clot, which would require you to return to the emergency
department for re-evaluation.
-The blood in your stool is expected to be seen in an
inflammatory or infectious cause of your colitis. Fortunately,
your blood counts on your lab draw was normal and indicates that
the blood that you have passed in your stool has been a very
small amount.
-Pay attention to your symptoms. If you experience any of the
following or any other symptom that worries you, you should
return to the emergency department right away:
___ blood or something that looks like coffee grounds
___ a bowel movement that looks like tar or has a lot of
blood in it
___ weak, light-headed, or woozy
___ a racing heartbeat
___ severe belly pain
___ much paler than normal
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | ___ year old female with no significant past medical history
presented with 1 day of acute onset bloody inflammatory diarrhea
and abdominal cramping.
#Colitis, infectious versus inflammatory
#Question of portal vein left branch thrombus
-Her diarrhea did not recur on admission so no stool culture or
sample was able to be collected.
-Continue empiric
PO ciprofloxacin and PO metronidazole for ___t
home.
-H/H is normal. She did not have clinically significant
bleeding.
-The patient tolerated oral diet well without any nausea or
worsening abdominal pain.
-Patient will need GI referral and possible colonoscopy for
evaluation of inflammatory bowel disease, if any symptoms
persist
after resolution of this acute episode as an outpatient.
-CT A/P shows descending colitis and possible left portal vein
thrombus in segment 3.
-I spoke to the radiologist after we obtained a Doppler
abdominal
US on ___. Preliminarily, the Doppler ultrasound shows no
thrombus and patent flow throughout
the visualized portal vasculature. Given that the patient has no
evidence of cirrhosis on exam or imaging and with normal liver
panel, no family or personal risk factors for
thrombophilia, combined with the Doppler US results, I do not
think she has a significant acute portal vein thrombus. No
anticoagulation is
indicated at this time. I explained this to the patient who also
understood my instructions that if she were to develop worsening
abdominal pain or new nausea, she would need to return to the
emergency department for re-evaluation. I also sent a secure
email to the PCP regarding the hospital course and discharge
plan/instructions. She is arranged for PCP follow up next week.
-Urine hcg was negative
Greater than 30 minutes was spent on discharge planning and
coordination | 430 | 258 |
16133115-DS-22 | 23,568,178 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-Your fistula was clotted and your potassium level was high
WHAT HAPPENED IN THE HOSPITAL?
-You had a temporary dialysis line placed to receive dialysis
-You had a fistulogram to unclog your fistula
WHAT SHOULD YOU DO AT HOME?
-Follow-up with your doctors as ___
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | ___ year-old man with ESRD ___ IgA nephropathy undergoing
transplant workup on HD ___, ___ s/p L nephrectomy, severe
aortic stenosis w/ planned aortic valve replacement (on hold as
developed recent URI), chronic atrial fibrillation on warfarin,
who presented w/ clotted fistula and hyperkalemia admitted for
dialysis
#HYPERKALEMIA: Secondary to not receiving dialysis, 8.0 on
admission peaked t-waves on ECG. S/p 2g calcium gluconate,
insulin & dextrose in ED w/ improvement to 6.9. Admitted for HD,
with K 4.8 on discharge.
#CLOTTED FISTULA: Fistula w/o thrill and not working at HD. Had
temporary HD line. Fistulogram performed ___ with thrombectomy
of clotted LUE brachiobasilic AV fistula and resultant positive
thrill.
#ESRD ON HD: ___ IgA nephropathy, undergoing transplant work-up.
Had HD ___ while inpatient. Renal recommended resuming
normal HD schedule ___. Continued lanthanum and cinacalcet. Plan
to resume outpatient HD on ___.
#ATRIAL FIBRILLATION: Chronic atrial fibrillation on warfarin.
CHADS2-VASc 0. INR subtherapeutic on admission. Reports INR
generally 1.5-2.5. Rate controlled on digoxin, metoprolol.
Continued on home warfarin dosing, INR 1.3 day of discharge.
Will f/u with PCP for titration. | 71 | 176 |
17235040-DS-14 | 26,473,446 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
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:
- History of smoking
- Slightly elevated cholesterol
We are changing your medications as follows:
- START Aspirin and continue this indefinitely
- START Plavix and stop taking it on ___
- START Atorvastatin 40 mg every night
- START Midodrine 15 mg in the morning and 10 mg at night
- START Bowel medications to help with your constipation
Please take your other medications as prescribed.
Part of the reason your symptoms continue to happen is because
your blood pressure drops when you sit or stand due to your
___ disease. When your blood pressure drops, blood can't
push past the narrowed vessel in your brain. This leads to
decreased oxygen supply to the part of the brain that is
involved with speech. It is important that if you have these
symptoms, you lay down immediately until your symptoms resolve.
If they DON'T resolve after 30 minutes to one hour, you should
call your neurologist and/or go to the emergency room as you may
be having a stroke.
To help with your low blood pressure, you should wear the
compression stockings during the day, especially when you are
sitting, standing or walking. Additionally, you should wear and
abdominal binder. Eat salty foods and hydrate often. Take your
midodrine at 8am (or when you get up in the morning) and around
midday. Do not take it if you plan on being sedentary, because
this can cause high blood pressure.
It is okay to take an extra dose of midodrine 5mg if you plan to
be up for an extended activity, appointment, etc.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden 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
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with PMH of ___
disease who presented with 3 weeks of self-resolving aphasia
spells, one of which was associated with right arm weakness,
subsequently found to have left MCA thrombus, atherosclerotic
plaque vs. stenosis and scattered subacute/chronic foci in left
MCA territory. | 484 | 51 |
11119839-DS-13 | 20,065,832 | You were admitted to the hospital with abdominal pain. You
underwent a cat scan of the abdomen which showed numerous
gallstones. You were taken to the operating room where you had
your gallbladder removed. You are slowly recovering from the
surgery. You are preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites. | The patient was admitted to the acute care service with right
upper quadrant abdominal pain. Upon admission, he was made NPO,
given intravenous fluids, and underwent imaging. A cat scan of
the abdomen done at an outside hospital showed stones near the
common bile duct. He underwent an ultrasound of the gallbladder
which showed a distended gallbladder with stones in the neck.
Because of these findings, he was taken to the operating room
for a laparoscopic cholecystectomy. His operative course was
stable with a 50cc blood loss. He was extubated after the
procedure and monitored in the recovery room.
The post-operative course has been uneventful. He was started
on clear liquids with advancement to a regular diet. His vital
signs have been stable and he haas been afebrile. His surgical
pain has been controlled with oral analgesia. He is preparing
for discharge home with instructions to follow-up with his
primary care provider and with the acute care team member. | 275 | 171 |
12140206-DS-17 | 26,782,912 | Dear Ms. ___,
You were admitted to the intensive care unit after you were
found on the ground. You had a breathing tube placed and this
was removed. You were treated for a pneumonia while you were ___
the hospital.
When you leave the hospital, you should take the antibiotic that
you have been prescribed (Bactrim) twice a day, according to the
directions found on the label. You need to take this antibiotic
to complete treatment for your pneumonia until ___.
___ addition, you should call your primary care doctor's office
on ___ to schedule an appointment within 2 weeks
from discharge from the hospital. We encourage you to call your
psychiatrist's office and schedule an appointment within 2 weeks
as well. ___ addition, please call ___ to make an
appointment with a pulmonologist at ___ for treatment of your
COPD.
Please seek medical care if you develop trouble breathing, chest
pain, or fever >102 degrees Fahrenheit.
We wish you the best ___ your recovery,
Your ___ care team | ___ woman with history of COPD, bipolar disorder,
anxiety, polysubstance abuse with prior suicide attempts who
presented as a transfer from ___ after being found down
with concern for possible toxic ingestion, found to have
pneumonia and possible COPD exacerbation.
==========================
Hospital Course by Problem
==========================
# Acute hypoxemic respiratory failure, resolved
# Pneumonia, aspiration
She was initially intubated for airway protection after found
down at grocery store, minimally responsive. No improvement
with narcan. Reported to have been found with drug
paraphernalia. Patient denied drug overdose, either intentional
or unintentional, and doesn't recall the details prior to
admission. ___ ICU, she was extubated uneventfully and was
weaned to room air. She was found to have an E Coli PNA,
presumed aspiration. Initially, she was covered broadly for her
pneumonia with vnac/cefepime/doxy. Azithromycin deferred due to
prolonged QTc. Her sputum culture grew E. coli and GPCs;
antibiotics were narrowed to cefepime. She received nebulizer
treatments and used her home inhalers as needed. She received
two doses of prednisone 40 mg PO but this was discontinued as
COPD exacerbation was felt less likely, and given her breathing
had improved to her baseline and her O2 saturations were ___ the
mid to high ___ on room air. At the time of discharge, she was
breathing comfortably on room air and ambulating well without
dyspnea. She was prescribed a 7-day course of
trimethoprim-sulfamethoxazole (Bactrim) at discharge to be
completed as an outpatient since fluoroquinolones weren't an
option ___ prolonged Qtc (457).
# Psychiatric: Patient denies SI/HI at present. Patient's
parents recently died. She has history of multiple overdoses
(clonazepam), self-injurious behavior (cutting). She follows
with an outpatient psychiatrist every ___ weeks. She was seen by
Psychiatry who also found the context of her being found-down
unclear. There was no definite evidence that it represented an
overdose or a suicide attempt. They concluded that she does
possess multiple risk factors for dangerous behaviors following
discharge, including history of overdoses (both unintentional
and deliberate), history of psychiatric hospitalizations, and
ongoing substance misuse (which she does appear to be minimizing
on interview); but believed that these factors were sufficiently
mitigated by the fact that she currently denies an acute
worsening of depressive symptoms, denies suicidal thoughts, is
connected to outpatient treatment, has strong social supports ___
the form of family and committed partner, and has a pet to whom
she feels responsible. They did not believe psychiatric
hospitalization was warranted at this time. She was offered
higher (voluntary) levels of psychiatric care, including crisis
stabilization and partial hospitalization, but declined these
for after discharge. During her hospitalization she was
continued on her home psychiatric medications: Lamotrigine,
Clonazepam, Aripiprazole, Fluoxetine, Quetiapine fumarate.
# Toxic-metabolic encephalopathy: Patient initially found
confused, concern was for toxic ingestion. Utox was positive for
benzos and THC. Non-contrast head CT scan was unremarkable. Her
EEG was without seizure activity. Her altered mental status
during the hospitalization was thought to be most likely related
to infection vs. ICU delirium. At the time of discharge her
confusion was resolved. She was oriented to person, place, and
time. She was goal oriented and expressed an understanding of
her condition and the treatment that she was receiving.
==========================
Transitional Issues
==========================
1) She should complete a 7-day course of Bactrim to complete the
treatment of her pneumonia, to end on ___.
2) She should schedule a follow-up appointment with her primary
care doctor within 2 weeks of discharge (Dr. ___
___.
3) We encouraged her to schedule an appointment with a
pulmonologist for further management of her COPD. She has not
seen a pulmonologist ___ ___ years.
4) She should schedule a follow-up appointment with her
psychiatrist (Dr. ___
___ ___ Counseling) within 2 weeks of discharge from
the hospital. ___ the future, she should likely not be prescribed
any benzodiazepines given her history of overdose. | 171 | 635 |
11878137-DS-9 | 24,597,675 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you had lost
consciousness. We did extensive testing to identify the cause of
your loss of consciousness all of which did not identify a
cause. We consulted the cardiologists who believe that this may
be related to problems with your heart rhythm. We stopped your
sotalol and replaced it with a new medication called metoprolol
which you should continue taking.
You will leave the hospital with a device that you should wear
throughout the day to monitor for abnormal heart rhythms that
may be causing your symptoms.
You should follow-up with your cardiologist within ___ weeks of
leaving the hospital.
We wish you a speedy recovery,
Your ___ Care Team | Mr. ___ is a ___ man with history of persistent
atrial fibrillation ___ cardioversion in ___, mitral valve
prolapse/regurgitation ___ mechanical mitral valve placement in
___ now on warfarin, CAD ___ CABG also in ___, HFrEF (EF
43%), hypertension, prior h/o stroke in ___, duodenal ulcer
___ billroth II in ___, and recent hospitalization for
hemorrhagic hepatic cysts ___ ___ drainage who presents as a
transfer from an outside hospital after an episode of syncope
and reported non-fluent aphasia on ___.
ACUTE ISSUES
# Syncope:
Etiology of the syncope remained unclear. Cardiac enzymes
reassuring against ACS. TTE without clearly explanatory
findings. Orthostatic vital signs negative. Low suspicion for PE
in the absence of suggestive signs or symptoms and given
therapeutic anticoagulation. In the context of report of
accompanying transient aphasia, resolved by the time of
admission and without other neurologic deficits, he was seen by
neurology, with low suspicion for neurogenic etiology, hence EEG
or brain MRI not advised; noncontrast head CT without acute
intracranial abnormalities, and carotid ultrasounds without
clinically significant stenosis. He was seen by the
electrophysiology service, with syncope not felt to be clearly
cardiogenic; his symptoms were not felt to be consistent with a
conversion pause, and he did not report prodromal symptoms
clearly suggestive of causal tachyarrhythmia. At the suggestion
of electrophysiology, sotalol was discontinued in favor of
metoprolol XL, uptitrated to 50mg daily prior to discharge.
Hdischarged with ___ event monitor and scheduled for F/U with
___ Cardiology.
# Liver Cyst:
Recently hospitalized (___) for management of a hemorrhagic
cyst that was aspirated with no growth on microbiology and
negative cytology. On this admission, he reported occasional
mild pain in the RUQ similar to that which he had prior to
hospitalization in ___. CT abdomen on this admission
revealed mild/moderate intrahepatic bile duct dilation with
compression by known hepatic cyst. Although formal image report
mentions recommendation for MRCP, in review of serial imaging by
radiology, including MRCP performed at ___ in ___,
radiology advised that hepatic dominant cyst had recurred,
advised no further imaging. Interventional radiology was
consulted, with repeat drainage not felt to be useful, given
recurrence within a month, surgery consult advised. Surgery was
consulted, and there was felt to be no immediate indication for
intervention. Follow-up with Dr. ___ was advised for
evaluation of surgical removal of the liver cyst.
# Hyponatremia:
He experienced transient hyponatremia to 129-31 of uncertain
etiology that normalized without dedicated intervention. He had
no neurologic deficits.
CHRONIC ISSUES
# Atrial Fibrillation/Atrial Tachycardia:
He was transitioned from sotalol to metoprolol as above.
Therapeutic anticoagulation with warfarin was continued as
below.
# Mitral Valve Prolapse | Severe MR ___ Mechanical Mitral Valve
Replacement
Warfarin with goal INR 2.5-3.5 was continued.
# CAD ___ CABG x3
Home aspirin and atorvastatin were continued.
# Hypertension
Home lisinopril was continued.
# Chronic normocytic anemia
History of small intestinal resection with Billroth procedure in
___ due to duodenal ulcer. Hgb remained stable and consistent
with recent baseline at 11.4-12.
Ferrous sulfate, pantoprazole, and sucralfate were continued. | 123 | 487 |
19103658-DS-5 | 28,419,791 | 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 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- TDWB
Physical Therapy:
TDWB RLE
Treatments Frequency:
Dry sterile dressing to wound if oozing, change daily | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on <<>> for <<>>, 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
patients home medications were continued throughout this
hospitalization.
Cardiology and Geriatrics Teams followed Mr. ___ while
inpatient. Their medication regimen changes were implemented.
Cardiology recommended the pt maintain a Hct 26 or higher, with
goal of Hgb 8.5-9.5. He received prbc transfusions on POD#2 and
4 to maintain this goal. His angina was well controlled with his
home dose nitropatch.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient 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 TDWB in the right lower extremity,
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. | 161 | 287 |
11457437-DS-16 | 28,191,882 | -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.
-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.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-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)
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | Mr. ___ was admitted to Dr. ___ service with a
left 6mm proximal ureteral stone and ___, cr 1.6. He was
prepared for operative intervention hospital day two. While
awaiting intervention his creatinine improved, pain improved and
thus the urgent intervention was cancelled in favor of elective
procedure as outpatient in the near future. At discharge on
HD2, Mr. ___ pain was controlled with oral pain
medications, he was tolerating regular diet without nausea,
ambulating without assistance, and voiding without difficulty.
He was explicitly advised to follow up as directed for
definitive management. | 285 | 95 |
17875843-DS-6 | 21,527,627 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because you had a car
accident, in which you sustained right sided rib fractures and
had fluid in your right lung space. You had a tube placed to
drain the fluid. After the fluid was drained, the tube was
removed, and your lung is fully expanded.
You then developed an infection, caused by a gallstone. This
stone was removed, and you were treated with antibiotics for it.
You will continue your antibiotics until ___.
You were seen and evaluated by the physical therapists who
assessed your gait and stability. You are now ready to be
discharged to rehab to continue your recovery.
Please note the following discharge instructions related to your
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.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please continue to take all medications as prescribed.
We wish you the very best!
Warmly,
Your ___ Team | Mr. ___ is a ___ y/o man with a PMH of coronary artery
disease s/p CABG (___), stroke (___), numerous squamous cell
carcinoma, hypertension, hypertension, diverticulosis with GI
bleed, chronic systolic heart failure w/ severe mitral/tricuspid
regurgitation, moderate aortic regurgitation, severe pulmonary
hypertension, cardiac amyloidosis, and atrial fibrillation (not
on anticoagulation), transferred from ___ s/p motor
vehicle accident with blunt trauma and three rib fractures and
pleural effusion concerning for hemothorax.
# Rib fracture. Right rib fractures ___. Pain was controlled
with acetaminophen and tramadol. He required no operative
intervention.
# Cholecystitis/choledocholithiasis. He was found to have
leukocytosis to 20, with CT demonstrating choledocholithiasis
and findings compatible with concurrent cholecystitis. He
therefore underwent ERCP with successful removal of his stone.
He was initially treated broadly with vancomycin, cefepime, and
metronidazole; these were subsequently narrowed to
ampicillin/sulbactam, and he was discharged on a total 7 day
course of amoxicillin/clavulanate, to be completed ___.
# Acute toxic metabolic encephalopathy. He subsequently
developed delirium thought to be acute toxic metabolic
encephalopathy from pain and infection. Was initially agitated
requiring Haldol and subsequently transition to hypoactive
delirium. Delirium cleared after treatment of his infection and
improved PO intake.
# Pleural effusion/traumatic hemothorax. Chest tube was placed
for his pleural effusion, which was found to be transudative in
nature and thought to be secondary to decompensated heart
failure. His chest tube was successfully removed with resolution
of his effusion.
# Acute, decompensated systolic heart failure. Found to have
___, with proBNP of 11,000 and evidence of volume overload on
examination. He was actively diuresed with 20 mg IV Lasix to a
dry weight of 46.5 kg. TTE demonstrated reduced LVEF 45-50% with
regional systolic dysfunction c/w CAD. He had a troponinemia
that peaked to 0.08, with no chest pain. Lisinopril was held
because ___ and not restarted owing to normal blood
pressures. No beta blocker was started because of history of
bradycardia.
# Acute kidney injury. He also had a mild acute kidney injury to
Cr of 1.4, which was also thought to be cardiorenal and improved
with diuresis. Cr of 1.2 on discharge.
# Hypernatremia. He was found to have hypernatremia to 148,
which was thought to be due to volume contraction from reduced
PO intake. He received 500 cc D5W.
# Left anterior fascicular block. He was also found to have a
left anterior fascicular block, which was new from his prior
EKG. TTE as above. No ACS.
==============
CHRONIC ISSUES
==============
# Coronary artery disease. He was continued on simvastatin 40 mg
daily. Aspirin 81 mg daily was held because of ERCP, to be
restarted on ___.
# Atrial fibrillation. He was continued on digoxin, but the dose
was reduced to 0.0625 mg q.o.d. because of elevated levels and
age.
# Hypertension. He was continued on his home nifedipine for
hypertension. Lisinopril held as above.
.
===================
TRANSITIONAL ISSUES
===================
# Discharge weight: 46.5 kg
# Discharge Cr: 1.2
# Antibiotic course. Will be on Augmentin for a total 7 day
course (to end ___.
# Medication changes. Digoxin dose reduced to 0.0625 mg q.o.d.
Aspirin held until ___. Lisinopril stopped for ___. Please
restart at your discretion. Antibiotics as above.
# Digoxin level. Level noted to 1.3; dose reduced. Please
recheck on ___.
# Hypernatremia: Noted to have sodium to 148 on day of
discharge, likely from free water deficit. Given 500cc D5W and
encouraged to drink. Please repeat sodium on ___.
# Please repeat CXR in 4 weeks. If persistent right pleural
effusion, consider need for further work-up as outpatient for
transudative effusion.
# Heart failure. Diuresis held given free water deficit. Please
resume at your discretion.
# Hypophosphatemia. Will receive three more doses of phosphorus
250 mg to complete ___. Please recheck phosophorus level on
___.
# Aspirin. Held for ERCP. Please restart ___.
# CODE: DNR, OK to intubate
# CONTACT: CONTACT/ HCP: ___ (wife) ___,
___ Daughter ___- daughter- ___ | 319 | 645 |
12271567-DS-5 | 20,985,638 | Ms ___,
You were admitted with pain and shortness of breath after your
procedure. You may have a pneumonia. You improved with pain
control and antibiotics. It is important to take your medication
and continue to take deep breaths. Please follow up as directed. | Ms ___ is a ___ yr old female with longstanding metastatic
hormone receptor positive breast cancer diagnosed ___, status
post right mastectomy and left removal of metastatic lesion on
long-term therapy with Lupron and tamoxifen.
# Pneumonia - Pt presents w/ fever and new infiltrates on
imaging. Likely in setting of atelectasis/effusion post RFA. She
received vanco/zosyn in the ED and was transitioned to PO
Levofoloxicin and she improved. She will compete a 5 day course
with the first dose on ___.
# Pleural effusion - Developed post RFA. Given excellent control
of her disease more likely post-procedure than malignant. It
appears small. She was seen by ___ who did not feel that it was a
hemmoragic effusion and it was unclear what sampling it would
change management. Her pain was controlled and she as stable for
discharge from the hospital. She should have follow up imaging
in ___ weeks to see if she has interval change in her effusion.
If continues to be present the she may require diagnostic
sampling.
# Metastatic breast cancer - post mastectomy w/ solitary hepatic
lesion now s/p RFA ___. Has had excellent control w/
longstanding tamoxifen/lupron.
- Continued while in the hospital.
# Constipation- in setting of recent narcotic use last ___ 5 days
ago
- Started colace, senna, miralax and up titrate as needed. | 43 | 224 |
18179260-DS-21 | 29,940,456 | 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 had chest pain
and were found to have a in-stent restenosis of a previous stent
in your heart's artery
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a scan called CT Angiography that looked for clots in
the lungs, which it did not find.
- You were started on medications to help thin your blood
- You underwent cardiac catheterization that allowed us to map
your blood vessels. We saw there was a blockage in one of the
arteries in a former stent that was placed. We placed a second
stent in that artery to help keep the vessel open
- After the procedure your chest pain had gotten better
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- If you are experiencing new or concerning chest pain that is
coming and going you should call the heartline at ___.
If you are experiencing persistent chest pain that is not
getting better with rest or nitroglycerine you should call ___.
We wish you the best!
Your ___ Care Team | SUMMARY STATEMENT:
==================
Ms. ___ is a ___ with CAD s/p CABG ___, L.
radial graft - PDA) and complex PCI with ___. Cx with 60% LAD
jailing, iCM (55-60%) who presented with unstable angina and EKG
changes concerning for posterior ischemia with negative
troponins. She subsequently underwent cardiac catheterization
and was found to have ISR w/ component of thrombus of LCx, now
s/p DES to LCx. On day of discharge patient was optimized for
medical management and chest pain free. | 217 | 79 |
11492378-DS-5 | 22,489,748 | Dear Mr. ___,
You were admitted to the hospital after being transferred from
the ___ with a new abnormality on a CT
scan of your brain and urinary retention.
The abnormality on your head scan was concerning because it
could represent a cancer. We performed a variety of tests to
determine the cause, including a brain MRI, MRI of your spine,
two lumbar punctures (spinal taps), and an EEG (test to look at
brain waves). You were also seen by specialist doctors from
___, neurosurgery, and urology.
These tests showed no evidence of cancer or other abnormalities.
However, you will have to follow up with your doctors for
further tests.
Because of your continued urinary retention, we would like you
to follow up with your home urologist as an outpatient for
further testing. It may be that your urinary problems are a
result of benign prostate enlargement, but you will need
additional tests to confirm as well as possible treatments to
improve your symptoms. We started you on a medication called
tamsulosin to possibly help with this symptom.
We read the CT scan of your belly from ___ which
showed possible obstruction of your pancreatic duct. Because of
this, we recommend that you have another scan called an "MRCP"
as an outpatient to further look at this to rule out cancer.
Your primary care doctor should follow this up but we recommend
that you ask about it if he or she does not.
MEDICATION CHANGES
==================
-We increased your phenytoin ER to 400 mg daily from 300 mg
daily because your levels were low
-We started you on a medication called tamsulosin to help with
urinary retention
We wish you the best,
Your ___ Care Team | ___ with PMH of epilepsy and hx of prostate cancer with recent
elevation in PSA who presented as a transfer from an OSH after
being found to have urinary retention and new R ill-defined
frontal lobe lesion on CT head.
#Brain lesion: The patient was noted to have history of gait
abnormality during his visit to an OSH ED for which a CT head
was performed. This examination showed an ill-defined right
frontal lobe lesion concerning for neoplasm versus cerebritis
with meningitis. The patient was transferred to ___ for
neurosurgery evaluation and MRI brain. An MRI brain here also
showed an ill-defined lesion concerning for neoplasm,
post-seizure changes, infection, subarachnoid hemorrhage, or
demyelinating disease. Neurosurgery and neuro-oncology were
consulted, the former recommending further imaging with deferral
to neurology until additional testing had been performed. A
lumbar puncture was performed, which showed no evidence of
infection or SAH, however did show atypical cells on cytology
that were uncharacterizable. Because of this, a second lumbar
puncture was performed with negative cytology and flow cytometry
which was pending at the time of writing this discharge summary.
Because of his history of epilepsy, he had a 24 hour EEG which
showed mild encephopathy but no focal slowing nor epileptiform
activity. The patient should follow-up with neuro-oncologist Dr.
___ (appointment has been scheduled).
#epilepsy: History of epilepsy on phenytoin 300 mg ER QHS,
phenytoin 30 mg QHS (non-ER), phenobarbital 64.8 mg QHS, and
Keppra 750 mg BID confirmed by his outpatient neurologist. He
underwent a 24 hour EEG as above which showed mild
encephalopathy but no focal slowing nor epileptiform discharges.
Neuro-oncology was consulted for his above issue, with levels
for pheyntoin and phenobarbital being performed. His phenytoin
level was low so his extended-release phenytoin was increased to
400 mg QHS from 300 mg QHS. The phenytoin 30mg po qhs dose was
continued unchanged. He was discharged to follow up with
neuro-oncology as well as his neurologist as an outpatient.
#Urinary retention: Patient with urinary retention for one month
prior to admission, presenting to OSH with abdominal pain with
CT abdomen showing enlarged bladder. Foley was placed prior to
transfer. On admission, he was noted to have a UA with pyuria
and no epithelial cells, so was treated with ceftriaxone IV for
two days until his culture came back negative. His CTX was d/c'd
at that time. During his course, we attempted a voiding trial
but his bladder expanded to 700 ml without urination so this was
replaced. An MRI C/T/L spine was performed whcih was negative
for cord compression. Urology was c/s, who felt that this was
likely a mechanical obstruction, and recommended leaving the
foley in place for 5 days prior to performing a voiding trial
and having him follow up for urodynamics with his urologist as
an outpatient. His foley was removed on the day of discharge. He
is due to void by 10pm. If he does not void, the foley should be
replaced.
#Confusion/agitation: Noted to have worsening confusion and
agitation upon admission of unclear etiology. He was able to be
re-directed and per his wife was at his baseline mental status
of A&Ox2 (not to time).
#DVT: One on the right leg - on lovenox at home, recently had a
IVC filter placed. His home Lovenox dose was 100 mg daily,
however this was fractionated to 70 mg q12h during his course.
He was discharged on his home dose of 100mg daily.
#Poor PO intake: Per family, hasn't been eating much over the
past three weeks. Nutrition consult was performed and he was
given Ensure supplements with improvement.
#Hypertension: continued home ramipril 5 mg daily
#Prostate cancer: Treated with definitive radiation therapy ___
years ago, with a possible recurrence at his left S1 neural
foramina treated with cyberknife. At the time of the detection
of his S1 tumor, his PSA had risen to >8. His PSA was checked
this admission and was 3.9. A MSK-protocol S-spine MRI was
performed which showed that this tumor was still present and was
slightly decreased since ___
#S1 nerve sheath tumor: Treated with cyberknife ___.
- MR sacrum with evidence of slight decrease in size of mass
since ___.
#?Pancreatic lesion: OSH abdominal CT with evidence of
dilatation of the main pancreatic duct within the head of the
pancreas. The patient will need an MRCP as an outpatient to
exclude an obstructing mass.
#GERD:
- omeprazole 40 mg daily
#folate deficiency: Continued folate 1mg daily
#Vitamin D deficiency: Continued vitamin D ___ IU daily
TRANSITIONAL ISSUES
===================
[ ] Focal hypodensity within the head/uncinate process of the
pancreas is favored to represent focal fat. However, there is
also associated dilatation of the main pancreatic duct within
the head of the pancreas and therefore, MRCP is recommended to
exclude an underlying obstructive lesion.
[ ] The patient will need a urology follow up regarding his
urinary retention. His foley was removed on the day of
discharge. He is due to void by 10pm. If he does not void, the
foley should be replaced.
[ ] The patient should undergo a bone scan to assess for
prostate cancer recurrence
CODE: DNR, ok to intubate (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: Wife ___ | 276 | 853 |
18262854-DS-12 | 20,241,534 | Dear Mr. ___,
It was a pleasure taking care of you during your admission. You
presented with worsening lower extremity edema and were found to
have a worsening of your congestive heart failure. We gave you
IV medication to help remove the fluid from your body. You are
discharged on Torsemide 60mg BID. Your discharge weight is
134kg.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow up with the appointments below. | Mr. ___ is a ___ gentleman with a history of sCHF (EF
___, thought to be due to senile cardiac amyloid, who
presents with worsening edema, abdominal distention, and SOB
consistent with sCHF exacerbation.
# Acute-on-Chronic Systolic Heart Failure: LVEF ___ on
___. Pt presented with worsening lower extremity edema found
to have acute on chronic systolic heart failure. He was diuresed
with Lasix gtt and metolazone then transitioned to torsemide. He
was discharged home on Torsemide 60mg BID. He was continued on
metoprolol. He was not started on an ACE-I due to ___. His
discharge weight was 134kg.
# Atrial Fibrillation: Patient has a CHADS-2 of 4. He is s/p
failed ablation. He was rate-controlled. He was continued on
coumadin, metoprolol
# ___: Present with acute on chronic kidney disease. This
was most likely due to pre-renal from his CHF exacerbation. Cr
on discharge was 2.2.
# DM: Given limited PO intake patient's insluin was reduced to
glargine 15 mg BID for now. He was maintained on a sliding
scale.
# ___ wounds: Noted to have b/l ___ toe wounds. No osteomyelitis
on cxr. Seen by Podiatry who provided wound care recs.
# HTN - Continued home meds
# BPH - Continued tamsulosin
# Hyperlipidemia - Continued simvastatin
# Chronic Pain: Due to cervical fusion. Patient was seen by
palliative care who recommended splitting up the percocet then
starting patient on oxycontin.
# CODE: Full (confirmed)
# CONTACT: Patient, wife ___ ___
___ issues:**
-recheck INR on ___
-Recheck BMP at PCP ___ (electrolyte and Cr monitoring)
-titrate torsemide dosage prn
-continue goals of life and code status discussion
-titrate pain meds (on oxycontin) | 76 | 288 |
13694829-DS-14 | 25,701,495 | - 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:
- TDWB LLE
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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
___ LLE
Treatment Frequency:
Staples to be removed on POD14
Dressing changes prn drainage | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction and percutaneous
pinning, 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 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
touch-down weight bearing in the left 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. | 247 | 256 |
16367950-DS-19 | 24,327,140 | Dear Mr ___,
You were admitted for obstruction of your bile duct. The stent
you had in place was clogged. This area was cleaned out and
the stent was removed. A new stent was put in its place. You
did well after this procedure. You will need to continue
antibiotics for an additional several days (see below). | Assessment and Plan: ___ with stage 2 pancreatic
adenocarcinoma,
recently s/p CyberKnife radiation therapy, and 5 cycles
gemcitabine monotherapy presents with biliary obstruction.
LFTs were suggestive of biliary obstruction. ERCP was performed
which revealed stones and sludge in stent. The stent had also
migrated. This was removed, the bilary duct was swept, and a
new stent was placed. He did well after the procedure with no
pain. He was able to tolerate POs without difficulty. He will
complete a course of Unasyn as an outpatient. | 65 | 92 |
13209879-DS-8 | 26,916,026 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital for left facial swelling, redness, and
pain. ___ were found to have a cellulitis, likely caused by an
irritation within your mouth. ___ were treated with IV
antibiotics and then switched to oral antibiotics. Your pain
continued and was controlled with oxycodone and low doses of
tylenol.
ENT came and saw ___ and want ___ to follow up closely with them
as an outpatient to ___ for resolution of your symptoms. ___
should also follow up with a dentist to further evaluate tooth
pain.
While ___ were here, your liver tests were noted to be elevated.
___ are likely having a flare of your autoimmune hepatitis. ___
should continue taking your tacrolimus every day and follow up
with Dr. ___ discharge.
An US fluid building up in your right kidney. We think it is
from holding your bladder frequently. It was recommmended that
___ repeat imaging in a few months to look for improvement.
We wish ___ the best of health,
Your medical team at ___ | ___ y/o F with PMHx significant for SCC of the left alveolar
ridge s/p resection in ___, ITP, autoimmune hepatitis on
prograf, DMII who presents with 4 days of left facial swelling,
erythema, and pain.
# Left facial cellulitis: No abscess seen on CT neck. Exam
consistent with cellulitis, possibly due to irritation of gums
from dentures. ENT evaluated and saw granulation tissue but did
not see anything overtly concerning on oral exam. Will need
close follow up with ENT. Panorex did not show any fracture of
jaw. Treated with IV vanc/unasyn and transitioned to augmentin
to complete a 10 day course of treatment (D1 ___, end date
___. She had persistent pain treated with oxycodone 10mg
q6h and low dose tylenol.
# Acute flare of chronic Autoimune hepatitis: LFTs elevated on
admission. Tacro level was undetectable. Pt missed a dose while
in the ED. LFTS trended down. Dr. ___ aware. Likely flare
of autoimmune hepatitits, with uptitration of Tacrolimus and
improved tacro levels her LFTs downtrended to baseline. Will
follow up with Dr. ___ as an outpatient.
# ITP: Chronic ITP, developed in ___. Treated with IVIG,
steroids, and rituxan x2, danzol, weekly romiplostim. Received
weekly romiplastin on ___. Platelets stable >200. Per Dr.
___ can have heparin for dvt ppx, but patient doesn't want
it. Will ambulate.
# Hydronephrosis: RUQ US showed right hydronephrosis. Pt states
that since starting Invokana she has been urinating frequently
and has been holding her bladder. Holding inovakana while
inpatient as non-forumulary. Transitional issue: repeat renal US
to monitor for resolution of hydronephrosis. Ultrasound findings
discussed with patient who cited understanding and will follow
up with outpatient providers for repeat imaging.
# DM2: Chronic, poorly controlled, complicated. Patient reports
that she is allergic to insulin. Did not have receive januvia
or Invokana in house. ___ controlled <250. | 184 | 317 |
10660679-DS-7 | 25,423,116 | Dear Mr. ___,
It was a pleasure being involved in your care. You were
admitted because of a fall. You had a CT scan of your head at
___, which showed a small amount of bleeding in your
brain. You were evaluated by neurosurgeons at ___
___ and it was determined that the bleed is most
likely not an acute process. Repeat CT scans of your head
showed that the bleeding was stable. Your blood thinning
medications were stopped to prevent further bleeding. You will
need to follow up with the neurosurgeons in 1 month.
.
You had an image of your legs done to look for any clots given
your recent hospitalization for clots in your lungs. You were
found to have a clot in the left leg. You underwent a procedure
where a filter is placed in the large vein that drains into your
heart to prevent the clot from traveling to your lungs.
.
Please continue your home medications with the following
changes:
--STOP Coumadin 5mg
--STOP Lovenox ___
--STOP Aspirin 81mg
--Increase gabapentin to 100mg three times a day for pain | This is a ___ gentleman with hx of Alzheimer's dementia,
unsteady gait, AFib on Coumadin, recent bilaterally PE on
Lovenox, and CHF who presents s/p fall with leukocytosis of 17.8
and head CT showing 4mm subdural hemorrhage.
.
ACUTE ISSUES
# Fall, Ataxic gait: The patient's fall was most likely
mechanical given history and his risk factors including
Alzheimer's and unsteady gait. However, given patient's
extensive history of aspiration PNA c/b sepsis, Afib, and CHF,
other causes for syncope needed to be ruled out. Patient did
have a leukocytosis of 17.8 with (87.6% polys). Patient's CXR
does not show evidence of acute process and UA was negative for
infection. Blood and urine culture were sent to rule out
systemic infection but are negative to date. Patient's
leukocytosis was likely a result of his recent high dose steroid
use and recent c.diff infection. His WBC trended down toward
normal during hospitalization. Patient had no evidence of
orthostatic hypotension and no evidence of ischemia on EKG. He
was seen by physical therapy who recommended rehab after
discharge to balance and mobility issues.
.
# SUBDURAL HEMATOMA: It is unclear whether the subdural
hemorrhage is from the patient's most recent fall or prior
injuries. Patient was seen by neurosurgery in the ED and the
___ was thought to be subacute on imaging. Patient's INR on
admission was 2.8 and he was given 2 doses of Vitamin K and one
unit of FFP. Patient's anticoagulation was held as well and his
INR decreased to 1.0 at discharge. On ___, the family
noticed increased slurred speech. Two head CTs done 6 hours
apart on ___ showed a stable (if not improving) bleed. His
slurred speech subsuquently improved. Patient's mental status
remained stable during hospitalization. He will follow up with
neurosurgery in 1 month.
.
# RECENT BILATERAL PULMONARY EMBOLISM: Given patient's recent
history of bilateral pulmonary embolism during his admission on
___, a lower extremity doppler was done to evaluate for
the presence of DVT. He was found to have a thrombus at the
confluence of the left deep femoral vein and femoral vein. A
permanent IVC filter was placed due to contraindications to
anticoagulation. Please follow up with neurosurgery in 1 month
regarding restarting your anticoagulation.
.
# RIGHT FACIAL DROOP: The patient's facial droop was new
according to his wife. It is possible that his lack of ability
to lift his lips and eyebrows on the right side is due to the
swelling of his right face after the fall. There was no evidence
of intraparenchymal hemorrhage in CT. Patient's right facial
droop improved throughout hospitalization as the swelling
decreased.
.
# ATRIAL FIBRILLATION: Patient was on Coumadin on admission,
which was held due to the presence of the subdural hemorrhage.
Patient was monitored on telemetry and was discovered to be
intermittently in and out of AFib. He was asymptomatic and was
well rate controlled.
. | 183 | 497 |
14623286-DS-19 | 25,106,103 | Dear Ms. ___,
You were admitted to ___ and
underwent incision and drainage of an infecton in your left
groin and Wound VAC placement. You have now recovered from
surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Ms. ___ is an ___ female w/ history of CAD, HTN, A-fib, PAD
s/p aorto-iliac stenting. She presented to our institution on
___ for a left groin abscess s/p femoral embolectomy with
femoral cutdown from an outside hospital. On CT scan she was
found to have air in the underlying tissue. Upon admission
patient was started on IV piperacillin-Tazobactam and IV
Vancomycin.
Multiple discussions were had with the patient and her family
regarding the need to proceed with exploration and drainage of
the wound site. During each conversation, her family asked for
more time to consider their options, leading to delay of surgery
by 2 days
She was taken to the OR on ___ for drainage and debridement
of the left groin under general anesthesia. A pus-filled cavity
was found upon incision, superficial and deep tissue was sent
for culture, no arterial involvement or arterial infection was
noted in the OR. The cavity was packed with saline on a Kerlix,
an ABD pad and dry dressing were also placed. Patient was
extubated in the OR and taken to the PACU prior to returning to
the floor. Please see operative report for further details of
procedure.
IV antibiotics and daily BID dressing changes were continued
post-operatively. The tissue collected in the OR grew GNR, GPC
in pairs and chains, patient was switched to ciprofloxacin. On
POD 1 patient had inaccessible lines and was taken for PICC
placement. On POD2 heparin drip was discontinued, patient was
started on her home dose of apixaban and a wound VAC with white
foam in the cavity and overlying black foam was placed. At this
time patient was stable for discharge home with ___ for wound
care. She was tolerating a regular diet, pain controlled on PO
pain med and voiding. | 58 | 295 |
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