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19030295-DS-17 | 24,520,396 | Dear Ms. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You came in
with shortness of breath and fatigue, and were found to have
worsening of your heart failure, most likely because you were
not on a diuretic (a water pill) at home. Your labs did not look
like a new heart attack. You were treated with intravenous
diuretics and oral diuretics to get fluid out of your body, and
your breathing and weight improved. We are starting you on an
oral diuretic to go home with to prevent future symptoms from
extra fluid in your body. You will continue taking lasix (or
furosemide) 40mg daily.
If your symptoms return, or you notice that your weight
increases by more than 3lbs in a day, you should call your
doctor or return to the Emergency Room to be evaluated.
Your medication list, including your new medication, as well as
your future medical appointments are listed below for you.
Please continue to take all of your medications as prescribed
and go to your follow up appointments to monitor how you are
feeling.
Please weigh yourself every morning, and call your doctor if
weight goes up more than 3 lbs. Your weight on your last day in
the hospital was 148 lbs.
We wish you the best with your health!
Sincerely,
Your ___ Care Team | Ms. ___ is ___ yo female with history of CAD (discharged 1
week ago from BI 1 week ago with NSTEMI treated medically), PVD
s/p aortobifem bypass, DM2, CKD, HTN, HL presented with a 1 day
history of dyspnea and fatigue. | 229 | 41 |
15685720-DS-8 | 26,826,383 | You were admitted to the hospital after a CT scan showed fluid
buildup in your lungs and around your heart. You were seen by
cardiology, and while there is a tumor near your heart, it does
not seem to be affecting your heart function right now. You had
a large amount of fluid around your right lung, for which you
had a drainage tube placed. Your breathing was much more
comfortable after this fluid was drained and the catheter was
removed. The fluid may reaccumulate, so if you have shortness of
breath again please call your doctor. You will see
interventional pulmonology in 1 week for placement of a more
permanent drainage catheter. The tumors in your lungs have grown
in size and it is clear that IL-2 did not work to control your
cancer. You are being switched to a different medications called
pazopanib. | The patient was admitted for further workup of his pleural and
pericardial effusions. He had a bedside echo in the ER and then
a formal echo. These showed that he did not have any significant
pericardial effusion and no evidence of tamponade. As such,
there was no need for pericadiocentesis or pericardial window.
There was a large lung mass impinging on the R atrium but not
causing any significant problem at the moment. For the pleural
effusion, the patient was seen by interventional pulmonology on
___ and had a right ___ chest tube placed, as well as biopsy
of a pleural mass. Biopsy was performed to confirm renal cell
origin of tumors, given the rapid growth despite IL-2 therapy.
final results are pending at this time. The chest tube drained
650mL initially. the patient reported an improvement in his
dyspnea. by ___ there was minimal drainage so the chest tube
was pulled. IP will see him in one week to assess for fluid
reaccumulation and consider pleurx placement at that time for
ongoing management. Regarding rapid progression of his renal
cell cancer, discussed with patient and son that this is
unfortunately a bad prognostic sign and that he may have only
months to live. We also discussed that given low burden of side
effects and potential for disease control (albeit low), it is
reasonable to start second line therapy with a TKI such as
pazopanib. The patient was seen by his outpatient oncology team,
given paperwork regarding pazopanib, and the process of ordering
this medication started. He will follow up in 1 week with Drs.
___. | 145 | 267 |
19838860-DS-17 | 20,662,769 | Dear Mr. ___,
It was a pleasure taking care of you!
Why you were admitted:
- You had shortness of breath and cough.
- A chest x-ray showed fluid in your right lung that has been
there for many weeks.
What we did for you:
- Ultrasounds of your legs did not show any clot.
- We drained the fluid from your right chest and set it for
testing.
What you should do after discharge:
- please follow up with your primary care doctor and the
interventional pulmonologist to go over the results of the lab
tests we ran on the fluid in your lungs.
Best,
Your ___ Care Team | Mr. ___ is an ___ y/o m with HOCM, afib on xarelto, CHB s/p
PPM, HFrEF who presents with dyspnea on exertion worsening over
the last three months, sent in by his PCP for evaluation of a
pleural effusion
# Pleural effusion:
# Dyspnea on exertion: Endorses progressive dyspnea on exertion
for the past several months, which may be due to HOCM vs right
pleural effusion vs worsening heart failure (less likely as no
signs of volume overload aside from elevated proBNP). Unlikely
PE despite mildly positive age adjusted d-dimer as he has no new
symptoms, is on rivaroxaban, and no other risk factors; however
CTA to completely rule PE out could not be performed secondary
to his ___. He underwent uncomplicated thoracentesis on ___
and elected to have his results followed up outpatient. He was
discharged after being transitioned back to a decreased dose of
Xarelto in the setting of CKD.
# Acute kidney injury on CKD: Baseline Cr unknown but in ___
was 1.3. Admission cr 1.8 with BUN/Cr ratio > 20. No signs of
infection and no hypotension in ED. We ordered urine lytes and
encouraged PO hydration. His renal function improved to 1.5
prior to discharge, which may be a new baseline for him.
# Paroxsymal atrial fibrillation: Rates stable on home
metoprolol succ 25 mg daily. On home xarelto 20 daily. Held
xarelto with heparin bridge until thoracentesis. Xarelto
restarted post-procedure at a reduced dose as above.
# Hypertrophic cardiomyopathy: ___ be causing his dyspnea on
exertion. He is on Lasix 40 mg PO daily at home. proBNP elevated
to 4700, but chronically elevated to 5000+ in ___. Held Lasix
on admission due to ___ (per notes diuresis recently increased
secondary to effusion). Restarted upon discharge.
# CHB s/p dual chamber PPM: Placed on ___ for CHB. Set to DDR
60-130, recently interrogated in ___
# HLD: Continued home atorva 20 mg daily
# Gout: Held home allopurinol due to ___. Resumed on discharge.
# Presumed COPD: Continued home albuterol prn and spiriva
# Hx of CVA
# Hx of focal seizures
-------------------
TRANSITIONAL ISSUES
-------------------
[] Rivaroxaban dose was decreased to 15 mg daily in the setting
of acute kidney injury. Please resume 20 mg daily dosing once
___ has resolved.
[] Patient underwent thoracentesis on ___. Pleural fluid
studies pending at time of discharge and will be followed up by
Pulmonology.
[] Concern for pulmonary embolism on admission, however lower
extremity ultrasound without deep vein thrombosis, patient on
anticoagulation, normal vital signs, and no acute change in SOB.
If still concerned for pulmonary embolism, please consider
outpatient CTA once renal function normalizes.
[] Please check renal function at next PCP ___.
Discharge Cr 1.5.
#Contact: ___ (Wife, HCP) ___, Son ___
___ | 103 | 445 |
19821716-DS-17 | 27,901,250 | Dear Mr. ___,
You were admitted because you were feeling short of breath and
had weakness. We gave you medications that helped remove fluid
from your lungs to help your breathing. You also had low vitamin
levels that may have contributed to your weakness so we gave you
vitamins. Please follow-up with your PCP and oncologist after
discharge.
For the site of your liver biopsy:
1.Cleanse with wound cleanser, gently pat dry with gauze.
2.Apply sacral Border(heart shape) mepilex to sacral area.
Change Q3 days, PRN.
4. Encouraged Frequent repositioning while awake, Q2 hours.
5. Use Waffle cushion while sitting up in chair& continue to
shift positions while sitting. Support nutrition and hydration.
It was a pleasure taking care of you,
Your ___ Team | Mr. ___ is a ___ with h/o Lynch syndrome and metastatic
urothelial carcinoma who presents for weakness, dehydration and
poor PO intake. It was thought that patient's shortness of
breath and weakness were multifactorial in etiology due to
metastatic disease, volume overload, some days of poor PO
intake, hypocalcemia and hypophosphatemia. Patient was flu
negative and CXR showed no e/o PNA. Patient had evidence of
volume overload on exam and was diuresed with 40 mg IV lasix x2,
with improvement in respiratory status noted. Patient was
subsequently weaned from O2 to RA. Patient's phosphate and
calcium were repleted and patient's diet was supplemented with
Ensure. He was evaluated by ___ and did not have any acute rehab
needs. Patient was restarted on his home diuretics to maintain
euvolemia (he was discharged on Lasix 40 mg daily). Patient's
antihypertensive medications were held given his SBP < 160 with
plans to resume medications as needed as an outpatient. Given
recent dx of widely metastatic cancer and extensive medication
list, patient and PCP were previously engaging in simplifying
medication list prior to admission. Patient was resumed on
metformin on ___ given that he no longer had evidence of ___.
As insulin requirements in house were ___ units per day, he will
lilely no longer require ISS as an outpatient. | 120 | 218 |
16660420-DS-12 | 23,613,982 | You were admitted to ___ on
___ with complaints of abdominal pain. You were
evaluated by the Acute Care Surgery team, who believed you had a
small bowel obstruction. You were initially given bowel rest
(nothing to eat, IV fluids only). Your symptoms improved during
the following days as your bowel function returned and you
tolerated a regular diet. As a result, you did not require a
surgical intervention.
General Discharge Instructions:
You are being discharged on medications to treat the pain. These
medications will make you drowsy and impair your ability to
drive a motor vehicle or operate machinery safely. You MUST
refrain from such activities while taking these medications.
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. | Mrs. ___ was admitted to the inpatient floor for further
management and observation of her small bowel obstruction. She
was kept NPO and IV fluids were initiated. An NG tube was
inserted for gastric decompression. Parenteral narcotic
analgesics were administered for pain control.
Initially, Mrs. ___ nausea persisted despite having the
NGT in place. Gastric aspirate looked bloody, so the patient
was given an intravenous proton pump inhibitor. As her NG tube
output subsequently diminished, a clamping trial of her NGT was
attempted on hospital day three. She had no residual gastric
contents, so her NG tube was discontinued. On day 4, the
patient was started on clear liquids, which she tolerated well.
Mrs. ___ diet was advanced to regular on hospital day 5.
She has had no abdominal pain or episodes of nausea/vomiting. | 248 | 144 |
17734739-DS-20 | 26,740,680 | Dear Mr. ___,
You were admitted to the ___ for stent irritation. Your stent
was removed on ___. During the operation, the interventional
pulmonologists noted a tracheitis for which you received
antibiotics. Your antibiotic course ended ___. While inpatient,
you experienced numerous coughing spells which resolved with
Ativan and pain control. We also optimized your pain regimen to
oxycontin 40mg twice a day with oxycodone 30mg prn for
breakthrough pain.
Your bloodwork showed elevated fungal markers, but we did not
see any signs of infection. We encourage you to follow-up with
your primary care doctor about this.
While inpatient, you also developed abdominal pain, high liver
enzymes, and joint pain. We did a CT of your abdomen which
showed some a large spleen, which according to Dr. ___ was
approximately the same as your baseline. We did NOT find any
evidence of cancer. We did find that you had an EBV viral
infection which puts you at first for a disease called Post
Transplant Lymphoproliferative Disorder, a reactivation cancer.
Please follow up with Dr. ___ this matter.
Additionally, the CT showed us that you have signs of bone
destruction (avascular necrosis) in your hips. MRI showed early
signs of this type of destruction in your knees. This is one of
the known complications of long-term steroid use. Avascular
necrosis may cause you to require orthopedic surgery in the
future. Please continue to have your doctors ___ for
this condition.
Lastly, your blood glucose (sugar) levels were very high. We
suspect that this is from your steroid use. Please follow-up as
an outpatient.
Due to your tracheitis, unfortunately you were unable to undergo
the bronchoplasty on this hospital stay. You should go to
pulmonary rehab and reschedule the surgery in one month.
Please follow up with your outpatient providers and all your
scheduled appointments. Thank you for allowing us to be involved
in your care.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ w/ PMH of CML (___ ___ c/b GVHD; IS),
MRSA PNA/bacteremia, and TM (s/p stent ___ p/w N/V/cough ___
stent irritation. He underwent endotracheal stent removal on
___. Had persistent episodic severe coughing with hemoptysis
following the procedure. Cultures obtained growing MRSA, and he
was treated for a 10 day course of vancomycin with improvement
of his symptoms (___).
During his admission he subsequently developed new LUQ and
epigastric pain with mild transaminitis. A CT scan of his
abdomen demonstrated splenomegaly to 16.7 cm, which is mildly
enlarged from prior. Labs returned demonstrating EBV with a
titer of 7793. CT scan also had findings concerning for
avascular necrosis of the hips on CT.
He developed severe bilateral knee and ankle pain during
admission. An XRay of his knees was obtained that demonstrated
no bony changes, although bilateral effusions. Rheumatology was
consulted and joint was tapped without evidence of infection. An
MRI was obtained which demonstrated bony infarcts of both distal
femurs bilaterally c/f avascular necrosis. Orthopedics was
consulted and felt that he could be discharged with close
orthopedic follow-up at home. His pain was controlled with
Oxycontin 40mg po q12h and oxycodone 30mg po q4h prn. He
occasionally requiring hydromorphine 2mg IV boluses during his
admission for acute onset of pain.
**MICU COURSE ___
================================
#Nausea/vomiting/cough:
#Bronchogenic infection:
#Tracheomalacia s/p stent ___:
Cough likely secondary to residual irritation from stent
tracheitis and nausea/vomiting is post-tussive. He was started
on oxycodone 30 mg q4h PRN and standing dilaudid for chest pain
before transitioning to a dilaudid PCA for better control. He
was also given lidocaine nebulizers and benzonatate 100 mg TID.
A CT chest showed bronchogenic infection. Interventional
pulmonology was consulted and removed his endotracheal stent on
___. ID was consulted and he was started on vancomycin. After
his stent removal, he was called out to the floor the next day.
On the floor, his dilaudid PCA basal rate was discontinued and
he had a concerning coughing fit that transferred him back to
the MICU, when he was called out again the next day after
restarting his dilaudid and started gabapentin.
#Chronic myelogenous leukemia (___ ___ c/b GVHD): Continued
home dex 4 mg BID, Bactrim DS, acyclovir, posaconazole. Dosed
tacrolimus for goal of ___.
#Atrial fibrillation:
Intermittently with AF/RVR in the setting of coughing fits. He
spontaneous converted to sinus within minutes. He was continued
on home coreg 25 mg BID.
#Depression:
Continued home paxil 20 mg qd
**INPATIENT MEDICINE COURSE ___ - **
================================
#Tracheobronchomalacia c/b Tracheitis: As above, the patient was
continued on vancomycin for MRSA positive cultures for a total
of 10-days. While on the floor he had intermittent coughing
spells c/b hemoptysis. Improved with IV hydromorphone and
lorazepam as needed. He was placed on Bipap at night, and should
have a sleep study set up as an outpatient. His symptoms
resolved during admission. Should be set up with outpatient
pulmonary rehab with plan for repeat surgical evaluation by
thoracics in one month.
#Abdominal pain: On ___ reported new epigastric and LUQ
abdominal pain. A CT scan of his abdomen was performed which
demonstrated splenomegaly to 16.7 cm. On review of his home
records his prior splenomegaly had been 16.2cm. Serologies sent
that returned positive with EBV with titer of 7793. Lactates
were elevated, although blood pressure remained normal, and this
resolved with IVF. Felt to be unlikely ischemic abdominal
events. CMV negative. Patient refused HIV testing. Lactate ___
was 7.4 and ___ was 4.9. Daily uric acid and LDH were trended
and were unremarkable. Blood smear x 2 were reviewed by
hematology/oncology consult and did not show evidence of blasts
or recurrent AML. This should be followed up as an outpatient.
___ be related to underlying hereditary spherocytosis. Per ID,
he could be at risk for Post-Transplant Lymphoproliverative
Disease given degree of positive EBV, therefore this should be
followed up as outpatient.
#Avascular Necrosis: Patient reported joint pain and knee pain
on ___. Initially concerning for viral process given concurrent
abdominal pain. His knee pain persisted and became very severe
during hospitalization. Xrays obtained of his knees bilaterlly
which demonstrated effusions. Rheumatology was consulted and
tapped his right knee without any evidence of infection. MRI
obtained that demonstrated multiple distal femur infarcts c/f
avascular necrosis. Also noted to have likely AVN of bilateral
hips on CT, although did not complain of hip pain. He was
evaluated by Orthopedic Surgery who recommended outpatient
follow-up with Orthopedics and physical therapy.
#Thrombocytopenia. Slight downtrend to a nadir of 86 on ___.
Baseline in 130s, although this reportedly baseline for the
patient. Low suspicion for HITT based on 4T score of 3.
#Elevated B-glucan and galactomannan: Beta glucan and
galactomannan came back positive (450, 0.57), but felt unlikely
to have invasive aspergillosis given lack of fungi on bronchial
washings and on long-term posaconazole. Urine histo antigen
negative. Ophthalmology consulted and not concerned about fungal
eye infection, however felt he needed eye exam for glasses as an
outpatient. Tracheal stent material per IP was silicone covering
a nitinol scaffold with a string, so the stent is unlikely to be
the cause of false elevation of fungal markers. ID consulted.
WBC on ___ was 15.8, repeat B-glucan was 82, and galactomannan
undetected. No changes were made to antifungal therapy. Could
consider transitioning to voriconazole as an outpatient.
#Pruritus: GVHD of skin. Continued diphenhydramine 25mg IV prn
during hospitalization.
#Hyponatremia
#Hyperglycemia: 132 on ___. Was thought to be due to
pseudohyponatremia in the setting of elevated glucose in the
200s. A1c checked was 5.3%, although difficult to interpret in
the setting of anemia. This should be followed up as an
outpatient for concern for steroid-induced diabetes mellitus.
#CML (___ ___ c/b GVHD)/
#Leukocytosis: While inpatient, tacrolimus was initially
withheld for elevated levels. Tacrolimus requirement may be
lower i/s/o recent vancomycin. He was given tacrolimus with a
target level ___ ___. We continued his home Bactrim
DS, acyclovir, and posaconazole. He was given diphenhydramine 50
mg IV prior to tacrolimus doses. Discharged on tacro 0.5mg po
BID.
#EBV+/?PTLD: Inpatient hematology/oncology, infectious disease,
and rheumatology came to evaluate. Patient was EBV positive
(___), so should be followed up given risk for Post Transplant
Lymphoproliferative Disease. Please consider either CT chest to
look for lymphadenopathy or gold standard PET/CT scan as an
outpatient for further workup and determination of need for
rituximab treatment.
#Depression: Continued home Paxil 20 mg qd
#Diarrhea: Patient had two days of increased bowel movements.
Per Dr. ___ patient has had chronic diarrhea for some
time, and GVHD of GI tract in the past was ruled out with
biopsy.
****TRANSITIONAL ISSUES****
============================
[]Pulmonary therapy: Patient will need 1 month of outpatient
respiratory therapy to be optimized prior to thoracic surgical
intervention
[]Sleep study for BiPAP: The patient will require a sleep study
in order to qualify for BiPAP through insurance. Please ensure
that patient has a sleep study appointment as soon as possible.
BiPAP: Settings:
Inspiratory pressure (Pressure support) 10 cm/H2O
Expiratory pressure (EPAP Fixed) 5 cm/H2O
IPAP 15
[]Bronchoplasty: Please follow-up with Dr. ___
timing of surgery after completion of pulmonary rehab.
[]Pain control: Patient was discharged on acetaminophen,
oxycontin, oxycodone, and will need titration of medications as
needed.
[]Transaminitis, Hyponatremia, Leukocytosis, Thrombocytopenia:
Please monitor with repeat labs on ___ to check for LFTs, CBC,
and BMP
[]EBV+/?PTLD: Inpatient hematology/oncology, infectious disease,
and rheumatology came to evaluate. Patient was EBV positive
(7793), so should be followed up given risk for Post Transplant
Lymphoproliferative Disease. Please consider either CT chest to
look for lymphadenopathy or gold standard PET/CT scan as an
outpatient for further workup and determination of need for
rituximab treatment.
[]Avascular necrosis: The patient had CT findings of avascular
necrosis of both hips from which he was asymptomatic. The
patient developed knee pain, and MRI revealed infarction but no
necrosis of the bone. Please follow-up on this issue and
consider tapering of steroids when medically appropriate to
prevent further damage. Additionally, the patient will need to
be worked up further with possible orthopedic surgical
intervention in the future. Will also benefit from outpatient
physical therapy.
[]Hyperglycemia: Random glucose in the 200s concerning for
diabetes mellitus secondary to steroids. Normal A1c of 5.3%,
although difficult to interpret in the setting of anemia. Please
follow-up as outpatient.
[]Elevated fungal markers: The patient had beta-glucan and
galactomannin elevated to the 400s. On discharge, the patient
had a WBC of 19.2. Please repeat the beta-glucan and
galactomannin testing on next PCP ___. If patient's fungal
markers again rise, consider as outpatient switching from
prophylactic posaconzaole to therapeutic voriconazole.
[]Splenomegaly: Compare CT findings of 16.7cm from ___ to
patient's home records.
[]Abdominal pain: Continue to monitor.
[]Myopia: Patient was found to be nearsighted on exam by
inpatient ophthalmologist. Recommend follow-up as outpatient
given patient will need glasses.
[]Gabapentin: This was stopped inpatient as the patient reported
he had not been taking this at home.
[] hx of BMT: On tacrolimus at home. On discharge only required
0.5mg po BID with last Tacro level of 3.2 on ___. Please
follow-up as an outpatient with repeat level on ___.
>30 minutes spent in counseling and coordination of care on day
of discharge. Extensive communication with patient's outpatient
providers to coordinate care. Of note, the work-up and
management of the patient's avascular necrosis, LFTs, and
abdominal pain will be ongoing. He strongly preferred to
continue his care back at home in ___. We reviewed the
potential risks of traveling back to ___, although his
overall stability suggests that these risks would most likely be
minor, such as worsening pain while en route. It was not felt
that these risks constituted an indication for AMA discharge. | 312 | 1,580 |
19992365-DS-21 | 20,220,175 | Dear Mr. ___,
You were hospitalized due to symptoms of nausea resulting from
an ACUTE HEMORRHAGIC STROKE, a condition in which a blood vessel
providing oxygen and nutrients to the brain bleeds. 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 bleeding 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
Please follow your medication list closely.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Mr. ___ is a ___ year old man with a history of anxiety,
COPD, LVH with diastolic dysfunction, and left cervical
radiculopathy who initially presented to the ED with tachypnea
and dyspnea. During his time in the ED, he had intermittent
nausea and nystagmus and development of left arm ataxia and an
ataxic gait. A code stroke was called and NIHSS was 1 for ataxia
of 1 limb. ___ revealed a left cerebellar hyperdensity
indicative of IPH. CTA showed no underlying vascular
abnormality. MRI showed no enhancing mass. The etiology of his
hemorrhage is possibly HTN, occult AVM or occult mass, which is
why the patient will have follow up imaging (see below).
# Neuro:
- Left cerebellar intraparenchymal hemorrhage: etiology unknown,
possibly hypertension or occult lesion not seen on MRI
- He was admitted to the Neuro ICU for close monitoring for
change in exam which could indicate edema/obstructive
hydrocephalus. He was on Mannitol Q6 and his exam remained
stable, so mannitol was discontinued by hospital day 4.
- SBP goal < 140
- Avoid anti-platelets and anticoagulation
- repeat MRI/MRA in ___ months
- Neurology Stroke Clinic follow up
# Cardiopulmonary:
- trops 0.01->0.3->0.16, CT chest/EKG neg, no chest pain
- Goal SBP<140
- continue lisinopril 10, metoprolol 25 BID
- will need follow-up of pulmonary nodules seen on CT chest in
___ months
#Psych:
- history of anxiety - he had some nausea and vomiting the first
day in the ICU secondary to presumed anxiety which quickly
resolved when he was put on his home dose of alprazolam 0.25mg
BID prn.
- continue home lorazepam 0.5mg prn insomnia
- continue home alprazolam 0.25 mg BID prn
# Transitional Issues:
- needs outpatient colonoscopy
- needs follow up MRI/MRA Head with contrast in ___ months
- will need follow-up of pulmonary nodules seen on CT chest as
outpatient in ___ months
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ] | 274 | 406 |
12635433-DS-10 | 23,622,378 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | COURSE ON MEDICINE SERVICE:
BRIEF SUMMARY
=============
___ y.o. man with history of pulmonary sarcoid, thyroid cancer
s/p thyroidectomy, but otherwise no previous cardiovascular
history presenting following cardiac arrest. Found to have total
occusion of ___ LAD requiring CAB.
ACTIVE ISSUES
==============
# S/p Cardiac Arrest: The patient had cardiac arrest while
running that was presumed VT/Vfib arrest. He received an EP
study that was normal. Cath revealed occlusion of ___ LAD,
so etiology of the arrest was believed to be ischemic. Given his
history of pulmonary sarcoid, he received a CT chest, which did
not show evidence of lung involvement. A serum ACE level was
sent and was _____. He was treated for his coronary disease as
below.
# Coronary artery disease: Left heart cath notable for total
occlusion of ___ LAD. He was evaluated by cardiac surgery
for CABG and went to the OR on ___. He received _______. He
was continued on ASA, simvastatin 20 mg daily, metoproll
succinate 100 mg daily. | 108 | 160 |
18302119-DS-3 | 28,161,755 | Dear Mr. ___,
It was our pleasure caring for you during your hospital stay at
___. You were admitted due to chest pain. We checked an EKG
and your cardiac enzymes and they were not concerning for a
heart attack. We think that your chest pain was due to the fast
heart rates from your atrial fibrillation. We performed a
cardioversion to correct this abnormal rhythm. We also increased
the dosage of your sotalol. We are discharging you with a
monitor that sends Dr. ___ regarding your
heart rate and rhythm and he will adjust your medications as
needed.
We think that your shortness of breath was due to a combination
of your atrial fibrillation and some extra fluid in your lungs.
We performed a nuclear stress test and this did show any
evidence that your shortness of breath was due to decreased
blood flow to your heart. We gave you a water pill and your
shortness of breath improved. You should continue taking this
water pill as an outpatient.
We are not sure what is causing the "head rush" sensation you
described with walking. Your heart rates and blood pressure were
stable when you walked, so we do not think it is related to your
heart or your blood pressure. If it persists, you should see
your neurologist or primary care physician.
Your discharge weight is 112.6kg. You should weigh yourself
daily. If your weight goes up by more than 3lbs in one day,
please call your doctor.
You should follow up with your cardiologist and primary care
physician after you leave the hospital.
We wish you the best.
- Your ___ Care Team | ___ with history of HTN, a-fib s/p failed ___ ___, on
metoprolol and rivaroxaban, who presented with chest pain and
dyspnea.
ACUTE ISSUES:
=============
#Chest pain: Patient reported SOB with stairs at baseline but
new new associated non radiating pressure/burning sensation in
central chest that resolved with rest. Exertional nature of
chest pain was concerning for typical angina but with all
troponin <.01 during admission and EKG without any ischemic
changes. CKMB elevated to 11, but otherwise non elevated. Chest
pain was felt to be due to atrial fibrillation. No further
episodes of chest pain were experienced during hospital stay.
Sotalol (started 2 days prior to admission) was uptitrated to
120mg BID. Patient was cardioverted to sinus rhythm.
# SOB: Patient admitted for dyspnea ___ and newly diagnosed
with atrial fibrillation during that hospital stay. Thus current
dyspnea was initially felt to be due to atrial fibrillation,
however it persisted after cardioversion when patient was in
normal sinus rhythm. Patient was noted to be volume overloaded
on exam ___ Echo showing left ventricular systolic function
mildly depressed and LVEF= 40-45 %). Patient was digressed with
IV lasix with subsequent improvement in dyspnea on exertion.
MIBI was performed ___ to rule out dyspnea as anginal
equivalent, which revealed normal myocardial perfusion and
increased left ventricular cavity size with normal systolic
function. Patient was discharged on 20mg po lasix daily and
potassium 20mg KCL daily. Discharge weight 112.6kg.
# Bradycardia:Hospital course complicated by bradycardia status
post cardioversion. Thought to be due to residual metoprolol in
system as metoprolol was administered on AM of cardioversion.
Patient required 1L IV NS due to associated hypotension post
cardioversion with subsequent improvement in BP. The resting
heart rate remained in the high ___ with augmentation into the
___ with ambulation. Case was discussed with Dr. ___
recommended continuing sotalol with ___ monitoring.
If pulsation in the head and dyspnea on exertion persists with
ambulation despite adequate diuresis then PPM may be needed for
SSS/chronotropic incompetence.. Metoprolol was discontinued and
patient was discharged on sotalol 120mg BID.
# Atrial fibrillation: Newly diagnosed in ___ after patient
admitted for exertion dyspnea. Patient was status post failed
cardioversion ___. Patient was started on sotalol 80mg BID 2
days prior to admission in addition to metoprolol 100mg BID.
Was rate controlled and anticoagulated at time of admission.
Sotalol was increased to 120mg BID on admission and patient was
cardioverted on ___. Patient subsequently in sinus rhythm.
Continued on xarelto 20mg daily.
# Hypertension: Status post cardioversion patient with
hypotension per above. Admission medications of
valsartan 80mg daily and HCTZ 12.5mg daily subsequently
discontinue due to adequate blood pressure control without
medications.
#"head rushing" symptoms: Patient described sensation of "head
rush" with ambulation. Blood pressures and HR appropriate and
orthostatics were negative. No nystagmus or ataxia were
observed. Unclear etiology. ___ represent chronitropic
incompetence versus heart failure. Patient discharged on lasix
20mg daily with plan to increase to 40mg daily if still
dyspneic. If persists thereafter, may require a pacemaker for
presumed chrontropic incompetence
CHRONIC ISSUES:
================
# Hyperlipidemia: Continued pravastatin 40mg
# Gout: Continued allopurinol ___
Transitional Issues:
=======================
#Sotalol: Increased to 120mg BID. Please titrate as clinically
warranted.
___ of Hearts: Patient discharged with Holter monitor, results
relayed to Dr. ___
#CHF: TTE from ___ showing mildly depressed left ventricular
systolic function (LVEF= 40-45 %). Patient discharged on 20mg
Lasix daily and 20mg potassium daily.
#Head rushing symptoms: Patient described sensation of "head
rush" with ambulation. Blood pressures and HR appropriate and
orthostatics were negative. No nystagmus or ataxia were
observed. Please follow up and consider neurology referral if
clinically warranted. ___ alternatively be due to chrontropic
incompetence versus heart failure. Consider up titration of
diuretics versus pacemaker placement in future, per above.
CODE STATUS: Full code
CONTACT: ___, wife, ___ | 276 | 631 |
19869932-DS-9 | 24,863,978 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or,
if applicable to you, the indwelling ureteral stent. You may
also experience some pain associated with spasm of your ureter.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urinethis, as noted above, is expected and will gradually
improvecontinue to drink plenty of fluids to flush out your
urinary system
-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 active ingredient of Advil, Motrin, etc.) may be
taken even though you may also be taking ACETAMINOPHEN
(Tylenol). You may alternate these medications for pain control.
-For pain control, try TYLENOL FIRST, then the ibuprofen (unless
otherwise advised), and then take the narcotic pain medication
(if prescribed) as prescribed if additional pain relief is
needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Docusate sodium (Colace) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks | ___ was admitted to the urology service for
nephrolithiasis management. She underwent right ureteroscopy,
laser lithotripsy and stent placement.
She tolerated the procedure well and recovered in the PACU
before transfer to the general surgical floor. See the dictated
operative note for full details.
Intravenous fluids, Toradol and Flomax were given to help
facilitate passage of stones. At discharge, patients pain was
controlled with oral pain medications, tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged. | 364 | 98 |
15560995-DS-7 | 27,827,432 | You were admitted to the hospital for evaluation of a left
frontal brain mass.
When to Call Your Doctor at ___ for:
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___ the patient presented to the ___ ED after an
unwitnessed fall onto her left side in her assisted living
facility. A non-contrast head CT showed growth of a known L
frontal meningioma and no acute hemorrhage. Films of her L
knee, humerus, shoulder, and neck were negative for fracture.
She declined neurosurgical intervention and she remained in the
ED overnight so that she could be seen by physical therapy in
the morning.
On ___ that patient remained neurologically stable and was seen
by physical therapy who recommended that she be discharged to a
rehab. The patient agreed and was admitted for dispo planning.
Neuro-oncology was also consulted and requested the patient get
an MRI for further evaluation of the lesion.
On ___ the patient remained neurologically stable. She is
waiting MRI and a bed and rehab.
On ___, the patient's neurological exam remained stable. Await
MRI as disposition planning is in progress.
On ___, the patient remained neurologically and hemodynamically
stable. MRI was completed which showed increased sized of known
left fronta. extra-axial mass, likely meningioma, with local
mass effect and edema. The patient was approved for a rehab bed
and discharged in stable condition with plans for follow up in
Brain Tumor Clinic. | 111 | 209 |
16916476-DS-18 | 25,415,397 | Dear Mr. ___,
You were admitted for an episode of worse cholangitis.
Fortunately you don't need another ERCP at this time. You will
go home on Ciprofloxacin and stop taking Amoxicillin. Take Cipro
along with your other meds until you see Dr. ___ office
___ reach out to set up follow up in the coming several weeks.
Sincerely,
Your ___ Team | # Recurrent cholangitis/transaminitis:
Patient presented with epigastric and RUQ abdominal pain
consistent with prior episodes of cholangitis, with prior
episodes of cholangitis occasionally occurring without
significant lab abnormalities. He received Zosyn in the ED. He
appeared stable without any signs of overt infection, although
given his history of recurrent cholangitis and chronic
outpatient suppressive antibiotics, was continued in the ___
on broad-spectrum antibiotics, cipro and metro. MRCP showed
evidence of cholangitis, as expected. ERCP team and outpatient
hematologist Dr. ___ in favor of no ERCP given the
MRCP showed no masses, the findings all appeared cholangitis.
- At least until seeing Dr. ___ in clinic, after discharged he
would continue ciprofloxacin 500 BID (new) and Bactrim (old) for
suppressive antibiotics, and he would stop taking amoxicillin
(old)
- He had a few PO dilaudid pills leftover from prior encounters
that he could use if needed for pain on the way home
- Dr. ___ planned to call within the next 3 weeks to
set up follow-up
# ___'s disease:
- Continued home ursodiol.
# PCKD s/p renal transplant:
Patient is s/p cadaveric transplant in ___ for PCKD. He takes
MMF and sirolimus at home, missed one dose of sirolimus in the
ED.
- Renal endorsed staying the course with home regimen, which we
did.
- Checked Sirolimus level ___ was wnl
- Continue home Mycophenolate Mofetil 500mg PO BID
- Continued Sirolimus 0.5mg PO daily
- Continued Bactrim SS 1 tab daily prophylaxis.
# HTN:
- Continued homed Metoprolol tartrate 12.5 mg PO BID
# Gout:
- Continued homed allopurinol ___ mg PO daily
# Hyperlipidemia:
- Continued homed pravastatin 40 mg PO HS.
# GERD:
- Continued home omeprazole 20mg po daily | 58 | 268 |
15549843-DS-17 | 20,046,885 | Dear Ms. ___,
You were admitted to the hospital with a severe cough and you
were found to have a pneumonia. You were treated with IV
antibiotics and your symptoms improved. Your blood pressure was
also low and we gave you fluids and medicine to help bring your
blood pressure up. While you were here you also needed a blood
transfusion. You were discharged with an IV in your arm to
continue antibiotics are your facility. We spoke to your son
___ who is aware of what happened during your hospitalization.
We wish you the best,
Your ___ Team | ___ yo F with PMH of multiple myeloma and Sjögren syndrome who
presented with lethargy and hypoxia and was admitted to the ICU
for hypotension. Her hypotension was noted only while sleeping,
and was thought to be most likely due to hypovolemia and sepsis.
A central line was placed in the ED and she was given low-dose
norepinephrine, which was rapidly weaned off. She was treated
with broad-spectrum antibiotics for pneumonia. Her course was
also notable for hyponatremia and ___ which improved with
fluids. Hospital course is outlined below by problem:
==============
ACUTE ISSUES
==============
# HCAP, hypoxia: Hypoxia was attributed to pneumonia given
bibasilar opacities on CXR, productive cough, and mild shortness
of breath. Started on broad-spectrum antibiotics, vancomycin and
cefepime (day 1: ___. She was initially on 4L NC. Her cough
and dyspnea improved with treatment of her pneumonia. Patient
did received lasix 20 mg IV x1 dose on ___ due to concern for
mild pulmonary edema. At the time of discharge patient required
2L NC (and at times was on RA). Patient was discharged on
cefepime 2g q24h (day 1: ___, day 8: ___ and vancomycin 750g
q12h (day 1: ___, day 8: ___. Patient will need a vanc level
drawn on ___.
# Hypotension: Most likely due to a combination of sepsis and
under-resuscitated hypovolemia. Patient likely has pneumonia.
Patient's UA was positive however she denied symptoms and UCx
was negative. She was mildly hypovolemic on exam and endorsed
significant thirst. Her labs were remarkable for hyponatremia
and likey pre-renal ___, all supporting hypotension that is
secondary to hypovolemia. Levophed was weaned rapidly and BPs
remained in normal range. Blood pressure was monitored on the
floor and remained stable.
# Asymptomatic bacteriuria: UA was positive however patient was
without urinary symptoms and urine culture showed no growth.
# Acute kidney injury: Cr was 1.1 on admission from a baseline
of 0.4. This was attributed to pre-renal ___ given her clinical
exam and concurrent hyponatremia. Creatinine improved to 0.4
with IVF.
# Hyponatremia: Na was 128 on admission and improved to 132 with
fluids. Patient received one dose of diuretic on ___ due to
concern for pulmonary edema and in the setting of pRBC
transfusion. Sodium declined to 128 after receiving diuretic.
Recommend rechecking electrolytes in ___ days.
==============
CHRONIC ISSUES
==============
# IgG-lambda multiple myeloma (on C6 melphalan/prednisone with
recent addition of velcade on ___: Velcade was not
administered during her hospitalization. She has a heme/onc
appointment on ___.
# Atrial fibrillation: Continued home amiodarone.
# Hypothyroidism: Continued home levothyroxine.
# Chronic pain: Continued home chronic pain regimen.
# Psych: patient was noted to be intermittently anxious. Her
home clonazepam 0.5 mg BID was restarted and her symptoms
improved.
=====================
TRANSITIONAL ISSUES
=====================
- patient will be discharged on vancomycin 750 mg q12h (day 1:
___, day 8: ___, cefepime 2g q24h (day 1: ___, day 8: ___
via ___. Recommend checking vanc trough while at facility on
___
- recommend checking electrolytes and renal function in ___ days
as sodium was 128 at the time of discharge. This was attributed
to hypovolemia. Also recommend rechecking phos in ___ days as
phos was low at 1.7 at discharge. She was discharged on a short
course of phos repletion at 500 mg BID x2 days.
- patient was discharged on 2L NC. This can be weaned at her
facility.
- patient will have f/u with her oncologist on ___
- EMERGENCY CONTACT HCP: ___ ___
- CODE STATUS: DNR/DNI | 96 | 565 |
15761543-DS-8 | 20,220,427 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital because the incision site of
your hernia surgery had re-opened.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
-You had two procedures to fix the surgical site requiring
removal of dead/infected tissue.
-Further evaluation of the tissue removed during your surgery
revealed a condition called calciphylaxis. We started to treat
you for this with a medication called Sodium Thiosulfate. It
also revealed an infection with multiple kinds of bacteria. We
treated this infection with antibiotics by mouth and through
your IV with the help of our Infectious Disease specialists.
- Your kidneys were damaged because your blood pressure was low
during your surgical procedures. We worked closely with our
kidney doctors and started ___ on hemodialysis to help protect
your kidneys,
- Your ascites re-accumulated and you developed fluid around
your right lung. We also took fluid off with thoracentesis and
paracentesis.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- If you have any chest pain, shortness of breath, worsening
abdominal pain, nausea/vomiting, bloody or black/tarry stools,
or any other symptoms that concern you please let the staff at
your rehab know and seek medical care.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
========
___ year old man with cirrhosis s/p incarcerated umbilical hernia
repair with mesh on ___ who was readmitted with the incision
opening after sutures removed in surgery clinic on ___.
Underwent debridement of wound ___. Intra-Op tissue
pathology revealed calciphylaxis and culture grew VRE, vanc
sensitive enterococcus, bacteroides, and acinetobacter. Patient
had initially been treated with augmentin which was broadened
per ID recommendations as culture data resulted to unasyn and
linezolid (10 day course). He was noted to be hypotensive during
both debridement procedures which was felt to be the cause of
his acute kidney injury and oliguric renal failure as he likely
was suffering from ATN. He was initiated on hemodialysis and was
unable to recover renal function. He was started on IV sodium
thiosulfate to treat his calciphylaxis. Patient experienced
significant nausea with STS administration which was well
controlled with Zofran. Course was complicated by hypoxia ___
right hepatic hydrothorax that was diuretic refractory and
quickly reaccumulating despite interval chest tube placements.
He required a 1 day MICU stay after become acutely hypoxic ___
re-expansion pulmonary edema after large volume thoracentesis on
___. He was not a good candidate for PleurX placement given
ongoing liver transplant workup. Given stability with no oxygen
requirement since his last thoracentesis (chest tube removed
___ - he was felt appropriate to discharge to rehab with
continued outpatient dialysis and liver transplant workup. | 247 | 231 |
16991615-DS-7 | 21,424,460 | Dear Ms. ___,
You were admitted for ongoing abdominal pain and diarrhea. You
were found to have an infection called Giardia and were started
on antibiotics (Flagyl), which you should continue to take for 7
days.
Continue to take omeprazole (or pantoprazole, but not both)
twice a ___ until your pain/indigestion improves. You can take
Tums or Carafate before meals as well to help you advance your
diet. You can take Zofran for nausea, and Tylenol for pain.
Please AVOID ibuprofen/Advil/Motrin/Aleve as they may irritate
your stomach further.
Please make sure to drink plenty of fluids so you don't get
dehydrated.
Please follow up with your primary care doctor within one
(listed below) to make sure that your symptoms are improving.
We wish you all the best. | ASSESSMENT - Ms. ___ is a ___ PMHx migraine, GERD,
depression, endometriosis and prior ovarian cyst s/p diagnostic
laparoscopy who is referred from clinic for evaluation of
ongoing abdominal pain, diarrhea, found to have giardia and
clinically improved prior to discharge.
# Giardiasis
# Abdominal pain, Diarrhea - Pt presents with ongoing
diarrhea/abdominal pain for nearly 2 weeks prior to admission.
Given her CT findings of possible adenitis, most likely etiology
is infectious. Labs, ultrasounds and CT scans were otherwise
without any other abnormalities to explain her symptoms. Her
stool cultures from clinic returned with Giardia, so she was
started on Flagyl for a ___ course. GI was consulted to
consider EGD and colonoscopy, and deferred further evaluation
once giardia returned positive. Abdominal pain improved. Diet
advanced slowly, tolerating good hydration PO and starting
full/bland diet at discharge.
- complete Flagyl course
- follow up with PCP
- symptomatic treatment for cramping, nausea, reflux/GERD given
at discharge
# Transaminitis - No evidence of biliary obstruction seen on RUQ
US, trended and improved.
- repeat in ___ weeks as outpatient
# GERD- She was recently uptitrated on her GERD regimen to see
if it would improve her abdominal pain. She has not had any
relief with uptitration of her meds, and given the Giardia
finding, her H2B and carafate were stopped once giardia returned
positive, however primary symptom upon discharge was primarily
___ and so Carafate, PPI, Tums recommended at discharge
with PCP follow up to determine course and need for GI follow
up.
# Depression - Continued on home wellbutrin and fluoxetine
# Fatigue - Patient underwent recent ___ for increased
fatigue. TSH wnl. Awaiting sleep study as outpatient. Follow
up with PCP. | 124 | 288 |
10221767-DS-6 | 21,843,161 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touchdown weight bearing right lower extremity in ___
brace locked in extension
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 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
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:
Touchdown weight bearing right lower extremity in ___ locked
in extension
Treatments Frequency:
Dry sterile dressing changes as needed | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right patella fracture and right tibial plateau fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for right patella
ORIF, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weight bearing in the right lower extremity in a
___ locked in extension, 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. | 282 | 264 |
16162028-DS-10 | 22,704,755 | Dear Ms. ___,
It was a pleasure taking care of you here at the ___
___. You presented to us with left-sided
abdominal pain. We performed a CT scan of your abdomen and it
was remarkable for some swelling in the Lt kidney. You were also
found to have blood in your urine. Thus, we believe you most
likely passed a kidney stone. We recommend that your drink a lot
of fluids to stay hydrated to prevent future kidney stones from
forming. Your CXR was notable for small amount of fluid and
suspicious for pneumonia. We treated you with antibiotics and
you will be discharged on them for 3 more days. Given your
limited mobility and rib fractures, we consulted physical
therapy and managed your pain with tylenol.
Please take your medications as instructed. Please attend your
follow up appointments. Please stay hydrated. | ___ year old female with hx. asthma, RA, depression, HTN,
multiple known rib fractures after a mechanical fall who
presents with abdominal pain, found to have leukocytosis and CXR
concerning for pneumonia vs. pulm edema with atelectasis.
# Left-sided abdominal pain: Given that pain was acute in onset
and in the left side, corresponding to CT scan findings in the
Lt kidney (perinephric stranding around the left kidney and
stranding the ureter), and presence of hematuria in the UA, the
most likely explanation of her symptoms is passing a kidney
stone. Given that CT shows perinephric stranding with stranding
the ureter, pt most likely passed the stone. Since the pain
resolved by the time pt was admitted to the floor, we did not do
any further intervetnions. It is very likely that her
leukocytosis is a reactive process to nephrolithiasis. To
prevent further kidney stones in the future, we instructed pt to
stay hydrated and we also reduced her calcium bicarbonate dose
from TID to only once a day.
# CXR findings: CXR is remarkable for atelectasis, pulmonary
edema and ? RLL consolidation even though pt has no respiratory
symptoms (no cough, no dyspnea, saturating well on RA, and no
fever) but has a leukocytosis. Given the possible consolidation
on CXR and presence of leukocytosis, we treated her for CAP with
azithromycin and ceftriaxone (received one dose). She also
received one dose of doxycyclin in the ED. We discharged her on
Z-pak to complete her 5-day course, last dose on ___. Regarding
pulmonary edema, lung exam is not concerning for rhales and/or
crackles, BNP 578; thus, we will defer treatment/diagnosis for
now. Given that CXR is significant for atelectasis and low lung
volumes, it is a very poor study and the edema may be associated
with atelectasis. A study such as TTE is recommended as
outpatient to rule out CHF.
# Hematuria: Most likely due to passed renal stone. No
indication of UTI on UA. We recommend outaptient follow up.
CHRONIC ISSUES
# Rib fractures: Due to mechanical fall on last admission. We
managed pain with alternating tylenol and oxycodone prn. Since
pt reports very limited activity and ambulation, physical
therapy was consulted and recommended discharge to rehab.
# Compression fractures: revealed incidentally on CT scan,
likely chronic as patient not c/o pain over spine. She has known
diagnosis of osteoporosis. We managed pain with alternating
tylenol and oxycodone prn. We reduced calcium to only once a day
given concern for nephrolithiasis. We continued vitamin D.
# T2DM: We held home metformin and placed her on a weak ISS.
# GERD: we continued prevacid.
# Primary prevention: we continued aspirin.
# Rash: A new rash on legs and abdomen was noted. It is a
macular rash very similar to the rash on previous admission
which was thought to be a heat rash. Thus, most likely heat rash
vs. drug rash. We discontinuted ceftriaxone and continued
azithromycin for pneumonia treatment. | 142 | 492 |
19492222-DS-18 | 22,241,191 | Mr. ___,
You presented to ED with shortness of breath, chest pain.
Imaging revealed a small right subsegmental pulmonary embolism
as well as resolving hematoma and possible reactive changes
versus colitis. You were admitted for therapeutic
anticoagulation and treated with antibiotics. Ultrasound of your
lower legs were negative for a deep vein thrombus.
You are being discharged home on anticoagulation( Xarelto) for
treatment of your pulmonary embolism. You will take this
medication for a total of 3 months (including doses in
hospital), please finish the entire prescription. Please monitor
for any signs of bleeding: fast heart rate, bloody bowel
movements, abdominal pain, bruising, feeling faint or weak. If
you have any of these symptoms please call our office or seek
medical attention immediately. Please avoid any contact activity
and take extra caution to avoid falling while taking Xarelto.
Other instructions:
Take your medicines exactly as instructed. ___ skip doses. If
you miss ___ dose, call your provider and ask what you should do.
Please wear compression stockings.
Walk several times a day.
While sitting for long periods of time, move your knees,
ankles, feet, and toes.
Try to exercise at least 30 minutes on most days.
When traveling by car, make frequent stops to get up and move
around.
Call your provider right away if you have:
Pain, swelling, and redness in your leg, arm, or other body
area. These symptoms may mean another blood clot.
Blood in your urine
Bleeding with bowel movements
Bleeding from the nose, gums, a cut
Chest pain
Trouble breathing
Coughing (may cough up blood)
Fast heartbeat
Sweating
Fainting
Heavy or uncontrolled bleeding. If you are taking a blood
thinner, you have an increased chance of bleeding.
Best Wishes,
Your ___ Care Team | Mr. ___ is a ___ with a past medical history significant
for ___'s thyroiditis and recent complicated
diverticulitis s/p single incision laparoscopic sigmoid
colectomy on ___ who now presents after developing chest
pain, shortness of breath, tachycardia, chills, and intermittent
suprapubic pain. His imaging reveals a small right subsegmental
pulmonary embolism as well as resolving He was admitted to
colorectal service for therapeutic anticoagulation with lovenox
and antibiotics (cipro & flagyl); antibiotics d/c on HD#4.
Hospital course was stable. He was passing flatus, had BM's and
was given a diet which was well tolerated. His abdominal exam
was benign. He was transitioned from Lovenox to Xarelto for
treatment of a provoked pulmonary embolism due to surgery and is
to complete a 3 month course of anticoagulation therapy.
Discussed potential need for outpatient hematology workup for
genetic testing. Patient was discharged home with scheduled 2
week followup appointment with Dr. ___. | 273 | 150 |
16678478-DS-15 | 23,518,966 | Dear Ms. ___,
WHY WAS I HERE?
-You came into the hospital because you were having shortness of
breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You initially went to the intensive care unit for advanced
oxygen support
-You were found to have fluid in your lung which was removed
with medication. Your breathing improved with the fluid removal.
-You continued to have more difficulty breathing than you
normally do even after the fluid was removed. We spoke to the
lung doctors and repeated ___ of your lungs that showed
advancement of your 'interstitial lung disease'
WHAT SHOULD HAPPEN WHEN I LEAVE THE HOSPITAL?
-You should take all of your medications as prescribed
-You should weigh yourself every day and call your heart doctor
if you gain more than 3 lb in a day or 5 lb in a week. Please
take double your daily diuretic dose if you gain more than 3 lb
in one day in addition to calling your heart doctor.
It was a pleasure taking care of you,
Your ___ Care Team | SUMMARY STATEMENT:
=================
Ms ___ is a ___ y/o F with PMH significant for severe COPD (on
3L NC home oxygen), ILD (likely NSIP), remote hx of lung cancer
(s/p partial lobectomy, diverticulitis (complicated by
colovesicular fistula, s/p hemicolectomy with ostomy in
___, presented to the ED for hypoxemia in the setting of
pulmonary edema, requiring admission to the MICU for BIPAP and
diuresis. Patient respiratory status improved and she was able
to be transferred the floor; however, she continued to have
increased oxygen requirement from baseline and underwent
evaluation by pulmonary service showing progression of
interstitial lung disease.
ACUTE ISSUES
===============
# Acute on Chronic Hypoxemic Respiratory Failure
# COPD (on 3L NC at baseline)
# ILD (likely NSIP)
# Acute on Chronic Diastolic CHF
Patient presented with acute on chronic hypoxemic respiratory
failure that is likely multifactorial, all in the setting of
known severe emphysema, hx of RUL resection, progressive ILD
(likely NSIP), and history of chronic nitrofurantoin use. She
initially presented with clinical evidence of hypervolemia, her
TTE on ___ showed right heart strain (RV pressure and volume
overload with moderate global free wall hypokinesis) and CTA was
similarly concerning for pulmonary edema. She was diuresed to
euvolemia however sustained oxygen requirement above reported
baseline of 3L NC. Pulm was consulted and repeat CT Chest was
obtained confirming progression of underlying disease; however,
the risk of steroids were deemed to ultimately outweigh the
benefits and therapeutic intervention was deferred. Respiratory
status otherwise compromised by aspiration event on ___ with
worsened hypoxia, however patient quickly recovered and was back
to her pre-admission baseline of ___ L at time of discharge with
PO maintenance diuresis (home dose of 40 PO Lasix) as well as
incentive spirometry and flutter valve support.
#Aspiration Risk
Bedside swallow eval after event on ___ noted functional swallow
but increased aspiration risk due to underlying lung disease.
Recommended soft solids and thin liquid diet. Should have
aspiration precautions (upright for meals, HOB 30 degrees all
times, frequent oral care). If significant secretions can trial
saline nebulizer, flutter valve and having patient "huff."
#GPC bacteremia
___ blood cultures from ___ with enterococcus (pan-sensitive)
and coagulase negative staph. ID was consulted and felt that
these cutlures are likely contaminated. Patient had short course
of Vancomycin and remained without fevers, leukocytosis, or
other infectious signs for duration of hospitalization after
stopping abx.
#Ostomy Prolapse
Underwent colectomy ___. Colorectal surgery evaluated and
noted prolapse is common with type of colectomy she underwent,
and as the ostomy is reducible, no intervention was required.
CHRONIC ISSUES
===============
# CAD:
Continued home ASA 81
# HTN:
Patient home lisinopril held due to borderline hypotension.
Remained normotensive without pharmacologic blood pressure
control.
# Depression:
# Sleep/wake cycle
Tachycardia may be related to bupropion/modafinil (particularly
modafinil). Modafinil weaned to 100mg per day.
Continued home bupropion
TRANSITIONAL ISSUES
===================
-Please ensure patient receives PO Lasix on arrival at rehab on
___
-Consider re-initiation of home lisinopril
-Monitor patient weights and adjust diuresis accordingly.
Discharged on 40 PO Lasix daily. discharge weight 61.3 kg
-Ensure patient attends pulmonary follow up with Dr. ___ d/c modafinil, as this appears to be causing baseline
tachycardia (weaned down during admission)
-Patient has stoma prolapse which should be closely monitored
with consideration of colorectal surgery if needed
-Please ensure patient uses flutter valve and incentive
spirometer after discharge
New Medications: None
Changed Medications: Modafinil (200--->100)
Held Medications: lisinopril | 169 | 545 |
17494592-DS-16 | 24,780,503 | Ms. ___,
You recently underwent emergent exploratory laparotomy and left
salpingectomy with evacuation of hemoperitoneum for ruptured
ectopic pregnancy.
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
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication | Ms. ___ was admitted after emergent exploratory laparotomy,
left salpingectomy, and evacuation of hemoperitoneum for
ruptured ectopic pregnancy. Her course is summarized by system
below:
GYN: Patient underwent above procedure for presumed ruptured
ectopic pregnancy. However, while pathology revealed
trophobastic tissue, it did not reveal chorionic villi, which is
necessary for definitive diagnosis of ectopic pregnancy. Repeat
hCG showed appropriate decline. Patient will be followed with
hCG levels until they reach zero. She is scheduled for repeat
hCG on ___ when she comes for staple removal.
Heme: Patient had acute blood loss anemia and was initially
hemodynamically unstable with hematocrit nadir at 12
intra-operatively. She received 4 units PRBCs in the OR. Her
hematocrit recovered and ultimately stabilized. She had
persistent tachycardia, which ultimately improved; see below for
more details. She was otherwise asymptomatic from her anemia.
She was prescribed iron.
CV: Patient experienced persistent tachycardia greater than 120
and as high as 140s while ambulatory. She was asymptomatic and
pain well-controlled. Urine output was good. Abdomen benign. ECG
performed showing only sinus tachycardia. Repeat hematocrits
stable. TSH normal. CTA negative for pulmonary embolus. Patient
was placed on telemetry. Tachycardia ultimately resolved on
post-operative day 2 without intervention.
Renal: Patient failed initial trial of void after Foley removal.
Foley was replaced. Patient was noted to have polyuria and urine
and serum osmolality and electrolytes were obtained showing
appropriate clearing of fluids. Foley was removed and patient
was able to void on her own.
Patient was ultimately discharged on post-operative day #3 in
good condition: ambulating and voiding without difficulty,
tolerating a regular diet, and with pain well-controlled on PO
pain medication. She is scheduled for follow-up for staple
removal on ___ and post-operative follow-up and Mirena IUD
insertion on ___. | 232 | 290 |
12112476-DS-18 | 26,588,615 | Mr ___
It was a pleasure taking care of you while you were
hospitalized. As you know, you were admitted for the flu, which
was complicated by a pneumonia. Fortunately you improved
dramatically with treatment, and completed your course of
antibiotics/antivirals. You can continue the cough suppressant
as long as it helps. Please be aware that it can be sedating
Please continue to take phosphorus daily and vitamin d weekly as
your levels were persistently low. Please also be sure to quit
alcohol and smoking for the reasons that we discussed as both
are really hurting your health.
Please stop your cholesterol medication because your liver does
not appear to be tolerating it. Please be sure to eat a high
salt diet and limit your fluid intake to 1.5 liters per day to
ensure your sodium remains stable or improves.
Please be sure to attend your ___ clinic appointment with
Dr ___. | ___ PMH COPD, alcohol abuse and recurrent lung adenocarcinoma on
nivolumab who was admitted with weakness, myalgia, dyspnea,
found to have influenza with possible superimposed PNA (s/p
Levaquin/Tamiflu course), who improved with treatment but had
hospital course c/b hyponatremia and bilirubinemia, was
discharged with close outpatient oncology followup.
#Bilirubinemia/Transaminitis
During stay patient had mild transaminitis with
hyperbilirubinemia, but no elevation in Alk Phos. No e/o
obstruction on RUQUS, it revealed steatosis only. No known
metastatic lesions to liver. ETOH abuse at baseline likely
contributes to baseline transaminitis but did not explain
hyperbilirubinemia. In withholding fenofibrate LFTs improved, so
patient may be intolerant of such agent. Fenofibrate
discontinued on discharge, patient to have LFTs re-checked at
next outpatient oncology appt.
#Hyponatremia:
Admission Na 129, temporarily normalized then held steady below
130. Ulytes earlier in course suggested inappropriate ADH (pt is
euvolemic), and again were consistent. Intolerant of salt tabs
___ vomiting. No obvious offending meds. Cortisol/thyroid tests
normal. Fluid restriction not making significant difference.
Renal evaluated patient ___ and felt that hyponatremia will
be chronic due to poor solute intake ___ alcoholism + ADH
release from pathology in lungs. They noted that in view of
intolerance of salt tabs his Na should be left alone. Patient
was encouraged to eat a high salt, high solute diet and follow
fluid restriction at home. Per renal, in outpatient setting
baseline Na can be considered to be 128-130 and can be left
alone so long as he is not symptomatic. If becomes symptomatic
could try to obtain urea salts to see if he tolerates
#Acidosis
#Elevated Lactate
#Hypophosphatemia, hypomagnesemia, hypokalemia
Patient had mixed AG and non gap acidosis. Lactate checked and
was elevated possibly ___ demand to due increased work of
breathing, normalized on re-check without any intervention.
Given electrolyte abnormalities renal felt that patient may have
slight RTA but rec'd just continuing electrolyte repletion as
needed. CHEM to be trended at oncology f/u appts. If HCO3 drops
below 18 could consider sodium bicarb tabs
#Influenza c/b bacterial pneumonia
#COPD
#Acute Hypoxic Respiratory Failure
Admitted with weakness, myalgia, dyspnea, found to have
influenza with possible superimposed PNA, slowly improved with
levaquin/Tamiflu and completed both courses during
hospitalization. Remaining crackles in lungs may be ___
fibrosing lung disease as has no e/o hypervolemia on exam.
Patient passed amb O2 sat but had occasional episodes of dyspnea
which resolved with albuterol use. Patient instructed to
continue inhalers at home and was provided cough suppressant as
coughing fits preceded dyspnea.
#Metastatic Lung Cancer
Known mets to brain. No focal deficits. On nivolumamb q4 weeks
for progressive disease. Last received C25D1 ___. Patient had
f/u appt already scheduled in early ___ and was instructed to
ensure that he followed up as scheduled
#ETOH Abuse
Reported Drinks ___ beers/day. No history of withdrawal per
patient and none seen during stay. Patient was counseled on
cessation extensively.
#Tobacco Abuse:
Nicotine patch discontinued due to bad dreams and patient's
insistence that patch was cause. Patient was counseled on
cessation extensively.
#HLD:
Treatment held as above in light of transaminitis/bilirubinemia
discussed as above | 150 | 499 |
10251262-DS-2 | 26,787,243 | Dear Ms. ___,
Thank you for choosing ___. You were admitted for vomiting
blood in the setting of a very low platelet count due to ITP
("immune thrombocytopnia"). You were stabilized in the Intensive
Care Unit with platelet transfusion, Intravenous immunoglobulin
(IVIG), and steroids. With these interventions your platelet
count increased so you are safe for discharge home with
Hematology follow-up. Please have outpatient blood tests done
in 3 days (on ___ to check your platelets, which will
be followed up by Hematology. You have been given a lab slip
for this.
The cause of your initial vomiting and blood are unclear. You
might have had a viral illness causing wretching, resulting in a
small esophageal tear. But it is also possible that you could
have peptic ulcers, which could be supported byt the fact that a
tests suggested that you have H.pylori, a bacteria which can
cause ulcers. You should complete a 2 week course of
antibiotics/acid suppressors in order to eliminate this bacteria
(Amoxicillin, Clarithromycin, and Omeprazole). In addition, you
should have an EGD (upper endoscopy), which has been scheduled
for you.
While on the antibiotics, you should be aware they can cause
side effects of easy sun burn, interactions with alcohol, and
birth defects. Please avoid the sun and use sunblock, minimize
or avoid alcohol consumption, and use two methods of
contraception.
MEDICATIONS
- Start Prednisone (this medication will be tapered down based
on your discussion at your upcoming Hematology appointment)
- Start Omeprazole, Amoxicillin, and Clarithromycin for 2 weeks | Ms. ___ is a ___ year old af am female with past medical
history of thyroid cancer s/p
thyroidecomy and RAI ___ years ago who presented with bloody
emesis after nausea and vomiting and noted to have severe
thrombocytopenia to 5. Initially managed in ICU with IVIG and
PLT transfusion, then transferred to the floor where a diagnosis
of ITP was made.
.
# Thrombocytopenia: Most likely due to immune thrombocytopenic
purpura. Differential includeed aspartame induced
thrombocytopenia from her hawaiin cool aid, infections (HIV or
HepC) induced thromboyctopenia. Peripheral smear without
shistocytes argued against TTP. Normal coagulopathy. No new
medications to suspect cause of thrombocytopenia . In the ICU,
the patient was started on IV solumedrol 125 mg and gave 1 unit
of platelets. PLT increased to 44 then trended back down, so pt
was started on IVIG. No signs of active bleeding with stable
Hct. Pt was transitioned IV steroids to prednisone 100 mg po
qdaily (1mg/kg). Checked HIV ab and HepC ab, HCV VL, HIV VL
(all negative). After transfer from ICU, pt was continued on PO
Prednisone 1mg/kg, and PLTs trended up, and on discharge were
88. On day of discharge Pt was at her home functional baseline,
tolerating a full diet, moving her bowels, and urinating. There
were no s/s of bleeding. She was discharged on a regimen of 50mg
prednisone BID (pt preference to take BID rather than 100mg
daily).. Taper will be directed by hematology. She was
instructed to follow up for serial CBC monitoring. ITP could
have been promoted by H.pylori, see below.
++++ Pt should continue bactrim for PCP ppx as well as calcium
and vitamin D for bone health while on prednisone therapy.
.
# HEMATEMESIS/UGIB: Differential includes ___ tear
complicated by thrombocytopenia vs peptic ulcer disease vs
variceal bleeding vs gastitits vs dieulafoy's lesion, no history
of NSAID use. Initially managed in ICU. HCT and hemodynamically
stable during entire admission. Pt never experienced any
evidence of GIB during admission. HPylori test done and was
positive. Pt was started on triple therapy of Omeprazole PO,
Clarithromycin 500mg BID, and Amoxicillin 1g BID x 14 days. We
recommended the patient to follow up with GI for an EGD
.
#leukocytosis-likely a result of steroid use. No signs of
infection noticed during admission. Would monitor CBC after
discharge.
.
## TRANSITIONAL
- Discuss with your PCP about EGD to definitively evaluate for
cause of hematemesis and to evaluate for PUD.
- Discuss with Hematology regarding Prednisone taper/dosing
- Monitor your blood glucose since you are now on Prednisone. | 254 | 424 |
15873483-DS-3 | 20,593,200 | Dear Ms ___,
WHY YOU WERE ADMITTED
- You were having chest pain and shortness of breath
WHAT WE DID FOR YOU
- You received nitroglycerin under your tongue that improved
your symptoms
- You had blood tests and an EKG that ruled out an acute heart
attack
- You had a stress test that ruled out heart disease
- Your liver numbers were elevated but you had an ultrasound
that did not show any gallbladder disease. It did show fatty
deposition in the liver that can cause liver disease in the
future, but can be treated with weight loss
WHAT YOU SHOULD DO WHEN YOU LEAVE
- Please take your medications and follow up with your primary
care doctor
- Please monitor for symptoms and return to the hospital if you
are experiencing worsened chest pain, shortness of breath,
palpitations, dizziness, abdominal pain,
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team | ___ year old woman w/PMH HTN, DM, who presented with
fever/chills, chest pain and shortness of breath. Chest pain/SOB
concerning for unstable angina given quality of pain and risk
factors for CAD. EKG/trop/stress test ruled out ACS and coronary
disease. Fevers/leukocytosis in the absence of localizing
infectious sx points towards a viral etiology which is likely to
explain transaminitis that improved on repeat. Just fatty
changes noted on RUQUS. | 148 | 70 |
16508811-DS-40 | 26,607,153 | Mr. ___, you were admitted to ___ for fever. While you
were here, your temperature was normal which was reassuring. You
were not given any antibiotics. You may have had fevers due to a
gout flare. Your allopurinol dose was increased. Your left foot
wound is healing well. It is very important that you follow up
with Podiatry.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo gentleman with history of diabetes, ESRD on HD, s/p DDRT x
2, most recent in ___, peripheral vascular disease presented to
ER with one low grade fever. Afebrile while inpatient, and only
given abx was home doxycycline. Patient's fever likely due to
gout flare involving R wrist and L knee. Uric acid 8.3, so
allopurinol increased to 200mg daily. Recently admitted ___
for MSSA cellulitis/possible osteo of left foot. Left heel wound
was C/D/I and patient had finished course of cefazolin on
___. Patient will f/u with Podiatry.
# Fevers: Likely due to gout flare involving R wrist and L
knee. Afebrile while inpatient, and no antibiotics given. The
wound looks to be healing quite well with no clinical signs of
infection. UA and CXR both normal. Had been having diarrhea,
however that has resolved. Recently admitted ___ for MSSA
cellulitis/possible osteo of left foot. Left heel wound was
C/D/I and patient had finished course of cefazolin on ___.
Patient will f/u with Podiatry.
# Foot ulcer: Recently admitted ___ for MSSA
cellulitis/possible osteo of left foot. Left heel wound was
C/D/I and patient had finished course of cefazolin on ___.
Patient will f/u with Podiatry. NS wash, betadine, DSD, kerlex
daily. Non-weight bearing on left foot.
# ESRD s/p transplant in ___: Cr at baseline, on stable
immunosuppressive regimen. Continued prednisone, tacro, and MMF
at home doses. Tacro 5.8 on discharge.
# Diabetes mellitus type I: Very well controlled. Continued home
insulin regimen: lantus 37units hs + SSI + carb count. ___ QID
(ok for patient to check his own)
# Gout: Recent flare involving R wrist and L knee. Uric acid
8.3, so allopurinol increased from 150mg to 200mg daily. Has
home colchicine prn.
# Hypertension: Continued home meds - labetalol, lisinopril,
nifedipine.
# Chronic diastolic CHF: last EF >55%, currently
well-compensated. Continued home regimen: beta blocker
(labetalol), aspirin, lisinopril, lasix 40mg BID. Continued low
Na / DM diet. Discharge weight 83.55 kgs (184.19 lbs) on
___.
#CODE: Full
#CONTACT: wife ___ (HCP) ___
#DISPO: ___ service to home
### TRANSITIONAL ISSUES ###
-Patient will f/u with Podiatry, Transplant ___ clinic
-Increased Allopurinol from 150mg to 200mg daily | 71 | 365 |
13136308-DS-9 | 21,130,506 | Dear Ms. ___,
Thanks for choosing ___ as your site of care.
Why was I admitted?
-You had abnormal levels of calcium and magnesium.
-You were also having trouble breathing.
What was done for me while I was hospitalized?
-You were given calcium and magnesium.
-We took a sample of lesion in your lung, and found that it was
cancer
-You developed a fever and an infection in your brain and we
gave you antibiotics
-Your mental status improved after receiving antibiotics and
medications to prevent seizures
What should I do when I leave the hospital?
-Please continue taking all of your medications as prescribed.
-You will follow up with your providers as detailed below.
Thanks,
Your ___ treatment team | PATIENT SUMMARY FOR ADMISSION:
===============================
Ms. ___ is a ___ former smoker with PMH
significant for HTN, HLD, DM2, GERD, CKD3, diverticulosis who
presented to the ED after receiving routine labs by her PCP
showing hypocalcemia, hypomagnesemia, and leukocytosis. In the
setting of dyspnea, Ms. ___ underwent a CTA which
demonstrated a 3.5cm cavitary lesion. She subsequently underwent
an extensive evaluation of her cavitary lesion with bronchoscopy
and biopsy and was treated empirically for a pulmonary abscess.
Biopsy revealed adenocarcinoma.
Following the bronchoscopic procedure on ___, her mental status
declined and she developed a persistent fever with tachycardia
and leukocytosis. CSF analysis ___ raised concern for
meningitis, and she was started on empiric bacterial meningitis
therapy with vancomycin/cefepime/ampicillin, as well as
acyclovir. MRI did not reveal evidence of a meningeal process
such as leptomeningeal carcinomatosis. EEG revealed triphasic
waves, prompting initiation of lacosamide and phenytoin with
further EEG monitoring. Repeat lumbar puncture ___ showed
resolution of initial findings, and she completed these parallel
courses of treatment for bacterial and viral meningitis with
resolution of her persistent fevers. Her mental status slowly
improved off anti-epileptics suggesting encephalopathy due to
aseptic meningitis rather than seizure, but leukocytosis, and
tachycardia persisted. | 108 | 197 |
15398519-DS-32 | 27,742,368 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
Why were you admitted to the hospital?
=========================================
- You were having a hard time breathing, thought to be from COPD
or asthma.
- You also had high blood pressures.
What did we do for you?
=========================================
- You needed a pressure breathing machine (called BIPAP) to help
you breathe and got steroids (prednisone). You quickly got
better.
- We re-started your home blood pressure medication, and your
blood pressure improved.
What should you do when you leave the
hospital?================================================
- Take 3 more days of prednisone.
- Take your blood pressure medication (lisinopril).
- Follow up with your PCP, ___.
- Return to the hospital if your breathing worsens or you have
any concerns.
- Remember, please avoid smoking cigarettes or any substances at
all as these can be VERY dangerous to your breathing.
We wish you the best of luck in your health!
Warmly,
Your ___ Care Team | Mr. ___ is a ___ year old man with COPD and asthma with
history of exacerbations requiring intubation, HIV (CD4 ___ and history of polysubstance use, who
presented with shortness of breath concerning for COPD/asthma
exacerbation.
#Respiratory failure
#COPD/asthma exacerbation
Patient presented with acute wheezing, shortness of breathing
requiring BIPAP. ABG was not drawn in the emergency room to best
characterize his respiratory failure, but he had significant
work of breathing. He quickly improved with nebulizer and one
dose of IV solumedrol. His symptoms were attributed to
COPD/asthma, but he improved very quickly that there was concern
there may have been another trigger for his symptoms that was
unidentified. Toxicology screen was negative. He will complete a
five day course of prednisone, last day ___.
#HTN
Patient with significantly elevated BPs in the ED 180s/110s,
with no pulmonary edema and no symptoms to suggest emergency.
His home lisinopril was restarted and BP was in 120-130s/90s. He
may need uptitration of this given his elevated diastolics.
#HIV
His CD4 count is down to 600 from 800 ___. Continued HAART.
Patient will follow up with his PCP and ID team at ___.
#History of polysubstance use disorder
From chart review patient has history of use of multiple
substances and concern for fentanyl overdose in the past.
Patient denied active drug use and toxicology screen was
negative. | 152 | 216 |
14329697-DS-20 | 25,850,355 | You came to the hospital with headache, dizziness and a question
of right facial puffiness. You had an MRI which did not show a
stroke. You headache has improved. You likely are having a
migraine.
Based on Dr. ___ from last ___, you are
overusing Fiorecet which may actually be worsening your
headache. You should stop taking it. While you are transitioning
off of it you can use tramadol. You can also try taking an
herbal supplement called Butter Bur 50mg daily to prevent
headaches. This can be purchased at a supplement store. | This is a ___ year old woman with a history of migraines who
presented with headache, nausea, right face "puffiness" and
possible dysarthria.
The patient was admitted to the stroke service for possible
stroke. She had an MRI which was negative for stroke. Her
symptoms are most likely due to migraine, possibly in
combination with medication effect from fiorecet.
After review of the records it seems that the patient had been
seen by Dr. ___ her ___ in the past who
recommended against the use of fiorecet due to concern for
medication overuse headaches. We reaffirmed this recommendation
and prescribed a small amount of tramadol as well as an herbal
supplement, ButterBur daily to prevent headaches.
The patient will follow up with Dr. ___. | 92 | 122 |
18369788-DS-5 | 22,472,111 | You were admitted with fevers, abdominal pain and inability to
eat and were found to have a severe infection from an infected
gallbladder (cholecystitis). You had a tube placed in your
gallbladder to drain it and were started on antibiotics. Your
infection improved. Please follow-up with surgery as scheduled
to discuss having surgery on your gallbladder.
Your Coumadin was held initially, after discussion with Dr.
___ Coumadin was restarted and we recommend continuing
it until ___ and then stopping it. The goal INR is ___. | ___ yo M with ___ relevant for recent knee surgery (___) on
Coumadin for DVT prophylaxis, meningioma s/p resection, seizure
disorder, NIDDM and HTN who was transferred from ___
___ on ___ for concern for acute cholecystitis and
septic shock.
#Septic shock with lactic acidosis and ___ due to
#Acute cholecystitis
#Gram negative rod bacteremia
Initially required aggressive IV fluids and was briefly on
Levophed. Status post percutaneous cholecystostomy tube on ___
with significant improvement in symptoms. Abdominal pain and
leukocytosis resolved. Blood cultures at ___ grew E. coli
sensitive to all antibiotics tested except for ampicillin,
Unasyn and cefazolin. He was initially on Zosyn and
de-escalated to ciprofloxacin.
-Continue ciprofloxacin for two week course (day ___
-Continue cholecystotomy drain care per radiology recs
-Will need interval cholecystectomy, follow-up with general
surgery scheduled.
#Abnormal LFTs
No evidence of stones or ductal dilation on CT or US. Possibly
due to local inflammation from cholecystitis. ERCP was
consulted and recommended clinically following. LFTs
downtrending with normal bilirubin, unlikely to have biliary
obstruction.
-Recommend repeat LFTs in ___ weeks.
-If LFTS rising will need to discuss with ERCP team proceeding
with MRCP vs ERCP
#Recent right TKR on ___ at ___, he was placed on Coumadin for DVT
prophylaxis with plan for 4 weeks of Coumadin. INR was reversed
at OSH and Coumadin was initially held. After cholecystostomy
tube placement Coumadin was restarted. The staples from this
knee incision were removed and steri-strips were placed.
-Continue Coumadin with goal INR ___ until ___.
-Follow-up with Dr. ___ 1 week.
#DM II: On admission his home oral meds were held and he was
placed on a sliding scale.
-Continue home regimen on discharge.
#HTN
#HL
Initially home cardiac medications were held in setting of
shock. They were slowly restarted and his BP and heart rate
remained stable.
-Continue Carvedilol, aspirin, simvastatin, chlorthalidone
#Seizure disorder: continue Keppra
#FEN/PPX: diabetic diet, heparin SC
Full code
Dispo: home with services | 90 | 333 |
14663313-DS-7 | 25,705,689 | Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for nausea, vomiting, back pain, and concern for GI
bleed. Fortunately, you did not show signs of bleeding and your
nausea, vomiting, and diarrhea stopped. Your back pain,
however, was severe so a CT was obtained which demonstrated
multiple lumbar disc herniations and narrowing of your spinal
canal. The orthopedic doctors saw ___ here and recommendation
you follow up with them in clinic
-Please take dilaudid every 6 hrs AS NEEDED - DO NOT Drive or
drink alcohol while taking this medication as it may make you
very drowsy.
-Contnue to take senna and colace daily to have normal bowel
movements. Do NOT take these should you start to have loose
stool
-Please make sure to follow up with the ortho spine doctor at
___
-___ should discuss having a colonoscopy with your primary care
doctor as we found you have small amounts of blood in your
stool. | Impression: Pt is an ___ y/o M with PMHx significant for COPD,
HL, HTN, obesity, DM, CKD who presented with nausea, vomiting,
and acute renal failure with associated subacute worsening of
back pain
#Lower back pain- Pt reported worsening of his lower back pain
about ___ prior to admission. He had an outpatient spine
appointment planned for the near future. His pain was difficult
to control and refractory of morphine and oxycodone, so dilaudid
was given which helped. CT L spine here with severe spinal
stenosis, multiple disc herniations, and DJD. Given the severe
findings, ortho spine was consulted who saw the patient and
recommended outpatient follow up as there was nothing that
warranted immediate surgical intervention. He was sent out on
PO dilaudid and spine f/u.
#ARF on CKD- likely pre-renal etiology vs. AIN (piroxicam with
Eos). Pt's creatinine markedly improved from 2.1 to 1.3 with 2L
IVF. His ___ and hydrochlorothiazide were initially held
#?GIB: Concern for GIB given "coffee ground emesis" and +FOBT.
Patient's description was somewhat concerning for GIB, but he
had no true melena, and his +FOBT may indicate occult cancer or
polyps. The one significant risk factor that he did have was
piroxicam for which he was taking daily. GI was consulted in the
ED who do not think he needed to be scoped as likely not acutely
bleeding given no melena. His hct was monitored and was stable
throughout admission. He did not have any episodes of melena or
coffee ground emesis. Piroxicam was d/c and he was advised not
to take NSAIDs in the future
#Nausea/Vomiting/Diarrhea- likely viral gastroenteritis. These
symptoms resolved before he arrived on the floor. He was fluid
resuscitated as above.
#Transaminitis with abdominal distension: Patient had mild
transaminitis that downtrended at time of discharge. RUQ
ultrasound with dopplers showed fatty liver, but nothing else
significant. They may have been due to viral gastroenteritis.
#Eosinophilia- Leading cause would be AIN given NSAID exposure.
Other causing including parasites, malignancy, adrenal disorders
are less likely in this presentation. CBC w/ diff was repeated
with persistent eosinophilia. Piroxicam d/ced. The remainder
of the workup was to deferred to outpatient providers given the
resolution of his primary issues.
#COPD- Continued albuterol nebs and IH. Received fluticasone
instead of symbicort while in house as non-formulary.
#HTN- held ___ and HCTZ. HCTZ was restarted before discharge
#HL- Continued statin
TRANSITIONAL ISSUES
-Pt needs follow up of eosinophilia and repeat CBC w/ diff
-Pt needs follow up of steatosis found on RUQ ultrasound and
consideration of further imaging
-Patient was found to have guaic positive stool. He needs
outpatient screening for colorectal cancer
-Pt will be discharged with PO dilaudid as morphine and
oxycodone were not adequately controlling his pain
-Pt should NOT be taking piroxicam any more for concern of GI
bleed (also was not effective)
-Losartan has been held due to acute kidney injury (resolving) | 163 | 505 |
15935923-DS-7 | 21,000,854 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you were not feeling well, you had intermittent chest
pain and left arm numbness, and you also had pain in your upper
abdomen with nausea and sweating. When you presented to the
hospital, the chest pain and arm numbness resolved.
We evaluated you for a cardiac reason for your chest pain, and
we do not believe that it is due to a heart attack. Your
abdominal pain and discomfort, nausea and sweating, are most
likely due to gastritis, or possibly peptic ulcer disease, which
you have had in the past. We also found microscopic blood in
your urine, and we had a special image of your abdomen and
pelvis to evaluate the kidneys, but nothing abnormal was found
in either the kidneys or the abdomen.
We encourage you to have an outpatient follow up appointment
with a gastroenterologist, Dr. ___, to evaluate you for peptic
ulcer disease, which might be the reason for your abdominal
discomfort. You should also follow up with urology to further
evaluate the microscopic blood in your urine and previous biopsy
results.
We wish you the best,
Your ___ team | Mr. ___ is an ___ PMH CAD s/p MI with CABG, s/p cardiac cath
(___) with severe three-vessel disease, DM II, CKD stage 3,
and HTN who presents with a three-day history of left-sided
chest pain associated with left arm numbness, in addition to
epigastric pain, nausea, and diaphoresis most likely consistent
with gastritis and non-cardiac chest pain. | 196 | 58 |
17513369-DS-12 | 21,409,169 | Surgery:
- You underwent surgery to remove a ___ mass from your ___.
- You may shower at this time, but please keep your surgical
incision dry.
- It is best to keep your surgical incision open to air, but it
is okay to cover it when outside.
- Please call your neurosurgeon if there are any signs of
infection such as fever, pain, redness, swelling, or drainage
from your surgical incision.
Activity:
- You may take leisurely walks and slowly increase your activity
at your once pace once you are symptom free at rest. Don't try
to do too much all at once.
- We recommend that you avoid heavy lifting, running, climbing,
and other strenuous exercise until your follow-up.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for at least 6 months.
- No driving while taking narcotics or any other sedating
medications.
- If you experienced a seizure, you are not allowed to drive by
law.
Medications:
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- You have been discharged on levetiracetam (Keppra). This
medication helps to prevent seizures. Please continue this
medication as prescribed. It is important that you take it
consistently and on time.
- Please do not take any blood thinning medications such as
aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin),
etc. until cleared by your neurosurgeon.
What You ___ Experience:
- You may experience headaches and pain at the surgical
incision.
- You may also experience some postoperative swelling around
your face and eyes. This is normal after surgery. You may apply
ice or a cool or warm washcloth to help with this. It will be
its worst in the morning after laying flat while sleeping but
should decrease once up.
- You may experience soreness with chewing. This is normal after
surgery and will improve with time. Softer foods may be easier
during this time.
- Feeling more tired or restless is common.
- Constipation is also common. Be sure to drink plenty of fluids
and eat a high fiber diet. You may also try an over the counter
stool softener if needed.
Please Call Your Neurosurgeon At ___ For:
- Fever greater than 101.4 degrees Fahrenheit.
- Severe pain, redness, swelling, or drainage from the surgical
incision.
- Severe headaches not relieved by prescribed pain medications.
- Extreme sleepiness or not being able to stay awake.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
- Nausea or vomiting.
- Seizures.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden severe headaches with no known reason.
- Sudden dizziness, trouble walking, or loss of balance or
coordination.
- Sudden confusion or trouble speaking or understanding.
- Sudden weakness or numbness in the face, arms, or legs.
Diabetes type II:
- While inpatient, the ___ diabetes team was consulted to
adjust your medications while on Dexamethasone.
- At the time of discharge, you were receiving fixed Lantus
28units QHS, fixed NPH insulin 15units at breakfast, fixed
Humalog 10units with all meals and sliding scale Insulin QACHS.
- On ___, you should reduce your NPH to 10 units QAM,
reduce Humalog to 6 units
with meals and continue Lantus 28 units QHS.
- On ___, after you have been on your Dexamethasone maintenance
dose of 2mg QD for 24-hours, you should discontinue your NPH. | ___ year old male found to have a right temporal ___ mass.
#Right temporal ___ mass
The patient was admitted on ___ for further evaluation
and management and was taken to the OR on ___ for a right
craniotomy for resection of the right temporal ___ mass. The
operation was uncomplicated. Please see OMR for further
intraoperative details. The patient was extubated in the OR and
recovered in the PACU. The patient was transferred to the step
down unit postoperatively for close neurologic monitoring. He
was continued on Keppra and dexamethasone postoperatively.
Dexamethasone taper was written. Postoperative MRI of the head
showed good resection with expected postoperative changes with
some residual tumor. The patient remained neurologically stable.
He was seen by Neuro Oncology and Radiation Oncology while
admitted. His neurologic exam remained stable to improved over
the course of his admission.
#Leukocytosis
Patient labs revealed elevated white count. Patient was afebrile
and had no s/s of infection. Elevated white count likely
secondary to steroids. He was monitored closely through his
admission for s/s of infection. His white count gradually
decreased as his steroid dose tapered.
#T2DM
Patient with T2DM on home glipizide and Tresiba. Tresiba was non
formulary, so sugars were managed inpatient with his home
glipizide and insulin sliding scale. ___ was consulted for
management recommendations - they recommended holding his
Glipizide and adjusted both fixed and sliding scale insulin
orders as needed. Metformin 500mg BID was resumed ___ (patient
had previously stopped due to diarrhea). They also recommended
short interval follow-up.
#Disposition
On ___, he was afebrile with stable vital signs, mobilizing
with assistance, tolerating a diet, voiding and stooling without
difficulty, and his pain was well controlled with oral pain
medications. He was discharged to rehab on ___ in stable
condition. | 554 | 287 |
19477643-DS-18 | 28,580,149 | 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:
- Weight bearing as tolerated
Physical Therapy:
Weight bearing as tolerated
Treatments Frequency:
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.
- Daily dry gauze dressing. No dressing is needed if wound
continues to be non-draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for operative treatment of
right valgus impacted femoral neck fracture with cannulated
screws, 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 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
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. | 233 | 240 |
14814375-DS-21 | 29,104,300 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing left lower extremity in unlocked
___
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Touchdown weightbearing left lower extremity and unlocked
___, okay to remove when in bed
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left lateral tibial plateau fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of the left lateral tibial plateau, 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 minimal oral medications, incisions were clean/dry/intact,
and the patient was voiding/moving bowels spontaneously. The
patient is touchdown weight bearing in the left lower extremity
and is in an unlocked ___. The patient 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. | 629 | 272 |
11874038-DS-10 | 29,884,268 | Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a car crash.
- You also had several fainting episodes over the last week.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were having a dangerous abnormal heart rhythm. This was
likely provoked by cocaine use. You were started on medications
to help your heart beat regularly.
- You had several imaging studies that showed that your
coronary stents are working properly.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
- Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ year old man with history of heart failure
due to ___ (___) complicated by cardiac arrest requiring
urgent PCI x2 (LAD and LCx), alcohol use disorder, and cocaine
use disorder who presented after one week of multiple syncopal
episodes in the setting of cocaine use, ultimately culminating
in a low-speed motor vehicle accident. His hospital course was
complicated by an in-hospital cardiac arrest and multiple
episodes of polymorphic ventricular tachycardia requiring
several ICD shocks. Pt was transferred to the CCU for closer
monitoring and started on IV anti-arrythmics.
TRANSITIONAL ISSUES
===================
[ ] interrogate device within one month
[ ] counsel on cocaine cessation
[ ] counsel on ETOH abstinence
[ ] ongoing discussion of whether long-term amiodarone is
indicated given that his arrhythmia was likely provoked iso
cocaine use and he has ICD in place. To continue on Amiodarone
400mg BID through ___ before starting 400mg daily ___.
ACTIVE ISSUES
=============
# Cardiogenic syncope
# Motor vehicle crash
# Polymorphic ventricular tachycardia
Mr. ___ was admitted with one week of multiple syncopal
episodes. He was originally admitted to the medicine service for
workup of syncope. On the floor, however (___), he had a PVT
cardiac arrest. His device discharged, he was started on
amiodarone, lidocaine, and magnesium, and he was transferred to
the CCU. In the CCU, Mr. ___ had several episodes of PVT
that responded to lidocaine and amiodarone. His ICD was
interrogated and, over the last week, his ___ ___ ICD
had detected 22 episodes of VT/VF and delivered 17
defibrillation shocks. He underwent coronary angiography (___)
which demonstrated no in-stent stenosis or significant coronary
disease. Ultimately, his PVT was attributed his underlying
ischemic heart disease and recent cocaine use. He was discharged
on amiodarone 400mg BID, to transition to daily on ___.
# HFrEF ___ ___ s/p PCIx2
Mr. ___ had a ___ in ___ that was treated with two
stents. Upon discharge, he was lost to follow-up and was not
taking his prescribed medications, except for a daily aspirin.
During this hospitalization, he was started on lisinopril and
atorvastatin. Beta blockade was not started given recent cocaine
use.
CHRONIC ISSUES
==============
# Cocaine use disorder
Patient reports weekly intranasal cocaine use. He was counselled
on cocaine cessation.
# Alcohol use disorder
Patient reports drinking 12 beers per day. He was placed on a
___ protocol and counseled on alcohol cessation | 191 | 388 |
18567979-DS-40 | 29,577,459 | Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted because you had difficulty breathing. We found that
you had pneumonia and an exacerbation of your heart failure. We
treated you with antibiotics. We also treated you with
medications to help remove excess fluid from your lungs to
assist your breathing.
You also had back pain, which is an ongoing issue. We treated
you with Tylenol around the clock and your back pain improved.
You can take up to 3 tablets of 650mg tylenol each day when you
go home for back pain.
You have continued to have occasional mild nausea and heartburn.
This may be related to constipation, so we recommend using
laxatives to ensure ___ bowel movements/day.
Weigh yourself every morning. If your weight goes up by 3
pounds, please call Dr. ___.
We made the following changes to your medications:
STOP amlodipine, a blood pressure medication
STOP lidocaine patch and tramadol, used for back pain
STOP lorazepam and famotidine, which can worsen delirium
STOP furosemide, a diuretic
START Tylenol for pain
START hydralazine for blood pressure
START senna and Miralax as needed for constipation
START albuterol nebulizers, ipratropium nebulizers, guaifenesin
syrup, benzonatate, and cepacol for cough
START lidocaine and Nystatin swish and swallows for thrush
START miconazole cream for fungal rash
START insulin for high blood sugar
START Cipro, an antibiotic, for 3 days for urinary tract
infection
REDUCE carvedilol and aspirin doses
Please follow-up with your physicians as listed below. | ___ w/ CAD (s/p PCI ___, CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain and DOE with a cough. Imaging
consistent with PNA and CHF. Hospital course complicated by
worsening CHF exacerbation and difficulty with diuresis ___ CKD
requiring transfer to the MICU for agressive diuresis.
.
# Acute on Chronic Systolic CHF: *****PATIENT'S DRY WEIGHT IS 46
KILOGRAMS***** Patient has known CAD with past PCIs and an
ischemic cardiomyopathy. Most recent ECHO prior to this
admisison showed 2+ MR and EF 40%, found to be worsened to 30%
with 3+ MR on ECHO during this admission. Her home dose of
Lasix is 80 mg BID. Initial exam was notable for elevated JVP
and bilateral crackles. CXR consistent mostly with PNA with
mild vascular congestion. During the first few days of
admission, patient did not respond to Lasix 80 mg IV or 120 mg
IV (output ~200-250 to each dose). She initially had mild
improvement in symptoms but had increasing O2 requirement to
4LNC overnight on ___. CXR showed worsening of bilateral
vascular congestion. This may have been in the setting of
elevated SBP in the 160-170s. BP control with nitropaste and
uptitration of amlodipine to 10mg (from 7.5) daily and imdur to
90mg (from 60mg) daily and carvedilol to 25mg (from 12.5mg) BID.
Patient not on ___ due to history of hyperkalemia on ___.
More aggressive diuresis attempted with 10mg metolazone
followed by 100mg torsemide, with only mildly better results.
On ___ morning, the patient was noted to desat to 80% on
4.5LNC, 74% on RA and 90% on NRB and was sent to the MICU. In
the MICU she was placed on a lasix gtt, in addition to
continuation of metolazone 10 mg bid, averaging net negative one
liter per day. This diuresis was augmented by decreasing her
carvedilol dose to 12.5 mg bid in an attempt to increase cardiac
output. Her oxygen requirement decreased to ___ NC on transfer
out of the MICU and she was breathing much more comfortably.
There was discussion of possible UF session to remove fluid or
placement of a BIV pacer, but the patient declined both of these
procedures. *****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
.
On the floor, her diuresis was held due to worsening kidney
function. Gentle diuresis with Lasix was restarted for several
days to help her reach her dry weight, which clinically appears
to be 46kg. As her Cr increased again, her diuretics were again
held and she remained close to euvolemic thereafter. She is not
being discharged on diuretics in order to allow further recovery
of her renal function. It has been observed that she naturally
diureses when her HR is over 70, thus her carvedilol was reduced
in order to maintain her heart rate and improve her urine
output. If her weight goes up while her HR is > 70, she may
require diuresis. However, given her renal dysfunction, this
should be carefully considered in cooperation with her PCP and
___ to avoid future HD.
.
# Community Acquired Pneumonia: Patient presented with chronic
DOE, but much worse from baseline in the week prior to
presentation. In the ED, there was concern for PE and patient
underwent non-contrast CT (due to baseline CKD) which showed no
evidence of PE. Leukocytosis (WBC 13.3 with PMN predominance),
CXR with hazy right lung base opacity and CT showing
perivascular infiltrates/ground glass appearance all suggested
pneumonia. She was treated for CAP (although she has been
hospitalized in ___ and mild CHF exacerbation (see above).
Urine legionella antigen was negative. She was treated with
ceftriaxone (x8 days) and azithromycin (x5 day). Her dry,
congestive cough responded well to albuterol nebulizers,
expectorants and chest ___. She continued to cough at discharge,
although without fever or leukocytosis to indicate continued
infection. We anticipate this dry, occasionally productive
cough with wheezing will resolve over the next ___ weeks with
continued nebulizer treatments and cough suppressants.
.
# Chest pain/troponin elevation: Dyspnea was occasionally
accompanied by anterior chest pain, reproducible with palpation,
that resolved with improvement in respiratory status. Unlikely
coronary origin. However, patient did have a troponin bump to
0.21 (from 0.02 on admission) on ___ in the setting of acutely
worsening CHF, h/o CAD and CKD. Troponins remained stable in
the low .2's. CKMB negative. Patient was continued on aspirin
81mg daily.
.
# Back Pain: Patient has chronic back pain, had worsened over 3
days prior to admission. Patient has h/o spinal stenosis and
pain was similar in quality to baseline. Per patient, she only
takes at most one tablet of tylenol per day for fear of it
injuring her kidneys. Pain well-controlled on standing tylenol
___ q8h.
.
# Chronic Kidney Disease: Baseline creatinine 1.9-2.1. Arrived
at baseline and increased with diuresis, peaking at 3.3. This
was likely due to poor forward flow from CHF exacerbation and
diuresis. Diuresis was paused with improvement in creatinine to
3.1. The Nephrology team was consulted and felt that the
patient would likely recover over time, although possibly to a
lower baseline. She was discharged with planned outpatient
Renal follow-up. As diuresis worsens her renal function, it is
important to avoid diuresis if possible by controlling fluid
input and heart rate.
.
# HTN: Blood pressure mildly elevated, usually worsening in the
evening and overnight to SBP 160s and then stabilizing in SBP
130s-140s after morning home medications. In the setting of CHF
exacerbation and MR, BP control tightened. Nitropaste used prn
and home meds uptitrated. Patient not on ___ at baseline,
had history of hyperkalemia.
.
# Hyponatremia: Likely due to CHF exacerbation and renal
injury. Controlled with fluid restriction.
.
# Constipation: Patient reported chronic mild constipation at
home, was taking docusate. Responded to colace and senna.
Patient experienced mild nausea when constipated, resolved with
bowel regimen.
.
# Altered mental status: Patient had an episode of
disorientation and agitation, likely hospital-acquired delirium,
perhaps exacerbated by uremia. Famotidine and benzodiazepines
held.
.
# Groin rash: Mild irritation secondary to having restricted
ambulation. Miconazole topical started.
.
# Thrush: Patient was found to have mild thrush, treated with
Nystatin, viscous lidocaine.
.
# Diabetes: Type II, controlled with diet at home. The patient
had persistent hyperglycemia in the 200s. We started her on NPH
prior to discharge for improved control, but this will likely
need continued titration.
.
# GERD: Continued home famotidine until episode of delirium,
then held. | 239 | 1,108 |
19300976-DS-20 | 24,744,081 | Dear Ms. ___,
You were admitted to the hospital because you had shortness of
breath and swelling in your right face.
While you were in the hospital, we performed imaging of your
chest and neck which showed you have chronic superior vena cava
syndrome, caused by a mass near your right neck. Your imaging
additionally showed vascular congestion, also known as extra
fluid in your lung vessels. You were evaluated by vascular
surgery for a possibility of stent placement, which they did not
recommend at this time. You were also seen by radiation
oncology. They recommended you follow up in Dr. ___
___ as radiation treatment may help relieve your symptoms.
When you are at home, look out for the danger signs below; if
you experience any of them, please seek medical attention.
Additionally, please expect a phone call from Dr. ___
___ ___ clinic to set up an appointment for radiation
therapy.
It is important to take your blood pressure medications. If you
have a headache or feel dizzy call your doctor.
Your blood pressure medications are:
Lisinopril 20 mg
Amlodipine 5 mg ___ tab)
You should take these medications in the morning.
It was a pleasure taking care of you,
- Your ___ Care Team | ___ is a ___ year old female with history of metastatic
ovarian cancer and multiple myeloma who presented with acute
exacerbation of her chronic SVC syndrome, namely SOB and
right-facial edema.
She presented to the ED afebrile, but with vitals significant
for BP 174/96 after missed dose of Lisinopril and amlodipine.
Oxygen saturation of 88%. She was placed on nasal cannula oxygen
of 2L. Her CXR was notable for perihilar vessels likely
representing mild congestion. Her CTA showed no blood clots, but
was significant for pulmonary metastasis of 6mm and mediastinal
lymphadenopathy that was unchanged from prior imaging. She was
noted to have a known SVC obstruction from a supraclavicular
calcified mass at the base of her right neck.
#SVC
#DYSPNEA ON EXERTION
To help with her symptoms she received diuresis with IV Lasix,
for which she responded well. Additionally, vascular surgery and
radiation oncology were consulted. Vascular surgery did not
recommend a stent at this time, as her symptoms were improving.
Radiation oncology recommended following up as outpatient with
Dr. ___. On day of discharge, patient's vitals
were stable and she was breathing on room air comfortably. Her
symptoms and facial swelling had greatly improved. Her
ambulatory oxygen saturation was normal.
#HYPERTENSION
She was also restarted on her home blood pressure medications to
correct her hypertension and then she remained normotensive.
# Metastatic Ovarian cancer: Currently on Gemzar and Avastin, as
well as Zometa which she tolerates well. PET scan in ___ showed
some very slight increase in disease, likely very slow
progression
# Multiple Myeloma: last treated with revlimid and velcade,
stable.
# Asthma: not on nebs or inhalers at home.
- albuterol nebs prn
# Diabetes mellitus type 2, diet-controlled
Transition Issues
=================
- Amlodipine 5 mg
- Lisinopril 20 mg
- follow up with Dr. ___ office to call patient
to set up appointment
- follow up with oncology on resuming Gemzar, Avastin, and
Zometa
- CODE STATUS- DNR DNI
- Emergency Contact: ___ ___ (home);
___ (cell) | 212 | 317 |
15693883-DS-4 | 28,431,680 | Dear Ms. ___,
You were admitted to ___ because you had black
stools.
WHILE YOU WERE HERE:
- You had an endoscopy that showed an ulcer. Bleeding from the
ulcer probably caused the black stools.
- You had worsened kidney function and fluid overload (leg
swelling and trouble breathing). You were given Lasix and
torsemide which helped with this.
WHEN YOU GO HOME:
- Your medications have been changed. Please see below.
- Your follow up appointments are below.
- Weigh yourself every day and call your doctor if weight goes
up > 3lbs in 1 day or 5lbs in 1 week.
It was a pleasure taking care of you and we wish you good
health.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ pmhx PBC and autoimmune hepatitis c/b
varices, HE, on liver tx list who presented with with melena,
nausea, emesis, fatigue, and abdominal distension. EGD was done
and showed healing ulcer, which was likely cause of bleeding.
She had small varices that were unlikely to be the cause. She
had no more melena after the procedure, but course was
complicated by hypoxia, briefly requiring non-rebreather, in
setting of albumin challenge causing pulmonary edema. This
improved with aggressive diuresis and she was discharged on a
new diuretic regimen and PPI.
# Melena
She remained hemodynamically stable with stable Hgb during the
admission, and never required pRBC. Initially, concern for
variceal bleeding given prior EGD with 2 cords of grade II
varices in lower third of esophagus, as well as varices at the
fundus. Therefore, ceftriaxone and octreotide were started. EGD
was done on ___ revealed small varices and portal gastropathy,
but also healing ulcer at GE junction. Most likely source of
melena being healing ulcer at GE junction (see report). Since
EGD, she had no melena. She was discharged on PO PPI BID.
# Hypoxia and ___ edema:
Initially on 2L nasal cannula. Received albumin challenge with 3
doses of 1mg/kg on the first 3 days on admission, in addition to
IV lasix. In this context, she developed worsening hypoxia
requiring NRB. CXR consistent with pulmonary edema. EKG negative
and troponin negative x1 (chest pressure at time of event,
resolved). Hypoxia improved with holding further albumin
infusions and aggressive diuresis with 40mg IV Lasix boluses,
and she was weaned to room air. However, failed PO Lasix trial
and was placed instead on torsemide. She was discharged on
torsemide 20mg daily, along with 40mg potassium daily for
repleteion. She will require labs to check electrolytes at her
next outaptient appointment.
# Ascites
Initially, concern for SBP given worsened ascites over the past
month. Tenderness improved on exam. There was not enough fluid
visualized for paracentesis. Ceftriaxone was initiated for
melena as discussed above, but was discharged after EGD revealed
ulcer and less concern for SBP on exam. Ascites improved with
diuresis.
# ___
Initially had elevated Cr to 1.2 from baseline 0.8-1.0. She was
given albumin challenge, in addition to Lasix for hypoxia
(discussed above), with worsened creatinine to 1.6. Creatinine
improved with diuresis to 0.8 and then worsened to 1.2 at time
of discharge (in setting of receiving both Lasix and torsemide).
She will need follow up laboratory testing to assess for
improvement in creatinine while being on torsemide only.
# Cirrhosis
Primary biliary cirrhosis that has been complicated by
autoimmune hepatitis, also has hepatic encephalopathy. Childs C,
MELD-Na 29 on discharge. On transplant list. Cotninued home
lactulose and ursodiol.
# Hyponatremia
Na 123 on admission. Improved with albumin. Likely ___ poor PO
intake, nausea/vomiting, and decreased effective circulating
volume in setting of cirrhosis.
# Chronic
Depression - cont citalopram
Cont home multivitamins, mag ox, gabapentin, and calcium
carbonate
===================================
TRANSITIONAL ISSUES
===================================
[ ] She was discharged on torsemide 20mg daily, along with 40mg
potassium daily for repleteion. She will require repeat CBC an
Chem10 at her next outaptient appointment, and continued
titration of her diuretic
[ ] Patient discharged on Vitamin D, E, and A
[ ] Home Spironolactone increased to 100 mg PO QDaily
[ ] She was discharged on PO PPI BID.
[ ] 9 mm left lung nodule, should be followed up with a chest
CT.
[ ] IPMN, should be followed with MRCP in ___ year.
Hgb at discharge: 8.2
Cr at discharge: 1.2
#CODE: Full (confirmed)
#CONTACT: Husband ___ ___ | 110 | 575 |
10976602-DS-38 | 22,278,098 | Dear Ms. ___,
It was a pleasure caring for you during your time at ___. You
were admitted for a large blood blister on the left leg. You INR
was found to be elevated, and your warfarin was stopped. We gave
you a unit of blood and, in finding that you were
iron-deficient, started you on iron supplements. The blood
blister on your left leg did not resolve on its own and had to
be opened up with surgery. After opening the wound, your pain
improved and plastic surgery will follow-up with you regarding
skin grafting. You were also found to be holding onto a little
more fluid due to your heart failure. We gave you diuretics to
remove this fluid and your torsemide was continued at discharge.
Please remember to have yourself weighed every morning and to
call an MD if your weight goes up more than 3 lbs.
We wish you all the best!
Your ___ care team | ___ year old female w/PMH of Afib w/RVR on warfarin, chronic
venous insufficiency, and peripheral neuropathy who presents for
LLE swelling and redness.
ACUTE ISSUES
============
# Left leg hematoma: In the setting of recent trauma to the left
leg and recent HCT drop, she was transfused 1u PRBCs. Her
warfarin was held in the setting of her supratherapeutic INR and
she was given vitamin K. On the floor, she remained afebrile and
her vital signs were stable. Because there was also question of
a cellulitis in the left leg through open sores (edematous,
erythematous, warmer LLE), she was treated empirically Keflex
___ Q8H for 7 days (___). Wound was consulted, and
the left leg hematoma was initially managed with commercial
wound cleanser, dry gauze, Xeroform, and Kerlix wrap while her
pain was managed with standing Tylenol, tramadol, and oxycodone.
However, she re-bled into the LLE hematoma. At that time,
surgery and plastics were consulted, who recommended evacuation
of the hematoma and debridement of necrotic tissue overlying the
hematoma, which was completed and a wound VAC was applied.
Plastic surgery recommended that the wound VAC stay in place
until sufficient formation of granulation tissue was noted upon
reassessment in the outpatient setting. Follow-up with plastic
surgery was scheduled for ___ at 9:00 AM. They recommended
that the wound continued to be covered with a wound VAC until
her follow-up appointment. ___ evaluation recommended that the
patient would need rehabilitation for deconditioning during her
prolonged hospitalization.
# Paroxysmal Afib: Currently in sinus, previously
anticoagulated. She presented with a supratherapeutic INR of 4.7
and warfarin was held on admission. She was given vitamin K 5mg
PO x 2 and her INR downtrended. The patient's skin is also
extremely sensitive to the effects of warfarin, evidenced by the
left leg hematoma and diffuse ecchymoses. Alternatives into
anticoagulation were explored. However, the patient's high
CHADS2 score and irreversibility of make newer anticoagulants
not a suitable alternative. Contact was made with the patient's
outpatient cardiologist to continue warfarin when the hematoma
had resolved. After evacuation of the hematoma, hemostasis had
been confirmed by the surgical team, and INR had returned to the
therapeutic range, warfarin was restarted at a decreased dose of
1mg daily (rather than 1mg on M/F and 1.5mg on all other days).
She should have a repeat INR on ___.
# Acute Diastolic CHF: The patient's weight on ___
was slightly increased from dry weight and so 80mg torsemide
daily was continued in-house. Her electrolytes were monitored
daily. Her KCl was held initially due to elevated Cr.
After surgical evacuation of the LLE hematoma, the patient
received an increased dose of pain medication. On ___, the
patient developed hypotension to ___ and lactate elevation
to 3.9. She received 1U pRBCs and 1.5L fluids but had ongoing
hypotension to ___, which prompted transfer to the MICU. A
TTE was performed, which showed EF 55%, similar to prior in
___. Cardiology was consulted and did not believe patient
was in cardiogenic shock, but did recommend resuming her home
diuretic, torsemide 80 mg daily. The patient did not have any
signs of infection to suggest sepsis, as blood cultures were
negative, she remained afebrile, and there was no leukocytosis.
Labs showed BNP 4979 and troponin trend of 0.08 -> 0.11 -> 0.12,
reflecting demand ischemia. The most likely etiology of her
hypotension was a diastolic heart failure exacerbation by fluid
resuscitation and was noted to be up 20lbs up from her dry
weight during hospitalization. She was diuresed with Lasix and
metolazone with good response of blood pressure back up to
baseline 100s SBP and resolution of ___. She was restarted on
her torsemide in-house and trended back to her dry weight. Home
KCl was restarted in the setting of continued diuresis and
return of Cr to baseline.
# ___: On admission, Cr was increased to 1.6. After received 1u
pRBCs, her Cr decreased to 1.5 and remained stable. Additional
fluids were not given in the setting of CHF. However, the
patient developed ___ and oliguria in the setting of hypotension
on ___. Urine lytes suggested pre-renal azotemia. However, this
was in the setting of a likely exacerbation of her diastolic
dysfunction and fluid overload. She was diuresed with Lasix and
metolazone with good response of blood pressure back up to
baseline 100s SBP and resolution of her ___. She continued to
have good urine output after restarting her home torsemide 80mg
PO daily. She trended back to her dry weight. Her home KCl was
restarted in the setting of continued diuresis and return of Cr
to baseline. Her Cr returned to baseline and her electrolytes
were stable on discharge. She will need close follow-up with BMP
measured on ___ and then weekly to monitor electrolytes
and Cr. Adjustments to her torsemide and KCl doses should be
made accordingly.
# Possible Bacterial UTI: Pt endorsed dysuria and suprapubic
pain on ___. She also had incontinence and increased
urine output. A UA showed leukocytes, but no nitrites or
bacteria. Because of her symptoms and prolonged catheterization
during her hospitalization, treatment for a catheter-associated
UTI was initiated with Bactrim DS BID for 7 days (through
___. However, this course should be discontinued if the
urine cultures are negative.
# Iron deficiency anemia: With microcytosis noted on her CBC,
follow-up iron studies revealed iron-deficiency anemia. She was
started on ferrous sulfate, which will be continued on
discharge.
CHRONIC ISSUES
==============
# GERD: The patient's esomeprazole was substituted with
omeprazole as an inpatient. On discharge, the patient was
restarted on esomeprazole.
# Peripheral neuropathy: Her gabapentin was continued in-house
and at discharge.
TRANSITIONAL ISSUES
===================
# Follow-up urine cultures. Pt had a mildly positive UA in the
setting of prolonged catheterization. She was started on Bactrim
DS BID for a 7-day course for catheter-associated UTI (through
___. However, this course can be discontinued if
cultures are negative.
# Warfarin was continued on discharge as the patient's hematoma
had been evacuated and her INR trended back into the therapeutic
range. She should have her INR checked on ___.
# Torsemide 80mg PO daily was continued in-house and at
discharge as the patient had excellent urine output and was near
her dry weight. She should have daily weight at rehab. A BMP
should be checked ___ for follow-up of electrolytes and
Cr, and then weekly. She has been restarted on her KCl 10mEq
daily with recovery of renal function (Cr at baseline). Her
torsemide may be decreased in setting of overdiuresis or KCl may
be increased in the setting of hypokalemia.
# Pt was started on ferrous sulfate for iron-deficiency anemia.
# Plastic surgery will follow-up the patient's left lower
extremity wound, which should continue to be covered with a
wound VAC until re-assessment on ___.
# The patient should be scheduled for a follow-up with her PCP
upon successful recovery at rehabilitation.
# Communication: Patient, ___ ___ ___
(___): ___ Alternate HCP ___ (___):
___.
# Code: Full (confirmed) | 157 | 1,137 |
19371972-DS-45 | 29,516,079 | You were admitted due to a fever. This was likely the result of
recurrent cholangitis, although this remains uncertain. You were
free of any fevers after being started on antibiotics. We
recommend that you continue taking augmentin for 3 days after
discharge, and continue taking vancomycin orally to prevent c
diff infection for 1 week. You can follow-up with your
outpatient doctors as planned. You will be contacted with the
results of the paracentesis. Please contact your doctors ___
return to care if you have any recurrent symptoms or concerns. | ___ w recurrent pancreatic adenoca s/p chemo/XRT,
pancreaticoduodenectomy, biliary stent malfunction with
recurrent cholangitis, recurrent bacteremia of several
organisms, recurrent C diff, CAD s/p MI ___ presents with
fever, abdominal
distention. Found to have new pleural effusion, ascites, and
pancreatic tail cyst on CT.
# severe sepsis (leukocytosis, tachycardia, fever, lactic
acidosis, ___
# transaminitis, mild hyperbilirubinemia
Suspect recurrent cholangitis +/- bacteremia given his history
and hyperbilirubinemia on presentation that subsequently
resolved. However patient never had acute abdominal pain, so
this is not proven. Treated with ___ given prior VRE
until blood cultures negative x72 hours, then transitioned to
augmentin to complete 7 day course. Initially deferred tap of
ascites or pleural effusion per patient preference (see below).
#Pleural effusion
#New ascites
#New pancreatic tail cyst (possibly dilated ducts)
___ edema
#Hypoalbuminemia
Differential for effusions includes malignancy vs direct result
of complicated abdominal anatomy, stent malposition, and
recurrent infections, +/- worsening hypoalbuminemia. Patient
initially preferred to avoid tap because of discomfort but given
potential therapeutic benefit of paracentesis he agreed and went
for ___ tap on ___. Low suspicion for SBP since no cirrhosis,
and PMN count <250 (although s/p abx for several days). Will
need cytology and cultures followed up.
#History of recurrent c diff
#Diarrhea
Reports recent persistent diarrhea. C diff neg. Had recent trial
of rifaxamin for ?bacterial overgrowth that was not helpful.
Unclear cause. Some diarrhea during this admission, which may
have also been antibiotic related. Used PO vanc for c diff ppx.
Will need further outpatient work-up if fails to improve.
#Anemia:
Hgb 7.1-8.2 - Close to baseline. Likely multifactorial with iron
deficiency and chronic inflammation. has iron infusions as
outpatient. Did not transfuse as inpatient due to infection.
#Pancreatic cancer:
Unclear current status. Had whipple in ___ then cyberknife in
___. Some concern that new ascites could be worsening disease.
Cytology from para pending, and ca ___ pending. Patient seen by
palliative care during admission. Multiple outpatient providers
involved in ___ discussions with primary team during admission.
================================== | 90 | 325 |
14769058-DS-9 | 21,854,006 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing to RLE
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower. | Patient presented to the emergency department and was evaluated
by the orthopedic surgery team. The patient was found to have a
right tibia/fibula fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right ORIF of R tibia/fibula, 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
non-weight bearing in the right lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ in two weeks. 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. | 444 | 256 |
15628922-DS-10 | 25,178,524 | Dear Ms ___,
It was a pleasure to take care of you here at ___. You were
admitted because of nausea, vomitting and diarrhea. Because of
your nausea, vomitting, and longstanding diarrhea and other ,
our gastroenterology team performed a colonoscopy and EGD
(esophagogastroduodenoscopy). Given the results of these studies
the GI team feels that you had a healthy stomach, small
intestine, and large intestine. Therefore you will be asked to
follow up closely with your primary care physician and also ___
gastroenterologist to review other studies that have been done
in the hospital with results still pending. | In summary this is a ___ year old woman with a history of
hypertension, type 2 diabetes, obesity, hyperlipidemia, Grave's
disease, anxiety, left renal cell carcinoma who presented with
nausea/vomiting, and diarrhea for four weeks.
.
# Nausea/vomiting: the pt did report mild nausea withou
vomitting while an inpatient here. These symptoms could be due
to gastroparesis given that her gastric emptying study per
outside hospital record was moderately abnorma: "moderately
prolonged gastric emptying time." However, it was thought that
the nause and vomitting could be an infectious process as well,
although pt did not have any localized symptoms. Malignancy was
also on the differential given the patient's endorsement of 50
pounds weight loss and history of renal cell carcinoma, and
heavy tobacco use. During her hospital stay, Gastroenterology
say her and suggested that an EGD with bx of the duodenum would
be beneficial. This procedure was performed on ___ and the
preliminar results of the study showed: Normal mucosa in the
esophagus, Mild erythema in the antrum compatible with mild
gastritis (biopsy),Normal mucosa in the duodenum (biopsy),
Otherwise normal EGD to third part of the duodenum. The biopsy
results are still pending.
.
# Diarrhea: Before being admitted here pt had had symptoms for
approximately 4 weeks. The differential included infectious
(parasite, giardia, CDiff) vs. malignancy (pt has 100+ pack/year
smoking hx and hx of renal cell carcinoma) vs. bacterial
overgrowth vs. inflammatory bowel disease (although without
blood and extraintestinal symptoms) vs. celiac disease vs.
chronic pancreatitis (unlikely given no risk factors) vs
irritable bowel syndrome (also unlikely given symptoms). Pt was
followed by GI and a colonoscopy was done on ___. The
impression on colonoscopy was Mild erythema in the descending
and ascending colon compatible with nonspecific erythema
(biopsy)Normal mucosa in the colon internal hemorrhoids.
Otherwise normal colonoscopy to cecum. Biopsy result is pending.
Many labs were ordered to evaluate the cause of the patient's
diarrhea including: Stool cultures, Cdiff assay, O&P, TTG and
IgA for celiac disease. T
.
# Microcytic anemia: The patient had a stable but low hematocrit
while here ranging from 25 from 32 overnight. This could be due
to a dilutional effect from IV fluids. She received 1 L of NS in
the ED. Also on the differential was a GI bleed or some kind of
malignancy. Anemia is concerning given her post-menopausal state
and given hx of smoking with 100+ pack/years. Pt's vitals
remained stable while on the floor and was not concerning for a
GI bleed. Iron studies were ordered and pt was restarted on her
ferrous sulfate and folic acid.
.
#Acute renal failure: Unclear if this was acute on chronic given
no prior baseline recently. However, with patient's
nausea/vomiting and diarrhea, it is likely she was hypovolemic.
Pt's creatinine ranged from 1.1 to 1.4 (her baseline is 1.1).Hre
home HCTZ was held while in the hospital.
.
# Hypertension: remained stable. Pt continued home lisinopril,
valsartan
Her HCTZ was held given vomiting, diarrhea and creatinine 1.2
.
# Type 2 diabetes: Stable, HgbA1c was 5.6
- Her home glyburide was held and she was started on humalog
insulin sliding scale in-house
.
# Hyperlipidemia: Remained stable and she was continued on home
atorvastatin.
.
# Grave's disease: Remained stable. She was continued on home
levothyroxine.
.
# Left renal cell carcinoma: s/p RFA and patient stated MRIs
have been clean since.
.
# CODE: Full code
# CONTACT: ___ (son, ___ ___ (daughter
___
# DISPO: Home | 97 | 568 |
12892520-DS-21 | 28,520,629 | Dear Mr. ___,
You were hospitalized due to symptoms of slurred speech and
difficulty walking 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:
- Diabetes
- Hypertension
- High cholesterol
We are changing your medications as follows:
- Decrease your glipizide to 10mg twice a day
- Increase your atorvastatin to 80mg at bedtime
- Stop aspirin
- Start clopidigrel (Plavix) 75mg once a day
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
We wish you a speedy recovery,
Your ___ Neurology Team | ___ is a ___ man with a history of multiple vascular
risk factors who presented to the ED with transient right leg
weakness and dizziness followed by persistent gait unsteadiness
and slurred speech beginning the following day. On exam he has
dysarthria, cerebellar signs on the left, decreased temperature
sensation on the left, and brisker reflexes on the right. MRI/A
confirmed R pontine ischemic stroke.
His blood pressure was allowed to auto regulate to < 180 with
hydralazine as needed. His home antihypertensives (with
exception of clonidine and half dose beta-blocker) were held
initially, restarted day of discharge. His home ASA was stopped
and he was instead started on plavix which he is to continue for
life. He was maintained on aISS while in house. Endocrinology
evaluated him and recommended decreasing his glipizide as his
home dosing was higher than the maximum recommended dosing, and
continuing metformin 1000mg BID. His LDL was 126 so he was
switched from simvastatin to high dose atorvastatin 80mg daily.
.
.
============================== | 286 | 164 |
17517809-DS-21 | 29,977,381 | You were hospitalized for drug-induced liver injury from
valproic acid. Your MRI did not show any cause of your liver
injury, though you do have a condition called pancreas divisum,
meaning you were born with a split pancreas. You may have an
increased risk of pancreatitis but there is nothing you need to
do to prevent this.
You must avoid valproic acid from here on out.
You should avoid alcohol until your liver function tests are
normal.
You may take up to 2 grams of tyelenol, but it is best to avoid
it if you can.
You should have weekly blood tests until your liver function
tests are back to normal. | ___ PMHx AS s/p bioprosthetic AVR (___), viral encephalitis
complicated by seizure (___) on keppra, and recent admission
to wean valproate secondary to liver toxicity who presented with
resolving drug-induced hepatitis due to valproate toxicity. | 113 | 35 |
15887215-DS-8 | 26,007,903 | Dear Ms. ___,
You were admitted to ___ with a
broken left tibia and bleeding in your brain. You underwent ORIF
of your left tibia. You are recovering well and are now ready
for discharge. Please follow the instructions below to continue
your recovery:
Your left leg:
--Weight bearing as tolerated on your left leg
--Physical therapy as an outpatient
--Please follow-up with an orthopedic surgeon in ___
Your brain:
You had bleeding in your brain and may have difficulty
concentrating or remembering things. You may also have headaches
more frequently than before. Keep an eye out for any major
changes in your neurological status, and go to the emergency
room if you have symptoms that concern you.
--Continue your keppra for seizure prevention until you see a
neurologist in ___.
--Please see a neurologist in ___ for follow-up in ___
weeks.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*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. | ___ was admitted to the trauma surgical ICU with traumatic
brain injury and open L tibial fracture. She received
antibiotics and tetanus at OSH prior to arrival. Neurosurgery
and orthopedics were consulted upon arrival. She had bitemproal
hemorrhagic contusions, subdural hematoma, and bilateral
post-parietal epidural hematomas. She also was found to have a
right parietal bone fracture. She had frequent neuro checks and
her exam was unchanged. She was confused at times, but otherwise
neuro intact. She was given keppra for antiseizure prophylaxis
and her blood pressure was initially kept under strict control
with nicardipine drip. The drip was discontinued when her blood
pressure parameters were liberalized. Repeat head CT scan did
not show any significant changes. A bone fragment was seen in
the superior sagittal sinus and therefore she underwent MRV to
further evaluate for any thrombus, which showed a non-occlusive
thrombus in her transverse sinus. On HD2 she underwent
uncomplicated I&D and ORIF of her left tibial fracture.
Postoperatively, she had some initial difficulty with pain
control. She was give intravenous pain medication until she was
able to tolerate a diet, at which point she was given oral pain
medication.
On HD3, her neuro checks were liberalized to Q4h and her pain
was well controlled with oral and intermittent IV pain
medications. She was restarted on her home psych medications.
She was transferred to the hospital floor and the remainder of
her hospital course is summarized below.
N: She remained alert and oriented throughout the remainder of
her hospital coarse. The severity of her headaches waxed and
wanted. Acute pain service and neurology were consult to help
manage her pain. A repeat non-contrast head CT was done on HD 6
that was stable. On the night of ___, she had an episode
where she could not see, and a repeat head CT was done, which
showed no acute abnormalities and improvement of her
intracranial bleeds. Per neurology, she was continued on keppra,
and will continue on keppra for seizure prophylaxis until she
follows up as an outpatient in ___.
C/V: She remained hemodynamically stable, vital signs were
routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was on a regular diet which she tolerated
well. 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.
Physical therapy evaluated the patient and due to her unsteady
gate and impulsivity recommended discharge home with 24 hour
monitoring and outpatient ___.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with supervision, voiding without assistance, and
pain was better controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 311 | 529 |
10859759-DS-12 | 23,010,195 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you presented to the hospital:
- You were having fatigue and leg swelling
What happened while you were here:
- We found that your blood pressure was significantly high
without your blood pressure medications
- You were started back on blood pressure medications
- Your blood counts were also low, for which you were given a
unit of blood
- You had worsening kidney function, which remained stable while
here
What you should do once you return home:
- You should continue taking your mediations as prescribed. They
were called into your pharmacy (___) and should be ready
for pick up
- You should follow up with your primary care provider as
outlined below
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ y/o female with a significant history of
T3N1 gastroesophageal adenocarcinoma on chemotherapy, type 2
diabetes complicated by retinopathy, hypertension, and
depression, who presented to the ED for fatigue and leg
swelling, found to be hypertensive and anemic. Her home BP
medications were re-initiated with improvement in BP.
Additionally, she was given 1u pRBC without further drop in
blood counts and was monitored for persistent ___.
ACUTE/ACTIVE PROBLEMS:
======================
#Hypertensive Emergency
#Hypertension
Patient presented with fatigue and leg swelling, found to be
hypertensive to the 190s. She reported not taking all her
medications at home for the last several weeks after finding out
that she not longer had diabetes mellitus. Initial assessment
notable for pulm edema and ___ concerning for a component of
hypertensive emergency. Additionally, her BNP was 4144. She was
restarted on her home amlodipine and carvedilol (increased to
25mg BID) as well as prn hydralazine with improvement in BPs.
Blood pressures at time of discharge were 150-160s. Recommended
outpatient follow up with initiation of ACE-I and uptitration as
needed, once ___ resolves.
___
Cr 1.8 on admission, baseline 1.1. Urine studies c/w intrinsic
disease, but microscopy without casts. Trialed diuresis with
minimal improvement. Further diuresis held given euvolemic exam.
Her hospital course was complicated by intermittent diarrhea iso
bowel regimen leading to a dehydrated state. She was given IV
fluids trials with slight improvement. Overall etiology felt to
be intrinsic (possibly ATN) with a small component of pre-renal.
She was discharged with plan to increase oral intake and follow
up with PCP for repeat labs and further management if not
improving with time.
#Acute on chronic anemia
Hgb 6.5 on admission, down from baseline ___. She was given
1u pRBC in the ED with an appropriate bump. Hemolysis labs
negative. Low retic count more concerning for marrow suppression
iso chemotherapy or nutritional deficiency/acute illness.
Additionally, Tsat 18% pointing towards a potential component of
iron deficiency anemia. There was concern for GI bleed iso
malignancy though no recent melena and stool guaiac was
negative. Last colonoscopy in ___ was unremarkable. Last EGD
in ___ showed the known gastric cancer. After receiving 1u
pRBC, her Hgb remained stable around 8 for the remainder of the
hospitalization. She should follow up with her PCP and possibly
GI as an outpatient to discuss repeat EGD/colonoscopy.
#Leg swelling
Initial exam notable for bilateral leg swelling iso acute
hypertension. BNP elevated to 4144 and Cr elevated all
concerning for acute heart failure exacerbation. TTE showed mild
LVH with normal regional/global biventricular systolic function.
DVT felt to be unlikely given bilateral nature. She was given
Lasix 10 mg IV initially and maintained on a low salt diet. She
quickly became euvolemic and then hypovolemic iso diarrhea.
Given persistent ___ as above, she was trialed with IV fluids as
above. At discharge, she was euvolemic on exam.
#CAD
A stress MIBI in ___ showed EF 66% with mild fixed defect
inferior wall. When this was discovered, the plan was for
medical management per Dr. ___ on asa, statin, beta
blocker. The patient, however on admission was not taking her
home meds. TTE w/ preserved overall function but did have some
evidence suggestive of mild diastolic dysfunction. Aspirin was
held in the setting of possible bleed and ACE-I iso ___.
Continued on carvedilol and statin.
#T3N1 gastroesophageal adenocarcinoma
Receives her oncologic care at ___ and is s/p partial
gastrectomy, NGT placement, chemo and radiation until that she
completed in ___. No recurrence per appt 1 month prior to
admission.
#GERD
Described significant reflux symptoms, particularly burning
within her chest. She was started on pantoprazole BID with
improvement in symptoms. She should follow up with her PCP/GI
for further management.
CHRONIC/STABLE PROBLEMS:
========================
#DM2
History of DM c/b retinopathy. A1c on ___ was 5.1%, showing
her DM had resolved. | 124 | 629 |
10189889-DS-20 | 28,110,950 | Dear Ms. ___,
You were hospitalized at ___
because of pneumonia and asthma exacerbation.
You were given antibiotics and completed a five day course while
in the hospital.
You will be discharged with a prednisone taper and a new inhaled
steroid. Make sure to wash your mouth out with water after using
the inhaled steroid.
Please follow-up with your primary care physician.
We wish you the best!
-Your ___ Team | Ms. ___ is a ___ with history of asthma, obesity, and
diabetes mellitus, who presents with 2 weeks of cough and
dyspnea, and was found to have a right middle lobe community
acquired pneumonia and asthma exacerbation. She never required
oxygen. She was treated with a five day course of levofloxacin,
which completed on ___. She was also treated with prednisone
for asthma exacerbation (peak flow was 230 from baseline in high
300s). Her respiratory status improved, and ambulatory
saturations were above 90%. She was seen by the social worker
and a plan was worked out to allow her to obtain inhaled
corticosteroids for minimal cost, which she had been unable to
obtain as an outpatient. As a result, she was started on
fluticasone inhaler for her severe persistent asthma. She will
also be discharged with a prednisone taper. She should follow-up
with her primary care physician and pulmonologist.
===================
ACUTE ISSUES
===================
# COMMUNITY ACQUIRED PNEUMONIA: Patient presented with 2 weeks
of dyspnea and productive cough, that initially got better, and
subsequently got worse. Admission CXR showed RML lobe pneumonia.
Flu swab was negative. She was treated with a 5 day course of
levofloxacin, with improvement. She was able to ambulate
comfortably without desaturations prior to discharge.
# ASTHMA EXACERBATION: She has faint wheezing and her peak flow
is below her baseline (current 230, baseline high 300s),
consistent with exacerbation in the setting of infection. She
was treated with prednisone 40mg po daily with improvement in
her respiratory status. She will be discharged with a taper of
prednisone (see below). She also reported difficulty in
affording inhaled corticosteroids as an outpatient, which is
likely contributing to repeated exacerbations and ED
visits/hospitalizations. With the help of social work and
financial counseling she was able to get a fluticasone inhaler
for free and will be able to get refills at the ___
pharmacy.
===================
CHRONIC ISSUES
===================
# ELEVATED LACTATE: She had an elevated lactate on admission of
4.9. She had no signs of hypoperfusion. This was likely due to
albuterol administration and subsequently resolved.
# Pseudo-hyponatremia: Na 130 on admission but with glucose of
325, corrects to 134. Resolved with improved glycemic control.
# Diabetes mellitus: Glycemic control likely worsened in the
setting of steroid administration. She was treated with an
insulin sliding scale with improvement in her glycemic control.
Her home metformin/glimepiride were held while inpatient but
restarted on discharge. Home gabapentin was continued.
# OSA: Continued CPAP.
# HTN: continued amLODIPine 10 mg PO DAILY, Labetalol 100 mg PO
BID, Lisinopril 40 mg PO DAILY
# Bipolar disorder: she was hospitalized for this in ___.
Continued Perphenazine 8 mg PO daily, LamoTRIgine 200 mg PO
DAILY
===================
TRANSITIONAL ISSUES
===================
-started fluticasone 220mcg IH BID with spacer
-discharged with prednisone taper: she will take 30mg x 2 days,
then 20mg x 2 days, then 10mg x 2 days, then stop.
-f/u with pulmonary as previously scheduled
-repeat x-ray in ___ weeks to ensure resolution of findings
#Emergency Contact: ___
___
#Code: DNR/ok for intubation (confirmed this admission)
>30 min spent on discharge coordination on day of discharge | 64 | 521 |
10531667-DS-15 | 21,654,431 | Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech and left
sided weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high blood pressure
- high cholesterol
- previous stroke
We are changing your medications as follows:
- please stop taking Aspirin
- start clopidogrel 75mg once daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | ___ ___ F w PMHx cryptogenic R PCA-territory stroke
in ___ (on home ASA 81mg), HTN (previous ED visits for HTN
emergency), and HLD (on home high dose statin, pravastatin 80mg)
presented w L facial droop and dysarthria upon waking ___
AM. NCHCT showed a R MCA territory infarct. Pt also c/o prodomal
sx (subjective fevers, body aches, and GI distress) in the days
prior to presentation. The pt's deficits improved steadily
throughout her admission. At the time of discharge, she had a
persistent (but improved) L facial droop, some L pronator drift,
minimal dysarthria, and no LUE and LLE clumsiness/ataxia. Stroke
work-up was unrevealing (CTA wnl, Tele monitoring w 1st degree
HB - no episodes of Afib captured, TTE wnl). Etiology of infarct
is likely from a proximal embolic souce given that the patient
also has had a posterior circulation infarct in ___ - stroke
work-up at that time was also unrevealing.
The team considered discharging the patient on coumadin for
empiric anticoagulation for presumed (cardiac) embolic source.
Due to patient medication compliance issues, however, we will
start plavix (and discontinue home ASA) upon discharge.
**************
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL = 86
) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A | 311 | 436 |
14679533-DS-32 | 29,814,428 | Hello Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because of volume
retention due to heart disease. Here we gave you IV medicines to
take off the fluid. You were also evaluated by the
electrophysiology specialists who tried to upgrade your
pacemaker to better synchronize the contraction of your heart.
However, they discovered that the veins leading to your heart
were difficult to pass through so recommend that you schedule an
appointment for another attempt at the procedure in the future.
Please weigh yourself every morning and call MD if weight goes
up more than 3 lbs. Please continue to take the rest of your
medications and follow up with your doctors.
New medicines:
lisinopril 5 mg once per day for your heart
Levofloxacin 500 mg every other day, last dose on ___
Sarna lotion as needed itchiness of the skin | ___ w/ hx of IDDM, HTN, HLD, sCHF (EF 35%), s/p MVR, CHB s/p
pacer, CAD c/b MI s/p CABGx3 and PCI who presents w/ worsening
edema and more SOB
# CHF Exacerbation: The trigger a combination of increased PO
intake, UTI, medication adjustment. Patient presented
hypervolemic clincially and radiographically. Her last echo
(___) showed EF of 35% and previous discharge weight was
122 pounds. In house she was diuresed with IV medications and
then transitioned to her home dose of torsemide. She was
discharged at a weight of 125 pounds. She was also started on
lisinopril. Per conversation with her outpatient cardiologist,
her volume has been difficult to manage. With her poor EF, and
prolonged QRS she underwent a bi-v pacemaker upgrade procedure
but the pacing wires could not be advanced due to vein stenosis.
She will follow up with her cardiologist to re-schedule an
appointment for an elective procedure. She will also complete a
7 day course of levofloxacin on ___ for routine
post-procedural reasons.
# CAD: s/p MI x2, multiple CABG and PCI. continued on ASA,
clopidogrel, isosorbide mononitrate, simvastatin, metoprolol
# CHB s/p pacer: history of A fib and complete heart block s/p
pacemaker placement. She was a-paced throughout admission on
telemetry and continued on metoprolol
# DM: linagliptin was held. She was managed on glargine and ISS.
Sugars were noticed to be trending high at night. Upon further
questioning, the patient reported that she usually takes her
glargine in the morning. Re-evaluation of her insulin regimen
will be required as an outpatient.
# Tropinemia: Patient has chronic kidney disease and is at her
baseline from previous admission. Although has significant
coronary disease, no concern for ACS given symptomology, chronic
kidney disease, and EKG.
# CKD: Likely due to combination of HTN and DM. Creatinine at
baseline. At discharge, creatinine elevated form baseline
1.7-1.9 to 2.1 presumably from dye required in the EP study. For
the EP study, she received pre and post hydration.
# Depression: continued sertraline
# Urinary incontinence: history of not being able to hold urine
while trying to reach the bathroom suggestive of urge
incontinence. She was counseled that there are treatments
available from exercises to medications for her symptoms that
she should discuss with her PCP.
Transitional Issues
- Will finish a 7 day course of levofloxacin for routine post
electrophysiology procedure reasons on ___
- Patient would like support for urge urinary incontinence:
recommend evaluation for exercises to strenghthen pelvic floor
- Will follow up with Dr. ___, to schedule
elective bi-v upgrade
- DNR/DNI | 146 | 421 |
15782217-DS-12 | 28,161,515 | It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your cough and
found to have a pneumonia. You were given antibiotics to treat
this infection. You were also found to be in an abnormal heart
rhythm called atrial fibrillation. You were given medications
to help slow your heart rate and control this problem. An ECHO
cardiogram was performed and showed that your heart is pumping
well. We contacted your primary care doctor Dr. ___
see you as an outpatient in the next several days. Because of
your heart condition it is important that you avoid stimulating
drugs such as caffine, pseudophed, affrin and albuterol all of
which can trigger your fast heart arythmia. You are being
prescribed benzonate and gaufenisen with codine to help with
your cough. You were discharged with a holter monitor to record
if you have any more episodes of the afib that you are not aware
of, these results will be sent to Dr. ___. You can also try
breathing humidified air and drinking warm caffine free teas.
The Following changes were made to your medications:
-START Levofloxacin 750 mg daily for 4 additional days
-START Codine/gaufenisen ___ mL every ___ hours as needed for
cough
-START Benzonate 100 mg three times a day for cough | ASSESSMENT AND PLAN: Ms. ___ is a ___ year old female with a
history of asthma who presents with three days of fevers and a
productive cough and was noted to have likely atrial
fibrillation with RVR in the ED.
.
# Community Acquired Pneumonia: Patient presented with new
productive cough and fevers at home for several days. In the
emergency department the patient had a CXR demonstrating a RLL
pneumonia for which she was started on levofloxacin. She had no
health care of community risk factors and a urinary antigen was
negative for legionella. She continued on levofloxacin for a ___nd received codiene, gaufenisen, benzonate for cough
supression. She was never hypoxic and had peak flows of 280
which was near her baseline. She continued to recieve her home
inhaled medications as well as ipatropium nebs. She recieved
solumedrol in the ED but a significant asthma flare was not felt
to be contributing and she was not treated with additional oral
steroids.
.
# Leukocytosis: patient had a WBC of 15K felt to be from acute
infection and steroids recieved in the emergency department, she
was afebrile, blood and urine cultures were no growth to date at
time of discharge.
.
#Atrial Tachycardia: patient was found to have an asymptomatic
atrial tachycardia that on telemetry and EKG could not be
clearly classifed as afib or multifocal atrial tachycardia. She
had a RVR of 120 bpms at presentation and ultimately converted
to sinus rhythm after initiation of diltizem drip. She was
transitioned to her home long acting dilitzem without additional
evidence of tachy arryhtmia. To better understand if her
symptoms were the result of acute pneumonia and increased
albuterol use at home vs paroxysmal disease she was discharged
with ___ of Hearts monitor with results sent to her PCP. A
decision was made not to anticoagulate the patient at this time
given her complex medical issues and indeterminant long term
risk. An ECHO cardiogram was also obtained and did not
demonstrate significant structural heart disease, note was made
of mild aortic stenosis.
.
#Bilateral lower extremity swelling: Patient had chronic lower
extremity edema that was felt to be from venous insufficency
rather than right heart failure, pulmonary hypertension or lower
extremity DVTs as LENIs were negative.
.
#Asthma: Patient was noted to have a peak flow of 280 and an
lung exam without wheezing and good air conduction. acute
astham exacerbation was not felt to be complicating her
respiratory status and she was maintained on her home
medications alone without additional oral steroids.
.
#Hypercholesterol: at reccent outpatient visit patient's LDL
was seen to be elevated to 161, after discussion with her PCP
initiation of statin therapy was deffered to the outpatient
setting.
.
#Hypothyroidism: Stable, with non-elevated TSH in house
maintained on home levothyroxine.
.
#Depression: stable, continued home effexor and adderol though
sympathomemetic drugs were felt to be a possible contributor to
her new atrial tachycardia.
.
#Bladder dysfunction NOS: continued home oxybutinin.
.
#OSA: patient continued on home BiVAP in house with ECHO not
suggestive of pHTN and atrial enlargement.
. | 227 | 538 |
11516863-DS-20 | 25,097,324 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for shortness of breath and
leg swelling.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given medications to remove fluid from your body
(diuretics).
- You were seen by our nephrologists to help with your volume
management.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at
___ if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 104.9 kg (231.26 lb). You should use
this as your baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
___, primarily ___ speaking, with history of HTN, pulmonary
HTN, HFpEF (LVEF 53% on ___, permanent AF with chronotropic
insufficiency status post PPM (on apixaban), CKD,
hypothyroidism, type II DM, and OSA (on home CPAP), who was
found to have a HF exacerbation. The patient was diuresed with a
Lasix gtt to a max of 20mg/hr with intermittent Metolazone.
==================== | 166 | 62 |
14989637-DS-20 | 20,347,034 | It was a pleasure taking part in your care at ___. You were
admitted with abdominal pain. We contacted your GI doctor, and
set you up with an appointment with a gynecologist, as well as
your PCP and GI doctor closer to discharge. We controlled your
pain, started you on a new constipation regimen, and also
started protonix for you.
Please make the medication changes as listed on the following
pages, and follow up with your doctors are detailed below. | ___ with hx of chronic abdominal pain x ___ years, depression p/w
abdominal pain.
BRIEF HOSPITAL COURSE
Ms. ___ was admitted for abdominal pain, inability to take
POs, and constipation. Her abdominal pain was treated with NPO
and gradual advancement of diet. Given constipation, we
streamlined her medications for her constipation. She was also
started on Reglan with meals, as well as a higher strength PPI.
She felt much improved on this new regimen. Finally, we set her
up for an outpatient gynecology appointment for further
evaluation (See below).
HOSPITAL COURSE BY PROBLEM
# Abdominal pain: etiology unclear but may be related to her
chronic abdominal pain which could be in the setting of chronic
pelvic dyssynergia or other process, like gastritis or
dysmotility. Per pt and notes from PCP, has had an extensive
workup at ___ including colonoscopy, EGD
and multiple CT scans. CT abd/pelvis negative and labs wnl today
which are reassuring, however patient is frustrated by lack of
improvement in symptoms or diagnosis in the last ___ years. Given
description (pain that is much worse when she stands), doesn't
relieve when evacuates bowels, doesn't exacerbate with food,
___ in the upper quadrants without radiation), it is difficult
to pinpoint an exact cause. Ddx remains broad and I would also
consider endometriosis as a possibility given her known hx. The
patient denies cyclical pain, however the pt is on a birth
control pill that suppresses her menstrual cycle. As such, we
set Ms. ___ up with outpatient gynecology evaluation. Of
note, given the lack of relief with recent diarrhea, I do think
that functional process may be less likely the case, and
constipation is not contributing. Also would consider delayed
gastric emptying/gastroparesis, however she doesn't have a
history to support that (Eg: diabetes). We did empirically
start her on Reglan with meals, as well as a higher dose PPI in
case this was c/w gastritis, which actually did improve her pain
significantly to ___. Lack of pain with food make other
diagnoses (biliary colic, median arcuate ligament syndrome) less
likely. We tried to avoid morphine given propensity to cause
constipation. We also set her up with closer follow up with GI.
She lives at ___, but was discharged at ___ after
receiving Protonix and Reglan with meals. We continued Protonix
at discharge, however held Reglan given possibility of
interaction with venlafaxine and serotonin syndrome.
# Inability to take POs: We started her on NPO, and she was
noted to be able to take regulars at the first meal. She did
develop nausea, however she didn't vomit at the time. She
remained on a regular diet and was pretreated with Reglan each
time. Reglan was held at time of discharge as above.
# constipation: may be contributing to abdominal pain, although
has been an issue for a couple of months. She feels as though
she needs to have a BM, however only has small bowel movements.
She has been taking several different medications at home and
notably was not using a stimulant such as senna, and only using
stool softeners. As such, we started senna, continued docusate
and MiraLax. Of note, we do not think that constipation is
playing much of a role, as even after she had diarrhea when
using milk of mag and prune juice, she still had the same
symptoms.
# anxiety/depression: continued home venlafaxine and clonazepam.
# endometriosis: per pt's history. will be seen by gynecology
as an outpatient for ? contribution to her abdominal pain. | 84 | 599 |
16879381-DS-17 | 22,091,865 | Dear Ms. ___,
It was a pleasure taking care of you during your stay here at
___.
You were admitted for hemoptysis, which is coughing up blood. A
CT scan of your chest found a mass in the right upper lung. A
flexible
bronchoscopy was performed to sample this mass and the
surrounding lymph nodes. The culture and pathology results are
still pending.
We could encourage you to stop smoking, even after your
discharge from the hospital. We have included a prescription
for nicotine patches to help with smoking cessation.
The following changes were made to your medication regimen:
STOP aspirin
START nicotine patches as needed | ___ year old female with s/p liver/kidney transplant ___ who
presented with hemoptysis, found to have 2.7cm necrotic RUL mass
s/p flex bronchoscopy ___.
# Hemoptysis: Patient has large mass in her RUL with central
necrosis with a feeding bronchial artery which is the source of
her hemoptysis. This lesion is concerning for malignancy vs
infection given chronic immune suppression. Did well on room air
and did not require transfusion throughout her stay. Pt
underwent flexible bronchoscopy ___ for biopsy of mass and
surroudnings lymph nodes. Ruled out for TB with 3 negative
smears and an afb via bronch. Cultures, pathology and cytology
are still pending. Glucan, galactomannan still pending. She is
going to follow up with IP as an outpt for these results.
Aspirin, which she had previously been on for a mesenteric
artery clot prior to transplant in ___ was stopped upon
admission. Smoking cessation was encouraged and a nicotine
patch was provided.
# s/p combined Liver and renal Transplant: Tacro levels within
normal limits, continued on tacro and myfortic. She was
continued on Bactrim SS daily for prophylaxis. She was
scheduled for outpatient follow up.
TRANSITIONAL ISSUES:
- f/u bronchoscopy results
- f/u BAL cytology
- f/u glucan, galactomannan
- f/u mycolytic blood cultures | 106 | 211 |
14717988-DS-6 | 27,756,672 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
WHY DID I COME TO THE HOSPITAL?
--You developed a seizure at home.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
--We monitored you for seizures. You did not have any additional
seizures in the hospital. We started you on a new anti-seizure
medication called "lacosamide". You are still taking your home
divalproex and zonisamide.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
--Please continue to take your medications as prescribed and
follow-up with your doctors as ___. You decided that you
did not want to continue follow-up with your previous
Neurologist, so we set you up with Neurology follow-up at ___.
We wish you all the best,
Your ___ care team | Ms. ___ is a ___ year old right handed woman with history of
right parietal hemorrhagic infarct (___) secondary to aneurysm,
with resulting seizure disorder, cognitive impairment and mild
left sided hemiparesis, who presented with 1 day history of
intermittent left leg shaking episodes and intermittent
squiggles in her L visual field.
#Seizures:
The etiology for presenting episodes of left leg shaking is
consistent with breakthrough focal motor seizures, likely
arising from right hemispheric focus from prior
encephalomalacia. Possibly related to missing morning AED dose.
Also noted to have left inferior visual field cut not previously
documented which is likely chronic, consistent with known
lesion. MRI and CTA head without acute process. At home,
maintained on zonisamide 200 mg BID and divalproex (delayed
release) 250 mg BID, which were continued. Given poor tolerance
to zonisamide (recent nephrolithiasis), was started on
lacosamide 100 mg BID with the goal to ultimately titrate off
zonisamide completely in the outpatient setting. Notably has a
history of poor tolerance to multiple AEDs in the past including
phenobarbital, dilantin, keppra, and carbamazepine. Had no
additional seizures during admission. We were unable to reach
her outpatient Neurologist to discuss the changes made to her
AED regimen. Patient decided that she would like to establish
care with Neurology at ___ moving forward. | 119 | 212 |
17429794-DS-20 | 28,183,399 | Dear Mr. ___,
You were admitted to ___ with abdominal pain and were found to
have a spontaneous pelvic hematoma. You were admitted to the
Acute Care Surgery service for further medical care. You
required blood transfusions and close monitoring in the
Intensive Care Unit. You blood counts are now stable. You were
noted to have decreased blood flow and skin changes to your
feet. You were transferred to the Vascular Surgery Service for
further medical care. You underwent several procedures for your
vascular disease. Theses included a debridement and right first
toe amputation (___), a repeat right foot debridement
(___), and left ___ toe amputations. You also underwent
several angiographies with placement of bilateral iliac stents
(___), angioplasty of your right popliteal stent (___),
and placement of left superficial femoral artery stents
(___).
You are now medically cleared to be discharged from the hospital
to continue your recovery.
While in the hospital you were seen and evaluated by the
psychiatry team who started you on an antidepressant. You should
follow up with your primary care provider to discuss continuing
this medication.
Please continue to follow up with your outpatient vascular team
to address your lower extremity wounds and perfusion.
Your potassium was found to be elevated while admitted. Please
follow up with your primary care doctor to have your potassium
checked after discharge.
Please note the following discharge instructions:
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
spontaneous pelvic hematoma; you were then treated for your
vascular disease with several angiographies. To perform these
procedures, small punctures were made in the artery. You
tolerated the procedure well and are now ready to be discharged
from the hospital. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
Division of Vascular and Endovascular Surgery
Lower extremity Angiography
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
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.
CALLING FOR HELP/DANGER SIGNS
If you need help, please call us at ___. Remember,
your doctor, or someone covering for your doctor, is available
24 hours a day, seven days a week. If you call during
nonbusiness hours, you will reach someone who can help you reach
the vascular surgeon on call.
Call your surgeon right away for:
Pain in the groin area that is not relieved with medication,
or pain that is getting worse instead of better
Increased redness at the groin puncture sites
New or increased drainage from the groin puncture sites, or
white yellow, or green drainage
Any new bleeding from the groin puncture sites. For sudden,
severe bleeding, apply pressure for ___ minutes. If the
bleeding stops, call your doctor right away to report what
happened. If it does not stop, call ___
Fever greater than 101.5 degrees
Nausea, vomiting, abdominal cramps, diarrhea or constipation
Any worsening pain in your abdomen
Problems with urination
Changes in color or sensation in your feet or legs
CALL ___ in an EMERGENCY, such as
Any sudden, severe pain in the back, abdomen, or chest
A sudden change in ability to move or use your legs or severe
pain in your legs
Sudden, severe bleeding or swelling at either groin site that
does not stop after applying pressure for ___ minutes
ACTIVITY
You should keep your toe amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility in your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage,
you may leave the incision open to air.
Your staples/sutures will remain in for at least 4 weeks. At
your followup appointment, we will see if the incision has
healed enough to remove the staples.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain | Mr. ___ is a ___ year-old male admitted to the Acute Care
Surgery service on ___ with abdoiminal pain and fatigue. He
has a past medical history significant for atrial fibrillation
on Coumadin with a recent spontaneous pelvic hematoma. INR was
1.3 His Coumadin, was held initially and he transferred to the
TICU for q6H hematocrit checks. He was started on ceftriaxone
for a UTI. He was later transferred to the surgical floor on
___ as he was hemodynamically stable.
On HD1, the patient was written for oral pain medicine, his home
metoprolol dose was increased and hydralazine was added for HTN.
He was started on a regular diet which was well-tolerated. On
HD2, the patient was evaluated by social work and Psychiatry for
depression. Cymbalta was started. He worked with ___ and
his losartan was restarted. Flomax was started. On HD2, the
patient's foley catheter was removed. On HD3, the patient's ctx
was discontinued and Cymbalta was increased. On HD4, the patient
was restarted on warfarin, but the patient refused dose. On
___, vascular was consulted ___ ulcers, ABIs/PVRs were
ordered. On ___, ABI records were requested from ___.
The patient was started The patient had hypertension to the 160s
systolic. The patient refused his warfarin. On ___, the
patient was started on a heparin drip per Vascular
recommendations. On ___ the patient had a potassium level
of 5.8. He received 10U regular insulin. Follow-up potassium
was 5.3 and he received kayaxelate and calcium gluconate IV.
On ___, the patient was transferred to the Vascular Surgery
service for further medical care.
Vascular Surgery Hospital Course
Mr. ___ was transferred to the Vascular Surgery Service
for ongoing management of his peripheral vascular disease once
his pelvic hematoma was found to be stable. He underwent
multiple procedures for revascularization, including angiography
with multiple stent placements (bilateral iliac stents, left SFA
stents) and multiple debridement procedures, including a right
first toe amp with revision of a prior TMA and left ___ toe
amputations; please see operative notes for details. He was
discharged to rehab with plans for a right below knee amputation
once his wounds adequately healed.
Neuro/psych: The patient was alert and oriented throughout
hospitalization; pain was managed with a combination of PO and
breakthrough IV pain medications. He was evaluated by the
chronic pain service, who recommended adjusting gabapentin for
optimal pain control. He was also seen by the inpatient
psychiatry team while admitted to the ACS service and was
started on duloxetine for his underlying depression, on which he
was discharged with instructions to follow up with his PCP.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He was noted
to be intermittently hypertensive; this was controlled by
resuming and increasing the dosage of his home anti-hypertensive
medications along with PRN hydralazine for breakthrough
elevations.
Pulmonary: The patient had an intermittent oxygen requirement
during his hospital stay. He did experience some sustained
shortness of breath on ___ a CXR obtained at the time
showed a large right sided pleural effusion that was drained at
the bedside. Fluid was sent for analysis, and this was found to
be a simple effusion. He also received PRN albuterol and
ipratropium along with gentle diuresis using furosemide in order
to alleviate his shortness of breath and prevent re-accumulation
of fluid in the pleural space. He was monitored with serial
chest x rays. Otherwise, good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was made NPO and placed on IV fluids as
appropriate for procedures. Otherwise, he tolerated a regular
diet. He was noted to have a persistently elevated potassium
that was intermittently treated with PRN insulin, calcium
gluconate, kayexelate, and furosemide. This appeared to be his
baseline in the setting of his chronic kidney disease and was
asymptomatic with no ECG changes. He was directed to follow up
with his primary care doctor for repeat potassium level checks.
Electrolytes were repleted as needed.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. He was started on broad
spectrum antibiotics for potential wet gangrene of his distal
lower extremity. An ID consult was obtained, please see their
notes for details about their recommendations. His antibiotics
were narrowed to tigecycline on ___ (6 week course) based on
culture sensitivities from his ___ OR cultures.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. He was kept on a heparin
drip while hospitalized in order to maintain anticoagulation in
the setting of chronic warfarin usage. He was noted to have
bilateral upper extremity DVTs while hospitalized while on a
heparin drip; his PTT was noted to be difficult to maintain in a
therapeutic range intermittently. He had a PICC placed in his L
arm early during hospitalization around which one of his DVTs
developed, this was removed on ___ a right side PICC was
placed subsequently. He was started on Plavix during this
hospitalization to maintain stent patency; this should be
continued until ___. He was started on warfarin prior to
discharge; his heparin was discontinued and he was placed on a
lovenox bridge.
MSK: ___ underwent several debridements of his right lower
extremity and ___ toe amputations on his left lower extremity.
His ulcers were covered with dry non-adherent dressings that
were changed daily. He worked with the physical therapy service
while hospitalzed and when his weight bearing status permitted
it; ___ recommended rehab for ongoing care.
Prophylaxis: At the time of discharge, the patient was doing
well, afebrile and hemodynamically stable. The patient was
tolerating a diet, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions and verbalized agreement with the
discharge plan. | 1,792 | 978 |
17818329-DS-21 | 26,003,459 | It was a pleasure caring for you at the ___. You were
readmitted here from your rehab facility after becoming very
short of breath over two days. You were recently hospitalized
because you developed an accumulation of fluid in your lungs
after your aortic valve procedure which caused episodes of low
blood pressure and a rapid heart rate. When you were released
last week, your fluid status and breathing had improved
significantly. We decreased your dose of diuretics because your
risk of developing heart failure was lowered by having your
valve replaced. Since you developed shortness of breath you had
to come back to the ___ for more diuretic therapy to relieve
your symptoms. Overall, you did well and we were able to reduce
the fluid in your lungs. However, you did develop a urinary
tract infection for which you will take one more day of
antibiotics.Your weight upon discharge was 123 pounds. Your
diuretic therapy will be continued at ___ 20 daily. This
dose might change if you start to feel short of breath, develop
swelling in your legs or gain weight quickly.
Because of your COPD we also continued your prednisone taper to
your baseline dose of 5mg daily. You should continue taking
prednisone to help with your breathing, as well as your Xopenex
inhaler as needed. Your INR when you were released was 2.2.
Continue to take your coumadin. Weight yourself every day at the
same time and call your cardiologist, Dr. ___ you gain
___ over one day or 5lbs over 3 days. | This is an ___ year old woman with a PMH of severe AS s/p
___ TAVR on ___, atrial fibrillation,
tachycardia-bradycardia syndrome s/p PPM (___) and heart
failure with a preserve ejection fraction who presented to ___
with acute shortness of breath at rehab.
ACTIVE ISSUES
# DYSPNEA. The patient presented with worsening effusion and
pulmonary edema, consistent with fluid overload. She had no
fevers, cough or increased sputum production, which was not
consistent with COPD exacerbation or pneumonia. TTE demonstrated
no misplacement or misalignment of her ___. Her heart rate
was well controlled. She has been on a very protracted taper of
prednisone; her dose was dropped from 11 mg qd to 10 mg qd 1 day
prior to admission. Her BNP was elevated on admission, also
consistent with fluid overload. She was gently diuresed with
good response, and close monitoring of her chemistries. Her
dyspnea was likely multifactorial, with anxiety and COPD playing
a role, however, she appeared volume overloaded on exam as well
on admission. On discharge her CXR revealed much improved
pulmonary edema and pleural effusions with trace pedal edema.
Her COPD and anxiety were managed, as below.
# ACUTE KIDNEY INJURY. The patient's baseline creatinine is
0.7-0.8. Upon arrival at ___, it was elevated to 1.1-1.2 range
- likely secondary to renal vascular congestion. Creatinine
returned to baseline with careful monitoring of fluid status.
# COPD. The patient is already on prednisone (protracted taper).
She had intermittent mild wheezing, that was treated with
levalbuterol and ipratropium nebulizers, however due to lack of
fevers, cough or increased sputum production, and no antibiotics
were added. Home Advair also continued. Prednisone was tapered
and discontinued.
#ANEMIA: patient was noted to have gradually declining
hemoglobin (9.2 on admission, nadir 8.3). She received
transfusion of 1U pRBCs. Hgb on day of discharge was 9.8.
#UTI - patient was found to have leukocytosis, positive UA and
endorsed dysuria. Urine culture was pending at the time of
discharge. She was treated with ciprofloxacin, total course 7
days, to be completed as an outpatient on ___.
INACTIVE ISSUES
# ATRIAL FIBRILLATION. Her rate was under good control during
her hospitalization, and was not attribued to her the etiology
of her dyspnea. Metoprolol, diltiazem and warfarin were
continued (INR remained therapeutic). Rate control was difficult
to achieve, and so she was started on digoxin 0.125mg every
other day, which was a medicine she had been on prior to TAVR
but was discontinued on prior discharge.
# ANXIETY. Gentle and monitored dosing of benzodiazepines were
administered, as needed, for anxiety symptoms.
# DIABETES MELLITUS. Her home oral antidiabetic medications were
held while in house, in favor of ISS.
*** TRANSITIONAL ISSUES ***
-Ciprofloxacin for UTI day of antibiotics ___
-Should have chem7, INR, and digoxin level check ___ while
at rehab. Titrate potassium chloride dosing as necessary as
patient is taking torsemide
-Torsemide started at 20mg PO daily. She had formerly been on
torsemide 20mg PO BID.
-Digoxin 0.125mg PO every other day started. Patient was taking
this prior to hospitalization for TAVR procedure, and it was
restarted since rate-control for A-fib was difficult even with
diltiazem and metoprolol. | 258 | 521 |
14951470-DS-12 | 20,192,241 | Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted for a recurrence of your POTS syndrome. Since your fall
caused you to have increased shoulder/rib pain as a result, we
had done x-rays of both regions to investigate the possibility
of fracture, but fortunately both were normal. Accordingly, we
would recommend that you treat the pain in both regions with
tylenol and ice packs. Moreover, we would recommend that you
continue to follow up w/ your neurologist Dr. ___ in order
to optimize control of your POTS syndrome. | Brief Hospital Course:
==========================
___ F with h/o POTS syndrome, complex daily migraines, TBI, R
Bell's palsy, anxiety, IBS and chronic fatigue syndrome who
presented with persistent left rib and back pain following one
of her typical syncopal episodes ___ POTS syndrome. | 100 | 40 |
15942934-DS-78 | 29,651,004 | Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for worsening of
your chronic pain. We evaluated you for life threatening
infections or bowel obstructions. We did not find anything life
threatening. You improved with IV fluids and your home pain
medication regimen.
Additionally, you were found to have low blood counts on the
second day of your hospitalization. We gave you 2 units of
blood which improved your fatigue.
Please take all your medications as prescribed.
Please make a follow up appointment with your primary care
doctor Dr. ___ the next ___ days. You will need to have
your visiting nurse check your hematocrit level and blood
creatinine level on ___. The results of these
blood tests should be faxed to Dr. ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to participate in your care. | ___ with h/o cervical cancer s/p TAH/BSO (___), XRT c/b
radiation enteritis, multiple small bowel resections and
subtotal colectomy with ileostomy c/b short gut syndrome and
need for TPN and recurrent SBO's admitted for abdominal pain due
to pSBO vs. colitis. | 158 | 43 |
17059964-DS-5 | 22,920,539 | Dear Mr. ___,
You were admitted to the hospital after you were found to have
bacteria growing in your blood that was taken during your last
hospitalization. You were feeling fevers and chills at home
because of the infection. You were treated with antibiotics and
responded appropriatly. Please continue to finish your course of
antibiotics, your last day is ___. You will also need your
vancomycin level checked frequently and have the results sent to
your primary care doctor who will adjust the dose of the
antibiotic. It is also very important for you to seek addiction
help, as we discussed.
Wishing you the best of luck in the future,
-Your ___ care team- | ___ yo man with recent history of IVDU admited to the hospital
after blood cultures from previous hospitalization grew
coagulase negative staph aureus in one bottle. Patient endorsed
fevers and ndight sweats at home and was found to have elevated
CRP on admission. Because of symptoms and response of CRP to
antibiotics patient was initiated on 14 day course of
vancomycin. TTE done while inpatient did not reveal evidence of
vegetations. No new murmur was appreciable on exam and no other
evidence on physical exam of endocarditis.
Patient was seen by social work service in regard to IVDU
history. He reported he does not intend to use any more
methamphetamines in the future. He also signed a contract to use
___ line only for intended purposes before discharge.
*******TRANSITIONAL ISSUES:*****
-Last day of vancomycin ___
-Please draw vancomycin trough before ___ dose on ___ as
vancomycin was increased to 1500 ___ in the AM and fax to
patients PCP ___ ___
-Please draw surveilance labs ___ cbc, chem 7 and fax to
patients PCP ___ ___
-Speciation and sensitivities pending at discharge. If
speciation reveals staph lugdunensis patient may benefit from
TEE.
-Patient was continued on home truvada but eluded to the fact
that he may not be taking it consistently. Please evaluate
whether prophylaxis is appropriate.
-HIV 1 tested on this admission was negative | 115 | 226 |
18259094-DS-35 | 26,180,497 | Ms. ___,
You were admitted for evaluation of confusion and shortness of
breath. You were found to have a pneumonia and were treated with
antibiotics which will need continue for a couple more days
after discharge.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | MICU COURSE:
===============
Ms. ___ is a ___ ___ female with hx of
T2DM, HTN, CAD, HFpEF, A-fib on warfarin, PVD s/p RLE amputation
presenting with shortness of breath, cough, and somnolence found
to have hypercarbic respiratory failure.
# Acute hypercarbic and hypoxic respiratory failure: Patient
initially presented with hypoxia, with recent cough.
Subsequently found to have hypercarbic respiratory failure with
pCO2 up to ___ and pH of 7.24. Hypoxia likely multifactorial.
Consolidation on CXR and fevers, consistent with pneumonia given
clinical presentation. Patient was placed on BiPAP due to
hypercarbia. She was thought to be overloaded so she was
diuresed with Lasix 80mg. Her respiratory status improved and
she was able to be weaned off of BIPAP to nasal canula prior to
transfer. Her home dose of torsemide was restarted on ___.
# Pneumonia: Patient had fevers to ___ on arrival. Possible
sources included pneumonia given cough prior to presentation.
Also with recent URI. Flu negative. U/A unremarkable but ucx
with pan-sensitive Klebsiella. Pt without clear UTI symptoms.
She was started on vanc/zosyn/azithro given her recent
hospitalization. BCX NGTD, sputum contaminated. Antibiotics
narrowed to ctx/azithro upon transfer out of the ICU.
Azithromycin course completed during admission. Pt discharged
with cefpodoxime in place of ctx to complete 7 day total course
of therapy. Eventhough, she did not have symptoms of a UTI, her
antibiotic course would treated anyway.
# Toxic metabolic encephalopathy: Altered on presentation.
Likely multifactorial from baseline confusion according to
recent hospitalization. Hypercarbia and infection were thought
to contribute. She was initiated on bipap and treated for
infection. Imaging was negative for any acute process. Her
mental status returned to baseline prior to transfer from the
MICU.
#Afib: HR was in ___ on admission. EKG in ED w/lateral ST
depressions, elevation in AVR. Has been seen on prior ECG and
attributed to strain in consult with cardiology. Recently
uptitrated on dilt and metorpolol during last discharge. On
warfarin for anticoagulation with therpauetic INR 2.1. She was
continued on home warfarin. She was also given metoprolol IV due
to the inability to take PO. When she was able she was restarted
on metoprolol and diltiazem (fractionated) prior to transfer
from the MICU. Home doses were restarted on ___.
#CAD/PVD: Trop negative x 2. Continued home Plavix, statin.
#Diabetes, type II: Glargine 32 units QHS at home. Glargine was
decreased to 20units QHS as her appetite was not at baseline.
Would reconsider need to increase at upcoming PCP ___.
#social-plan of care discussed with pt's dtr ___. Pt's
son/HCP is "overseas" at this time and pt's dtr ___ reports
she is now the decision maker.
#foley dc'd prior to discharge after voiding trial | 50 | 443 |
16579495-DS-23 | 23,055,267 | Dear Mr. ___,
You came to the hospital because you were having nausea and
vomiting which caused you to become dehydrated and made you
dizzy. You were given fluid through your IV and medications to
help your nausea. We did an MRI of your brain which showed that
your cancer in your skull may be causing increased pressure in
your head. You were started on a medication called
"dexamethasone" to reduce the swelling which made you feel
better.
Please take Ondansetron every 8 hours as needed for nausea
Please take Prochlorperazine every 6 hours as needed for nauea
Please take dexamethasone once a day regardless of your symptoms | ___ with AFib and anterior mediastinal extraskeletal
osteosarcoma
with intra/extracranial mets s/p palliative XRT presents with
nausea and vomiting.
#NAUSEA AND VOMITING:
Patient presented with persistent nausea and vomiting.
Initial etiology was unclear but upon discussion with patient,
he may not have been
taking his Zofran/Compazine at home. MRI imaging demonstrated
interval enlargement of metastatic calvarial lesions with mass
effect, however after discussion with neuro-oncology, this was
thought to be minimally changed from his recent MRI. He was
started on dexamethasone and Zofran/compazine with improvement
of symptoms. The patient's case was discussed with his
outpatient oncologist and radiation oncologist who agreed with
dexamethasone and continuing with radiation treatment. The use
of oral anti-emetic medication was discussed in detail with the
patient with an in person interpreter.
-cont Zofran and Compazine PRN
-cont dexamethasone daily with omeprazole
-will need PJP and VitD/Ca pending on duration of steroid
treatment
#PRESYNCOPE: Patient did not have orthostatic hypotension based
on formal criteria.
Symptoms improved with IV fluid. This was likely due
to hypovolemia in the setting of nausea, vomiting and poor PO
intake.
#OSTEOSARCOMA
#CHRONIC MALIGNANCY ASSOCIATED PAIN
#GOALS OF CARE: Osteosarcoma has progressed through multiple
lines of therapy and is currently receiving palliative XRT for
his extra and intra-cranial metastatic disease. he received
fractions ___ and ___ while in house. His chest pain is stable.
Discussed goals of care with patient and explained that his
disease has progressed. The patient was interested with meeting
with palliative care. Given his clinical stability, will arrange
for outpatient palliative care consultation.
A family meeting was held with the patient and his outpatient
oncologist where they discussed his current clinical condition.
The patient elected to pursue more chemotherapy. He wishes to
remain full code. He will follow up on ___ with his oncologist.
#ANEMIA OF MALIGNANCY: Stable
#LEFT PLEURAL EFFUSION: Underwent thoracentesis ___ with
improvement in sx. Lung sounds on admission slightly decreased
on L, though CXR appears grossly unchanged. Patient was without
dyspnea.
#PE AND LIJ THROMBUS: cont home enoxaparin
#AFIB: CHADS2VASC 0. Currently in sinus
-cont metoprolol | 104 | 323 |
14322005-DS-27 | 22,573,730 | You were admitted to the hospital after a bicycle accident. You
were found to have broken your right clavical and multiple ribs
on the right side. You are preparing for discharge home with the
following instructions:
Your rib fractures can cause severe pain and subsequently
cause you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory 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 report the following:
*increased shortness of breath
*difficulty catching your breath
*difficulty breathing
*dizziness, weakness
*fever
*sweats
*yellow or green sputum | Mr. ___ was admitted to the ACS service with HPI as stated
above. His injuries were managed conservatively; his pain was
controlled on oral medicines titrated to his history of liver
and kidney problems. He was given a sling for comfort. He
tolerated a regular oral diet and his pain was sufficiently
controlled. He was minimally motivated to undertake physical
activity but was able to ambulate independently and was observed
to do so by staff and the physician.
He sustained an episode of hypotension to approximately 70/40 on
___ and was noted to have pinpoint-pupils on
examination. He was otherwise asymptomatic and mentating
appropriately. He was at this time being treated with dilaudid
after oxycodone had been discontinued for concern for nausea and
his medical history of kidney and liver problems. The dilaudid
was discontinued, his antihypertensive medicines were held, and
he was bolused fluid and responded appropriately.
Antihypertensives were then resumed without further incident.
His pain regimen was subsequently altered to include tramadol as
his only narcotic pain medicine. He was also given a lidocaine
patch for his ribs twice daily as well as cyclobenzaprine and
tylenol ___ QID PRN pain. Toradol had been discontinued due
to concern for his renal function and a creatinine elevated to
1.5. It was reduced to 1.3 at the time of his discharge.
An x-ray from one of his previous visits noted an old right ___
matacarpal fracture and he had sustained a wrist fracture in
late ___. He sustained abbrasions to his right hand in
his bicycle accident and it is unclear if a fracture was
sustained; the patient declined an offer to x-ray his right
hand/wrist as an inpatient. He has a splint that looks like it
was applied in the emergency department but the patient is
uncertain.
He was previously seen for a wrist fracture in ___ ___ in Hand ___. He is set up for outpatient x-rays and
follow-up in Hand Clinic with either Dr. ___ Dr. ___ on
___ at 9:40 AM.
Mr. ___ failed to void during two trials as an inpatient
despite treatment with tamsulosin. He is sent home with a foley
and a leg bag following teaching for the same. He is set up
with his PCP's office for foley removal and a void trial next
week on ___ at 9:30 AM.
Physical therapy saw him and stated expectation that he would be
discharged to home, noting that he stated that he was able to
walk independently. Occupational therapy noted that the patient
denied OT services, and OT was unable to clear him for discharge
because he refused to get out of bed, stating that he didn't
"feel like it." He sustained no lower extremity injuries and
has appropriate use of his left upper extremity; he will
undertake appropriate range of motion exercises for his left
upper extremity as well as being seen in hand clinic as stated
above. Physician had ambulated him the previous night; he is
capable of ambulation independently and will be discharged with
MD clearance to ambulate. Patient has been made aware that he
must ambulate with care especially in the context of a foley
catheter that may catch if he is wearing loose clothing and that
he must be extremely careful not to trip.
He is sent home with pain medicines titrated to his increased
creatinine levels and history of liver transplant. He is also
sent home with appropriate discharge instructions,
prescriptions, and follow-up appointments already made. He is
discharged in stable condition on ___. | 302 | 615 |
13454189-DS-22 | 26,390,389 | Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
-You had low oxygen levels and shortness of breath
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You had imaging to determine why you were having a hard time
breathing, which showed your heart is not relaxing as well as it
used to
-Your blood pressure was very elevated
WHAT SHOULD I DO WHEN I GO HOME?
-Please start taking medications to keep your blood pressure
under better control
-Please follow up with your primary care doctor
Thank you for letting us be a part of your care!
Your ___ Team | This is a ___ year old female with past medical history of
constipation admitted with hypertensive urgency with flash
pulmonary edema, subsequently weaned to room air after improved
blood pressure control, TTE demonstrating diastolic CHF,
incidentally found to have large breast mass with signs
concerning for metastatic disease, with in-depth discussion with
patient and family, resulting in declining of further
workup at this time.
# Acute diastolic CHF secondary to hypertensive urgency
# Chest pain
# Hypoxemia
Patient presented with hypertension and sudden onset of dyspnea,
found to have initial oxygen saturation < 80%. Workup notable
for negative cardiac enzymes, EKG without concerning findings
for ischemia, CTA without evidence of pulmonary embolism or
aortic pathology. Symptoms completely resolved with control of
blood pressure. TTE did not show any wall motion abnormalities,
but was notable for likely diastolic dysfunction. Suspected
etiology of symptoms was hypertensive urgency causing acute
diastolic CHF. Patient initiated on amlodipine with improvement
in her hypertension. Symptoms did not recur, and patient
remained comfortable and satting well at rest and with
ambulation.
# Breast mass concerning for malignancy:
Patient incidentally found on CTA to have R breast mass with
right axillary lymphadenopathy and enlarged mediastinal lymph
node. Exam concerning for breast cancer as well. The diagnosis
of likely breast malignancy was discussed with patient and with
PCP, and patient was able to demonstrate understanding of
diagnosis; she declined any work up during this admission and
was able to state the risks of doing so, including worsening of
her disease and death. She declined a biopsy and referral to
oncology. With her permission, we discussed this with her
daughter, who agreed that this was consistent with patients
previously stated preferences to not take any additional
medications or seek additional care. With further discussion,
patient also stated a preference for focusing on quality of
life. Daughter and patient will consider establishing with
palliative care services, but they preferred to discuss as an
outpatient. | 92 | 332 |
12999495-DS-13 | 28,994,962 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you had nausea and abdominal discomfort. You
underwent a procedure to explore your biliary system called ERCP
which was well tolerated. They saw a stricture of your common
bile duct. In order to better character this stricture, you had
a CT scan of your abdomen. This showed a 2cm mass in the head of
your pancreas. We are unsure what this mass may be, but
unfortunately, we do suspect pancreatic cancer.
Please follow-up with Dr. ___ on ___ morning for your
procedure to biopsy the mass in your pancreas.
Please eat whatever you can tolerate at home to keep up your
strength.
There have been some changes in your medications:
- Please STOP taking your aspirin at home. You will be
instructed by Dr. ___ you can restart it.
- Please STOP taking your metformin & pioglitazone until ___
because you had a CT scan with contrast, which can have adverse
effects with metformin
- Please STOP taking Zetia until otherwise directed by your
doctors
- Please START taking insulin for your diabetes control and use
the sliding scale attached
Thank you for allowing us to participate in your care. | Impression: ___ yo F with h/o remote MI, DM, HTN, HLD,
hypothyroidism p/w nausea to OSH and found to have a mass in the
head of the pancreas and irregular biliary stricture, concerning
for malignancy.
**ACUTE ISSUES**
# Biliary stricture and pancreatic head mass: Initially, patient
was thought to have choledocholithiasis with RUQ u/s showing
cholelithiasis, CBD and pancreatic duct dilation and LFTs in
obstructive pattern. ERCP on ___, however, showed no stones
and an irregular biliary stricture of the distal CBD.
Sphincterotomy was performed and stent was placed. Subsequent CT
abd/pelvis with pancreas protocol showed 2cm ill-defined
hypodense mass in the head of the pancreas with concerning RP
nodes and liver nodules. Patient seen by hepatobiliary surgery
and scheduled for EUS with biopsy with Dr. ___ on ___.
Patient tolerated regular diet at discharge with downtrending
LFTs. CEA and ___ levels are pending.
# Goals of care: On admission, patient expressed desire to avoid
prolonged life-support and avoid "becoming a vegetable" like her
husband, who had recently passed away in an ICU. Would recommend
continued goals of care discussions, particularly in light of a
cancer diagnosis with poor prognosis.
**CHRONIC ISSUES**
# Hypothyroidism: Confirmed with ___ pharmacy
patient's home dose is 100mcg once daily, which was continued.
# Hypertension: Continued home nifedipine, atenolol, enalapril
with good blood pressure control.
# Type 2 Diabetes: Home pioglitazone and metformin were held and
patient managed on ___. Due to recent administration of
contrast, patient instructed to hold metformin and pioglitazone
through the weekend and was discharged with ISS. She will be
followed by ___ nursing to ensure adequate management of insulin
pen.
# Hyperlipidemia: Home Zetia was held as it can precipitate
cholestatic hepatitis. Home lipitor continued.
# Anxiety: Continued ativan as needed.
**TRANSITIONAL ISSUES**
- Patient initiated on insulin and told to hold metformin in the
setting of recent IV contrast, will need direct on when to
restart these oral hypoglycemics
- Aspirin held after sphincterotomy and patient will need
direction when to restart
- Patient planned for EUS with biopsy on ___ | 201 | 330 |
15917508-DS-12 | 21,026,520 | Dear Ms. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having chest
pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a stress test that showed there may be some poor blood
flow in your heart.
- We did a coronary angiography (catheterization) that did not
show any significant new blockages.
- We started a new medication can isosorbide mononitrate for
your chest pain
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Please carefully review the medication list that we attached,
as we made changes to your medications.
- Call your doctor or call ___ right away if you're having more
chest pain
Sincerely, | =================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old woman with a history of insulin
dependent diabetes mellitus, hypertension, hyperlipidemia and
coronary artery disease who presents with chest pain. She
recently had bare metal stents placed to RCA and OM1 on
___. Over the two weeks prior to her presentation, she
experienced exertional chest pain while walking her dog and
while going up and down stairs. On presentation, she was found
to have no ischemic changes on ECG and three sets of negative
cardiac enzymes. A ___ exercise stress perfusion imaging
study revealed reversible, medium sized, moderate severity
perfusion defect involving the LCx territory. A coronary
angiography on ___ did not show significant new disease,
and no intervention was performed. The patient was chest pain
free even with brisk walking, and she was discharged home with
the addition of imdur to her medication regimen.
====================
ACUTE MEDICAL ISSUES
====================
#Chest pain
#CAD s/p PCI in ___
Ms. ___ presented with exertional chest pain for two weeks in
the setting of having bare metal stents to the RCA and OM1 two
and a half months prior to her presentation. The pain did feel
like her prior anginal chest pain. She denied any pain while at
rest. EKGs and three sets of cardiac enzymes were negative for
ischemia. A exercise stress nuclear perfusion study revealed
reversible, medium sized, moderate severity perfusion defect
involving the LCx territory. She was chest pain free after her
initial presentation. She was continued on her home Plavix,
aspirin and statin. She was started on metoprolol. A coronary
angiography on ___ did not show significant new disease
and no intervention was performed. She was started on isordil
(to be converted to imdur on discharge) and walked briskly
around the floor without chest pain.
# DM
Poorly controlled diabetic. Consulted ___ who titrated her
inpatient insulin. Continue home insulin on discharge. Is
willing to try Jardiance after DC.
# HTN
Continued home lisionpril. Started metoprolol and nitrate
(isordil to be converted to imdur on discharge).
===================
TRANSITIONAL ISSUES
===================
- New Meds: Imdur 30mg daily. Metoprolol succinate 25mg daily.
- Stopped/Held Meds: Naproxen should be discharged at home if
her back pain can tolerate this.
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: Routine labs at
follow-up.
- Incidental Findings: None
- Discharge weight: ___: 88.5kg (195.11 pounds)
[ ] Patient will need close follow-up of DM, as she reports not
always taking correct regimen at home. Willing to consider
Jardiance. | 127 | 400 |
10646068-DS-5 | 28,091,281 | Dear ___ were hospitalized due to symptoms of left sided weakness,
and clumsiness, difficulty with sensation, and difficulty with
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 ___ 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 ovarian cancer
- Hypertension
- Hyperlipidemia
- Past tobacco use
We are changing your medications as follows:
- Adding Atorvastatin 80mg
- Adding Aspirin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing ___ with care during this
hospitalization. | Ms. ___ was admitted to the ICU following tPA administration
for chief complaint of left sided weakness/clumsiness,
parasthesias, and dysarthria, with an initial NIHSS of 7 for
left sided weakness, sensory loss, and dysarthria. Weakness was
predominantly in the left deltoid, triceps, IP, hamstring and
TA. Her initial NCHCT was normal. Her CTA showed a prominant
left middle cerebral vein, which was not thought to be
associated with her symptoms. All major arteries were patent.
She was given tPA at 10:45am and admitted to the neurology ICU
for post-tPA monitoring.
ICU COURSE
She passed her bedside speech and swallow and was started on a
regular diet. A few hours after arriving to the ICU, she
complained of increased weakness, which was evident on exam. She
was laid flat and given IVF for some improvement in symptoms.
She went for a STAT NCHCT which showed no bleed. Subsequent MRI
showed a right thalamocapsular infarct. Her 24-hr post tPA
non-contrast head CT again showed no bleed. Her blood pressures
were stable in the 140s-150s overnight, on only half-dose of her
metoprolol (other home blood pressure medications were held).
Her telemetry showed only occasional PVCs. She was started on
ASA 81mg and sub-Q heparin. She was transferred to the stroke
team, floor with telemetry.
Due to laying flat, she had some positional lower back pain for
which she was given tylenol, and then 5mg oxycodone.
FLOOR COURSE
# Right thalamocapsular stroke:- Ms. ___ arrived to the
neurology team in stable condition and over the course of her
admission demonstrated improving strength in the left arm and
leg as well as decreasing paresthesias. Her stroke was deemed to
be secondary to small vessel disease. She passed her speech and
swallow evaluation and was started on a regular diet. ___
evaluated her and determined she needed rehab for gait, standing
dynamic activities, therapeutic
exercise, functional mobility training. Her fasting LDL was
noted to be 185 and HbA1c=5.7 and therefore, started on
Atorvastatin 80mg qday. She was continued on SQ heparin, aspirin
81 and will be discharged to ___ with these. She will
follow up with Neurology/ Stroke clinic as outpatient.
# ___: Ms. ___ ECG, serial cardiac enzymes, telemetry were
normal. TTE with bubble showed no ASD or PFO as well as normal
global and regional biventricular systolic function. We kept her
off her antihypertensives (HCTZ, losartan) and resumed half her
home dose of her beta-blocker (metoprolol ER 75mg qd --> 37.5mg
qd)in order to allow her blood pressure to autoregulate with
goal SBP < 185 (goal SBP 140-180s). Her SBP remained in the 140s
off her home antihypertensives and therefore we refrained from
resuming home antihypertensives for now. These can be resumed at
rehab if she starts becoming hypertensive or prior to discharge
to home, with goal SBP<150.
# Onc: Given her history of malignancy, we did check D dimer
which was normal.
She is being discharged to ___ rehab for ___ needs. She
will remain on Aspirin, Atorvastatin and continue with her
bevacizumab. She can resume her home hypertensives when
appropriate or prior to discharge. She will follow up with her
primary care doctor as well as stroke neurology as outpatient. | 167 | 519 |
13237127-DS-18 | 27,583,794 | You were admitted to the hospital with nausea, vomiting,
dehydration and malnutrition. An endoscopy was performed and
consistent with a gastro-jejunal ulceration, which was treated
with intravenous pantoprazole. You were also given intravenous
nutrition through a PICC due to your inability to tolerate
adequate amounts of food and liquids orally. Additionally, your
stool culture was positive for clostridium difficile, for which
you are receiving antibiotics.
You are now preparing for discharge to ___ and will
continue your treatment. | Ms. ___ presented to the ___ Emergency Department on
___ with persistent nausea, vomiting and oral
intolerance. Upon arrival, given multiple electrolyte
abnormalities, K, PO4 and Mg were aggressively repleted. She
was also placed on bowel rest, given intravenous fluid including
a banana bag and intravenous protonix. An ABD CT scan was
performed and without evidence of obstruction. Once deemed
stable, she was transferred to the general surgical floor for
ongoing monitoring and work-up.
On HD2, an EGD was performed revealing a '2-cm deep cratered
ulcer at the mouth of the efferent limb'. Post-procedure,
intravenous pantoprazole was continued, twice daily and oral
sucralfate was initiated. Also, given severe-protein calorie
malnutrition with prolonged po intolerance, a double-lumen power
PICC was placed and TPN was initiated with close monitoring and
aggressive repletion of electrolytes due to high risk of
refeeding syndrome. The patient's diet was also gradually
advanced to Bariatric Stage 5, which was only tolerated in very
small quantities due to intermittent nausea and vomiting, which
is patient's baseline. However, these symptoms have improved
significantly while in-house. Given limited oral intake and
intermittent hypotension (SBP 80-110s), intravenous fluids were
provided during the day while TPN cycled and also concurrently
with TPN at a reduced rate.
Additionally, on HD3, the patient's stool sample was positive
for clostridium difficile, which the patient had previously and
was unable to tolerate oral metronidazole. Oral metronidazole
was retrialed and well tolerated until hospital day 7 when the
patient experienced an episode of vomiting. Intravenous
metronidazole was initiated, but can be retrialed as po as
patient currently without nausea and vomiting; patient reports
of diarrhea resolved by HD6.
At the time of discharge to ___, the patient was
afebrile with stable vital signs. She is tolerating small
amounts of oral intake requiring both supplemental intravenous
fluid and TPN, which is cycled over 12 hours with daily
electrolyte adjustment. Intravenous pantoprazole was also
continued at this time for healing of her ulcer; she will need a
repeat EGD in the future to assess healing and possibly remove
foreign body (stitch) noted on EGD. She will also require
ongoing treatment for clostridium difficile with oral
metronidazole. Finally, the patient's vitamin D level was noted
to be 26, she will require initiation of 1000 units vitamin D
daily. She has agreed to follow-up with both her primary care
provider and ___ at ___ and ___
___, respectively once discharged from ___
___. | 80 | 416 |
14061397-DS-61 | 29,012,666 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had an infection in your lungs from your oral secretions
or from food moving into your lungs.
What was done while I was here?
- Your lung infection was treated.
- We discussed hospice. You will meet someone from hospice when
you leave the hospital.
What should I do when I get home?
- Take all your medicines as prescribed.
- Make sure you eat ground solids or thin liquids only while you
are awake and sitting up to reduce the risk of food going into
your lungs. | ___ year old male w/ history of CVA, CAD s/p MI, HFrEF (EF 40%
___, Afib, ESRD on HD, COPD (baseline 2L O2 requirement at
night) presents from ___ to ___
___ initially with altered mental status and shortness of
breath found to have septic shock secondary to aspiration
pneumonia and toxic metabolic encephalopathy. Patient was
treated for aspiration pneumonia with Vancomycin and Cefepime
for seven day course (end ___. He received a CTA chest on ___
with predominantly bibasilar pulmonary consolidation consistent
with aspiration and with no evidence of PE; of note, did receive
empiric heparin drip for PE initially because echo showed
elevated right heart pressure and inability to get CTA due to
mental status.
Given presentation of aspiration pneumonia and imaging
findings, patient is likely chronically aspirating. Evaluated by
speech and swallow service several times during hospitalization
with evidence of aspiration. After discussion with family,
patient will have supervised feedings with the accepted risk of
aspiration. Patient will be given ground solids and thin liquids
as this is the lowest risk of aspiration for him per speech and
swallow. His PO meds will be crushed in apple sauce. Medical
team had several goals of care discussions with patient's family
and HCP during hospitalization. Patient is now DNR/DNI, but will
continue to receive HD and medical care. Patient's family met
with palliative care to discuss options for hospice at nursing
home. At the time of discharge plan was for family to meet with
hospice once the patient arrives at the nursing facility. A
MOLST form will need to be filled out with patient's HCP at the
nursing facility.
#Toxic Metabolic Encephalopathy: Likely exacerbated in setting
of acute infection and aspiration pneumonia. CT head negative.
Patient with functional decline from his baseline status prior
to hospitalization. He is intermittently agitated, which per
family is different from his baseline. At the time of discharge
patient was alert and oriented to person, place and date. He was
interactive, but not answering all questions appropriately.
#Septic Shock - Patient presented with septic shock thought to
be secondary to aspiration pneumonia. Patient with history of
chronic aspiration with evidence of ground glass opacities on
CTA chest. S/p 5 days levoflox/azithromycin and 7 days
Vanc/cefepime discontinued ___. Patient initially required
pressor support which was weaned within the first day of
admission.
#Mixed Hypoxemic/Hypercarbic respiratory failure- Respiratory
failure thought to be secondary to aspiration event. PE was on
the differential and he was initially treated with heparin gtt;
CTA on ___ was negative for PE. He also has hx of COPD
requiring 2L of O2 at night and CHF requiring toresemide (held
during admission) and HD which may have been contributing.
Patient was treated initially with Methylpred 60mg IV and
antibiotics as above.
#Aspiration pneumonitis: Ongoing aspiration pneumonitis with
ground glass opacities seen on CTA. Patient is not able to clear
secretions and is likely chronically aspirating. Evaluated by
speech and swallow on ___, patient did not participate in exam.
After discussion with family, patient will have supervised
feedings with the accepted risk of aspiration. Patient will be
given ground solids and thin liquids as this is the lowest risk
of aspiration for him per speech and swallow. His PO meds will
be crushed in apple sauce.
#Chronic DVT: ___ with evidence of chronic DVT. Patient was
started on heparin drip initially, which was discontinued after
CTA was negative for PE. Given DVT was chronic in nature
decision was made not to treat.
#Goals of care: Ongoing discussion with family regarding
patient's overall prognosis and goals for ongoing care. Patient
is now DNR/DNI, but will continue to receive HD and medical
care. Patient's family met with palliative care to discuss
options for hospice at nursing home. At the time of discharge
plan was for family to meet with hospice once the patient
arrives at the nursing facility. A MOLST form will need to be
filled out with patient's HCP at the nursing facility. | 102 | 656 |
15662806-DS-32 | 22,308,283 | Dear Mr. ___,
It was a pleasure to care for you at ___. You came to us for
continued weakness, nausea, and 1 episode of vomiting on ___.
On your last admission, you had a positive test for Norovirus,
which is a viral gastrointestinal illness, on your last
admission. We also sent out multiple tests on your blood and
stool during your last admission, which all came back negative.
We think that you most likely are continuing to have symptoms
from Norovirus, which can last longer in patients after a kidney
transplant. We made sure that nothing else was causing your
abdominal pain and weakness by checking tests on your liver and
your pancreas, which were normal. We also did a CT of your
abdomen, which also looked normal.
You complained of pain and swelling in your right arm after
dialysis on ___, and stated that it was similar to what had
happened in your left arm previously. We consulted our
colleagues, the interventional radiologists, who were able to go
into your veins and open up the narrowing in your veins that was
causing the swelling.
You were much improved after some fluids and rest, and the
procedure by the interventional radiologists. You were able to
eat full meals by the time you left.
Please follow up with your outpatient doctors.
Thank you for choosing ___.
We wish you the best,
Your ___ team | Mr. ___ is a ___ yo man with a PMH of ESRD secondary to FSGN
(s/p failed deceased donor graft placement in ___ with
subsequent removal in ___, now s/p deceased donor transplant on
___ but currently still dialysis-dependent), hepatitis C
(genotype 1, grade 1 fibrosis), DMII, Afib (on Coumadin), DVT
s/p IVC filter placement (___), HTN, and diastolic CHF with
recent admission for norovirus (___) who presented with
nausea, vomiting and weakness most likely due to incomplete
resolution of norovirus, also with acute right UE swelling from
central venous stenosis on ___ s/p angioplasty by ___ on ___
with resolution of swelling and edmea.
# Abdominal pain w/nausea and weakness: Patient had a recent
admission ___ positive norovirus test during his
last hospital stay. He was negative for EBV, BK, CMV, C.
difficile, O&P, and other stool studies during that admission.
Also had negative Ucx and blood cx during last admission. This
admission he had nl LFT's, lipase, CT abdomen. UCx, BCx, CMV and
adenovirus were negative. Tacrolimus levels were not high, which
made us less suspicious of tacrolimus as etiology of his
nausea/weakness. Although norovirus is usually a self-limiting
disease, it can persist for much longer in immunocompromised
patients (per a literature search, may persist for up to years
in some cases). Thus, we felt his GI symptoms were most likely
___ to incomplete resolution of norovirus. Abdominal pain
resolved on ___. No vomiting/diarrhea after admission. We
reduced his dose of mycophenolate from 1000 BID to ___ BID as
mycophenolate can contribute to abdominal pain, with plans to
uptitrate in outpatient setting as needed. We also continued
wound care in LLQ at site of incision for kidney transplant as
below.
# Acute right extremity swelling: After dialysis on ___, Mr.
___ developed increased pain and swelling in his right arm.
RUE U/S showed no hematoma or thrombosis, only diffuse swelling,
concerning for central vein stenosis. ___ performed angioplasty
on ___ which resulted in resolution of swelling and pain.
# ESRD secondary to FSGN: Patient is s/p failed deceased donor
graft placement in ___ with subsequent removal in ___, and s/p
deceased donor transplant in ___ c/b delayed graft function.
He was maintained on his dialysis schedule. We discontinued
calcium acetate 667 mg due to low phosphate. We continued other
medications for his transplant including mycophenolate mofetil
500 mg bid, nephrocaps 1 cap daily, prednisone 5 mg daily, and
trimethoprim-sulfamethoxazole DS 1 tab ___ and omeprazole 40
mg daily. We also continued lamivudine oral solution 10 mg daily
(patient is HBsAg negative, HBsab positive, and core ab positive
with negative viral load. Started on lamivudine in ___, as
reactivation of HBV replication has been reported rarely in
HBsAg negative but anti-HBc positive patients.)
# Pericardial effusion: Finding on CT of either pericarditis or
pericardial effusion. He denied any symptoms, and was without
SOB or heart palpitations. ECHO showed trivial/physiologic
pericardial effusion. Therefore, did not pursue further workup.
# A-fib: His initial INR was supratherapeutic at 8.9, and thus
we held his warfarin initially. He required 3 units of FFP
throughout his stay to reverse INR when he went for angioplasty
by ___. We started warfarin on evening of ___.
# LLQ wound: He presented with LLQ wound from site of prior
kidney transplant, and had wound care recs from ___.
Wound was clean and uninfected throughout stay, similar to last
admission. Wound care recommendations from ___ were as follows:
-Cleanse ulcer with wound cleanser set to "stream" pat dry, use
cotton tip swab as needed to remove excess cleanser
-Prep periwound tissues with No Sting Barrier Wipe fill ulcer
with aquacel ag rope
-Cover with dry gauze and secure with soft cloth tape
-Change daily with goal of every other day once home (if
drainage is managed well)
We communicated these instructions to him to continue at home.
# Hypocalcemia: Calcium 7.6 on ___, with Albumin 3.1, PTH 46.
Corrected calcium was 8.3. Phosphate was low at 2.1, and 25VitD
level was 22. We stopped calcium acetate given low phos 2.1, and
continued calcitriol 0.25 mcg daily. | 230 | 678 |
13279983-DS-7 | 23,241,425 | Dear ___,
You were hospitalized due to symptoms of headache and dizziness
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. We think your stroke was related to the hormonal
changes in your body that normally occur after giving birth. The
estrogen containing pill you were taking may also have
contributed. Sometimes strokes come from the heart but we did
two echocardiograms that showed no problem with your heart. We
recommend that in the future you use contraceptive methods that
are progesterone only.
We are changing your medications as follows:
- Atorvastatin 10mg
- Aspirin 81mg
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 | Ms. ___ was admitted to the Neurology Stroke service after
presenting with headache and dizziness and was found to have two
small infarcts in left posterior circulation (cerebellum and
thalamus). Her infarcts were very small and asymptomatic. The
etiology of her infarcts is ultimately most likely to her
post-partum hormonal changes with possibly some contribution of
her oral contraceptive pill. She had an extensive work-up given
the rarity of stroke in a healthy young woman. Her labs showed
normal TSH and Alc. Her LDL was 120 which is normal for the
average person, but given her now history of stroke she was
started on atorvastatin to reduce her LDL with a goal of <70.
She had an trans-thoracic echocardiogram which was normal so we
obtained a trans-esophageal echo to confirm no PFO. Both echos
showed normal function. She was monitored on telemetry and had
no signs of arrhythmia and was sent home on a Ziopatch heart
monitor.
TRANSITIONAL ISSUES
[] FOLLOW UP RESULTS OF THE HEART MONITOR
[] FOLLOW UP APPOINTMENT WITH ___. ___
[] CONTINUED ASPIRIN 81MG AND ATORVASTATIN 10MG FOR STROKE
PREVENTION
[] TALK WITH YOU OB/GYN ABOUT CONTRACEPTIVE OPTIONS THAT DO NOT
INCLUDE ESTROGEN
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 120 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist : it
is unlikely that her stroke was related to hyperlipidemia
therefore put on normal dosing statin
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not? - patient at baseline
functional status
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A | 336 | 528 |
13507232-DS-25 | 25,829,986 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
WHY DID YOU COME TO THE HOSPTIAL?
--you developed pain in your right leg
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
--you had a procedure to repair blood vessels in your right leg
--you developed multiple strokes
--you developed difficulty breathing requiring intubation and a
tracheostomy
--you developed difficulty swallowing requiring a ___ tube
--you developed an infection in your lungs and urinary tract
requiring antibiotics
--your blood sugar levels were very high and you needed large
amounts of insulin
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
--continue to take your medications as prescribed and follow-up
with your doctors as ___.
We wish you all the best,
Your ___ care team | Mr. ___ is a ___ year old man with past medical history of
poorly controlled diabetes, pacemaker for sick sinus syndrome,
transitional cell carcinoma of bladder (on maintenance BCG),
peripheral artery disease c/b multiple bilateral lower
extremities arterial occlusions s/p multiple thrombectomy and
lyses and L AKA, and HIV (not on ART) who presented to ED after
being found-down with right ischemic limb. He underwent right
femoral thrombectomy and endarterectomy, the following day
developed dysarthria and confusion, CTH/A showed right and left
cerebellar stroke, left pontine stroke, and a basilar artery
occlusion. Course further complicated by respiratory failure s/p
trach, dysphagia s/p ___, multiple infections, agitation and
NSTEMI. | 115 | 108 |
13996551-DS-33 | 29,521,408 | Dear ___,
You were admitted to the hospital with confusion and low blood
sugar, and found to have a UTI. We treated you with antibiotics.
While you were in the hospital, your kidney function worsened
and excess fluid built up in your extremities. Dialysis is not
an option for you as it cannot be performed safely. Ultimately,
you were transitioned to a long term care facility.
We wish you the best.
Sincerely,
Your care team at ___ | ___ w/ ESRD s/p ___ DDRT (on prednisone/Tacro/MMF), HIV (on
ART; CD4 192, VL 10^1.8), HFrEF (LVEF40%), 4+ TR with possible
RV failure, HTN, DM2 on insulin, dementia (likely vascular; AOx2
at baseline), PAD (s/p multiple amputations), CAD (s/p recent
NSTEMI), admitted w/ ___ (Cr 1.5-> 3.0) and Enterobacter UTI.
Her hospital course was complicated by worsening renal failure.
She had prolonged hospitalization given her worsened renal
failure, and unclear goals of care. Her ability to undergo
dialysis was limited due to the inability to check blood
pressures in the setting of peripheral vascular disease.
Ultimately a decision was made to transition to long-term care
and likely eventually to hospice given progressive renal failure
with no option for dialysis. She and her sister who is her
healthcare proxy are in agreement, though ___ still is
reluctant to accept this decision.
# Sepsis ___ UTI
Sepsis due to UTI, grew enterobacter and was treated with Cipro
___ - ___ with clinical improvement. She was given stress
dose steroids to help with hypotension, and these were tapered
off on ___.
# Toxic-metabolic enceophalopathy
# IDDMII with hypoglycemia
She presented with lethargy and confusion at home, found to be
hypoglycemic, possibly due to poor oral intake vs. metabolic
derangements in the setting of developing UTI. Her mental status
improved significantly after admission. Her discharge insulin
regimen is 2 units of lantus, and sliding scale.
# Acute renal failure on CKD, with oliguria
# Chronic kidney disease stage III
# Renal transplant status
Patient w/ history of ESRD, previously on HD via AVF, now s/p
___ DDRT. She has a baseline Cr of 1.8-2. Kidney function has
been worsening this admission, initially from ATN in the setting
of sepsis, though continued to worsen and thought to be from
decompensated right heart failure and subsequent congestive
nephropathy. She was significantly volume overloaded. Renal
consult team recommended initiation of dialysis, blood pressure,
dialysis was not an option. Her Prograf was stopped and as a
result her renal function started to improve slightly although
this will likely likely be sustained. She was discharged on
torsemide 40 mg daily which will hopefully maintain her renal
status and volume status.
# PVD
# Inability to measure blood pressure
s/p bilateral BKAs with inability to measure blood pressure in
either lower extremity. Patient has a right upper extremity
fistula so unable to measure pressure in right arm or left arm.
# Chronic systolic heart failure (LVEF 40%)
# Chronic RV systolic failure, possibly with acute exacerbation
# Severe TR
Patient developed frank anasarca and oliguria this admission.
This was suspected to be in the setting of right heart failure.
A Lasix drip was initiated without significant effect, and she
was ultimately transitioned to torsemide 40 mg po daily, though
it is unlikely that this will long term be continued.
# Herpes flare
Evaluated by dermatology, found to have herpes on lower back.
Treated with Valtrex
from ___ with improvement in rash. Could consider ongoing
suppressive therapy given history of multiple outbreaks
# CAD
Patient with NSTEMI during recent admission. Home aspirin,
statin were continued. Metoprolol was held in setting of
bradycardia to ___.
# Seizure disorder
Continued keppra
# HIV on ART:
During last admission, switched Descovy/raltegravir to Juluca
(dolutegravir 50mg/rilpivirine 25mg) and entecavir 0.5mg given
poor renal function. Most recent VL 63 copies/ml which is near
suppressed. She was seen by ID consult this admission who
recommended continuing current regimen. Entecavir was changed
to weekly dosing due to acute renal failure.
# Pancytopenia
Suspect ___ CKD and HIV, medication effect (MMF, tacro, ARVs).
Consider outpatient hematology evaluation if persists
# Seizure disorder:
Continued levitiracetem
# Goals of care:
Overall there are multiple discussions of goals of care for
___ throughout her hospitalization. Her health care proxy
was invoked as ___ could not understand fully decisions for
herself. Ultimately in a meeting with ___ and ___
sister/healthcare proxy ___, it was determined that
dialysis is not an option, and given her progressive renal
failure and volume overload, this will likely be the cause of
her death within months. Her sister agreed that dialysis would
likely not help her condition, and in addition, given her
progressive renal failure, and volume overload, and her poor
prognosis, it was not offered by nephrology. She was
transitioned to long-term care and likely ultimately hospice. A
molst form was completed prior to discharge with her sister,
which supported no intensive treatment, as well as no transfer
back to the hospital. | 79 | 744 |
15612850-DS-18 | 27,142,852 | Dear Mr. ___,
It was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
- You were having eye blinking, arm shaking, and leg twitching,
where were concerning for a seizure.
- You were transferred from ___ for further workup of
this.
WHAT HAPPENED IN THE HOSPITAL?
- The Neurologists saw you, and they felt that your symptoms
were not from seizures.
- We obtained an MRI of your brain, which showed evidence of
past, chronic strokes and brain atrophy but no acute changes.
- The Physical Therapists saw you and helped you and your father
develop strategies to increase your mobility.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed and attend your
doctor's appointments.
- Please work with Physical Therapy at home to improve your
strength.
We wish you all the best,
Your ___ Care Team | ====================
PATIENT SUMMARY
====================
___, left-handed, with history of MELAS complicated by epilepsy,
cortical blindness, hearing impairment and progressive cognitive
decline, and also with functional-appearing shaking episodes,
who initially presented to ___ with eye blinking, arm
shaking, leg twitching, and possible lack of responsiveness
which were initially concerning for seizures. ___
transferred the patient to the ___ where Neurology felt his
presentation to not be consistent with seizure but rather
behavior-related. MRI revealed chronic infarcts and progressive
brain parenchymal atrophy without acute changes. Services were
set up for the patient at home. Physical Therapy saw the patient
with his father and provided recommendations for safety and
mobility strategies at home.
====================
TRANSITIONAL ISSUES
====================
[] Home services: Please continue to evaluate home services for
the patient and adjust as appropriate.
[] Seroquel: The patient is on 50mg BID currently. He may
benefit from ongoing titration of this for management of
agitation and anxiety.
====================
ACUTE ISSUES
====================
# Tremors, head shaking, eye fluttering consistent with
behavioral disturbances
# History of epilepsy
The patient initially presented with arm shaking, eye
fluttering, head shaking, and apparent lack of responsiveness at
home which were concerning for seizure. His known seizures are
1. complex partial seizures with visual aura followed by
generalized tonic clonic seizure or 2. staring, confusion, lip
smacking and mouth twitching. Neurology saw the patient, and
further such episodes were observed in-house, during which time
he was responsive to voice after multiple attempts. Neurology
did not feel these to be due to seizures and did not feel that
an EEG was warranted. These episodes were felt to be secondary
to agitation and pain. MRI did not reveal any acute infarcts
though did show chronic infarcts and generalized brain
parenchymal atrophy. He was provided symptomatic relief of these
per below. He was continued on home lacosamide, gabapentin,
clonazepam.
# Acute on chronic lactatemia
Per patient's father and per ___ note, baseline lactate is
___ in setting of known MELAS. Initial lactate at ___
was 12. The etiology of this was unknown. He did not show
evidence of infection and had no history of hypotension. ___
have been secondary to a stress reaction.
====================
CHRONIC ISSUES
====================
# Anxiety
Continued on home Seroquel 25 BID, Prozac 60 QD, clonazepam 1 mg
qAM, 1mg 4pm, and 2mg QHS.
# Right knee pain
Secondary to fall ~3 weeks prior to admission. Exam was benign.
Has been seen by both PCP and ___ as outpatient. Put on
Tylenol and lidocaine patch.
# MELAS
Continued on home L arginine, compounded TID, mitochondrial
cocktail vitamin 4 tabs qAM, 3 tabs qPM.
#CODE: Full presumed
___
Relationship: father
Phone number: ___ | 139 | 414 |
10754405-DS-7 | 27,045,600 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for high fevers and a cough.
We initially had a high suscpicion for a pneumonia (infection of
the lung), however, we did not see any signs of it on imaging
and anti-biotic therapy did not completely treat your signs of
infection. You also had no signs of infection in your blood,
urine, stool or on your skin. We removed anti-biotics because we
did not find a source of infection that we were treating; you
did not have increased fevers, just the intermittent temperature
spikes that you had on the medication as well. Your "White blood
count" (another sign of infection) was elevated and you had a
predominence of a certain cell type called "eosinophils"
(parasite fighting cells). With the help of the Infectious
Disease specialists, as well as the new information that you may
have had worms in your stool a few weeks ago, we concluded that
your infection was parasitic, and most likely called
"Strongyloides" (a parasite found in ___ and other areas of
the world). A test was sent for this parasite but is not
currently back yet. The Infectious Disease doctors ___ that ___
were doing well enough to send home. We felt that given your
likely infection, we should treat you, regardless of the fact
that it was not yet confirmed on laboratory testing. Today, you
received the 1st dose of this medication: Ivermectin 12mg and
tomorrow you should take another dose as well. You can then STOP
taking it for 2 weeks and take your 3rd dose on ___ which
will be your final dose. This should help with your fevers, and
hopefully, your cough as well.
When you were admitted, we noticed that you had very low levels
of salt in your body. After talking to nutrition, we recommend a
slight change in your tube feedings at home. In addition to what
you are already getting, you should receive 3 bottles of ___
spring water gradually over each day, as well as a Sodium tablet
(1gram) twice a day.
You also came in with constipation. After giving you medications
to help you have a bowel movement, you started having diarrhea.
Because of this, we decreased your stool softeners to only take
if you need it. When you go home, you should only take your
stool softeners if you haven't had a bowel movement that day. | Ms. ___ is a ___ year old ___ bed-bound female with PMH
of HTN, HLD, and seizure disorder s/p PEG tube on ___ (for
intake of AEDs) who presents with poor PO intake and especially
poor free water intake with cough, fevers, purulence of PEG
tube, hyponatremia, constipation and slight leukocytosis with
eosinophilia. | 406 | 54 |
10188275-DS-25 | 25,433,697 | Hello Mr. ___,
It was a pleasure taking care of you at the ___
___. You came because of increased work of
breathing and weakness. Here we monitored your breathing and
gave you breathing treatments. The psychiatrists also saw you in
order to adjust some medications. You have lung disease but we
believe that the reason you become acutely short of breath is
related to anxiety and its connection to your vocal cords. The
pulmonary doctors ___ and ___ the same way.
Please follow up with your primary care doctor, pulmonary
doctor, ___.
Here are adjustments to your medications:
Stop taking mirtazapine, buproprion, trazodone
Start seroquel 100 mg at bedtime. You may take 50mg in addition
if you need to for insomnia.
Please continue to take the rest of your medications.
Please follow up with your PCP within one week of your discharge
Please follow up with your pscychiatrists within two weeks to
review your recent medication changes. | Pt is a ___ y/o male with history of tracheobronchomalacia, COPD
on 3 L home O2, asbestosis, and multiple psychiatric issues
(PTSD/depression), who presented to the ED because of increasing
dyspnea and weakness.
# RESPIRATORY DISTRESS/ANXIETY/DEPRESSION: History of
tracheobronchomalacia, COPD on home ___ presenting with dyspnea,
wheezing, and increased oxygen need in ED (4.5L from 3L
baseline) s/p thoracentesis for a chronic R-sided pleural
effusion ___ and vocal cord botox injection on ___. Last
admission, patient had respiratory distress w/episodes of
"stridor," thought largely to be psychogenic - patient had a lot
of concern/anxiety surrounding his lungs w/recurrent plural
effusions, was supposed to have psych follow-up after this
admission that he missed due to hoarseness. CXR unchanged from
prior admission. On arrival to MICU, taken off BiPAP, satting
97% on 3L NC, his home O2 dosages. Has several episodes of
hoarse stridor, but is able to interrupt them to request food
and drink. Never desats. Pt was treated with NC oxygen and
albuterol/ipratropium neb Q6hr. He was placed on ativan and his
home dose valium 5mg for anxiety. Pychiatry consultation was
obtained. Psychiatry did not think that his respiratory distress
is due to psychiatric conditions, commenting that he has PTSD
and depression and not necessarily anxiety/panic disorders.
Based on psych recommendations, we discontinued his home
bupropion, mirtazapine, and seroquil. Pt was upset about psych
med changes. He sees multiple psych providers, ___ at the
___ follow up with his outpatient physicians.
Interventional pulmonology was also consulted and recommended
prednisone 40mg x3 days but patient reported history of
psychosis w/ steroids; thus; pt was given fluticasone inhaler.
IP also recommended an outpatient cardiopulmonary excercise
test. Pt complained of throat pain. Pain was managed with
tylenol and home dose oxycodone.
On day of discharge, patient was seen and examined and stable
with comfortable breathing, full saturation on room air,
tolerating light excercise in the room. His bicarb was noted to
be rising. ABG was done and consistent with compensated
metabolic contractile alkalosis due to diuretic use and
decreased po intake, with respiratory compensation. Discussed
results with pulmonary fellow.
# ___: Cr 1.3 on admission; 1.1 baseline. Likely pre-renal;
encouraged PO intake and renal function improved.
# Hypothyroidism: continue home levothyroxine. | 153 | 367 |
19716166-DS-18 | 27,704,745 | Dear. Mr. ___,
You were admitted because:
- You were feelings lightheaded and short of breath.
During your stay:
- You were given fluids through and IV.
- You had a chest x ray, which showed fluid around your lung.
Your symptoms improved and there was no urgency to remove this
fluid during your hospitalization.
After you leave:
- Please take your medications as prescribed.
- Please attend any outpatient follow-up appointments you have.
Be sure to follow up with interventional pulmonology to follow
up the fluid around your lung.
- Please weigh yourself every morning, call your doctor if
weight goes up more than 3 lbs in 1 day or 5lb in 1 week.
- Please continue to avoid driving until instructed by your
doctor.
- Please do not hold anything heavier than a gallon of milk for
a month.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ HealthCare Team | Mr. ___ is a ___ year old man with metastatic lung cancer on
gemcitabine, CAD s/p NSTEMI and recent VT storm s/p ICD presents
from home with progressive fatigue and dyspnea with progressive
left sided pleural effusion found on CXR.
#FATIGUE
#DYSPNEA:
Patient presented with progressive dyspnea, fatigue and
lightheadedness with standing. He was recently treated as an
outpatient for community acquired pneumonia. He was initially
improving, but subsequently developed progressive dyspnea and
fatigue. He had one episode of presyncope upon standing, which
prompted him to present to the ED. Workup showed progressive
left-sided pleural effusion found on CXR. He had no hypoxemia on
exam at rest or with ambulation. No evidence of ischemia. He
received one liter of IVF in the ED and his symptoms resolved.
His pleural effusion was thought to be contributing to his
dyspnea though his symptoms improved without intervention.
Adrenal insufficiency was considered given his adrenal
metastasis and fatigue; however, he was without hypotension or
electrolyte abnormalities and AM cortisol WNL. Lastly, it was
though his fatigue and pre-syncope could also be exacerbated by
his metoprolol and verapamil, which were started during his last
hospitalization. His blood pressures remained stable and the
doses weren't reduced. IP consult for thoracentesis was deferred
to outpatient setting.
#LUNG CANCER
#SECONDARY MALIGNACY OF PLEURA
#SECONDARY MALIGNANCY OF ADRENAL GLAND:
C2D1 of Gemcitabine was on ___.
#CORONARY ARTERY DISEASE
#S/P ICD:
No need to interrogate device at this time given other, more
likely cause for his symptoms. No chest pain. Negative trop x2.
Continued home ASA. Atorvastatin on hold due to elevated LFTs.
Continued home verapamil, metoprolol, and spironolactone.
#OSA: ordered CPAP while in house
#GERD: continued home omeprazole while in house
Name of health care proxy: ___
Phone number: ___
#CODE STATUS: full, presumed | 152 | 288 |
11502644-DS-10 | 27,855,265 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for confusion and a fall.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, we did a CT of your head and
did not see any bleeding
- We found that you had a urinary tract infection and also an
infection in your blood.
- We treated you with antibiotics and you got better.
- You were improved so we felt it was safe for you to go home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You will need to take IV antibiotics until ___.
We wish you the best!
Sincerely,
Your ___ Team | BRIEF SUMMARY OF ADMISSION
===========================
___ M with a PMHx of vascular dementia, pontine CVA c/b urinary
retention with chronic foley, CKD (b/l Cr 1.6-1.9), HTN, T2DM,
brought in by EMS for agitation following foley exchange and
subsequent fall, found to have Proteus urinary tract infection
c/b polymicrobial bacteremia (Proteus and MRSA).
TRANSITIONAL ISSUES
===================
[] ** Please check vancomycin trough ___ @ 8pm prior to ___
Vancomycin dose and send results to ATTN: ___ CLINIC -
FAX: ___ *
[] Please check weekly CBC with differential, BUN, Cr,
Vancomycin trough, CRP and fax to ATTN: ___ CLINIC - FAX:
___
[] Please repeat serum Cr in 1 week to ensure resolution ___
[] Lisinopril 40mg was held for ___, please restart if Cr stable
between 1.6 -1.9
[] Amlodipine 5mg QD was started on day of discharge, please
recheck blood pressure in 1 week to ensure well controlled
[] Please ensure patient follows up with urology for further
hematuria work up if it persists.
[] Consider referral to cardiology for evaluation for TAVR for
severe aortic stenosis noted on transthoracic echo
ANTIBIOTICS
OPAT Diagnosis: MRSA bacteremia | 155 | 180 |
13269859-DS-46 | 27,885,028 | Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted with confusion and
shortness of breath due to diabetic ketoacidosis. You were
admitted to the intensive care unit and treated with medications
including insulin. While you were in the intensive care unit,
there was evidence that your heart was damaged. Your kidneys
were also damaged, but these are recovering. You were seen by
the ___ who made recommendations on
increasing your insulin at home. You should follow up with the
___ shortly after your discharge.
Please continue to take your medications as prescribed and keep
your follow-up appointments.
It was a pleasure caring for you.
We wish you the best,
Your ___ Care Team | ___ with h/o T1DM x ___ (on Lantus & Humalog) c/b multiple
prior DKA, neuropathy, and retinopathy, ETOH abuse w/ binging,
HTN, neuropathy, depression, and anemia who presented to the
___ ED on ___ via EMS for altered mental status and
dyspnea, found to have DKA.
#DKA: Labs consistent with severe DKA (pH: 6.84, HCO3: 2,
Lactate: 3.2, BG >500, urine Ketones+) in context of
non-compliance with home insulin regimen and alcohol abuse.
There was no signs of infection; CXR, UA, and cultures were not
suggestive of infection. Also, troponin was positive but that
was likely ___ demand ischemia (see below). She was treated with
insulin drip until her gap closed then transitioned to the
following insulin regimen: 16U glargine BID with SSI. She will
follow up with ___ 2 days after discharge.
#Hypotension: Patient was hypotensive with BPs in
___ despite IVF resuscitation, requiring pressors
for a short period of time. There was initial concern for
infection given persistent hypotension so patient was treated
with broad spectrum antibiotics. Antibiotics were subsequently
stopped because of absence of evidence of infection and
resolution of hypotension.
#Leukocytosis: Likely due to DKA. Patient endorsed dyspnea but
CXR without evidence of pneumonia and UA was not abnormal. There
was no localizing symptoms of infection but patient was
initially hypotensive. She was initially treated with broad
spectrum antibiotics. Antibiotics were subsequently stopped
because of absence of evidence of infection and resolution of
hypotension. Leukocytosis resolved prior to discharge.
#Alcohol abuse/withdrawal: Patient is a heavy drinker for years
but denied any prior history of withdrawal, including seizures
and DTs. Last drink was ___ ___. She was placed on CIWA score and
was given thiamine and multivitamins. No seizures.
#NSTEMI: In the setting of diabetic ketoacidosis whe was found
to have elevated troponin in the absence of chest pain, with no
ECG changes and no regional wall mall abnormalities on TTE.
Elevation in troponin was likely demand ischemia. Continued on
home aspirin 81mg and atorvastatin 80mg. Given no history of
anginal symptoms
(typical or atypical) and that her troponin was thought due to
demand in the setting of a severe illness, we would recommend
considering non-urgent risk stratification with stress testing
as an outpatient (e.g. stress test or further testing)
___: Creatinine was found to be elevated to 2 on admission,
from a baseline of ~1. Elevation in creatinine was likely
pre-renal due to dehydration and hypotension. She received IVF
as part of DKA treatment and creatinine decreased. Creatinine on
discharge was 0.7. | 118 | 412 |
12517625-DS-17 | 21,861,244 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for the shortness of
breath you were experiencing. We think this may be secondary to
an asthma exacerbation versus your underlying TBM and vocal cord
dysfunction. Your symptoms improved with nebulizer treatments
and BiPAP. You were transitioned back to your home inhalers with
plans to follow-up with the pulmonary and intervention pulmonary
teams for further management.
We wish you all the best!
Your ___ team | Ms. ___ is a ___ yo woman ___ asthma, anxiety, TBM s/p Y stent
placed at ___ ___ (removed ___, ___ s/p ablation who
presented with dyspnea and SOB. On admission, the patient was
treated with steroids and nebulizers. She was placed on BiPAP
for comfort, however, she never became hypoxemic. Her course was
complicated by lactic acidosis likely in the setting of over-use
of albuterol inhalers, which was improving at time of discharge.
Bedside peak flow initially 390 which improved to 410 by time of
discharge. The patient's respiratory status improved and she was
transitioned to her home inhalers with plans to follow-up with
IP and Pulmonology for further management. | 82 | 111 |
17232216-DS-17 | 24,216,879 | Dear Ms. ___,
It was a pleasure looking after you. As you know, you were
admitted after a mechanical fall and ___ pain. You had ___
x-rays here, which fortunately did not reveal fracture or any
evident dislocation/hardware changes in the ___. You were
seen by physical therapy - who felt that you would certainly
benefit from ___ rehab with the aims of getting strong
enough to go home and live independently.
You also described having symptoms of restless leg. You
were started on a medication called Pramipexole - which
signficantly helped with the restless leg. Please continue it
for the time being - and may be re-evaluated when you see your
primary care doctor.
Your calcium level was high at 10.8. This is attributed to
the hyperparathyroidism (level 147). You were continued on
Magnesium Oxide. And also, because the Vit D levels were low,
Vitamin D was restarted (which inhibits the release of
parathyroid hormone). If your calcium continues to be elevated
while on Vitamin D, then it is possible that you would need to
stop it and try another medication to suppress parathyroid
hormone release.
Your other medications otherwise remained unchanged. Again,
it was a pleasure and we wish you quick recovery and good
health.
Your ___ Team | ___ h/o HTN/HLD, DM2 c/b neuropathy, CAD, PVD, s/p bilateral
TKR, sciatica presenting with left ___ pain after a fall.
# Mechanical fall
# Left ___ pain:
Ms. ___ presented w/ left ___ pain after a mechanical
fall. The mechanical fall was considered multifactorial in
etiology: deconditioning and sensory deficits related to PVD and
DM neuropathy (less likely myopathy). There were no signs of
orthostatic hypotension. TSH was near normal (mildly elevated -
no significantly abnormal enough to warrant treatment). ___
plain films here did not reveal any fracture or disloaction.
There was no clear signs of ___ instability on exam or during
physical therapy.
She was placed on fall precautions. Pain was controlled
with Tylenol. ___ was consulted and recommended transfer to STR
for general strengthening - with the ultimate goal of optimizing
strength/functionality in order to be able to go home and live
independently.
# RLS
Ms. ___ described restless leg symptoms. Ferritin levels
were normal, suggesting that Fe deficiency was not the cause.
She was initiated on Praxipexole with good response. She
described no longer having RLS symptoms (both during the day and
night).
# Hyperparathyroidism:
Her labs revealed mildly elevated Ca ___, alb 4.0. She has
h/o hypercalcemia with known hyperparathyroidism and has
previously discussed parathyroidectomy but declined. There were
no signs of related complications now (no significant
constipation, nephrolithiasis, mental status changes, etc..).
Vit D levels were low. As a result, Vit D was restarted with
aims of decreasing PTH levels. It is recommend that the Ca be
monitored while on Vit D. If the calcium becomes elevated with
the Vit D, she may be a candidate for another alternative: e.g.,
Cinacalcet to address the hyperparathyroidism. She was
continued on MgOxide | 235 | 311 |
13280235-DS-24 | 26,644,444 | Ms ___
___ was a pleasure taking care of you. As you know, we found that
you had a urinary tract infection and discharged you on
antibiotics.
We fully support your decision to go home with hospice, and are
proud of you for making such a courageous decision. We are glad
that you will get to spend time with your wonderful family.
We wish you the best. | ___ PMH of Refractory epilepsy (s/p vagal nerve stimulator
implant), metastatic colon cancer (on FOLFOX), who presented
with seizures after being unable to take AEDs from
chemotherapy-related mucositis, who had resolution of seizures
and improving mucositis, with hospital course c/b CAUTI and was
eventually discharged home on hospice.
# Fever, dysuria
# CAUTI
Suspect CAUTI in setting of pyuria, dysuria and improvement in
sx w/ Abx. Despite appropriate Abx (cefepime->ceftaz) urine
culture colony count increased on subsequent samples. Possibly
___ insufficient time on Abx as fever had finally resolved. Pt
was then
found to grow enterococcus in most recent sample so Vancomycin
restarted ___. Given transition to home with hospice patient
was prescribed augmentin/cipro for 5 day course to complete
treatment for CAUTI.
# Seizures in s/o not taking AED
# Refractory epilepsy s/p vagal nerve stimulator
As with prior admission, she had multiple seizures in the
setting of missing her oral AEDs (per her report on admission)
due to mucositis. However, she reported to neurology she did not
miss meds, so her seizures may have been typical breakthrough
seizures for her. Patient was continued on home regimen to good
effect and did not seize further during stay. As per neurology,
patient was discharged with prescription for 0.5mg Klonopin
disintegrating tab, that can be used to bridge patient if she is
unable to take PO AEDs due to mucositis.
# Chemotherapy related mucositis
Mucositis improved with time, but remained significant on
discharge. Patient had improvement in symptoms with Maalox, so
it was continued on discharge.
# Oral candidiasis:
Patient completed 7 day course of clotimazole during stay
# Anemia, chemo, malignancy related
# Thrombocytopenia
Developed ___. Had not received oxaliplatin in over a month
due to concerns for thrombocytopenia. Neuro felt unlikely to be
from AEDs. Wonder if due to malnutrition, myelosuppression from
malignancy + some contribution from hepatic dysfunction
(metastatic liver burden). Acute drop during this admission
likely happened ___ further BM stress in setting of acute
infection. No evidence of hemolysis or consumption. Patient
required
intermittent plt/pRBC transfusion during stay before she
ultimately elected for home with hospice.
# Metastatic colon cancer on FOLFOX
S/p C6 on ___ followed by Neulasta. Given overall decline and
multiple hospitalizations ___ complication of malignancy,
chemotherapy, and deconditioned state, Dr ___ met with
family and noted that chemotherapy would no longer be offered as
it would likely further worsen patient's state. She then
recommended hospice and patient/family agreed. Family already
had home equipment, and home hospice ___ was set up. Patient was
given prescription for new medications which were delivered
bedside.
I personally spent 65 minutes preparing discharge paperwork,
educating patient/family, answering questions, and coordinating
care with outpatient providers
___: Long/short acting opiates were needed for
malignancy associated pain as non-narcotic medications were not
potent enough to control symptoms. No new prescriptions were
needed as patient's family had enough from prior discharge at
home.
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. | 66 | 533 |
14412499-DS-20 | 23,257,407 | Dear Ms. ___,
It was a pleasure caring for you at ___. You came for further
evaluation of shortness of breath. Further evaluation showed
that you had fluid between your lungs and the chest wall, as you
have had before. This fluid was taken out. You also had a
headache which was treated with pain medications. Imaging of
your head showed no reason for your headache. It is important
that you follow up with your scheduled appointments and continue
to take your medications as prescribed.
The following changes were made to your medications:
We INCREASED your dose of furosemide, to better control your
fluid balance | ___ y.o female with PMHx of chronic hepatitis C(genotype
1/nonresponder to treatment) complicated by cirrhosis and HCC.
Cirrhosis has been complicated by ascites, hepatoma, portal
hypertension and history of variceal bleed several years ago,
hepatocellular carcinoma(status post RFA x2), recurrent right
pleural effusion s/p thoracentesis x3 who presents with
recurrent dyspnea
Active Issues:
#Hepatic Hydrothorax: Patient presented with SOB and a history
of necessitating multiple thoracentesis for hepatic hydrothorax.
On chest xray, she was seen to have a right sided pleural
effusion. Thoracentesis was performed and her breathing
improved. Follow up chest xray showed resolution of the pleural
effusion. Lasix and Spironolactone were increased to try to
prevent subsequent hydrothorax to 160mg and 300mg respectively.
As an outpatient, TIPS should be considered if she continues to
re-accumulate effusions.
#Migrainous Headaches: Patient reports having headaches for a
few days that encompass her whole head and go down the back of
her neck. These also have caused her to have nausea and
dizziness. CT was negative for an acute process, but given
family hx of multiple members with serious intracranial
processses and a sister who required neurosurgery, MRI with and
without contrast of the head and neck was performed. No
intracranial process was seen and patients headache resolved
with Tylenol. | 108 | 213 |
12227694-DS-8 | 25,363,599 | Dear Ms. ___,
You were admitted to the hospital because of belly pain and
nausea. We ordered a CT scan, which showed inflammation of your
esophagus. We started you on a medication (omeprazole) which
should help with your condition, and set you up with an
appointment to see a gastroenterologist. They may recommend
further tests and treatments as an outpatient.
It was a pleasure taking care of you.
Very best wishes,
Your ___ care team | ___ is a ___ yo woman with history of Down's syndrome,
VSD, GERD, and Alzheimer's dementia who presented with
epigastric abdominal pain, nausea and vomiting.
# Epigastric Pain: Most likely esophagitis given history of GERD
and findings on CT. ___ need EGD as outpatient to rule out
neoplastic process and better characterize esophagitis. She had
an EGD in ___ which was normal, but biopsies at the GE junction
showed chronic esophagitis. She was reportedly taking an OTC PPI
at that time. Symptoms are unlikely to be cardiac in origin
given negative biomarkers, ST elevations seen on prior exam
without reciprocal or other acute ischemic changes. We started
her on omeprazole 40 mg daily, and she was able to eat without
vomiting or nausea. She should follow up with GI as an
outpatient.
# Alzheimer's Disease: We continued home risperidone
TRANSITIONAL ISSUES
- We have made an appointment for her to see GI as an outpatient | 72 | 152 |
12697173-DS-15 | 25,925,192 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted after you passed out while driving and
experienced chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We checked cardiac enzymes and it was negative for heart
attack.
- Your pacemaker was checked by a cardiologist and it did not
show any abnormal heart rhythms.
- You had a cardiac catheterization ___ and it showed no
coronary blockages.
- Please follow up with your cardiologist next week as scheduled
(details below)
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications as prescribed (listed below).
- Follow up with your doctors as listed below
- Please do NOT drive until you follow up with Dr. ___
___ was a pleasure participating in your care.
If you have any urgent questions that are related to your
recovery from your hospitalization or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, you may call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
-Your ___ Care Team | =====Attending Addendum======
___ year old female with CHB s/p dual chamber PPM, IDDM,
hypertension, and atypical chest pain who was admitted after a
syncopal event while driving and chest pain. Interrogation of
PPM here revealed no arrhythmia during event. Cardiac biomarkers
were flat, with no ischemic changes on EKG. TTE was normal.
Stress SPECT showed partially reversible infero-apical defect,
with drop in LVEF during stress. Given this concerning high risk
feature, she was taken for coronary angiogram which demonstrated
no obstructive CAD. Unclear if her syncopal spell was related to
a vasovagal event. She was discharged on her home medication
regimen, and will not drive until she follow-up with Dr. ___
___ week.
================================
#Syncope
#CHB s/p dual chamber PPM
#Atypical chest pain
Patient reports syncopal event of unknown duration without
preceding symptoms or aura. She denies history of seizure. She
had a prior syncopal event prior to receiving PPM that was
reportedly likely ___ to CHB. She was not feeling hypoglycemic
prior to event. Her PPM was interrogated in the ED without signs
of arrhythmia. She had a TTE which did not demonstrate any
structural heart disease or valvular abnormality. She did not
have any acute lab abnormality on presentation to the ED and
glucose was in the 200s as well. She does not describe twisting
her neck to suggest carotid sinus sensitivity. She was admitted
and monitored on telemetry revealing no arrhythmias. She had a
p-MIBI ___ revealing partial reversible inferolateral
defect. On ___ coronary angiogram via right radial showed
no significant coronary artery disease. It is possible she had
some
excess vagal tone, although she does not describe preceding
event. Patient has been asymptomatic since syncopal episode. She
denies any further episodes of lightheadedness, dizziness. Given
negative cardiac work up to date, we will discharge her home
with close cardiology follow up. No need for event monitor as
she has a device.
- Follow up with Dr. ___ ___ 09:00a
- Restrictions: No driving until she follows up with Dr. ___
on the above date
___ year old female with CHB s/p dual chamber PPM, IDDM,
hypertension, and atypical chest pain who presented after
syncopal events and with chest pain.
#Syncope
#CHB s/p dual chamber PPM
#Atypical chest pain
Patient reports syncopal event of unknown duration without
preceding symptoms or aura. She denies history of seizure. She
had a prior syncopal event prior to receiving PPM that was
reportedly likely ___ to CHB. She was not feeling hypoglycemic
prior to event. Her PPM was interrogated in the ED without signs
of arrhythmia. She had a TTE which did not demonstrate any
structural heart disease or valvular abnormality. She did not
have any acute lab abnormality on presentation to the ED and
glucose was in the 200s as well. She does not describe twisting
her neck to suggest carotid sinus sensitivity. She was admitted
and monitored on telemetry revealing no arrhythmias. She had a
p-MIBI ___ revealing partial reversible inferolateral
defect. On ___ coronary angiogram via right radial showed
no significant coronary artery disease. It is possible she had
some
excess vagal tone, although she does not describe preceding
event. Patient has been asymptomatic since syncopal episode. She
denies any further episodes of lightheadedness, dizziness. Given
negative cardiac work up to date, we will discharge her home
with close cardiology follow up. No need for event monitor as
she has a device.
- Follow up with Dr. ___ ___ 09:00a
- Restrictions: No driving until she follows up with Dr. ___
on the above date
================
CHRONIC ISSUES:
================
#IDDM
Patient is on detemir 30u BID and Humalog ___ TID prn. Most
recent A1C 8.9% on ___.
-Continue home detemir/Humalog regimen
-Will hold metformin X48hs s/p contrast exposure, resume
___
#HTN
-continue home amlodipine, chlorthalidone, Lisinopril, and
metoprolol succinate
#Hyperlipidemia
Most recent lipid studies ___ with good control- chol 100,
LDL 29, HDL 53, trig 90
-continue home atorvastatin 20 qhs
#Asthma
-continue albuterol prn and Flovent prn | 217 | 619 |
13697954-DS-9 | 28,818,808 | Dear Ms. ___,
It was a pleasure to care for you here at ___ ___
___. You were admitted on ___ for pneumonia.
You were treated with antibiotics, which you will need to
continue after you are discharged till ___.
Again, it was great to meet and care for you. We wish you all
the best.
-Your ___ team | PRIMARY REASON FOR HOSPITALIZATION:
==============================================
___ woman with a history of fibromyalgia who was brought
to ___ with hypoglycemia and sister's concern for
AMS/poor self-care. She was found to have a diffuse pneumonia,
with initial hypoxemia, improved with antibiotics. | 56 | 37 |
18657942-DS-20 | 28,574,381 | Dear Ms. ___,
.
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
Abdominal instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol) regularly for the first few days
post-operatively, and use the narcotic as needed. As you start
to feel better and need less medication, you should
decrease/stop the narcotic first.
* Take a stool softener to prevent constipation. You were
prescribed Colace. Do NOT use miralax or a bowel stimulant for
constipation. Please call Dr. ___ if you have
constipation concerns since you had a bowel surgery
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
*** Lovenox injections:
* Patients having surgery for cancer have risk of developing
blood clots after surgery. This risk is highest in the first
four weeks after surgery. You will be discharged with a daily
Lovenox (blood thinning) medication. This is a preventive dose
of medication to decrease your risk of a forming a blood clot. A
visiting nurse ___ assist you in administering these
injections.
*** Wound Vacuum Care
* A nurse will be coming to your home initially to help with
wound vacuum changes.
***Wound cellulitis
* You developed an infection of your abdominal wound and your
staples were removed. You were taking antibiotics in the
hospital for this infection. Please complete the remainder of
the course of your antibiotics called ciprofloxacin. It is very
important that you take all of the antibiotic pills as
prescribed and that you do not miss any doses. Please monitor
and call ___ if you notice increased redness, pain,
swelling, yellow discharge, or bleeding from the incision. Call
your doctor if you notice a temperatute >100.4, fever, chills,
nausea, vomiting. | Ms. ___ was admitted to the gynecologic oncology service for
management of a small bowel obstruction. Please see the
operative report for full details.
*) Small bowel obstruction: She presented with worsening nausea
and vomiting, absent bowel sounds, and afebrile. CBC and
electrolytes were normal. Imaging was suggestive of a malignant
small bowel obstruction. A nasogastric tube was placed in the ED
to monitor output, and she was made NPO with IV fluids running
and given reglan for nausea. Her pain was controlled with IV
morphine and tylenol. Daily CBC and electrolytes were collected.
However, by hospital day 4, she continued to complain of severe
pain and no return of bowel function. Her NGT was repositioned
and confirmed by chest x ray. Abdominal x ray obtained showed
persistent small bowel obstruction, so patient was given 24hrs
of IV flagyl and ancef and taken to the OR for an exploratory
laparotomy, ileocecectomy, and side to side anastomosis on
hospital day 5. A 4 cm tumor was found to be obstructing the
distal ileum 7 cm from the ileocecal valve and a 1 cm tumor in
the midline rectus sheath above the umbilicus. Postoperatively
her pain was controlled with a dilaudid PCA, transabdominal
block, and IV acetaminophen. She was kept NPO with her
nasogastric tube in place. She continued to do well and her
nasogastric tube was clamped. She produced 0 ml of fluid during
the clamp trial, so her nasogastric tube was removed on
postoperative day 4. Given that she was having difficulty with
obtaining adequate caloric intake, the Nutrition team was
consulted who suggested TPN. Ms. ___ refused TPN, but she did
agree to receive PPN. She received PPN for 7 days and her diet
was advanced as tolerated.
*) Wound cellulitis: She began developing an incisional erythema
on postoperative day 5. The erythema continued to worsen with
some purulent drainage. She was started on Keflex for concern of
wound infection on postoperative day 6. Her wound was explored
that day with removal of staples and expressing of purulent
drainage. It was debrided and found that the fascia was still
intact with no evidence of necrosis. Wound cultures were sent,
and the wound was packed with wet to dry packing. Wound ostomy
team was consult and decision was made to completely open the
wound and have a wound vacuum placed on postoperative day 8 .
Wound cultures were growing gram negative rods, so she was
started on Unasyn and Vanc. Wound cultures speciated with
klebsiella. she was transitioned to po ciprofloxacin and sent
home with remainder course of antibiotics. Her wound dressing
was changed day of discharge and she was sent home with a wound
vacuum to be placed by home ___ nurse the next day.
*) Postoperative fever: She developed a temperatute of 100.8 on
posteoperative day 2. She was also tachycardic to 115. She was
asymptomatic at the time with a reassuring exa. Blood cultures,
urine cultures, CBC with diff were ordered. CTA from day prior
was negative for a PE. Her fever defervesced the same day.
*) Oliguria secondary to under resuscitation: She was noted to
have low urine output after her surgery. Her creatinine peaked
to 1.4. She was given several boluses of IV fluids. Urine
electorytes were measured and her FeNA was 0.1 making a prerenal
dehydration state the likely cause of her oliguria. Her
creatinine downtrended back to baseline of 1.1
*) Tachycardia: On postoperative day 1, she became tachycardic
with a heart rate between ___ along with an O2 saturation
of 90%. All other vitals were stable. An ECG showed sinus
tachycardia with a rate of 111. CBC was unconcerning for a
falling hematocrit. She continued to receive fluid boluses and
was also given albumin for additional intravascular repletion.
Despite these measures, her tachycardia persisted. A chest CT
was ordered which was negative for a pulmonary embolism but did
show small bilateral pleural effusions and atelectasis. Her
tachycardia resolved without further intervention.
*) Deconditioning: Given patient was NPO and admitted to the
hospital for several days, she was having difficulty with
ambulation. Physical therapy was consulted for recommendations.
They suggested she follow up home ___ and she went home with a
rolling walker.
*) DVT prophylaxis: She received lovenox daily while inpatient.
Her lovenox was held on day of surgery (hospital day 5) and she
was given subcutaneous heparin that morning. | 464 | 734 |
19932242-DS-27 | 20,351,538 | Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with shortness of breath. We
believe this was caused by your lung disease or your heart
disease. We treated you with steroids, antibiotics, and inhaled
medications, as well as some water pills to remove fluid from
your lungs. After these treatments, your symptoms improved.
After discharge, please continue to take your new inhalers as
prescribed. Please continue lasix, your water pill. Please
monitor your weight. You can weight yourself every morning and
call your doctor if your weight increases more than 3 pounds.
Please continue to take your antibiotics, levofloxacin through
___. Please take one additional dose of prednisone 20mg on
___. Please follow up with your oncologist for further
management of your breathing and multiple myeloma.
We wish you the best!
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ male with PMH of CAD s/p DES to RCA ___, CHF
(EF ___ 40-50%), COPD, multiple myeloma who presents from
clinic with dyspnea concerning for CHF vs. COPD exacerbation.
# COPD vs. CHF exacerbation: Pt presented to ___ clinic
with dyspnea. He was found to have marked wheezing on physical
exam. The patient was evaluated with labs, which were remarkable
for elevated BNP greater than baseline. CXR showed mild to
moderate pulmonary edema. The patient was thought to have COPD
vs. CHF exacerbation. He was treated with BiPAP, quickly weaned
to room air. He was given duonebs, prednisone, levofloxacin and
IV furosemide with improvement in symptoms. The patient was
treated with a prednisone taper, which he will finish ___ (one
additional dose prednisone 20mg PO). He was treated with
levofloxacin 500mg PO q48hrs, which he will continue through
___. His home COPD regimen was adjusted, started on
Fluticasone-Salmeterol Diskus (100/50) 1 inhalation BID and
Tiotropium Bromide 1 cap inhaled daily. His Fluticasone
Propionate 110mcg 2puff inhaled BID was discontinued at
discharge. The patient was started on furosemide 40mg PO qday
for volume management and management of intermittent
hypercalcemia. The patient will f/u with his outpatient
oncologist for further evaluation. Furosemide and
fluticasone-salmeterol can be increased, if needed as
outpatient. ___ consider increased diuretic with platelet or RBC
transfusion.
# Coagulase negative staph positive blood culture x1: The
patient was found to have coag negative staph in ___ blood
cultures. Further blood cultures were pending at the time of
discharge. The patient was treated empirically with 1 dose of IV
vancomycin, which was discontinued as the positive blood culture
was thought to represent contamination.
# Diarrhea: The patient had some episodes of diarrhea on
admission. He was found to be C diff negative and his diarrhea
resolved.
# Multiple Myeloma: The patient has a history of multiple
myeloma for which has declined further treatment per family
meeting during the patient's last hospital admission. The
patient was continued on his home acyclovir, allopurinol,
multivitamin. The patient's calcitonin nasal spray was held, per
previous report from outpatient provider. The patient's calcium
remained within normal limits during admission. He was started
on furosemide as above. The patient should f/u with his
outpatient oncologist for further management.
# CAD: The patient was restarted on his home lovastatin on
discharge. The patient should f/u with outpatient providers to
consider discontinuing this medication given goals of care.
# Hypertriglyceridemia: The patient's fenofibrate was held at
discharge due to concern regarding the risk of rhabdomyolysis in
the setting of concurrent statin use and worsening kidney
disease.
# Acute on chronic kidney disease: The patient had Cr of 3.0
elevated from previously baseline 2.5-2.8 after IV diuresis. The
patient was evaluated with urine lytes which showed FENa 9.0% in
the setting of IV furosemide therapy. Cr trended down to 2.8
upon discharge. The patient was continued on his home sodium
bicarbonate.
# Anxiety, depression: continued home escitalopram, pt will
restart home lorazepam at discharge.
# Hypertension: continued home metoprolol
# Neuropathic pain: continued home gabapentin
# BPH: continued home tamsulosin
# GI: continued ranitidine, omeprazole, simethicone
Transitional Issues:
- Continue levofloxacin 500mg PO q48hrs through ___
- Continue prednisone taper, one additional dose 20mg PO x1
___
- Pt should f/u with heme/onc for further management of
intermittent hypercalcemia
- Pt should f/u for further management of Lasix dosing and
volume status. ___ titrate up Lasix as needed. Consider
increased doses vs. IV diuresis with blood/platelet transfusions
- continue to monitor COPD, consider uptitration of advair as
needed
# CODE: DNR/DNR (confirmed w/pt) okay with ICU and okay with
BiPAP
# EMERGENCY CONTACT: ___ (cousin) ___ | 147 | 611 |
14550410-DS-7 | 29,968,578 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB RLE
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 may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R ankle fx, 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
NWB in the right lower extremity, and will be discharged on
aspirin for DVT prophylaxis. 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. | 266 | 245 |
16753323-DS-13 | 24,301,900 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for diabetic ketoacidosis and pancreatitis. This was the result
of missing doses of insulin. We treated you with insulin and
were able to better control your blood sugar. It is important
that you continue taking your insulin regularly. Please contact
the ___ to establish follow up within one
week.
We treated your pancreatitis with bowel rest and IV fluids,you
slowly improved and were eating normally prior to discharge.
While you were here, you also spoke to a psychiatrist who was
able to help coordinate with your outpatient psychiatrist to
help you get additional therapy and home nursing care. Please
follow up with your psychiatrist for further management.
MEDICATION CHANGES
CHANGE Lantus to 30 units at bedtime
Please continue taking all other medications as previously
prescribed. | Ms ___ is a ___ with h/o DMI who presented with acute
pancreatitis and DKA.
# DKA: Patient reported poor control of her diabetes and
non-compliance with her insulin regimen in an attempt to control
her weight. She presented with nausea, vomiting, abdominal pain
and found to have blood glucose of 433 and anion gap 26. She was
treated initially with an insulin drip, then transitioned to
insulin glargine and short acting sliding scale insulin with
improved blood glucose control and normalization of AG. The
patient was evaluated by the ___ with whom
she will follow up upon discharge. Psychiatry was consulted for
assessment of eating disorder, following this the patient agreed
to take her long acting inulin at bedtime.
#: Pancreatitis:
Patient with multiple hospitalizations for acute pancreatitis in
setting of DKA. Patient was recently discharged from ___
___ with acute pancreatitis. She presented with
nausea, vomiting and abdominal pain and found to have elevated
lipase. Patient denied h/o ETOH abuse, RUQ ultrasound was
negative for biliary pathology and triglycerides were WNL. Acute
pancreatitis was ultimately felt to be consistent with previous
episodes which occurred in setting of poor DM control and DKA.
She was treated with bowel rest, IV fluids and analgesics. She
recovered quickly and was tolerating regular diet without
abdominal pain prior to discharge.
# Psychiatric Disorder
Psychiatry was consulted out of concern for eating disorder as
patient reported restricting her insulin in an attempt to
control her weight, despite recognizing the consequences to her
health. Her presentation was in fact felt to be consistent with
diabulemia. In addition, psychiatry uncovered concerns for PTSD
and panic attacks. While the patient was being followed by a
psychiatrist in the community, it was felt that she was in need
of additional support. Her outpatient psychiatrist was
contacted, and follow up established. Arrangements were made for
weekly therapy and home visiting nurse.
#: Depression/Biopolar d/o:
There was initially some concern that Trileptal could contribute
to pancreatitis, however, rare adverse effect and ultimately not
felt to be cause of depression. Home medications resumed upon
discharge.
#: Neuropathy:
There was initially concern that Lyrica could contribute to
pancreatitis, however, ultimately not felt to be contributing
and resumed upon discharge.
#: Hyperlipidemia:
Continued simvastatin.
#: ___ edema:
Continued furosemide.
#: Recurrent Headaches
Propranolol initially held, but restarted upon leaving ICU. | 134 | 391 |
14219654-DS-21 | 23,339,760 | Dear Mr. ___,
You were admitted to ___ with
abdominal pain and were found on CT scan to have a bowel
obstruction caused by an internal hernia. You were taken to the
operating room and had the twisted piece of intestine removed.
You later had a complication where your abdominal muscle wall
opened and you were urgently taken back to the operating room.
You were monitored in the intensive care unit and were then
transferred to the floor when stable.
You are now doing better, are tolerating a regular diet, and are
ready to be discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Mr. ___ was admitted to the floor on ___ following
Exploratory laparotomy, lysis of adhesions, reduction of
internal hernia, right hemicolectomy
with primary anastomosis and closure of mesenteric defect. For
full details of the operation, please see operative report.
Floor course ___
Following the above operation, the patient's foley was removed
on POD1 and he was voiding spontaneously. On POD 2 he went into
atrial fibrillation with RVR requiring IV metoprolol. On POD 3,
he became delirious and agitated, pulling out his lines and
requiring IM Haldol. He was started on a CIWA scale for concern
for alcohol withdrawal and did receive Ativan. Later that same
day, his PCA was discontinued due to concern that it was
contributing to altered mental status. He also had an increased
O2 requirement with CXR showing vascular congestion. A lower
extremity ultrasound was negative for DVT. On POD 5, his eliquis
was restarted and he was weaned to RA. He tolerated a regular
diet. The following day, however he became more distended and
his abdomen was tender on exam. He was found to have a
leukocytosis of 12.6. On POD 7 he was found to have wound
dehiscence with evisceration and was taken to the OR. For
details of the operation please see operative report.
ICU course ___
The patient was transferred to the ICU on ___ after
exploratory laparotomy, abdominal washout, ileocecectomy and
ABThera placement for fascial dehiscence and anastomotic leak.
He remained intubated in anticipation of returning to the OR for
closure. He remained off pressors with stable vital signs,
minimal ventilation setting and adequate urine output. His labs
were checked routinely showing leukocytosis. There was no
concern for bleeding. On exam, his abdomen remained soft and
ABThera output was serous. On ___, the patient underwent
re-exploration of the abdomen, abdominal washout, ileocolic
reanastomosis, and ___ patch placement. For full details of
this procedure, please refer to the separately dictated
operative report. He appeared to tolerate the procedure well,
and was transferred back to the ICU for monitoring, still
intubated. He was able to stay off pressors overnight; however,
did have agitation that required IV Haldol to control. His wound
vac was putting out just clear serosanguinous fluid. On
___, he was taken back to the operating room for washout
and tightening of the ___ patch. During his ICU course, he
was in atrial fibrillation with elevated rates requiring a
diltiazem drip which was converted to PO on ___. On ___, he
was again taken to the ___ for Abdominal washout and Excision
___ Patch, Incisional debridement of fat and fascia,
Secondary closure of abdomen, and VAC placement 30x7 cm. He was
started on TPN for nutritional support. His wound vac was
changed ___. He was transferred to the floor on ___.
Floor course ___-
On ___ the patient was tolerating regular diet and his TPN was
discontinued. He was passing flatus and having bowel movements.
He was seen by ___ who recommended rehab. His wound vac was last
changed on ___.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
out of bed with assist, 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. | 401 | 549 |
11646865-DS-23 | 26,807,714 | Dear Mr. ___,
You were hospitalized due to symptoms of double vision and
question of facial involvement 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. Question of abnormal heart rhythm
2. High cholesterol
We are changing your medications as follows:
1. Please start taking Aspirin 81 mg daily
2. Please start taking Atorvastatin 40mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body | ___ is a ___ right-handed male with a PMhx of
bilateral cataract surgery and left macular degeneration who
presents with acute onset painless opthalmoplegia and vertical
binocular diplopia.
The patient presented to the ___ ED where he was evaluated by
Neurology. His exam was notable for mild hypertension, mild
anisocoria (R>L), and initially had difficulty with left eye
ABDuction on horizontal gaze, which has since improved greatly
since admission. He also reports left facial droop which was not
witnessed in the E.D, but patient states his friends pointed it
out to him. Patient likely suffered a TIA vs. small stroke that
was not seen on MRI. Patient received an echocardiogram which
did not reveal any cardiac source of embolus nor any PFO.
Patient worked with OT for functional evaluation. Patient's risk
factors were tested and were quite stable with HbA1c of 5.1. LDL
returned elevated to 142 and patient was put on a statin
(atorvastatin 40mg) and Advil.
Patient was stable and was discharged with ___ of hearts
monitor for further characterization. He was scheduled with
follow-up with the stroke Attending Physician.
Transitions of care issues:
-Patient to continue taking advil and statin
-Patient to follow up with stroke Neurologist
___/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 142) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A | 279 | 424 |
10129815-DS-22 | 29,313,907 | -Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
*It was a pleasure to have worked with you, and we wish you the
best of health.* | The pt was admitted to psychiatry for worsening depression and
affective destabilization following numerous medical problems
and polypharmacy treatment.
PSYCHIATRIC
#) DEPRESSION | 97 | 21 |
10686617-DS-5 | 29,656,062 | Dear Mr. ___,
Thank you for chosing ___. You were admitted for severe low
back pain. In the ED an MRI of your ___ was done that showed
two disc bulges in the L4-L5-S1 area. There was no concern of
spinal canal damage. Neurology physicians were consulted who
were also not concerned for neurological effects. After
starting pain management we observed significant improvement in
your pain, and your functional capacity. Physical therapists
evaluated you on two days and recommended that you follow up
with a physical therapist in the outpatient setting. On the day
of discharge, you were able to sit, walk, shower and use the
bathroom on your own.
In addition to physical therapy, we recommend that you follow up
with your Primary care doctor, ___, and pain
management specialists. Your primary care doctor ___ coordinate
appointments with the other specialists.
Please make sure to avoid medications like Ibuprofen, Motrin,
Advil that have "NSAIDs" - these medications are commonly use to
relieve pain but can worsen your abdominal symptoms and increase
risk of bleeding.
MEDICATIONS:
START Gabapentin 300mg twice/day
START Tramadol 50mg four times / day (when pain not controlled)
START Lidocaine Patch place on lower back for 24 hours on, 24
hours off
START Tizanidine 2 mg three times / day
START Acetaminophen 500mg four times / day
START Senna 1 tab twice / day (for constipation)
START Colace Docusate Sodium 200 mg twice / day (for
constipation) | Mr. ___ is a ___ w/ no major PMH who heard a pop of the
lower back two weeks ago with associated low back pain, he
continued working for the next week. Comes in ___ after
worsening/unbearable pain, found to have L4-L5-S1 bulge on MRI,
no s/s of compression syndrome. Neuro + Ortho is not concerned
for compression.
.
## BACK PAIN: Significantly improved on day of discharge. No
concerning signs or symtpoms of cord compression, no implication
of cord compromise on MRI. Pain is likely secondary to lower
lumbo-sacral disk bulging, especially considering pt realized a
"pop" a week or two back, w/ worsening back pain w/ movement.
Pt was evaluated by Physical therapy on two subsequent days and
they recommended home outpatient ___.
- Pain was significantly improved with Tizanidine, Gabapentin,
Tylenol, Lidocaine patch and PRN Ultram. Pt did receive 2 doses
of 10mg Oxycodone PO, however, this was discontinued due to
strong sedation response as pt is opioid naive.
- On day of discharge pt was able to shower, ambulate, urinate,
tolerate full PO diet and move bowels on his own. He reported a
___ pain, although he was still not at his functional
baseline, subjectively.
- Pt was informed that he needs to follow up with an Atrius
___ doctor, and pain management specialists. Pt was
instructed to call his Atrius PCP, who was made aware that the
patient needs additional specialist visits. Pt already had a
standing physical rehab appointment for day after discharge.
Pt was instructed to AVOID all NSAIDs give h/o gastritis.
.
## TRANSITIONAL
- F.u with PCP, ___, pain management, ___
- Avoid all NSAIDs, discuss this with patient at every visit | 233 | 282 |
11453260-DS-7 | 22,199,909 | Dear Ms. ___,
You were admitted to ___ for surgical repair of your right hip
fracture. While here, you were also treated for a urinary tract
infection. By discharge, you were able to move your leg and your
urinary tract infection had been treated.
It was a pleasure taking care of you. We wish you all the best. | Ms. ___ is an ___ year old woman with a history of
bilateral total hip arthroplasty, right total knee arthroplasty,
emphysema and chronic obstructive pulmonary disease on three
liters of oxygen at baseline, and a putative diagnosis of left
sided lung cancer status post radiation therapy, who was
admitted to ___ for management of a periprosthetic femur
fracture that she sustained after a mechanical fall at home. | 56 | 69 |
11593651-DS-17 | 26,954,289 | You came to the hospital because your heart was racing. A blood
test showed markers of cardiac damage, so you were put on
medications to treat a heart attack. You were taken for cardiac
catheterization and found to have narrowing of one of your
coronary arteries. A bare metal stent was placed in the Left
Anterior Descending artery to open it and blood flow was
restored. You were started on new medications that will prevent
clotting of the stent and decrease the work load on your heart.
It is absolutely necessary to take these medications every day.
If you do not take these medications as directed, you could have
another heart attack and die.
The following changes were made to your medications:
STARTED lipitor 40mg by mouth daily
STARTED metoprolol 25mg by mouth twice a day
STARTED plavix 75mg by mouth daily
INCREASED aspirin to 325mg by mouth daily
STOPPED Diovan
STOPPED prednisone
STOPPED benadryl
STOPPED simvastatin | Ms. ___ is a ___ with a history of hypertension,
hyperlipidemia, anxiety who presents with an episode of "racing
heart" and was found to have biomarker evidence of NSTEMI.
# NSTEMI/coronary artery disease: Patient initially admitted
with only complaints of tachycardia and not chest pain. Labs
were notable on admission for troponin 0.54, which trended down
during stay, but prompted treatment for NSTEMI with heparin
drip, statin, and aspirin in ED. No Plavix load was given due to
h/o spontaneous SAH. EKG progressed throughout admission from
sinus tachycardia and diffuse PR depressions on admission to
normalized PR segments the morning after admission and then
diffuse T wave inversions 2 days after admission. The latter was
concerning for NSTEMI as opposed to myopericarditis. She was
taken to the cath lab on ___ (3 days after admission) and the
LAD was found to have greater than 70% stenosis in proximal and
mid-LAD. Bare metal stent was placed and flow restored. Femoral
and radial arterial access was obtained (radial site
unsuccessful for PCI), and those access sites remained stable
after procedure without evidence of bleeding or swelling.
Heparin was stopped after PCI. Echocardiography for post-MI LV
assessment after the PCI showed an akinetic apex (new since
___, an EF of 45%, and mild-to-moderate aortic regurgitation.
Her medications were optimized by increasing aspirin dose from
81 mg to 325 mg daily. She was also started on Lipitor 40 mg po
daily (she had been prescribed simvastatin but had been
non-compliant due to concerns over side effects). She was also
started on metoprolol tartrate 25mg po BID which was switched to
metoprolol succinate in discharge. Her valsartan was stopped due
to dizziness when combined with the beta blocker. She can
discuss restarting this with her PCP or cardiologist in the
future due to her decreased LVEF. Physical therapy was consulted
and recommended rehabilitation placement. She was scheduled for
cardiology follow-up in ___ weeks. She was started on Plavix 75
mg po daily for at least 1 month, but should continue for up to
___ year if tolerated. She was strongly recommended to take
Plavix, metoprolol, and aspirin, and informed that the risk of
not doing so (specifically dual anti-platelet therapy) includes
death. Patient stated she understood the consequences of
medication non-compliance.
# UTI: Pt had 22 WBC/hpf on urinalysis on admission, then
endorsed symptoms of suprapubic pain, so she was started on
ceftriaxone 1g IV q24h for 3 days. Urine culture showed only
contamination. Patient has multiple drug allergies but tolerated
the cephalosporin without incident.
# Hypertension: Patient was normotensive throughout admission.
She was started on metoprolol and discontinued valsartan as
above. Pressures stable on this regimen.
# Anxiety: Social work consulted, and she was continued on home
lorazepam PRN.
# Asthma: Continued Flovent, albuterol IH PRN
# Recent allergic reaction: Unclear precipitant; however,
steroids appeared to have contributed to her anxiety (and
possibly to tachycardia) and she had no evidence of rash or lip
swelling on admission, so prednisone was discontinued. She did
not have any recurrence of symptoms. | 153 | 501 |
12569693-DS-4 | 27,011,097 | Care Of The Puncture Site:
- Keep the puncture site clean with water and soap and dry it
carefully.
- You may cover the puncture site with a Band-Aid if you wish.
Activity:
- You may take leisurely walks and slowly increase your activity
at your once pace once you are symptom free at rest. Don't try
to do too much all at once.
- We recommend that you avoid heavy lifting, running, climbing,
and other strenuous exercise until your follow-up.
- Please avoid all activities that increase your risk of head
trauma. No contact sports.
- No driving while taking narcotics or any other sedating
medications.
- If you experienced a seizure, you are not allowed to drive by
law.
Medications:
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Please do not take any blood thinning medications such as
aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin),
etc. until cleared by your neurosurgeon.
What You ___ Experience:
- Mild tenderness and bruising at the puncture site.
- Soreness in your arms from the intravenous lines.
- Mild to moderate headaches that last several days to a few
weeks.
- Fatigue is very normal.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try an over-the-counter
stool softener if needed.
Please Call Your Neurosurgeon At ___ For:
- Fever greater than 101.4 degrees Fahrenheit.
- Severe pain, redness, swelling, or drainage from the puncture
site.
- Severe headaches not adequately relieved with prescribed pain
medications.
- Extreme sleepiness or not being able to stay awake.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
- Nausea or vomiting.
- Seizures.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden severe headaches with no known reason.
- Sudden dizziness, trouble walking, or loss of balance or
coordination.
- Sudden confusion or trouble speaking or understanding.
- Sudden weakness or numbness in the face, arms, or legs. | ___ year old male found to have a brainstem venous varix.
#Brainstem venous varix
The patient was admitted to Neurosurgery for close neurologic
monitoring and continued work-up. He was started on
dexamethasone for cerebral edema. Neurology was consulted and
followed along throughout his admission. An MRI of the head was
obtained, which showed no obvious brain lesion or
cerebrovascular lesion. However, the patient underwent a
diagnostic cerebral angiogram on ___, which revealed a
venous varix within the brainstem. The procedure was
uncomplicated. Please see OMR for further intraprocedural
details. The patient subsequently experienced several episodes
of blurred vision and visual field deficits, which each lasted
only a few minutes before self-resolving. Repeat imaging at this
time was stable. Neurology also evaluated the patient at this
time and stated that the etiology of these episodes was most
likely local irritation of the optic chiasm. The patient had no
further episodes. He continued to be observed and remained
neurologically stable. On ___, he was afebrile with
stable vital signs, mobilizing independently, tolerating a
modified diet, voiding and stooling without difficulty, and his
pain was well controlled with oral pain medications. He was
discharged home with outpatient ___ and outpatient SLP on
___ in stable condition.
#Dysphagia
The patient expressed difficulty swallowing. He was evaluated by
SLP and was approved for a modified diet of ground solids with
nectar prethickened liquids. He underwent a video swallow study,
and his diet was adjusted to ground solids with honey
prethickened liquids. He tolerated this modified diet well and
was educated by SLP on how to maintain this modified diet at
home.
#Disposition
The patient was evaluated by both ___ and OT and was eventually
cleared for discharge home. He was discharged home with
outpatient ___ and outpatient SLP on ___ in stable
condition. | 328 | 294 |
12651711-DS-2 | 26,835,641 | Dear Mr. ___,
It was a pleasure caring for you during your recent admission to
the hospital. You were admitted for fevers, weakness and a
rash. We performed extensive blood tests to evalauate your
fevers and rash. We determined that you did not have any
infection that explained your symptoms. Your blood tests did
reveal extensive inflammation, and along with your nightly
fevers and rash, this was thought to be consistent with Adult
Onset Still's Disease. We started treating you with prednisone
for AOSD. Your fevers stopped and your rash went away. You
should continue to take the prednisone and follow up with your
rheumatologist. Please see below for details. While you are
taking prednisone, you are at a higher risk for high blood
sugars, infection, and bone problems. You should check your
blood sugar using a fingerstick glucometer daily to monitor your
glucose. Losing weight, exercising, and keeping a
low-carbohydrate diet will help. You should also take metformin
daily for your blood sugar elevation. You should take Calcium
and Vitamin D for bone health. You should also start taking
Bactrim to prevent infection. While you were in the hospital,
you also had diarrhea and were positive for an intestinal
bacteria called C. difficile. You were started on oral
vancomycin. You should continue this at home until the 14-day
course is complete. The details of your medications are below.
We wish you a speedy recovery.
Sincerely,
Your medical team at ___ | NEUROLOGY HOSPITAL COURSE
Mr. ___ is a ___ year-old R-handed man with a PMHx of HTN
and HL who presented with 5 days of sore throat, rash, weakness
and paresthesias of his hands and feet, found to have mild CSF
leukocytosis on LP. On general exam he had diffuse myalgias nad
arthralgias and a resolving macular rash affecting his lower
extremities. On neurological exam he was found to have slight
right eye ptosis, with patchy loss of pinprick in the arms and
legs. Initially it was believed that a viral process could
account for sore throat, chills, and rash, which, if spread to
the CSF, could cause the mild pleocytosis seen from his LP.
# NEURO:
- LP with 9 WBC in the setting of >1300 RBC was not convincing
for CNS infection
- Neuromuscular junction disorders and AIDP were initially
entertained but he had minimal weakness and very very supporting
clinical features.
- MRI head w/ and w/out contrast was done which showed no acute
infarct, mass, or infectious pathology
- MRI cervical spine was done to assess underlying cervical disk
disease C4-C6 and there appeared to be no significant
progression of his disease to account for symptoms
- For the possibility of HSV/VZV mild meningoencephalitis
acyclovir 700mg IV TID and droplet precautions. Only HSV had
returned negative at time of transfer
- For possibility of tick-borne illness, lyme coinfection the
following studies were sent and returned negative: anaplasmosis,
babesiosis. ID was consulted and they did not feel strongly
about the possibility of Lyme so ceftriaxone was discontinued
___
- Per Rheum and ID we also checked ANCA, HIV, CMV, CT chest w/wo
to assess for systemic vasculitis, trended ESR/CRP
- Workup: ___ negative, RPR negative. RF, ESR and CRP all
elevated.
- f/u ANCA, trend ESR/CRP
- Inflammatory markers increased
- O2 saturation in the ___ went from 95% on RA to 92% on RA, so
we checked Q6H NIFs and VCs which were normal
-CT chest w/wo contrast to evaluate small vessel vasculitis was
normal.
On ___ Care was transferred to the medicine service for
further evaluation of rash and spiking fevers which continued to
persist nightly to 100-103 despite acyclovir treatment.
Infectious disease was consulted and recommended ferritin
measurements: The following studies were also ordered and found
NEGATIVE: HSV, Lyme serum, RPR, EBV IgM VZV, CNS lyme, HIV, CMV,
Strep pneumo serotypes. C diff antigen returned positive and
the patient was treated with po vancomycin and IV flagyl
initially given elevated WBC and high fevers. The patient
continued to spike fevers to 103 nightly and IV flagyl was
discontinued. The serum ferritin was 8156 on ___ and adult
onset stills disease was suspected. Dermatology was consulted
and biopsied areas of the rash on the back which were read by
the pathologists as consistent with AOSD.
#Adult Onset stills Disease: The patient's ferritin continued to
rise and peaked at ___ on ___, however given concern for
infectious processes steroid were initially held. Rheumatology
and infectious disease were consulted and agreed with initiation
of corticosteroid therapy on ___. The rash slowly faded
and the fevers discontinued 1mg/kg prednisone. The patient was
discharged with instructions to follow up with Rheumatology for
adjustment of steroid dosing.
#C Diff Colitis: Pt was started initially on both PO vanc and
IV flagyl for a planned 2 week course. IV flagyl was
discontinued on ___ and PO vancomycin was continued on
discharge. The patient reports stools were somewhat formed on
discharge.
#Hyperglycemia: After initiation of corticosteroid therapy the
patients FSBG was elevated to the 300s. Pt was started on
metformin 500 BID with instructions to monitor FSBG as an
outpatient. Additional metformin or SSI may be required in the
outpatient setting if continuing high dose corticosteroid
therapy is required.
# Transaminitis: THe patients liver enzymes elevated, and the
etiology of this was initially unclear, although likely
secondary to AOSD. An atypical presentation of hepB or hepC was
considered and serologies for these virueses were negative. His
LFTs trended down at the time of discharge.
#Hypocalcemia. Unclear etiology. Asymptomatic, negative
chovstek's sign. Pt was Rxed calcium and vitamin D to prevent
osteopenia while on prednisone. He has also had hypomagnesemia,
which can decrease PTH sensitivity and worsen hypocalcemia. On
discharge Ca and Mg were within the normal range and he was
discharged on calcium and vit d supplementation.
Chronic Issues
#HTN Patient was continued on home antihypertensives throughout
hospital course.
#HLD: Pt was continued on home simvastatin 10 mg
# Anxiety. This started after his mother's passing and his own
subsequent illness. He is currently not anxious, but in the last
week lorazepam has helped when symptomatic.
-- Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety
Transitional Issues
-He should have repeat LFTs 6 weeks after discharge
-Hyperglycemia may worsen on chronic steroid therapy and FSBG
should be monitored every office visit while on steroids | 242 | 816 |
13435046-DS-5 | 27,509,845 | Dear Ms. ___,
You were admitted to the neurology stroke service given concern
your symptoms of dizziness. You MRI showed that you did not have
a stroke. The dizziness may be related to a transient inner ear
problem.
Please follow-up with your PCP. | Ms. ___ is a ___ woman with HTN and OSA who was
admitted ___ for acute onset vertigo and right arm
heaviness/numbness. Her neurologic examination is mostly
reassuring without focal weakness and no cerebellar findings.
Her CT/CTA was unremarkable. MRI negative for stroke. She was
discharged home with PCP follow up. | 42 | 51 |
17204468-DS-4 | 27,383,326 | It was a pleasure caring for you at the ___.
You were admitted with symptoms of depression and concern for
alcohol withdrawal. You were seen by psychiatry in the emergency
room who did not feel that you were an acute danger to yourself
or others. You were monitored on the medicine service and did
not have signs of acute alcohol withdrawal.
You are damaging your body by drinking excessive amounts of
alcohol. We would encourage you to seek the help necessary to
stop drinking.
Please continue all of your previous medications. We would
encourage you to take a daily multivitamin, which can be bought
over the counter at any drug store. | ___ with several previous admissions for depression and suicidal
ideation, alcohol withdrawl complicated by delirium tremens who
presents in the setting of depression wishing to abstain from
alcohol.
.
Alcohol withdrawl: Patient has signficant history of alcohol
abuse. Last drink was ___. He reports drinking more than 1
liter of hard alcohol per day for several years. He also has had
withdrawl complicated by DTs. Patient received BDZ in the ED but
since admission did not show signs or sequelae of EtOH
withdrawl. Patient did not score on CIWA and labs were also WNL
(LFTs, INR not suggestive of alcoholic hepatitis). Patient met
with social worker multiple times in effort to find patient
inpatient vs outpatient detox site; patient received list of
options and will be in communication with facilities for
accomodation of outpatient assistance. Patient was given
supplemental vitamins. Pt did not display any signs of ETOH
withdrawal while on the medical floor.
Depression: No active SI/HI. Pt was evaluated by psychiatry and
was not sectioned 12. Patient expresses desire to get better.
Patient's TSH wnl and was continued on wellbutrin sr 150mg
daily. He denied SI on day of discharge. He was encouarged to
continue following up with his established mental health
providers affiliated with PCP.
Hypertension currently well controlled HCTZ 25mg, lisinopril
5mg, and prazosin 2mg qhs, which was continued as outpatient.
Health maintenance: cholesterol panel WNL. | 108 | 231 |
11008891-DS-23 | 24,760,288 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for abdominal pain. Your pain
was characteristic of pain from the bile ducts, however, no
gallstones were seen on CT scan or ultrasound. Your pain
subsisded after 3 days. While the cause of your pain remains
unclear at this time, it is possible that you had a small gall
stone which was not seen on our scans, which passed on its own,
resulting in improvement in pain. You should follow up with your
outpatient GI doctor for further evaluation.
You were noted to have low blood sugar in house (with sugar down
to the ___ and ___, so your lanuts dose was decreased from your
home dose of 50 to 27 units of lantus in the morning in the
hospital. Since your diet may be different when you leave the
hospital, it is important that you monitor your morning
fingerstick sugars and increase your insulin dosing slowly if
you notice that your sugar starts to rise again. You will follow
up with your primary doctor who can help with this process.
It is important that you take all medications as prescribed, and
keep all follow up appointments. | Ms. ___ is a ___ ___ with a history of lupus, pancreatic
cancer, status post Whipple approximately ___ years ago who
presenting with right upper quadrant abdominal pain starting at
3 ___ the day prior to admission while folding her laundry.
#Abdominal pain, h/o pancreatic Ca, s/p Whipple and CCY ___ years
ago: Patient presented with RUQ pain, which started at 3PM the
day prior to admission while ___ patient was sitting down doing
laundry. The pain was stabbing, ___, lasting ___ second and
with some radiation to her right shoulder. She reported never
experiencing similar pain before. CT abdomen/pelvis was benign.
CXR benign. Lipase not elevated to suggest chronic pancreatitis.
Lactate wnl, making ischemic colitis unlikely. Abd US was
obtained and did not show any evidence of biliary process,
however, it was a technically difficult study any may have
further been limited by the patient's abnormal anatomy since she
is s/p Whipple procedure and CCY for Pancreatic Ca. Biliary
etiology was suspected given colicky nature of the pain (?
biliary stasis or stone formation in the absence of a gall
bladder). Consideration was given to MRCP but given the
patient's low GFR and ? h/o contrast allergy, it was deferred
for now. ERCP fellow was contact and did not feel ERCP was
indicated. The day of discharge, the patient said her pain had
mostly resolved, and she felt much better. It is possible that
she passed a gall stone which led to resolution of symptoms, but
etiology remained unclear at time of discharge. Pain was
controlled with Tylenol at discharge.
- ___ w PCP
- ___ with GI doctor outpatient, ? MRCP in the future
# Leukocytosis: so clinical signs or symptoms of infection. The
patient was on chronic steroids for her ILD, so this is likely
the etiology of leukocytosis. The patient remained afebrile.
# CRF: creatinine at baseline ___. She got some gentle IVF
on admission. Furosemide and losartan were continued.
# DM2, controlled: The patient was on 50 units of Lantus at
home, and took this the morning of admission. The next morning
she woke up hypoglycemic with sugars in the ___ and ___. She
responded to an amp of dextrose. Her insulin was decreased to 25
Lantus that day with sugars in the 100s and 200s, and increased
to 27 the next day based on insulin requirements.
- uptitrate insulin requirements outpatient (was previously on
50 units, discharged on 27), the patient was on a diabetic diet
in house which may have resulted in better glycemic control here
leading to hypoglycemia
# Asymptomatic bacteriuria: The patient's urine culture was
positive, however, since she was asymptomatic the decision was
made not to treat her urine culture.
- If she becomes symptomatic, would treat with Cipro since the
culture was sensitive to Cipro
# Hypothyroidism: cont levothyroxine
# CV: h/o aortic stenosis, mitral regurg. cont ASA and statin.
# ILD: cont Prednisone and Bactrim
# Lupus: the patient does not endorse any recent change in joint
pain or symptoms, no new rashes. No signs of a current lupus
flare.
TRANSITIONAL ISSUES
- ___ w PCP
- ___ with GI doctor outpatient, ? MRCP in the future
- uptitrate insulin requirements outpatient (was previously on
50 units, discharged on ___), the patient was on a diabetic diet
in house which may have resulted in better glycemic control here
leading to hypoglycemia
- Urine culture was positive, however, the decision was made not
to treat the patient since she had no signs or symptoms of UTI.
If she becomes symptomatic, would treat with Cipro since the
culture was sensitive to Cipro | 200 | 586 |
13662342-DS-3 | 23,802,207 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
due to nausea/vomiting and problems eating and drinking. You had
a CT scan which showed a mass ___ your esophagus. A biopsy was
taken of the mass and consistent with a cancer. You also had
large lung infection ___ your right lung, and we started you on
antibiotics for this. ___ addition, we checked your blood for
signs of tuburcolosis and this was positive for an inactive
infection. We started you on an antibiotic for this as well. A
stent was placed ___ your esophagus to help you swallow
liquids/food. Also a tube was placed ___ your stomach to help
your feeding. You were seen by the radiation oncology team who
started radiation treatment on you which will continue when you
leave the hospital. We also started you on chemotherapy for
treatment of your cancer, and you tolerated this well.
You were found to have a blood clot ___ your lung during your
stay. You were started on coumadin as treatment for the clot.
You also had a gout flare during your stay and received
colchicine and indomethacin as treatment. We also had the
rheumatology service (joint doctors) see you during your stay.
You will have followup with them as an outpatient.
You also had low sodium levels during your stay. We believe your
body is holding onto too much water. The treatment of this is to
limit your free water intake to less than 1.5 liters per day.
Drinks such as gatorade are fine.
MEDICATION CHANGES:
START Guaifensein take ___ by mouth every 6 hours as needed
for cough
START Isoniazid ___ table take one by mouth daily
START Pantoprazole 40mg take one tablet by mouth twice daily
START Aceteminophen syrup take 20ml by mouth every 6 hours as
needed for pain
START oxycodone 5mg as needed for pain
START Clindamycin take 900mg PO every 8 hours - this is ongoing
until told to stop by an Infectious Disease doctor ___
appointment below)
START Zofran 8mg tablet take one tablet by mouth every 8 hours
as needed for nausea
Start Coumadin 2.5mg daily
Start Endomethacin 75mg twice a day for gout flare
Start Colchicine 0.6mg daily for gout flare
You have several followup appointments as shown below.
Thank you for allowing us at the ___ to participate ___ your
care. | Mr. ___ is a ___ year old male with recent diagnosis of esophageal
cancer, gout, who presents with fatigue and lightheadedness
secondary to inability to tolerate POs, transferred to the ICU
for hypotension, with eventual transfer to OMED after
stabilization for continued workup and treatment.
.
# Esophageal fistula: On arrival to ___, patient was
comfortable without complaints. CT torso, CT neck showed
esophageal perforation, active contrast extravasation into
parenchyma of RLL lung, which has multiple loculated fluid
collections including one 11x7x10cm, bilateral simple pleural
effusions, simple fluid ___ the pelvis, also 2x1x1 cm cystic mass
on pancreas. Patient made NPO and transferred to ___
___ for a rigid and flexible bronchoscopy by IP
with therapeutic aspiration of tracheobronchial secretions and
diagnostic upper GI endoscopy without identification of fistula.
He was intubated for the procedure, and subsequently
transferred to ___ post-procedure where he was extubated
without issue. Pt had initially been on vanc/zosyn ___ the FICU
and was narrowed to unasyn ___ MICU ___. While ___ ___
___, microbiology notified team that abscess was growing thin
branching gram + rods concerning for norcardia. ID was
consulted who recommended continuing unasyn and adding high-dose
bactrim for nocardia coverage. Patient was then transferred to
___, ERCP team performed an EGD which showed an extensive
ulcerated mass from 29 cm to 41 cm and narrowed lumen. There was
an opening at 31 cm from the incisors suspicious for the
fistula. A 15cm by 18mm UltraFlex partially covered metal stent
was placed successfully over the wire and barium esophogram
showed showed patency of the stent. Patient was started on a
PPI. His diet as advanced to full liquids and he tolerated this
well. The Bactrim was eventually DC'ed with continuation of
Unasyn. On Day 10 of Unasyn the patient developed a diffuse
morbilliform rash covering the torso and back, non-pruritic,
non-painful and most c/w with a drug reaction. His Unasyn was
changed to Clindamycin.
# Hypotension: Thought to be secondary to hypovolemia from poor
PO intake although sepsis also possibility given given
esophageal fistula and lung abscess. Blood pressure was fluid
responsive ___ the ICU and required no pressors. He was initially
placed on Levofloxacin and CTX. However, given CT chest findings
with concern for necrotic abscess and esophageal perforation,
his abx were broadended initially to Zosyn/Levofloxacin, then to
unasyn/bactrim. Patient was temporarily on pressors during EGD
given sedation and paralysis, but quickly weaned off after
procedure. Since EGD, BP's were stable, low 100's to 90's
systolic.
# Necrotic right lung abscess: CT torso showed a large necrotic
mass with extravasation of oral contrast, suggestive of
esophageal perforation. Pt was made strict NPO. Thoracics
surgery was consulted, who recommended no acute surgery and to
consult IP and ERCP. IP was consulted, and recommended rigid
bronchoscopy. He was transferred across campus for rigid bronch
where the abscess was sampled and grew thin branching GPR's,
suspicious for nocardia. ID was consulted and recommended
empiric IV Bactrim until further data was obtained. Culture from
abscess revealing thin branching G+ rods and G+ cocci ___ pairs
and chains, no nocardia. Bactrim was stopped, unasyn continued.
CXR the day after rigid bronch showed collapsed RLL. After ERCP,
patient was still intubated so prior to extubation, patient
underwent repeat bronch with mucous pluggings removed. Follow up
CXR improved. Patient transferred to OMED on 2L NC satting ___
the mid-90s. On day 10 of unasyn, patient developed diffuse
morbilliform rash on torso and back, c/w with drug reaction.
Unasyn was stopped and patient was transitioned to Clindamycin.
___ addition to this patient had his Quantiferon gold checked
prior to starting his chemo treatment which was positive. ID
recommended starting INH which was started on ___ and patient
will continue to take this with monitoring of LFT's until ___.
Patient is to have repeat imaging on ___ and should
have follow up with ID for eval of progression/resolution of
abscess.
# Acute renal failure: Cr up to 1.4 on admission. Most likely
pre-renal given hypotension, recent inability to tolerate POs.
With fluid resuscitation his creatinine normalized.
# Anemia: Normocytic, likely secondary to chronic
disease/malignancy. He had an initial Hct drop, though thought
___ part to be dilutional given volume rescuscitation. He had no
s/s bleeding.
# Esophageal cancer: Squamous cell carcinoma on pathology from
___ EGD by PCP. This is likely cause of patient's low grade
fevers, dysphagea and possibly his current nausea/vomiting. He
underwent CT neck/chest that showed esophageal-pulmonary fistula
(see above), which has been stented. Patient then underwent a
PET CT for staging which did not show any diffuse metastatic
disease. Rad/Onc was consulted and the patient started rad tx on
___ with a plan for a total of 28 days worth of treatment. ___
addition, patient has been setup with primary oncologist Dr.
___. He started his chemo treatment on ___. ___
anticipation of radiation induced esophagitis, and poor
tolerance to chemo treatment, patient had a CT guided PEG tube
placed by ___ on ___. Nutrition was consulted and patient was
started on nepro TFs boluses. He will continue his rad treatment
as an outpatient.
.
# L Knee Pain: Patient complains of left knee pain for the past
several months. Attributes it to arthritis. On exam patient has
small effusion, no erythema. Patient does have history of gout,
but exam and history is inconsistent with this. Unasysn can
cause increased uric acid levels, but again, patient has had
this problem for several months. Now resolving.
- XRAY ___ no acute fracture
- defer on arthrocentesis given no obvious collection to tap,
will clinically monitor
- tylenol and oxycodone PRN for pain
- uric acid wnl
.
# L Calf Pain: Patient working with ___ today had pain ___ the L
calf and difficulty ambulating
- ___ Negative, will continue to monitor
.
# Latent Tuburculosis: Quantiferon gold positive. ID following.
- Isoniazid ___ QD started ___, will need 9 months until
___.
- Monitor LFT's
To recap, The patient was transferred to the MICU for rigid
bronch on ___ for evaluation of a lung abscess and was started
on IV clindamycin, and back to the FICU for esophageal stent
___ for an esophageal fistula, and then transferred to the OMED
service for further oncologic workup and therapy. The patient
had a G tube placed on ___ by ___. The patient started his
radiation therapy on ___ (planned for a total of 28
treatments). The patient was noted to be anemic Hb 7 so he was
transfused 2 units PRBC's on ___ prior to rad treatment to
increase sensitivity of treatment with appropriate response Hb
7->9. Hemolysis labs were negative. The patient received
cisplatin on ___ and ___ from ___.
The patient had a repeat CT scan of his chest on ___ which
showed improvement of his abscess, ? apiration, and also a LLL
PE. The patient was switched from IV clindamycin to PO
clindamycin on ___. Treatment for the PE was started on ___ with
a lovenox bridge for coumadin. On ___, the patient noted
moderate to severe R knee pain. There was swelling superior and
lateral to his R patella and he was very tender to palpation ___
this area. Later ___ the evening the patient spiked to 101. He
was pancultured and Rheumatology was consulted. Labwork showed
ESR 86 and CRP 117.5. After a joint tap of his knee and fluid
analysis, WBC was found to be 180k w/ 93% polys and negatively
birefringement crystals c/w gout were seen. The patient was
started on indomethacin and vancomycin was added. The patient
also received oxycodone for pain. Colchicine was added for a few
days, and the vancomycin was d/c'ed. Rheumatology was alright
with stopping the vancomycin since no organisms grew from the
joint fluid, and it was likely only a gout flare.
The patient had issues with hyponatremia during his stay. This
was thought to be caused by SIADH. We tried to fluid restrict to
1.5L/day. At the time of discharge his sodium had normalized.
The patient's INR was 2.6 on ___ after 2 doses of 5mg warfarin,
so the ___ and ___ doses were held. The patient was restarted
on coumadin 2.5mg daily on ___ and ___ with a d/c INR of 2.4.
The patient will followup with ID, Rheumatology, Oncology, and
his PCP. Radiation therapy will continue during weekdays until
early ___ (28 days total). He will be scheduled for his second
cycle of chemotherapy ___ two weeks. He will continue his
clindamycin indefinitely until Infectious Disease instructs him
otherwise. He should continue coumadin for at least 6 months
with a goal INR of ___. He will continue getting bolus tube
feeds at home and remain on a full liquid diet. The patient
should restrict his fluid intake to less than 1.5 liters per
day.
Although discharge instructions were discussed extensively with
the patient and the patient's ___ (HCP), there was a
language barrier and their insight into his disease is limited.
Since the patient does not have insurance, he will only receive
2 ___ visits. Extensive instructions were given to the patient
both verbally and written, but it is difficult to know how
compliant the patient and his ___ will be with
medications and attending followup appointments. | 382 | 1,536 |
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