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15951736-DS-19 | 26,063,449 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___! You were admitted for a urinary
retention and ___ abscess. You were seen by the
Colorectal Surgery and Interventional Radiology Team while your
were hospitalized. You were started on a new antibiotic called
Augmentin (Amoxicillin/Clavulanic acid) to treat your abscess
and urinary tract infection. Your abscess was drained by the
Interventional Radiologists. You had several imaging studies
done: an MRI and a CT scan which showed narrowing of your
sigmoid colon. With your family, you had a discussion with Dr.
___ Dr. ___ decided to defer surgery for now. You
are scheduled to see Dr. ___ to discuss future surgical
options and will have a drain study to evaluate the drain(see
appointment below).
You also had urinary retention during your hospitalization. This
is thought to be related to inflammation of your urethra. You
initially have a foley ___ place, however you requested to have
this removed and preferred intermittent straight
catheterization. You can continue with intermittent straight
catheterization and ___ with a urologist (see appointment
below).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Also, your Gleevec was held during your
hospitalization. You can resume this medication upon discharge.
You should schedule an appointment to see Dr. ___ to
___ with him.
Thank you for letting us take part ___ your care,
Your ___ Care Team | Ms. ___ is an ___ year old woman, with past history of CML on
Gleevec, CLL, pAF (not on anticoagulation), HFpEF, CKD, HTN, now
presenting with increased suprapubic pain and dyschezia, with
imaging concerning for rectal abscess now s/p ___ abscess
drainage.
___ abscess: Presented to ___ with several weeks
of suprapubic pain and constipation ___ the setting of recent
cipro treatment for a urinary tract infection. She had a CT
abdomen/pelvis which was concerning for potential abscess vs.
necrotizing mass. She was started on empiric IV cipro/flagyl
coverage and transferred to ___ for further work-up. MRI on
___ was consistent with abscess. She had ___ drainage of
the ___ abscess on ___ purulent fluid w/ pigtail
catheter ___ place. Microbiology showed Streptococcus Anginosus
and Escherichia Coli resistant to cipro, sensitive to
Ampicillin/Sulbactam, thus switched to PO Augmentin 500mg q12h
for total 10 day course (to complete ___. She was seen by the
colorectal surgery team who were concerned for perforation vs.
abscess. She had a CT abdomen/pelvis on ___ to assess need for
subsequent surgery. CT was concerning for stricture given
patient's history and difficulty injecting contrast during CT
scan. She had a flex sig on ___ which showed no definite mass
visualized, no signs of fistula, though unable to pass scope
beyond area of sigmoid narrowing. Dr. ___ Dr. ___
discussed with the patient and her family possible surgical
management. The decision was made to defer surgical management
at this time.
# Complicated UTI/Urinary retention: Patient completed 7-day
course of cipro as an outpatient. She continued to have urinary
symptoms and retention, thus had a foley placed at ___
and she was empirically treated with cipro/flagyl. We removed
her foley on ___. She failed her trial of void (went 14hours
w/o urinating) and there was no sign of urine ___ ___. Foley was
replaced. It is possible that retention is related to urethral
inflammation. Her urine cultures show E. coli resistant to
cipro, sensitive to Augmentin. Augmentin started ___, as above,
to complete total 10 day course on ___. We repeated a voiding
trial on ___ given patient's discomfort with foley. She failed
the trial of void again but expressed preference to continue
with intermittent straight catheterization rather than replacing
the foley. She will continue straight catheterization as needed
until ___ urology appointment.
==============
CHRONIC ISSUES
==============
# Paroxysmal Atrial Fibrillation: We continued her home
amiodarone 200 mg daily. Not on anticoagulation for CHADS2-VASC
score of 5 given history of GI bleeding.
# CML: Patient currently on treatment with Gleevec 200mg qAM
and 100mg qPM. We contacted her outpatient provider, Dr. ___
___, who recommended holding Gleevec for now. She will resume
this medication upon discharge and schedule an appointment to
see him as an outpatient.
# Hyperlipidemia: We continued her home simvastatin
# Insomnia: We continued her home zolpidem 5 mg
# CKD III. Cr 1.2 at discharge.
# HFpEF. No diuresis required on admission. Discharge weight
62.2 kg. | 238 | 495 |
14579724-DS-17 | 25,327,754 | It was a pleasure taking care of you during your stay at ___
___. You were admitted for groin pain
after a fall. You were found to have a small avulsion fracture
of your pelvic bone. No surgical treatment is needed for this
and it will improve with time. Your pain was controlled and you
were able to walk some but are not back to your baseline, so we
have recommended you go to rehab for a few days until you are
safe to return home. | ___ year old man with recurrent metastatic ___ cancer being
treated with Xeloda, admitted after fall for pelvic avulsion
fracture. He was initially monitored in the observation unit but
was unable to walk due to pain so was admitted for further pain
control and ___ evaluation.
1. Pelvic fracture: s/p fall, pelvic avulsion fracture and
muscle edema in adductor. His pain was controlled with standing
tylenol. He required a few doses of oxycodone initially but not
taking much at discharge. He had wound care to skin abrasions.
He was seen by ___ with recommendation for rehab before returning
home.
2. Metastatic ___ cancer: primary oncologist Dr. ___. It
was unclear when he last took Xeloda, so the plan is to hold for
at least 1 week then restart. He should restart it this coming
___ for a new cycle (2wks on, 1 wk off). Pt can
bring his own medications from home and take them while still at
rehab.
3. Urinary retention: likely related to BPH, s/p straight cath
once in ED. had some hematuria during this admission which
resolved. Likely related to catheterization, but if it continues
may need outpt urology appt. he was continued on doxazosin.
4. Possible Aspiration: evaluated by speech and swallow on
admission. Coughing with some food. Continue PO diet of soft
consistency solids and thin liquids. Take medications whole one
at a time with thin liquids or in puree, TID oral care and
aspiration precautions. Recommend speech and language reevaluate
at rehab.
5. Right arm cellulitis: On the day of discharge, pt noted to
have redness, swelling and pain at an old IV site on right arm,
c/w cellulitis. Pt was started of a 5 day course of Diclox. Pt
is documented to have Kelfex allergy.
He was continued on all of his other home medications. | 86 | 303 |
10313172-DS-18 | 27,410,597 | 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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon as advised.
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.
*You have steri-strips, they will fall off on their own. Please
remove any remaining strips ___ days after surgery.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | The patient was admitted to the General Surgical Service on
___ for concern of a closed loop bowel obstruction. Given
his CT scan findings and his tenderness on exam, he was taken
urgently to the OR for an exploratory laparotomy, lysis of
adhesions and enteroenterostomy. The procedure went well without
complication (Please see full Operative Note for details). After
a brief, uneventful stay in the PACU, the patient arrived on the
floor for further care.
Neuro: The patient received a dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The wound was evaluated
daily. He remained afebrile.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
post-gastrectomy diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 293 | 291 |
11187293-DS-21 | 20,051,451 | Dear Ms. ___,
You were admitted to the hospital for gait unsteadiness. We
performed an MRI of your brain which did not show an acute
stroke, We felt that your symptoms were likely due to multiple
factors, including arthritis and possibly decreased sensation in
your feet. We also felt it was probable that you had a TIA, or a
mini-stroke when the blood flow to a certain area of your brain
was transiently diminished. We found a possible abnormality of
one of your blood vessels in the brain, which appeared like a
small tear, which could support this. You also have history of
atrial fibrillation, which could raise the risk of developing a
TIA or stroke. We started you on aspirin to help prevent strokes
in the future.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Care Team | ___ is an ___ year-old right-handed woman with a
history of hypertension, paroxysmal Afib (in ___,
post-operative after hip surgery, not on ASA or Coumadin),
epilepsy (on phenytoin and phenobarbital), gait instability
related to multiple orthopedic procedures, and lumbar spine
stenosis, who initially presented following episodes of veering
to the right with possible posterior circulation TIA in the
setting of a R vertebral artery dissection.
#Neuro: Etiology is multifactorial with TIA and baseline gait
instability as likely contributors. At OSH prior to admission,
___ was negative for acute intracranial bleed and labs were
noted to be within normal limits. At ___, neurologic exam was
negative for focal weakness, sensory deficits to
LT/vibration/temp, or cerebellar findings. The patient was noted
to have a positive Romberg, cautious gait but was able to walk
without assistance. Evaluation at ___ included CTA head and
neck on ___, which showed a possible small dissection flap
along the outer curve of the V2 segment of the R vertebral
artery between C2 and C1 transverse foramina without luminal
narrowing. MRA on ___ was limited due to motion artifact but
was consistent with probable dissection flap in the V2 segment
of right vertebral artery, as seen on postcontrast
time-of-flight MRA of the neck. No aneurysms, stenosis, or
occlusions were noted. MRI neg for acute infarct. CTA revealed a
small dissection flap in the V2 segment of the R vertebral
artery without luminal narrowing.
Given imaging findings, patient's presentation was thought to be
consistent with posterior circulation TIA in the setting of a R
vertebral artery dissection identified on CTA/MRA with possible
embolus to the R cerebellum. Cardioembolic source is possible
given remote history of a transient a-fib following her ___ hip
surgery, but per PCP records, this episode was isolated with
spontaneous conversion to NSR and no additional episodes have
been recorded. The patient was started on ASA 81 mg while
in-house, to be continued at home. Patient's anti-hyptertensive
meds were initially held in house for auto-regulation of BP and
then gradually restarted. Stroke risk factors were assessed:
lipids (Chol 177, Triglyc 121, HDL 62, LDL 91) and HbA1c 5.6.
Other labs included TSH 0.84 and vit B12 284, both within normal
limits.
Other contributor is baseline gait instability due to multiple
orthopedic procedures (bilateral knee replacement, L hip
replacement) and spinal stenosis. Although the patient's AEDs
(phenytoin and phenobarbital) were sub-therapeutic at the time
of admission, seizure was thought to be unlikely given only
remote history of an episode while on current regimen. EEG on
___ was normal.
#ID: This admission, patient endorsed dysuria and urinary
urgency/frequency on ___, raising suspicion for a UTI. Urine
culture negative.
#ONC: CTA ___ showed an 8 mm pulmonary nodule in the apical
right upper lobe and a 6 mm pulmonary nodule versus nodular
pleural/parenchymal thickening in the apical left upper lobe. An
enlarged, heterogeneous thyroid, with multiple nodules,
measuring up to 1.8 cm was also noted. | 142 | 482 |
16056287-DS-14 | 25,771,685 | Dear Mr. ___,
You were admitted to the hospital after you had several days of
chest pain at home. We were concerned about a heart attack but
after checking the heart enzymes in your blood it does not seem
like you had a heart attack. Your chest pain may be due to a
stomach ulcer or irritation, or occur when your heart is beating
fast. You should ask your primary care doctor about getting a
endoscopy which is a procedure where a camera is placed down
your throat to evaluate your stomach.
Additionally, while admitted you complained of a dry cough, some
increased swelling around your ankles and the chest x ray showed
some fluid buildup in your lungs. For this reason, we changed
your lasix dosing to 20mg twice a day.
We attempted to start you on a medicine to better control your
heart rate and treat your heart failure called metoprolol,
however due to your low heart rate this was discontinued.
You should follow up with your cardiologist as to whether an
ablation procedure and pacemaker may help control your heart
rate better and treat your heart failure.
Please follow up with your primary care doctor, your
___ clinic and your cardiologists office at the
appointment dates below. It is very important that you get your
INR checked on ___ to make sure your coumadin level is not
too high.
Please also weigh yourself every morning, and call your MD if
your weight goes up more than 3 lbs.
It was a pleasure taking care of you,
-Your ___ care team- | ___ male with recent renal transplant in ___,
with nonischemic cardiomyopathy, sCHF (LVEF 35%), asymptomatic
atrial flutter with controlled ventricular rate not on any nodal
agents and, recently hospitalized for CHF/PNA at ___ on
___, who presents with atypical chest pain and diarrhea for
three days. C. difficile testing negative as well as stool O&P.
Patient was seen by transplant nephrology while inpatient and
tacrolimus dose was adjusted. Patients diarrhea improving at
time of discharge, with pending CMV VL, and plans for close f/u
by renal transplant team.
#Chest pain: EKG unchanged and troponin unchanged compared to
prior at 0.03 in setting of renal insufficiency. On review of
telemetry, chest pain appears to coincide with episodes of
relative tachycardia in atrial flutter, with rates ___.
Recent nuclear stress test showed no perfusion defects, making
ACS unlikely. Patient given loading dose of ASA and continued on
home aspirin 81 , atorvastatin 80 mg daily, Hydralazine and
isosorbide. Initially added low dose BB, although pt developed
bradycardia. Discussed without outpatient cardiologist; plan to
hold BB and consider PPM placement as outpatient to allow for
adequate rate control. Frequency of chest pain episodes improved
during hospitalization, with infrequent episodes of relative
tachycardia by telemetry.
# Nonischemic cardiomyopathy, sCHF (LVEF 35%): Admission CXR
read as mild congestion, and patient was found to have increased
lower extremity edema around ankles with complaint of dry cough
for the past several days PTA. Lasix was titrated during
admission to achieve euvolemia. increased from 20 mg daily to 20
mg BID.
#Diarrhea - concern for C. diff as patient had recent exposure
to antibiotics for HCAP during last hospitalization (dc ___
c. diff testing was negative as well as stool O&P. A problem
with initial lab sample resulted in delayed CMV viral load
testing; after discussion with renal transplant team, and given
improving diarrhea, plan for f/u CMV viral load as outpatient.
# Atrial flutter: With known atrial flutter with rates in the
60, although as above intermittently up to ___. On
admission, pt not on nodal blockers. Patient was trialed on a
low dose of metoprolol but was not able to tolerate it secondary
to HRs in the ___. Discussed with outpatient cardiologist as
above, plan to consider PPM placement as outpatient. Discharged
off of BB. Coumadin continued as above with goal INR ___.
# Supra therapeutic INR. INR found to be 3.8 on admission.
Coumadin held and restarted at home dose once INR< 3.0
# ESRD s/p ECD Renal Txp ___. On admission patients Cr at
baseline. Tacrolimus found to be therapeutic. Renal transplant
following and adjusted tacrolimus level to 6mg BID. Patient
continued on home immunosuppression: CellCept, tacrolimus, and
prednisone w/atovaquone and vit D, sodium bicarb
# HTN: stable. Patient managed on home regimen Hydralazine 25
TID and Isosorbide Dinitrate 30 TID.
# HL: Cont atorvastatin
# IDDM: Home NPH and HISS
# Gout: stable. Continued home allopurinol
# Code: full (confirmed)
# Emergency Contact: ___ ___
******TRANSITIONAL ISSUES:*********
#Patient may benefit from non-emergent EGD to continue to workup
the chest pain
#Lasix increased to 20mg BID due to increased ___ swelling,
congestion on CXR.
# Attempted to start patient on metoprolol 6.25 BID for atrial
flutter and CHF with EF <35%. However he was persistently
bradycardic to the ___ on telemetry, therefore metoprolol was
discontinued.
# Consider ICD placement in addition to pacemaker placement
given the severity of his heart failure and to optimize his
heart failure and rate management
#Transplant nephrology followed patient while inpatient.
Tacrolimus dosing reduced to 6mg BID on discharge. | 268 | 605 |
11886618-DS-19 | 21,512,565 | Ms. ___,
___ were admitted to ___ for an asthma exacerbation. ___ were
treated with IV steroids and nebulizers around the clock and
additional treatments as needed. We monitored your oxygen
continuously due to drops in your oxygen levels. It was
recommended that ___ not leave the hospital as ___ still
required treatment. We discussed the risks of leaving against
medical advice, including death. ___ decided to leave against
medical advice because of prior commitments. | ___ year old with asthma, tobacco abuse, presenting with asthma
exacerbation.
1. Asthma with hypoxemia and acute exacerbation: Most likely
precipitant is continued use of tobacco. We discussed cessation
at length. Also discussed stopping inhalation of marijuana. She
has had some changes to environment and has chemical exposure at
work. She has no peripheral eosinophilia. Will need PFTs as an
outpatient and possible work-up for GERD, allergies. She was
treated with IV steroids (says the pills never work) for three
days. She had persistent hypoxemia, the lowest to the ___ on RA.
There was concern that she may have taken a non prescribed
medicaion such as an opiate to suppress her respiratory status
as she appeared to be hypoventilating and her sats improved with
deep inspiration. She denied taking any substance.
She ultimately left AMA due to "having to go to work" even
though it was strongly discouraged. She was told of the risks
and she accepted them. She was encouraged to seek medical
attention for any concern. She was provided with a prescription
for prednisone for a longer taper (60mg x5 days, then decrease
by 10mg every two days) to try to continue to treat her
condition if she was refusing hospitalization.
A lot of time was spent on a daily basis during her
hospitalization trying to encourage smoking cessation,
follow-up, work-up and adherence to medications. | 75 | 228 |
13558380-DS-4 | 23,317,749 | Ms. ___,
You were admitted to the hospital for abdominal pain and bloody
diarrhea. Based on your symptoms and history of C Diff
infection, we started you on antibiotics and checked your stool
for evidence of infection. The tests indicated that you did not
have c diff so the GI doctors performed ___ to look
for signs of your ulcerative colitis. Their exam showed
inflammation of your colon which is consistent with a ulcerative
colitis flare and recommended starting you on steroids. They
took biopsies of the inflammed areas and will follow up the
results. You were feeling better and wished to be discharged.
You were eating well, and your symptoms improved. You will be
sent home with prescriptions for oral steroids, and sterdoid
enemas. If you are unable to tolerate the enemas, you may use
the steroid foam instead. Do not use both. We have scheduled
you follow up appointments with your GI doctor and primary care
physician.
As you know, the steroids can make you anxious. We will give
you a prescription for klonopin, but you will need to call your
psychiatrist for a lithium prescription.
Steroid taper instructions: You are to take prednisone 60 mg
daily for 1 week, then 50 mg daily for 1 week, then 40 mg daily
for 1 week. You will continue to decrease by 10 mg each week.
You are being given a prescription for the first 3 weeks of this
medication. Discuss this taper with Dr. ___ on ___ and
obtain further prescriptions from him. | ___ year old female with history of ulcerative colitis and C diff
infection s/p treatment in ___ who was doing well until few
weeks ago who presents with nausea, vomiting, bloody foul
smelling diarrhea, abdominal pain and fevers with decreased
appetite similar to her C. diff infection and not typical for
her UC flares. It is difficult to ascertain whether this is
recurrent C. diff or UC.
#Bloody Diarrhea - Pt currently not on steroids for UC. She was
empirically treated with PO vancomycin and switched to
cipro/flagyl to cover any other GI pathogens. She was given
bowel rest, IVF, main/nausea symptoms to control her symptoms.
Her stool was guiac positive, but her HCT remained stable.
Stool cultures came back negative for C Diff, and IV antibiotics
were discontinued. GI was consulted who performed a
sigmoidoscopy which was consistent with a UC flair. They
recommended BID steroid enemas and systemic steroids to control
the UC flair. Biopsies were taken which GI will follow up. The
patient was feeling better and her diarrhea decreasing and
wished to be discharged on oral steroids. She passed a PO
challenge and was sent home on a course of oral steroids (60 mg
PO prednisone daily for 1 week and decreasing by 10 mg each
week) and hydrocortisone enemas BID per GI's recommendations.
She was also given a RX for hyrdocortisone suppositories to use
if she was unable to tolerate the enemas.
# Depression: Continue wellbutrin and escitalopram
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: Pneumoboots. bowel regimen | 267 | 274 |
14335455-DS-15 | 25,790,558 | Dear Ms. ___,
It was a pleasure caring for you here at ___.
Why you were here:
- You were having weakness and were feeling generally unwell.
- We found that your kidneys were injured and not working, and
that your heart was in an abnormal rhythm called heart block.
What we did:
- Ultimately we talked with you and your son, in combination
with the kidney and heart team. You made clear to us that your
preference was to be as comfortable as possible, and not pursue
aggressive interventions such as dialysis and pacemakers.
- We arranged for you to be sent to a hospice house where the
team will continue to focus on keeping you as comfortable as
possible.
What to do when you leave:
- The hospice team will work with you to keep you as comfortable
as possible.
We wish you and your family the best,
Your care team | Ms ___ is an ___ woman with breast cancer (adenocarcinoma,
elected to not pursue tx in ___, HTN, HLD, hx of colon cancer
(s/p colectomy in ___, who presented with failure to thrive,
and found to have new ___ and complete heart block.
# Goals of Care
# Metastatic Breast Cancer
Ms ___ found to have biopsy-proven adenocarcinoma of the
breast in ___, and at that time she had chosen not to pursue
further management as she felt she had lived a good life and did
not want to have invasive procedures such as surgery or
chemotherapy/radiation. At that time, she endorsed understanding
that she would die from her cancer without treatment, and she
elected not to pursue any treatment.
When she presented to ___ on ___ with acute renal failure
and complete heart block, the ICU team held an extensive goals
of care discussion with her son ___ about Ms. ___
prognosis with untreated malignancy and now multiple severe
medical conditions and complications. Initially Ms ___ was too
altered to participate in goals of care discussions, and her son
was not sure what her wishes would be, and thought that she
might want to attempt dialysis. In this setting, a HD line was
placed and CVVHD was initiated. After ~12 hours of CVVHD, with
clearance of uremia and other non-volative toxins, Ms ___
became more alert, oriented, and was cognitively intact - she
was able to peronally engage in further conversation and clearly
expressed to the ICU team that her desire was to be as
comfortable as possible and avoid any invasive procedures
including dialysis and pacemaker placement. She clearly stated
that her goals of care were to specifically only focus on
comfort oriented care. Her son ___ was present for these
discussions, and he heard her preferences and endorsed
understanding of them.
She and ___ chose to pursue hospice care. The decision was
made to enroll her in inpatient hospice. She was given oral
oxycodone solution, olanzapine disintegrating tablet as needed,
and hyoscyamine as needed for symptom control.
# ___
# Hyperkalemia
On presentation Ms ___ was noted to have a serum creatinine of
4.7, up from 2.9 on ___ and 1.3 in ___. She had been taking
NSAIDS at home, which may have contributed to acute renal
failure, as well hypovolemia from months of poor PO intake. She
had no post-renal etiology on renal US. There was concern that
the uremia and/or hyperkalemia had worsened her underlying
conduction disease and predisposed to heart block. She was
started on CRRT for one night, but ultimately based on the
above-noted goals of care discussion, CVVHD was discontinued.
# Complete Heart Block
# Bradycardia
New heart block was found upon presentation to MICU. She had
been on metoprolol at home, and this was held in the setting of
complete heart block. The Electrophysiology service was
consulted and thought the heart block may have been triggered by
the electrolyte derangements from her renal failure. She had a
reliable and high junctional escape, with adequate mean arterial
pressures (requiring only modest doses of vasopressors), so no
pacing or atropine/dopamine was required per EP's
recommendations. After the above-noted goals of care discussion,
pacemaker and dialysis were not pursued.
# Acute Hypoxemic Respiratory Failure
Hypoxemia was due to pulmonary edema in the setting of renal
failure as above. She was given O2 for comfort once goals of
care changes.
# HTN: home anti-hypertensives were held.
# Lines: Right temp HD line
# Emergency Contact: ___ (son) ___
Transitional issues:
- HD line with VIP port was kept at discharge for administration
of IV medications for comfort as needed.
- MOLST form was filled out.
- Code status: DNR/DNI, comfort-oriented measures only | 153 | 610 |
11076111-DS-3 | 20,264,791 | Dear Mr. ___,
You presented due to symptoms of paroxysmal unsteadiness,
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Age, Diabetes, hyperlipidemia, atherosclerosis.
We are changing your medications as follows:
- Continue taking aspirin 81 mg daily.
- Start clopidogrel (brand name ___ 75 mg a day for 3 weeks.
- We are increasing your atorvastatin from 40 mg to 80 mg daily.
Please take your other medications as prescribed.
You were found to have high blood sugar and poorly controlled
diabetes please ___ with your primary care provider for
ongoing management.
You will also need to obtain a echocardiogram outpatient to
further ___ the cause of your stroke.
You are being discharged with ___ for monitoring for
paroxysmal atrial fibrillation (irregular heart rate) for the
next 4 weeks.
You were found to have mediastinal lymphadenopathy ___
inflammation), that you should follow up with your primary care
provider to determine if further workup is needed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ YO Right handed M with poorly controlled type
1 diabetes, who was admitted for ___ days of paroxysmal gait
unsteadiness with concern for posterior circulation compromise.
He had negative ___ on admission and was not
orthostatic. His exam on admission was normal and he remained
with a stable neurological exam on discharge. He had no cranial
nerve abnormalities or cerebellar signs. His gait was normal
without significant instability with tandem testing and without
Romberg.
Workup included CTA head and neck which demonstrated bilateral
extracranial carotid stenosis ~50%. There is evidence of
intracranial atherosclerotic disease, mostly in the posterior
circulation. He underwent MRI brain which demonstrated 3 mm
acute to early subacute infarct in the body of the right caudate
without associated edema or hemorrhagic transformation. Small
chronic infarct in the right parietal cortex. and other
___ findings. 24 hours of telemetry did not find any
paroxysmal atrial fibrillation.
Stroke risk factor labs demonstrated hemoglobin A1c of 8.7 and
elevated triglycerides with LDL 56. Etiology of his stroke is
most likely small vessel disease versus atheroembolic versus
less likely paroxysmal atrial fibrillation. He notably has left
PCA narrowing that we suspect is chronic and is not in vascular
distribution of his foci of diffusion susceptibility.
To complete the ___, we are ordering an outpatient
echocardiogram. As well as discharging him with a ZIO patch for
4 weeks to look for paroxysmal atrial fibrillation.
We have started him on ___ 75 mg a day for 3 months, he is to
continue his aspirin ongoing, and lastly we have increase his
atorvastatin to 80 mg daily.
Overall we wonder if he may have had unsteadiness related to
small caudate infarct vs incidental finding on MRI. | 346 | 282 |
11000743-DS-21 | 24,317,015 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for shortness of breath, and were found to have an
infection of your lungs from chronic aspiration. You were
treated with IV antibiotics and regular suctioning of oral
secretions, and your breathing improved. Your blood pressure was
also occasionally low, and received IV fluids. You were found to
have seizure activity during this hospitalization, and your home
doses of keppra was increased.
Please start taking the following medications:
1. IV vancomycin 1gm twice a day
2. Piperacillin-Tazobactam 4.5 g IV every 8 hours
3. Albuterol 0.083% Neb Soln every 6 hours as needed for
shortness of breath
4. Ipratropium Bromide Neb every 6 hours as needed for shortness
of breath
Please change the dosing on the following medications:
1. Levetiracetam 1500 mg twice a day
Please continue to take your other medications. | SUMMARY: ___ yo M w/ h/o Down's syndrome, non-verbal at baseline,
hypothyroidism, dysphagia s/p G-tube, h/o aspiration pna's,
hypoNa on 4___ QHS who presents w/ cough and hypoxia from group
home.
# Hypotension: Blood pressure on the floor dropped to 92/50 and
he was transferred to the MICU where his blood pressure
responded to fluid boluses (total 3L). The etiology of his
hypotension is likely secondary to acute infection. On CXR he
has a possible right lobe infiltrate that could represent
infection, pneumonitis or pulmonary edema. He was started on IV
Vanc and Zosyn for coverage of healthcare associated pneumonia
since he lives in a group home. At the time of discharge, his
blood pressure was at baseline (100s/80s) and did not require
pressors.
# Respiratory Distress: Initially hypoxic to 88% at group home.
No evidence of CHF by exam or CXR. No history of CHF in past.
Could be secondary to infiltrate in right lobe that could
represent pneumona, pneumonitis or pulmonary edema. EKG did not
have any ischemic changes. On ___ patient had RIJ placed and
follow up CXR showed small pneumothorax but there was no change
in the patient's respiratory status. He was put on supplemental
oxygen, and on ___ CXR showed resolution of the pneumothorax.
He was discharged on a total 14 day course of antibiotics for
his presumed HCAP, due to complete ___. At the time of
discharge, his oxygen saturation was high ___ on 2L nasal
cannula.
# pulmonary edema: No cardiac history, but patient developed
findings c/w pulmonary edema on CXR after minimal fluids. EKG
was unconcerning.
# Seizure Disorder: Etiology unclear. Myoclonic jerks observed
after transfer from MICU to the floor, and EEG showed seizure
activity. His home Keppra was increased to 1.5g BID.
# HypoNa: Chronic per facility records, though hypovolemic this
admission. Resolved with fluid resuscitation.
# Down's syndrome, non-verbal at baseline: Per NH at baseline.
Given his lack of responsiveness, head imaging was performed to
ensure lack of new pathology.
# Hypothyroidism: Continued on home synthroid. TSH was normal.
# Social: Over the last few months that patient's health has
been declining and he was made DNR/DNI by HCP (brother).
Currently in discussion with PCP about making CMO and moving to
hospice care. During this admission a meeting with the
patient's group home, ___ case worker, ___ social work and
case management, ___ medical staff, and the patient's two
brothers was held to discuss his prognosis and goals of care.
The medical team stated that the patient's overall life
expectancy is in the range of months, but that this could be
much shorter if he has an acute respiratory event. He will
continue to aspirate and may continue to have infections.
However, treating these infections may require him to remain in
a hospital, which his family agrees is not the best setting for
his comfort. His brothers recognized that moving to hospice/___
and taking him back to the group home would improve his quality
of life, but they were concerned that this might shorten his
overall lifespan. After discussion of the options, they decided
to complete this course of antibiotics (2 weeks) and then plan
to return him to the group home. They recognized that this
course of treatment may not provide him any long-term benefit,
and that he could die while undergoing the treatment. They
stated that they would consider a DNH order after this current
course of antibiotics.
FOLLOW-UP ISSUES
1. Please follow up on his blood cultures and sputum cultures.
They were pending at the time of discharge.
2. Please evaluate for evidence of seizure-like activity. At the
time of discharge, he was having occasional myoclonic jerks that
did not correspond to epileptiform discharges on EEG. He may
need an EEG at a future time.
3. Please check his sodium and fluid balance, as he presented
initially with hyponatremia, likely secondary to dehydration.
4. Patient tested positive for MRSA, and should be on contact
precautions.
5. Head CT read pending on discharge, may show signs of subacute
pathology that changes his overall prognosis.
6. IV Zosyn and vancomycin planned 14 day course through ___,
however this may be adjusted by the patient's response and
clinical situation. | 147 | 711 |
12935838-DS-21 | 25,653,285 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Ms. ___ was admitted from the ED with limited episode of
orthostatic hypotension at rehab and hypoxia. Her vital signs
remained stable since arrival to the ED. She appeared fluid
overloaded on exam. She underwent full work-up which included
lab work, chest x-ray and echocardiogram. She was continued on
her current medications and was given IV diuretics for presumed
effusions. Initial chest x-ray revealed small bilateral pleural
effusions. Echo showed bioprosthetic mitral valve with mildly
elevated gradients, albeit at a relatively high heart rate,
moderate elevation of pulmonary artery systolic pressure and
abnormal septal motion - likely due to post-cardiac surgical
state although right ventricular pressure/volume overload may
also be present. Repeat x-ray the following days showed large
right and small to moderate left pleural effusions. On hospital
day three she underwent a right thoracentesis that only drained
100-150 cc's. Clinically she remained stable, appeared much
improved with no hypotension nor episodes of hypoxia. On
hospital day four IP was consulted for a potential thoracentesis
since initial one yielded little. IP saw very small effusions
not amenable to thoracentesis and recommended continued
diuretics. Later this day she was discharged back to rehab with
the appropriate medications and follow-up appointments. | 132 | 199 |
11686040-DS-19 | 26,831,805 | Dear ___,
You were admitted to the hospital because of abdominal pain, as
well as prior blood in your stool and vomiting. Your blood
counts stayed stable and normal. You had a CT scan of your
abdomen that did not show any abnormalities.
You will need to see your gastroenterologist Dr. ___ in
the outpatient setting to further evaluate your abdominal pain.
You have an appointment on ___, but if you need
to confirm or reschedule, the number to call them to make an
appointment is: ___.
You were also found to have a bacteria in your urine, and you
were given 5 days of antibiotics (cefpdoxime): take 1 tab every
12 hours for 5 days.
Please also make an appointment to see your primary doctor, ___.
___, in the next week.
It was a pleasure to take care of you!
Your ___ Care team | Ms. ___ is a ___ female
with history of gastritis, uterine cancer, s/p CCY who presents
with abdominal pain, nausea and vomiting and history of
hematemesis.
# Abdominal pain
# Nausea with vomiting
# History of hematemesis
Patient with recurrent epigastric abdominal pain. Differential
includes recurrent gastritis, viral gastroenteritis, PUD. Less
likely pancreatitis given normal lipase and lack of typical
findings on CT scan and no clear risk factors. Patient is s/p
CCY
therefore gallstone disease is also less likely. Additionally,
patient's LFTs are not elevated. It is not clear how her
history
of hematemesis contributes to her current presentation as her
h/h
is stable and during this admission, she does not have
hematemesis. She has improved symptomatically with supportive
care. Her diet was advanced, and she tolerated a clear liquid
diet. Her stool was sent for H. pylori, but it did not yet
result on the day of discharge.
Her PPI was increased to pantoprazole 40mg bid. She was advised
to avoid NSAIDs.
She already had a follow up appointment with GI set up for
___, and she was given the information for this
appointment.
#UTI
Patient initially denied symptoms of UTI on admission, but then
the next day endorsed some symptoms of pain when going to the
bathroom. Her urine culture grew >100K gram negative rods. She
was given 5 days of cefpodoxime.
################################# | 140 | 208 |
12440965-DS-47 | 24,464,123 | Mr. ___,
You were admitted to ___ because of blood from your rectum.
This stopped and did not continue. Your blood counts were
normal. Your urinary catheter was changed.
Best Wishes,
Your ___ Team | ___ ___ speaking man from long term living
facility (___) with Dementia, ESRD s/p DDRT in ___
with chronic allograft nephropathy currently on MMF/low dose
Pred, Afib on Coumadin, dCHF, recurrent UTIs and urinary
retention s/p suprapubic catheter placed in ___ who was
brought to ED because of bright red blood per rectum. | 32 | 56 |
12406461-DS-28 | 25,057,168 | Dear ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for pharyngitis.
You were having throat discomfort and had been seen in clinic
due to concern for strep throat. Given the concern you were
started on antibiotics to complete this. Since you have
difficulty tolerating oral antibiotics you preferred treatment
with IV antibiotics. You should continue these for a total of 10
days to ensure treatment for strep throat.
You also had a fast heart rate and low blood pressure. These was
treated with IV fluids. You were also put on a beta blocker to
help control your heart rate and you improved. You should
restart your home betablocker when you get home.
While you were here your central line was stopped functioning
properly. You underwent a procedure with interventional
radiology to repair the line. Your line is now working.
Please follow up with your doctor as scheduled.
We wish you the best!
Sincerely,
Your ___ Team | ___ year old female with history of hypereosinophilic syndrome
with GI involvement including esophagus, stomach, and small
intestine, currently TPN dependent, several right subclavian
tunneled line infections, adrenal insufficiency, autonomic
dysfunction with recent admission to ___ from ___ for
pseudomonas/staph line infection, who presented to urgent care
with sore throat and fever to 101.5. Rapid strep in clinic was
negative. She was noted to be hypotensive and was send to the
___ ED.
# Pharyngitis: Patient presented with pharyngitis and a one day
rash. With her fever, tonsillar exudates, absence of cough, and
age, patient satisfies ___ centor criteria making group a strep
pharyngitis a possible etiology. A rapid strep was negative at
urgent care and culture is pending. WBC count is down to 7.3
from 10.3 on admission, with 92% polys. Could be viral with h/o
of rash, but elevated PMN's makes bacterial most likely. Patient
started on unasyn for a 10 day course. Last fever evening of
___. Throat continued to improve. Discharged to complete a 10
day course of unasyn. Culture still pending at urgent care at
time of discharge.
#Access/Nutrition: Patient is TPN dependent, but TPN lumen of
tunneled line stopped functioning ___ AM. Repaired AM of ___
and both lumens tested functioning and flushing easily prior to
discharge. Patient was given TPN through most of her stay and
additional fluids to make up for deficits when TPN line
non-functional.
# Eosinophilia/Eosinophilic esophagitis/gastroenteritis: TPN
dependent due to nausea and vomiting. Some meds sparingly
through G or J tube. On clinical trial with compassionate use
mepolizumab. Given diphenhydramine 50mg IV q6hr per home dosing
for pain.
# Secondary Adrenal Insufficiency: Given 100mg hydrocortisone in
ED one time. Switched to home dosing 7.5 mg PO QAM and 2.5 mg
PO QPM on floor and was stable
# Autonomic dysfunction: Has elevated HR at baseline. Reports
that it gets up to 120 when standing, but falls when she is at
rest. Continued pyridostigmine 60 mg PO Q8H and started
Metoprolol tartrate 25 mg PO BID as blood pressure stabilized on
antibiotics and fluids.
TRANSITIONAL ISSUES
======================
[] Unasyn to be completed on ___ for complete 10 day course.
If patient requesting switch to oral/liquid regimen can be
switched to amoxicillin
[] continue prior home services, TPN and home medications as
ordered
[] follow up outpatient strep throat culture - pending at
___ in ___ (___)
[] Throat cultures still pending at ___ in ___
(___) | 160 | 401 |
11834165-DS-25 | 20,887,677 | You were admitted to ___ with confusion. This was due to
kidney damage, a urinary tract infection, and drug use. We
advise you to not take any illicit drugs in the future and not
to use alcohol. Please take your medications as directed and
follow up with your doctors.
Your blood sugars were also noted to be low here, and your
insulin regimen was adjusted by the ___ team. | ___ male with a PMHx of DM, CAD s/p CABG, CKD, multiple
recent admissions to ___ for renal failure, depression, prior
polysubstance abuse and underlying dementia vs cognitive
impairment who presents with altered mental status found to have
___, UTI, and positive urine tox screen.
# T2DM, poorly controlled #Brittle, Labile blood sugars : Pt
with history of brittle DM, followed at ___. On 40U tresiba
at home, decreased to 20U lantus given ___, poor PO intake, and
low BS in ___. Nateglinide on hold. However, despite this, pt
continued to have poor PO intake and hypoglycemia. Long acting
insulin was stopped,
and patient now with increased BS. He initially presented with
profound hypoglycemia in the setting of acute intoxication and
sedation complicated by acute on chronic kidney failure. His
diabetic regimen was significantly down-titrated early during
his course due to persistently low sugars likely related to his
significantly impaired renal clearance at the time. His hospital
course over the past 5 days however has been complicated by
persistent hyperglycemia in the setting of continued dietary
indiscretions and now improved renal function (closer to his
baseline now) with increased insulin requirement for which his
insulin has been increased stepwise with close guidance from
___ service. Ultimately he was discharged on lantus 24U at
bedtime, glipizide XR 10mg daily with breakfast and will be
started on Tradjenta 5mg daily on discharge as well. He will
follow up closely with his primary care physician as well as the
___ team after discharge with continued close visits from ___
twice a day for diabetes management and medication
administration. Patient is high risk for decompensation after
discharge given continued concern for poor compliance, limited
understanding of the complexity of his medical conditions or the
risks of poor glycemic control.
# Toxic Metabolic Encephalopathy: Patient initially presented
with acute intoxication and severe toxic metabolic
encephalopathy which was likely multifactorial. Suspect
combination of acute intoxication, acute on chronic kidney
failure, hypoglycemia and labile blood sugars, and poor
underlying substrate.
# Cognitive impairment, chronic: given longstanding concern for
cognitive impairment and further collateral from his PCP who
confirmed that he was now back to his baseline mental status, we
renewed the psychiatry consult and have asked them to comment on
his baseline cognitive function, ability to make decisions for
himself and help arrange outpatient psychiatry follow-up for
continued management after discharge. He was seen prior to
discharge again by Dr. ___ Psychiatry who did agree that
patient has significant cognitive impairment and limited ability
to participate in higher level discussions about his health. He
will reach out to the Psychiatry Department to help ensure
outpatient follow up but this will require continued
coordination between providers, patient, family and his
outpatient social worker / case manager / visiting nursing team.
It is clear that this patient is at continued risk for
progressive decline and failure to thrive, and anticipate he
will likely reach a point where he would benefit from placement
at an extended care facility where he would get 24 hours care
but this will require ongoing discussions about capacity and a
willing presence from a family member who would be willing to
make these decisions on his behalf. Unfortunately his current
healthcare proxy continues to be difficult to engage in
conversations about patient's overall health or ongoing needs on
discharge. Patient is fortunately being followed quite closely
by a primary care physician who knows him well and is closely
engaged in coordination of care on his behalf. He also has a
significant amount of support in the form of outpatient case
management, social work and skilled nursing care team. Outside
of this, however, he continues to be at high risk for further
decline given limited family presence and cognitive impairments
as described.
# Possible Acute Complicated Cystitis: Urine cx contaminated.
However, given confusion on presentation and UA findings,
treated as infection. Only positive urine cx in our system is
pansensitive e.coli > ___ year ago. He was initially treated with
CTX, which was transitioned to PO cipro after he lost IV access.
He completed a 7 day course for presumed cystitis with last dose
on ___.
# Acute on chronic kidney failure: Cr 3.7 on presentation, last
2.0 in ___ at ___ and 3.1 at ___ on ___. Per recent ___
discharge summary, pt was found to have worsening urinary
retention without hydro on u/s. Worsening renal function was
thought to be due to worsening underlying disease (CKD secondary
to HTN, DM and possible prior post-obstructive renal failure)
and high doses of naproxen use as outpatient. He was discharged
with foley in place, which was removed in the ___ here. He
refused Foley replacement. Lisinopril and ranexa were held in
the setting of ___. Cr improved with supportive care.
# Urinary retention: Pt has known h/o BPH and per ___ discharge
summary, concern for prostate cancer as well given elevated PSA.
In fact based on more recent results from OSH communicated .
Foley to be exchanged in ___ however pt declined replacement.
Renal u/s without hydro. Pt repeatedly declined straight cath on
the floor. Continues to have urinary retention on the floor but
has generally refused straight cath's.
# Prostate Cancer with extensive mets - new result from ___
faxed in to PCP ___ ___ (see note in ___. After discussing with
his PCP and given concern for difficult coordination of care
after discharge, I have discussed his case with both Oncology as
well as Urology. Per urology, limited role from them given
advanced disease and distant mets and suggested discussion with
oncology regarding medical management. He will follow up in
___ clinic after discharge and appointment has been arranged
for this. In speaking with Oncology fellow, seems that his
erratic compliance with lab draws and office visits may limit
our options somewhat in terms of choice of therapy. In brief, we
discussed that he may be a better candidate for leprulide which
would require once monthly rather than daily administration. At
the same time, this may be tricky as more frequent lab
monitoring may be required and Leprulide may carry higher risk
of side effects so difficult to answer this questions without
further exploration. She further noted that initiation of oral
therapy today or even for a week rather than awaiting outpatient
Oncology visit and an established outpatient Oncology provider
___ not ultimately have a significant enough impact on his
overall course or prognosis to warrant immediate initiation
before establishing stable outpatient care in ___ clinic.
Arrangements have been made however for close follow-up in
___ clinic with one of our Prostate Cancer providers.
# Polysubstance abuse: Pt with h/o polysubstance abuse, now with
utox positive for opiates, cocaine, barbituates. Likely
contributing to acute encephalopathy on presentation. Pt denied
substance abuse. He was monitored on CIWA and received 1 dose of
valium. He was treated with thiamine, folate, and MVI. He was
maintained on his home naltrexone.
# Type 2 Demand ischemia #History of Coronary Artery Disease:
When he first presented he was noted to have RBBB and ST changes
on ECG new since ___. His cardiac enzymes were trended and
reassuringly negative. His home Ranexa was resumed on discharge
and he was continued on his home ASA, Lipitor and Metoprolol. As
above, his Lisinopril is currently being held with plan to
follow up in outpatient setting and resume if renal function
remains stable.
# History of depression with psychotic features: Continued his
home fluoxetine and ziprasidone.
# Essential Hypertension: Continued amlodipine, metop,
isosorbide. ACEi on hold as above. BP's remained elevated;
however, suspect that patient has poor BP control chronically.
# Hyperlipidemia: Continued home statin.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes. | 69 | 1,284 |
10562309-DS-5 | 29,741,810 | As you know, you were admitted to the ___
___ after nearly fainting. We examined the arteries
that supply blood to the heart and did not find any blockages.
We performed an ultrasound of the heart which showed that a part
of your heart is slightly larger than it should be which can
cause decreased blood flow when you are dehydrated. We believe
that this is the reason that you nearly fainted. We recommend
that you maintain adequate hydration, especially on warm days or
in warm environments. We recommend that you are seen by a
cardiologist please see your primary care provider for ___
recommendation for a new cardiologist.
.
Medication changes:
START Metoprolol
START Aspirin 81mg daily
Continue your previous medications as before the hospital stay.
Continue to take all of your other medications as directed | ___ year old woman with depression, anxiety and history of
alcohol abuse was admitted after presyncopal event and found to
have multiple lab abnormalities including ketoacidosis,
hypokalemia and acute renal failure. She had cardiac
catheterization given concerning EKG changes with elevated
troponins which showed normal coronary vessels. Echo showed
hypertrophic cardiomyopathy of elderly. She is encouraged to
maintain adequate hydration and discharged in stable condition
with follow up appointments.
.
#Presyncope: hypotensive by EMS and at triage that was fluid
responsive suggests hypovolemic etiology of presyncope vs
vasovagal; lack of focal neurological deficits makes primary CNS
event unlikely; history not consistent with seizure; there was
initial concern for cardiac origin (she has LBBB that seemed
rate dependent) given new EKG changes (T wave inversion in V3
and flat T wave in V4 that were not present on prior EKGs). She
was in sinus rhythm and she did not complain of chest discomfort
or shortness of breath during her stay. She had 20 beats of NSVT
per telemetry which made it necessary for her to be transferred
to inpatient cardiology service. However, this can be a real
NSVT or anxiety related tachycardia with LBBB looking like NSVT.
Otherwise, she was in sinus rhythm. There was no coronary artery
disease on cardiac catehterization (please see results). ECHO
was pursued which showed hypertrophic cardiomyopathy of the
elderly in which part of the septum is hypertrophic and causes
obstruction when patient is dehydrated. She was discharged with
instructions to maintain adequate hydration and to get a new
cardiologist.
.
# Psychiatric issues: She has history of alcohol abuse but
reports stopping drinking for the last 4 months. Also had
history of valium abuse in the distant past per patient which
was used to treat her anxiety. During her stay, she was very
tearful and anxious expressing some paranoid ideations about the
staff. She was reassured and also was evaluated by social worker
who recommended some therapists and the patient seemed
receptive. She will be seeing Dr ___ soon who is aware
of her situation. The patient did not seem unsafe to follow up
as outpatient.
.
#Ketoacidosis: likely starvation ketoacidosis given rapid weight
loss (per PCP ___ 185 lbs on ___ now ___ lbs (pt reports 20
+ lbs wt loss since stopping alcohol); diabetic unlikely given
no previous diagnosis and glucose < 200; alcoholic ketoacidosis
also unlikely if patient truthful about not drinking (serum
ethanol negative); osmolar gap negative for other ingestions;
serum toxicology was negative. She received thiamine and folate
during her stay with good hydration. Her gap
closed.
.
#Acute renal failure: likely prerenal azotemia due to poor oral
intake. Received IV fluids and renal function improved.
Lisinopril was held in the setting of worsening kidney function.
.
#Leukocytosis: Resolved. Afebrile. It was likely acute phase
reactant, no signs or symptoms of infection. Urine culture
showed no growth. CXR no signs of infection. Antibiotics were
not administered possibility of infection was low.
.
#Depression/anxiety: We continued home fluoxetine 40 mg once
daily. Social worker followed her during her stay as above. She
will follow up with psychiatry as outpatient.
.
FULL CODE
Emergency contact: ___ (wife) ___
Email sent to PCP ___ not current PCP,
___ PCP) and sent letter | 131 | 530 |
15245632-DS-7 | 23,434,244 | Dear Ms. ___,
You were admitted to ___ for numbness in your legs. We did a
lumbar puncture, and found that there was no infection. Due to
some small lesions that we saw on your spine MRI, we are
concerned for a disease called multiple sclerosis. For this, we
recommended 3 days of IV steroid treatment. Unfortunately, you
are leaving the hospital prior to the third IV treatment. We
will try to set this up as an outpatient however as you do not
have an established outpatient neurologist yet, this may be
difficult. Therefore, we are sending you home with a prednisone
taper.
Please take the prednisone as follows, starting tomorrow ___:
60mg (6 tablets) once per day for two days
40mg (4 tablets) once per day for two days
20mg (2 tablets) once per day for two days
10mg (1 tablet) once per day for two days
Then stop.
Please call or come back in if you have worsening of your
symptoms.
It was a pleasure taking care of you during this hospital stay. | Ms. ___ is a ___ yo female with borderline hypothyroidism who
presented with 24 hours of lower torso and lower extremity
numbness.
Routine CSF analysis was within normal limits. MRI of the
cervical and thoracic spine demonstrated very subtle patchy
areas of abnormal cord signal, which could be consistent with a
demyelinating process. Brain MRI did not demonstrate any
evidence of acute or chronic demyelination. Her presentation was
consistent with transverse myelitis, and she received IV
solumedrol for 2 days but unfortunately left AGAINST MEDICAL
ADVICE before the planned 3 day course of solumedrol can be
completed. Her symptoms improved over the hospital course.
She was written for oral steroid taper (over 8 days) and
famotidine to be taken before the prednisone. Given patient's
reported history of optic neuritis, there was concern that the
transverse myelitis may be part of a chronic demyelinating
disease, namely neuromyelitis optica or multiple sclerosis. She
and her family were informed of this possibility and planned to
follow-up with an MS specialist after discharge to discuss
further management. | 166 | 175 |
11900721-DS-26 | 25,886,140 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital for confusion, due to hepatic encephalopathy. You
had GI bleeding requiring a TIPS procedure. You then had
bleeding complications in your liver from this requiring
interventional radiology procedures. Your blood counts have been
stable and you are ready for discharge to rehab.
Please followup with the liver specialists upon discharge from
the hospital.
Take Care,
Your ___ Team. | ___ with cryptogenic cirrhosis requiring frequent large volume
paracenteses and a history of possible sarcoidosis who is
presenting with altered mental status.
# GI Bleed: She had a history of small varices without a history
of bleeding. She was guiaic negative on admission, however
developed BRBPR on hospital day 3. She was transferred to the
ICU urgently intubated and taken to EGD, which showed varices at
the lower third of the esophagus which were banded however
hemostasis was not acheived. ___ was placed and she was
taken for on ___ for TIPS procedure with significant
improvement in portal pressures (28 to 6mmHg). She was given a
PPI and sucralfate. There was no additional GI bleeding.
# Perihepatic and chest wall hematomas: The patient developed a
dropping hct several days after her TIPs, with a paracentesis
showing frank blood. CTA showed perihepatic hematoma near the
gallbladder (corresponds to hypodensity in that area seen
RUQUS). ___ embolized a bleeding artery, felt to be a TIPS
complication, and coiled a small pseudoaneurysm. Her hct trended
down again and she underwent another arterial embolization by
___. She then developed a moderate chest/trunk wall hematoma
which stabilized. Her hematocrit remained stable upon discharge.
In total,
she received 18 units pRBC, 12 units of plasma; 3 units
platelets; 4 units cryo.
# Altered Mental status: Admission diagnosis. Suspected hepatic
encephalopathy in setting of medication
noncompliance/constipation when she was first admitted. She was
mentally clear on HD2, prior to the GI bleed. However, she
became agitated and somnolent on the day her GI bleed presented.
She received SBP PPX for her variceal bleed. This persisted
after TIPS though improved with aggressive lactulose and
rifaximin. She also was enrolled in the OCERA encephalopathy
trial which she completed during this hospitalization.
# ___ on CKD: Pt had mild ___ in the setting of diuresis.
Resolved with holding of her diuretics. Discharge Cr 1.2 which
was stable. She tolerated numerous contrast based procedures
without worsening renal function.
# ASCITES: Requires weekly paracentesis of ___ at a time
generally. Last para on ___ with 3L off, continues to be bloody
in appearance (felt to be related to coagulopathy and oozing).
No e/o SBP. Diuretics were adjusted, with amiloride 10 daily and
lasix 60 daily at discharge. She was continued on a low salt
diet.
# Cirrhosis: Cryptogenic. Decompensated by HE, ascites, variceal
bleeding. She is not a transplant candidate. Her INR and
bilirubin stabilized after initially rising post-TIPS.
# Diet controlled DM: Initiated on insulin glargine and sliding
scale humalog. | 80 | 419 |
15046439-DS-11 | 27,756,800 | Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest discomfort after a
recent cardiac catheterization on ___.
- You were admitted because your heart rate was very fast.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were monitored on telemetry and your rates were
well-controlled.
- You received a blood transfusion.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take your home isosorbide mononitrate 30mg
daily.
- Please continue to take your metroprolol tartrate 12.5mg twice
a day. You will receive 25mg tablets, please cut these in half.
You will receive 12.5mg today before you leave (___). Take
another 12.5mg tonight after you go home.
- Please continue to take all other outpatient medications as
prescribed.
- Please attend your appointment with Dr. ___ on ___
___ at 11:30am.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ___ w/ h/o CAD s/p multiple stent placements, most recent stent
placed ___, CABG x3, severe AS, HTN, dyslipidemia and
thallasemia minor, who p/w chest pain.
# CORONARIES: s/p 3-vessel CABG, stents to RCA and LCx (most
recent on ___
# PUMP: EF 71% on stress
# RHYTHM: Normal sinus rhythm, rate of 77, normal axis, normal
intervals, <1mm STD V2-V4 worse from prior | 190 | 59 |
18223539-DS-17 | 20,366,442 | Mr. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted with diarrhea and were thought to have
a viral gastroenteritis. You were treated with supportive care
and your diet was advanced slowly. You improved and were
discharged with plans to follow up with your primary care
doctor's office next week.
You should get your INR checked at ___ next ___,
___. An order has been placed in the system for this. You
can walk in and don't need an appointment. | ___ yo male with atrial fibrillation, COPD and bladder cancer
presents with diarrhea found to be most likely viral
gastroenteritis.
ACTIVE ISSUES
# Gastroenteritis: The time course and symptoms were most
consistent with viral gastroenteritis or toxin-mediated
diarrhea. Patient febrile with non-bloody diarrhea on
admission. CT abd/pelvis did not show signs of colitis. Fever
curve downtrended. There were no other signs of invasive
enteritis. Diarrhea improved on second day of admission, and
stopped by the day prior to discharge. Supportive care with
fluids and bowel rest were provided; diet was advanced slowly
and patient tolerated well. He was discharged home with regular
diet.
# Chest pain: Patient complained of chest pain on presentation
to the ED. He received medications for possible ACS, and was
seen by cardiology who thought that pain was likely secondary to
gastroenteritis. ECG was not consistent with ACS findings, and
is consistent with prior. Cardiac enzymes negative x2.
# Abnormal liver function tests: Transaminitis on presentation
trended down to within normal limits over the 3 days of
admission. They were normal on discharge.
# Atrial fibrillation: The patient's warfarin was continued at
the same doses as was digoxin. Due to some low heart rates his
home BID metoprolol tartrate was switched to metoprolol
succinate 50mg daily on discharge. INR was 3 on the day of
discharge and therefore he was discharged with prescription to
get INR checked 3 days later.
CHRONIC ISSUES
# Thrombocytopenia: chronic, may due to history of cancer.
Stable at this admission.
# COPD: home albuterol continued.
# Bladder cancer: no acute treatment currently.
# Lung cancer: no active issues at this admission.
# Hypertension: Metoprolol changed to succinate 50mg daily.
# GERD: omeprazole continued.
# BPH: continued home tamsulosin.
TRANSITIONAL ISSUES
# Patient will get INR checked on ___ and will need titration
of warfarin dosing.
# Metoprolol changed to toprol 50 mg po daily
# Enrolled in PACT program | 92 | 318 |
14809002-DS-19 | 27,399,973 | Discharge Instructions:
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:
-Nonweightbearing left lower extremity
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:
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 2 weeks followed by aspirin 325
mg daily for an additional 2 weeks
WOUND CARE:
- You may shower. Do NOT get splint wet. 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 greater than 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 call ___ to schedule a follow up with your
Orthopaedic Surgeon, Dr. ___. You will also make a 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. | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have left pilon fracture and was admitted to the orthopaedic
surgery service. The patient was taken to the operating room on
___ for left pilon open reduction internal fixation,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 597 | 254 |
11570499-DS-20 | 27,716,545 | This information is designed as a guideline to assist you ___ a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
You were admitted for your left foot infection. While you were
___ the hospital you received IV antibiotics. You went to the OR
for a debridement of the ulcer and we also performed a
tendoachilles lengthening. You should keep your brace on at all
times and not put any weight on your left foot for ___ weeks.
You are being sent home with a PICC line so that you can receive
IV antibiotics for the next 4 weeks. You should follow up with
Dr. ___ ___ ___ ___ clinic. His office phone number is
___.
ACTIVITY:
There are restrictions on activity. On your left side you are
non weight bearing for ___ weeks. You should keep this site
elevated when ever possible (above the level of the heart!)
Physical therapy worked with you ___ the hospital and gave
instructions on weight bearing: please follow these accordingly.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
WOUND CARE:
Sutures/Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for their
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap ___ the shower.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which ___ turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your surgical site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low ___ total fat and
low ___ saturated fat and ___ cholesterol to improve lipid profile
___ your blood. Additionally, some people see a reduction ___
serum cholesterol by reducing dietary cholesterol. Since a
reduction ___ dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes ___ your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor. Blood glucose control is
absolutely imperative to your recovery and healing process.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels and consequently the foot. Don't let them go
untreated!
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | Pt was admitted from the ED on ___ for L foot infection. Pt
received IV abx on admission to the floor and was made NPO at
midnight for OR. All home medications were resumed. On HD#2,
after being consented with translator present, pt went to the OR
for debridement of her L foot ulceration and underwent
debridement with a ___ met resection. Upon recovering ___ the
PACU, pt was transferred back to the floor and resumed a normal
diet. While ___ house, pt continued to receive IV antibiotics.
She received non-invasive arterial studies on ___ which showed
right lower extremity disease at the tibial level. It was
decided that she would follow up with Dr. ___ vascular
on an outpatient basis. Pt was again made NPO on the evening of
___. She was again consented for surgery on ___ with
translator present and ___ the OR an additional debridement of
the ulcer with closure was performed. Pt also had a
tendoachilles lengthening on the L side. Pt recovered ___ PACU
and was transferred back to the floor ___ stable condition. While
___ house, pt's cultures came back positive for MRSA. PICC line
was ordered and once a malposition was corrected, it was deemed
safe to use. On ___, bivalve cast was ordered for pt to
maintain a 90 degree position of the L foot following her TAL.
On ___, plantar ulceration was closed at bedside and DSD was
reapplied. Pt was discharged to rehab on ___ and will follow
up with Dr. ___ also with Dr. ___ ___ ___ clinic. | 930 | 260 |
18841460-DS-9 | 24,232,164 | Dear Mr. ___,
You were hospitalized due to dilantin toxicity, which caused you
incoordination, weakness and unsteady walking. During your stay
we discontinued your Dilantin, and in consultation with your
PCP, started you on Vimpat, a new medication that will help you
control your seizures while having less toxic effects. We
monitored you on EEG to ensure that this new medication was
effective at controlling your seizures, and imaged your ___ to
ensure that nothing else was responsible for your symptoms.
Both of these tests were normal, and we expect you to have a
good response to Vimpat. Physical Therapy also evaluated you,
and recommended rehabilitation to ensure that you can safely
walk on your own.
You are being discharged to a rehabilitation facility where you
will be able to regain your strength.
In the coming months, please follow up with your PCP and your
neurologists. Please be aware of any changes in your
coordination or gait, as well as any new headaches,
lightheadness, confusion, visual changes or seizures, as these
might indicate problems with your new medications. Please reach
out to your neurologist or PCP if any of these occur.
Thank you for choosing ___!
Sincerely,
Your ___ Neurology Team
or change and any other acute changes in your health | Mr. ___ was intially evaluated at ___, where he was
referred to the ___ ED and seen on the evening of ___. He
was evaluated by the Neurology team, and admitted to the
Epilepsy service on the morning of ___.
On admission, he was found to have an unsteady gait, as well as
significant nyastagmus in all directions of gaze and FNF
dysmetria. Furthermore, he was weak in the lower extremities b/l
with only trace reflexes. His general and neurological exams
were otherwise normal.
His home medicine regiment for epilepsy included Diazepam,
Depakote, Keppra and Phenytoin. His phenytoin level was found to
be supratherapeutic at 27.4, which suggested AED toxicity.
Muscle inflammatory markers were negative.
He was monitored on EEG, and his Phenytoin was discontinued,
replaced with Vimpat after consultation with his outpatient
neurologist, Dr. ___. Vimpat was started at 100mg BID on
___, and advanced to 200mg BID. EKGs before Vimpat was
started , and after maximal dose, showed no conduction delays or
abnormalities.
He remained hemodynamically stable and afebrile throughout his
admission, and his exam improved in terms of nyastagmus, gait
and dysmetria. His EEG showed some overnight frequent
epileptiform discharges over the right > left frontal, central
and temporal leads, mostly under >10 seconds and subclinical.
Mr. ___ relayed feeling well and having experienced no spells.
His EEG was discontinued on ___, his VNS was turned off, and
he received an MRI, which showed no changes from prior.
He was seen by ___ who recommended home with ___ services. | 205 | 248 |
10101321-DS-10 | 26,537,257 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after you had left-sided numbness and were found to have brain
metastases on your brain MRI. You were continued on steroids
while in the hospital. You were seen by the Neurosurgeons,
Radiation Oncologist, and Neuro Oncologists. After further
discussion it was determined that the best treatment would be
whole brain radiation. Due to convenience you will follow-up
with Dr. ___ your radiation treatments.
You should continue to take the dexamethasone at home at a dose
of 4mg twice a day. Please follow-up with Dr. ___ to
determine the taper of this medication.
Please see below for your follow-up appointments.
All the best,
Your ___ Team | Ms. ___ is a ___ female with history of breast
cancer diagnosed in ___ s/p neoadjuvant chemotherapy, modified
radical mastectomy, and XRT followed by palbociclib until
___ and currently on Exemestane who presents with
left-sided numbness and found to have brain mets.
# Brain Metastases
# Left-Sided Numbness: She has had progressive numbness of her
left face, shoulder, hand, and foot. Lesion of right pons likely
explains her symptoms of numbness due to involvement of
spinothalamic tract. Likely from prior breast cancer. Currently
no weakness on exam. Continued on dexamethasone. Neurosurgery,
Neuro Onc, and Radiation Oncology were consulted. No surgical
intervention indicated by Neurosurgery. Radiation Oncology
recommended whole brain radiation which will be arranged at ___
___. Patient will follow-up with her Radiation
Oncologist at ___. She was continued on
dexamethasone with taper to be determined by her outpatient
providers.
# Breast Cancer: Continued exemestane. Will follow-up with
outpatient Oncologist.
# Leukocytosis: Likely from dexamethasone. No signs/symptoms of
infection.
# Depression: Continued citalopram.
==================== | 121 | 158 |
16907183-DS-5 | 21,829,863 | You were admitted due to confusion. Your evaluation did not
reveal any underlying cause. We are discharging you home and you
should follow with your PCP. | The patient is an ___ man with a history of diabetes,
multiple eye disorders, hypertension, atrial fibrillation
(anticoagulated), asthma, GERD, who is presenting with two days
of confusion.
.
# Confusion, of unknown etiology: Patient presented with
pseudohallucinations which were transient and resolved.
Attention intact throughout overnight admission. No specific
infectious etiology localized. Patient without specific
localizing signs or symptoms except ___ recall after 5 mins.
Gabapentin was discontinued on admission as concern for delirium
though recontinued on discharge. The patient does have
significant atrophy as shown on CT head, so dementia a
possibility though would not present with this acute
pseudohallucination. Electrolytes WNL, not hypoglycemic on
admission. Blood pressure elevated during admission. The patient
had small parietal hematoma found on CT, though he denied
fall/head strike, this may have been confusion post-fall. TSH
elevated though FT4 1.0, B12 elevated. Neuro was consulted and
did not feel this was acute intracranial pathology but rather
advancing dementia with pseudohallucinations, felt comfortable
he could be followed up in outpatient ___ clinic for further
eval.
.
# Acute kidney injury: Baseline creatinine appears to be
1.2-1.4. Patient's creatinine mildly elevated on admission.
Holding any additional fluid due to patient's edema. It was
stable without intervention
.
# Diabetes mellitus: Continued home regimen of glargine. Will
provide sliding scale for meals. DM contributing to neuropathy
so tight control recommended
.
# Atrial fibrillation/sick sinus syndrome with pacemaker and
anticoagulation via warfarin. Chronic, stable
.
# Hypertension: Stable, continued home regimen of enalapril,
metoprolol, amiloride.
.
# Lower extremity edema: Chronic, stable, was taken off
outpatient lasix for increasing creatinine prior to admission
# Gout: Continued allopurinol therapy.
.
# GERD: Continued home Nexium.
.
# Asthma: Continued albuterol | 26 | 295 |
18904237-DS-13 | 26,753,611 | Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for swelling of your leg, shortness of
breath, and pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with medication to remove extra fluid in your
body
- You had an episode of low blood sugar that was treated by
eating and drinking food items with high sugar
- We monitored the swelling and redness of your legs which
improved during your stay
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Keep your legs elevated whenever possible to decrease swelling
- Monitor your salt and fluid intake. Keep your fluid intake to
below 2 liters per day
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. You weighed 318 pounds when you left the hospital
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Summary: ___ year old woman with history of HFrEF (EF 43%),
morbid obesity, b/l TKRs, recent fall on the right leg without
fracture, DM2, HTN, presenting with bilateral lower extremity
edema, RLE erythema, and dyspnea, likely secondary to acute on
chronic systolic congestive heart failure exacerbation. Now
improved s/p diuresis.
ACUTE ISSUES
#Acute on chronic systolic heart failure (LVEF = 40%)
exacerbation:
Patient presented in the setting of increased ___ swelling at
home and decreased urination. On admission she was noted to be
>20lbs over her reported dry weight, with exam notable for
dyspnea on exertion, orthopnea, ___ edema, and bibasilar
crackles. Her pro-BNP was elevated to 997 on admission. Etiology
of acute heart failure exacerbation thought to be due to dietary
indiscretion given reported high salt intake and eating out at
restaurants multiple times per week. She received aggressive
diuresis with IV Lasix gtt and metolazone with significant urine
output. A repeat TTE showed EF 43%, left ventricular cavity
dilation with regional systolic dysfunction most c/w CAD (PDA
distribution) - findings similar to stress echo from ___.
Further w/u of regional dysfunction not pursued in house given
non-ischemic EKG, negative cardiac biomarkers, and unchanged EF.
She was diuresed to ___ with improvement in her dyspnea and ___
swelling. Once her creatinine normalized, she was started on
torsemide 60mg daily (uptitrated from home torsemide 40mg
daily). Her Lisinopril was initialy held due to ___, resumed at
half her home dose (5mg instead of 10mg) prior to discharge. She
was continued on carvedilol for neurohormonal beta-blockade.
Spironolactone initiation was deferred to outpatient
cardiologist given mild hyperkalemia.
-Discharge weight: 144.34 kg (318.21 lb)
-Please uptitrate medications as appropriate to achieve optimal
heart failure therapy
-Consider further w/u of regional systolic dysfunction in PDA
distribution
#RLE venous stasis:
Patient reported increased RLE warmth, TTP and edema. She had
received a x7 day course of cephalexin as an outpatient for
presumed cellulitis. On admission, she had no evidence of
infection on exam, and ___ was negative for DVT. She did not
receive antibiotics during her hospitalization. Her pain and
edema improved with diuresis and discontinuation of her home
amlodipine. She was encouraged to wear compression stockings on
discharge and elevated her legs while at rest/asleep.
#Insulin dependent diabetes, type 2:
Patient was initially continued on her home insulin regimen;
however in the setting of in-hospital dietary restrictions she
had an episode of hypoglycemia. Her FSBG were monitored, and her
insulin regimen was titrated. She was continued on gabapentin
for neuropathy. She was discharged on NPH 49u BID (in place of
home 53u BID). Home metformin was held and resumed on discharge.
-Recommend close outpatient follow up of her FSBG, encouraged
patient to check her FSBG
#Chest pain, likely due to reflux:
Patient endorsed intermittent chest pain during her
hospitalization, thought to represent acid reflux in setting of
non-ischemic EKGs and negative biomarkers. She was started on
omeprazole with improvement in her symptoms. TTE was largely
unchanged from ___, as above. She would likely benefit from
further cardiac evaluation as outpatient.
#Hypertension:
Home carvedilol was continued. Lisinopril was initially held, as
above, resumed at half home dose on discharge (5mg). Amlodipine
was discontinued given normotension and lower extremity edema.
#Acute kidney injury:
Cr rose to 1.8 on ___, likely secondary to overdiureis.
Improving to 1.2 at the time of discharge. Lisinopril was
initially held, resumed at half home dose prior to discharge.
Would benefit from repeat BMP at outpatient f/u appointment.
#Hyperlipidemia
Continued on her home atorvastatin 80 mg daily
#Depression
Continued on her home citalopram 40 mg daily | 162 | 577 |
12488949-DS-10 | 21,638,518 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were feeling short of
breath and you had a cough.
What did you receive in the hospital?
- You received medications to help your breathing and cough
including nebulizers and cough syrup.
- You were evaluated by the interventional lung doctors. ___
did not feel any further procedures were needed at this time.
What should you do once you leave the hospital?
- Please take all your medications as prescribed.
- Please pick up your 3% saline nebs and cough syrup with
codeine after leaving the hospital.
- Follow-up with your doctors ___ below for scheduled
appointments).
We wish you all the best!
- Your ___ Care Team | ___ with asthma, mild vocal cord dysfunction, GERD, depression
presenting w/ intermittent shortness of breath without hypoxia,
found to have severe tracheobronchomalacia s/p stenting on last
admission (___), presenting again for shortness of breath
and coughing without hypoxia.
TRANSITIONAL ISSUES
===================
[ ] For asthma, continue maximum medical therapy:
- continue albuterol/hypertonic saline nebs, Mucinex, codeine as
needed
- Not currently on NAC nebs due to cost, would benefit from
prior authorization to decrease cost as these have been helpful
in the hospital
- continue flutter valve 4 times per day
- continue ___, spiriva
- continue PPI
[ ] Patient reporting that she is unable to obtain
acetylcysteine nebs, and does not take them. Consider evaluation
for medication coverage for necessary medciations.
[ ] For anxiety, continued sertraline, buspirone, ativan qhs
prn. Suspect some contribution to shortness of breath episodes.
[ ] has interventional pulmonology appointment set up for repeat
bronchoscopy and stent removal (stents placed in L main and
trachea)
[ ] has general pulmonology follow up for asthma, with plan for
repeat PFTs
[ ] Has f/u with Dr. ___ Dr. ___ on ___ in
tracheobronchomalacia (TBM) clinic
[ ] Consider outpatient sleep study (patient felt subjectively
improved with CPAP on prior hospitalization but was unable to
obtain insurance approval).
[ ] Lactate was 2.9 at the time of discharge felt to be type B
lactic acidosis from albuterol nebs.
ACUTE ISSUES
============
# Dyspnea
# Severe tracheobronchomalacia
# Asthma
# Paradoxical vocal fold movement
She was recently admitted ___ for dyspnea felt to be
multifactorial secondary to vocal cord dysfunction, asthma and
also tracheobronchomalacia. Tracheal stent was placed during
most recent admission as a trial to see if TBM is a major
contributor to dyspnea. She was readmitted on ___, 1 day
following discharge, secondary to not being able to pick up
cough syrup with codeine at the pharmacy and ongoing severe
cough leading to severe dyspnea at home. She was not noted to be
hypoxic upon presentation to the hospital. She received one dose
of steroids in the ED for concern for stridor which was
subsequently discontinued given no evidence of stridor on
re-evaluation. She was evaluated by IP who did not feel any
further procedures were required at this time. She was continued
on her home regimen including saline nebs Q2H, albuterol and
acetylcysteine nebs Q4H, Mucinex and codeine PRN,flutter valve 4
times per day, ___ , tiotropium inh. Prior to discharge
guaifenesin/codeine cough syrup and hypertonic saline nebs were
filled at outpatient pharmacy. She will take these in addition
to her albuterol/ipratropium nebs until her pulmonary
appointment ___. Her subjective dyspnea was improved at the time
of discharge and patient's strong preference was to be home
managing her symptoms rather than in the hospital. Discharge
plan discussed with patient, her daughter, ___ and ___ PCP,
___.
# Stridor (resolved)
Present in ED, although noted to occur mostly when providers
were in the room and then improve when pt alone in the room. She
also received high-dose steroids while in ED. This was
subsequently discontinued on the floor and there was no further
evidence of stridor.
# Elevated lactate
Downtrending from prior admission (previously 4.4 on 2.4). No
evidence of hypoperfusion during this admission. Lactate was 2.9
at the time of discharge and felt to be due to type B lactic
acidosis from albuterol nebs.
CHRONIC ISSUES
# Major depressive disorder w anxious features
# History of suicide attempt in ___
Suspect a cycle of dyspnea contributing to anxiety contributing
to more dyspnea is occurring, however do not think anxiety is
her primary driver of her dyspneic symptoms. Of note, there is a
history of suicide attempt in ___, when patient was
hospitalized and found by her daughter to be attempting to
strangle herself with tubing. Patient denied any suicidal
ideation during this admission, and reports that prior suicide
attempt occurred in the setting of frustration secondary to
prolonged illness/hospitalization. Her home sertraline,
buspirone, and PRN Ativan were continued during this admission.
# GERD - Continued home omeprazole.
# Constipation - Continued home senna, miralax.
# Neuropathy - Continued home gabapentin.
# HLD - Continued home atorvastatin.
# Prior CVA - Continued home aspirin.
CORE MEASURES
# Contact/HCP: ___ daughter/HCP, ___
# Code status: Full, confirmed | 128 | 689 |
18935678-DS-15 | 23,159,025 | Dear ___,
___ was a pleasure taking care of you. You were admitted to the
___ for diarrhea. We believe
that your symptoms are from a minor case of an entity called
ischemic colitis, which may be combined with some irritable
bowel syndrome. Throughout your hospitalization, your symptoms
improved.
You should continue all of your medications as you had taken
prior to your hospitalization, EXCEPT:
ADD maalox
ADD senna
ADD colace
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Pt is an ___ y/o woman with a past medical history significant
for HTN, DMII(conservatively managed with lifestyle), CAD and
diastolic heart failure (EF>55% from ECHO in ___, who presents
with abdominal pain and generalized weakness. | 86 | 36 |
12906270-DS-23 | 24,122,972 | You were admitted to the hospital because of acute
cholecystitis.
You were treated with IV antibiotics with good effect. You will
continue to take oral antibiotics for 8 more days.
You were taken to the OR for a laparoscopic cholecystectomy and
tolerated this procedure well. You had no complications
following this procedure. A JP drain was placed during the
operation and this was removed prior to discharge.
You may continue with your regular diet.
You should not lift any objects greater than 5 pounds until
cleared to do so by your surgeon.
You should seek immediate medical attention if you develop
fevers, worsening abdominal pain, inability to eat food, nausea,
vomiting, chills, or any other symptom which is concerning to
you. | Mr. ___ was admitted to the ACS service with acute onset RUQ
pain on ___. An ultrasound was performed and was consistent
with acute cholecystitis. He was taken to the OR on ___ for a
laparoscopic cholecystectomy (reader referred to operative
report for further details). His case was uncomplicated and a JP
drain was left in place post-operatively. Following an
uneventful stay in the PACU, he was transferred to the floor in
stable condition. His diet was advanced, and he tolerated this
well. His home medications were begun immediately post-op, and
he was continued on antibiotic therapy (cipro/flagyl). He
remained stable and afebrile throughout his hospital stay.
On the day of discharge, he is stable, afebrile, tolerating a
regular diet without issue, on his home medications, and with
normal bowel/bladder function. He is ambulating without
assistance and reports baseline levels of his chronic pain on
his home regimen of 60mg q3 hrs prn.
He will continue on oral cipro/flagyl for 8 days to complete a
10 day course. He will need follow up in ___ clinic in ___
weeks. | 118 | 180 |
12761215-DS-6 | 27,115,697 | You were found to have a brain tumor. Please continue to take
keppra, it is a antiseizure medications.
Dr ___ will call you to discuss surgical planning.
Please continue your steroids (Dexamethasone) until surgery.
Please take this with food and with a stomach protectant such as
Protonix, Pepcid, or Prilosec.
Please continue your Keppra until surgery. | Ms. ___ was evaluated in the emergency room, then
subsequently admited to undergo a workup of this newly found
left parietal mass. She underwent an MRI with contrast and a
CTA to better charecterize this lesion, she was also placed on
steroids to bring down the swelling associated with the tumor.
On ___ she remained stable and was seen by ___ and OT. She was
cleared for home and given a cane.
Surgical planning was discussed with Dr ___ planned to
d/c patient home with the plan to electively resect the mass.
Patient was discharged home with a cane at Dr ___
___ who felt that no urgent surgical intervention is
necessary. | 54 | 114 |
17579658-DS-13 | 23,585,863 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge | The patient was admitted for evaluation for fatigue and atrial
fibrillation. The patient had alternating sinus bradycardia and
atrial fibrillation with RVR. The cardiology team was consulted
and she was her Lopressor dose was gradually increased. She was
started on amiodarone. She had a Zio patch placed prior to
discharge and will follow up with Dr. ___ as an outpatient.
Her fatigue improved with rate control of her atrial
fibrillation. At the time of discharge the patient was
ambulating without difficulty and her fatigue had resolved. She
was discharged on ___. | 117 | 92 |
16581153-DS-18 | 29,721,295 | Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abdominal pain and nausea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You underwent imaging to scan for disease in your abdomen,
chest and neck.
-You were found to have a blood clot and infection in your neck.
-You were treated with antibiotics.
-You were started on anti-coagulation medicine to treat a clot
in your neck vein.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and go to your
appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with Stage Ia
intra-ductal breast cancer of the left breast (ER+/PR-/HER2-)
s/p left partial mastectomy on C2D9 of taxotere/cyclophosphamide
adjuvant chemotherapy, meningioma, hypertension who presents
with nausea, abdominal pain and loose stools, found to have
right IJ thrombophlebitis.
TRANSITIONAL ISSUES
===================
[ ] Continue outpatient follow up with outpatient oncologist,
Dr. ___.
[ ] Continue follow up for incidental finding of Pancreatic
abnormality most c/w IPMN seen on CT. Per imaging report,
recommend non-contrast MRCP follow-up every other year up to a
total of ___ years. See CT report for details.
[ ] Follow up with outpatient provider given incidental finding
on CT of fluid collection in large left breast, most probably
representing post-operative changes, please see CT report for
details.
[ ] Continue follow up with outpatient dentist for molar pain.
[ ] Consider outpatient follow up with ___ clinic.
[ ] Follow up with the ___ clinic for antibiotic treatment
monitoring. Please draw weekly labs, including CBC with
differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, and send
to ___ clinic, Fax: ___.
ACUTE/ACTIVE ISSUES
===================
#Right neck pain and swelling
#Right molar pain
Has had molar pain previous to this admission that appears to be
waxing and waning, worse during her treatment cycles. However,
during this admission she has had extension to her mandibular
angle with fullness concerning for possible infection,
particularly given her neutropenia. CT neck with IV contrast
demonstrated an IJ thrombus with complete occlusion, possibly
originating from her tunneled port; possible infective etiology
with no clear source. Retropharyngeal swelling was also
identified with ill-defined fluid, could be concerning for a
phlegmon forming in the absence of neutrophils. Evaluated by
ENT, had no airway compromise throughout admission and thus was
not treated with dexamethasone. Per the Oral/Maxilofacial
Surgery service, not likely odontogenic. The infectious diseases
service was consulted and felt this was most consistent with R
IJ suppurative thrombophlebitis with associated RP stranding and
edema.
She was started on anticoagulation with IV Heparin and
broadspectrum antibiotics with zosyn. A chest CTA did not
demonstrate any PE or septic emboli and repeat venous phase
imaging of the neck demonstrated known clot with no abscess
formation and resolving edema. Antibiotics transitioned from IV
Zosyn to PO Flagyl with IV Ceftriaxone, which she will continue
for a total of four weeks; she was also started on loading dose
apixaban in lieu of IV Heparin and will continue apixaban for 3
months, then re-evaluated with her outpatient provider. Overall,
seems to be resolving with current treatment, which she will
continue at home. Her port was treated once with tPA empirically
for possibility of fibrin tail arising from the intra-venous
catheter. Though her neck pain has resolved, her molar pain is
still bothersome. After revision of CT neck (included teeth and
mandible) and conversation with OMFS, there is no indication for
urgent treatment and no sign of infection, the patient will
continue with pain control and anti-emetics and will follow up
with outpatient dentist as well as with ___ clinic as
outpatient. Of note, patient was given pre- and post-contrast
hydration to avoid contrast nephropathy, given her age,
comorbidities and having several scan in a short interim. Blood
cultures were obtained and did not grow pathogens ___ final
negative, ___ no growth for four days).
#Nausea
#Abdominal pain
#Loose stools
Presented with ___ days of symptoms with CT Abdomen and Pelvis
with possible diverticulitis. Her symptoms seem to recur with
each chemotherapy cycle. Differential diagnosis includes
infectious colitis, neutropenic colitis. Ischemic colitis can be
associated with docetaxel. Received cefepime and flagyl in ED.
She has been afebrile, UA and CXR negative. Lactate negative.
While on the floor, endorsed resolution of abdominal symptoms.
Antibiotic treatment continues with Ceftriaxone and Flagyl which
should also cover possible diverticulitis, ID has been
following. Stool studies were not obtained since her symptoms
resolved prior to arriving on the floor. Blood cultures were
negative. Pain was well controlled with acetaminophen and as
needed Tramadol. Nausea was well controlled with Zofran and
resolved at first, but mild nausea has returned, that may also
be secondary to Flagyl treatment, but is well controlled and
patient is doing well on Zofran and Compazine as needed, which
she will continue to take at home (Zofran, Compazine if Zofran
fails to alleviate symptoms). | 117 | 703 |
17591410-DS-6 | 29,831,720 | Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because you passed out at home. This is what we call
syncope. You have had numerous episodes, and we are not sure of
the cause, but we have excluded heart problems and think that
seizure is unlikely and were not noted on the EEG reports thus
far. We think that your problem is caused by dropping blood
pressure after meals. We suggest that you eat small, frequent
meals and avoid large meals. We also recommend that you remain
sitting for a period after you eat to prevent falls. Do strongly
recommend that you stop driving as you will be endangering
yourself and others on the road. We started a new medication
called florinef that we hope will help prevent syncope. | This is a ___ who was re-admitted to our service after another
episode of syncope, which occurred after eating breakfast. The
patient has had many episodes of syncope in the past several
years, almost all after large meals. He seems to be having more
frequent episodes recently. He was admitted for cardiac work-up
and had a pacemaker placed ___, but had a recurrent episode
and pacemaker was interrogated and working properly. Neurology
was consulted, and CTA head and neck were done, as well as an
EEG. The first EEG read is negative and 2 subsequent reports are
pending. Exam is suggestive of autonomic neuropathy with
parasympathetic dilation following large meals. We have had a
family meeting to discuss how to prevent readmissions for this
diagnosis, which the family will continue to work on after
discharge. The conclusion of all of these tests is:
1. There is likely not a dangerous underlying cause of his
syncope
2. The most likely cause of his syncope is autonomic dysfunction
3. The patient and his family need a better plan to deal with
this syncope then continuous hospital readmissions.
4. He should take florinef 0.1 mg daily unless another diagnosis
comes to light
5. He should follow up with BOTH cognitive neurology for
possible infarct and Dr. ___ for autonomic
neuropathy leading to recurrent syncope. She may recommend a
tilt table test in the future and medication changes
# VVI Pacemaker placement ___: no complications.
Interrogated with this admission, no issue.
# Afib: CHADS 2 score of 3, anticoagulated and rate controlled
-Should this be continued in the long-run given his high risk of
falls? It seems that all his falls have been while sitting, so
perhaps this does not increase his bleeding risk, but it
deserves an ongoing discussion
# CAD: As above, POBA ___ years ago of unknown vessel. Patient
without chest pain with activity. Echocardiogram with EF >55%
indicates excellent function in spite of atrial fibrillation and
CAD risk factors
- Atorvastatin 40 mg PO/NG DAILY
- Aspirin 81 mg PO/NG DAILY
# Recent hip replacement. Patient reports that he has not yet
set up outpatient rehab, although he has seen rehab recently as
an inpatient. He was seen by physical therapy on his first
admission to our service who did not feel that he would benefit
from outpatient services.
# Lower extremity edema/ Varicose veins: Negative LENIs and
anticoagulated.
- Patient scheduled to see Dr. ___ month
- Recommend compression stockings for this as well as his
presumed autonomic hypotension
# Diabetes: diet controlled. Last A1c was 6.4 here. He was not
hypoglycemic during any of these episodes | 136 | 429 |
11643452-DS-7 | 24,813,897 | Dear Mr. ___,
WHY YOU WERE HERE:
You were admitted with stroke symptoms and were found to have
left MCA strokes as well as splenic and renal infarcts.
WHILE YOU WERE HERE:
You were found to have right upper extremity deep vein
thrombosis (clot) and you were started on anticoagulation (blood
thinner). You underwent a liver biopsy that revealed
adenocarcinoma. Your right shoulder mass biopsy revealed
Metastatic adenocarcinoma. You have received chemotherapy and
radiation while in house. You tolerated the treatment well and
now you are ready to be discharged from the hospital.
WHAT YOU SHOULD DO WHEN YOU GO HOME:
- Please continue all medications as directed
- Please follow-up with the below doctors
___ for allowing us to take care of you,
Your ___ Care Team | Mr. ___ is a ___ yo male with history of HTN, NIDDM, and
___ esophagus with recently discovered necrotic right
shoulder mass who presented with dysarthria and difficulty
writing and was found to have DIC (likely due to underlying
malignancy) complicated by embolic left MCA, splenic and renal
infarcts, as well as right upper extremity DVT. He was diagnosed
with metastatic mucinous adenocarcinoma. He was initially in the
ICU, then transferred to the floor where he received FOLFOX and
radiation and was discharged for follow-up.
#Metastatic mucinous adenocarcinoma
Diagnosed with metastatic mucinous adenocarcinoma on liver
biopsy ___, shoulder lesion also consistent with this
pathology. He received radiation therapy to the shoulder and
started FOLFOX on ___. Continue heme-onc follow-up as
outpatient.
#DIC:
#CVA:
#RUE DVT:
Initially presented with dysarthria and difficulty writing.
Improving, but with ongoing word finding difficulty at times.
MRI confirmed left MCA territory strokes with embolic
distribution.
Likely in the setting of DIC with thrombosis due to malignancy.
TTE with bubble study
that did not reveal shunt or visible vegetation. He was also
found to have RUE DVT. Discharged on therapeutic lovenox for
anticoagulation, should have hematology-oncology follow-up. ___
and OT recommended home with 24 hour supervision. His
Atorvastatin increased from 40 mg to 80 mg oral QD. Re-check DIC
labs in clinic, which were resolved on discharge.
#Encephalopathy
Patient became transiently confused and somnolent ___.
Infection work-ups were obtained and negative. Patient's
narcotics were held and somnolence resolved. Pain medication
should be re-started in clinic pending stable mental status,
consider decreased dose.
#SVT: Possible AVNRT on ___ with HR 120s. He has been
asymptomatic and resolved with vagal maneuvers. No further
episodes.
#NIDDM: His home metformin has been held and started on insulin
sliding scale. Resumed metformin on discharge.
#Essential hypertension: He will be discharged on Lisinopril
10mg QD daily. Recommend checking electrolytes in clinic and
titrating BP regimen as appropriate.
#Incidental Findings:
- CT A/P Small abdominal aortic aneurysm amenable to
surveillance on future followup imaging.
- CT Chest with questionable new 1 pulmonary nodule in the right
lower lobe, 2 mm. Reassessment in ___ months is to be
considered.
TRANSITIONAL ISSUES
=====================
- Continue heme-onc follow-up as outpatient.
- Discharged on therapeutic lovenox for anticoagulation, should
have hematology-oncology follow-up.
- ___ and OT recommended home with 24 hour supervision.
- His Atorvastatin increased from 40 mg to 80 mg oral QD.
- Re-check DIC labs in clinic, which were resolved on discharge.
- Pain medication should be re-started in clinic pending stable
mental status, consider decreased dose.
- He will be discharged on Lisinopril 10mg QD daily.
- Recommend checking electrolytes in clinic and titrating BP
regimen as appropriate.
- Pending blood cultures should be followed up in clinic
- Consider outpatient palliative care referral
- Monitor R arm swelling in clinic, repeat US if not improving | 122 | 461 |
13462510-DS-19 | 23,376,828 | It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for your right foot infection.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please use the surgical
shoe/forefoot offloading shoe for you right foot until your
follow up appointment. It will be beneficial to use crutches for
balance and keeping pressure of your right forefoot. You should
keep this site elevated when ever possible (above the level of
the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
EXERCISE:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENTS:
Be sure to keep your medical appointments.
Please follow up with your Podiatric Surgeon, Dr. ___. If a
follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have concern for a possible abscess and was admitted to the
podiatric surgery service. The patient was given antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, wounds were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
partial weight bearing in the right lower extremity. 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. | 441 | 154 |
16887057-DS-8 | 27,338,863 | Dear Ms. ___,
You were admitted with symptoms of slurred speech, double
vision, lightheadedness, difficulty walking, and difficulty
thinking with memory problems. These symptoms are most likely
due to medication side effects. We have verified your
medications with your pharmacy, psychiatrist, and PCP and have
made some changes. Please follow your new list closely. You will
have close follow up with Dr. ___ Dr. ___.
Your fatigue and memory issues may be due to sleep apnea. You
will have a sleep study as an outpatient.
You should also start an exercise program with walking for 20
minutes ___ times a week. Weight loss with help with your sleep
apnea.
Your MRI did not show any acute problems in your ___. | Ms. ___ is a ___ year old RH woman with a history of DM, HTN,
HLD, anxiety, depression, who presented with intermittent
slurred speech, double vision, trouble swallowing, exertional
dyspnea, unsteady gait, dizziness, trouble thinking and mild
memory problems. On exam she had an intermittent esophoria,
which is likely causing the intermittent double vision. Her
speech and dysphagia are likely due to dry mouth from medication
side effects. Her medications were verified with her pharmacy,
psychiatrist, and PCP, all of whom had different lists. The
lists were consolidated, and medication changes were made in
discussion with her psychiatrist to attempt to minimize her side
effects. Her discharge med list is final. She was discharged
with a ___ for medication administration and teaching. Her
cognitive difficulties may be due to sleep apnea, and an
outpatient sleep study has been ordered. Her gait problems are
due to volume depletion and positive orthostatics, which
resolved with IV fluids. Her symptoms and diagnosis is not
consistent with myasthenia ___. | 116 | 165 |
14427915-DS-4 | 25,515,817 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | ___ The patient was admitted to the floor following
evaluation in the emergency departmnt where he was found to have
new right sided weakness, aphasia and was lethargic. He was
loaded with 1G of Keppra and his home dose of Keppra increased.
On ___, the patient was evaluated by neurology for work up for
possible seizures versu stroke. They suggested a MRI with and
without contrast which showed stable left SDH, no ischemia. They
also recommended continuous EEG monitoring.
On ___ EEG showed no evidence of seizure. In the afternoon he
became more aphasic. STAT head CT showed no change. Stroke
neurology was called to consult but felt it was not necessary
given that Neuro Medicine was following. A MRI brain was
obtained on ___ which showed no infarcts. EEG remained negative
although slowing was noted. EEG was discontinued on ___.
On ___, he continued to have episodes of aphasia. Neurology
recommended increasing the Keppra to 1500 mg BID. ___ saw the
patient and was leaning toward rehab placement.
On ___, The patient was evaluated by physical tehrapy and it was
recommended that ___ patient be discharged to rehab.The patient
remained neurologically stable.
On ___, The patient was neurologically stable, moving all of his
extremities, eyes were open spontaneously, staples were removed
from his surgical incision which was well healed. The patient
was discharged to rehab. | 139 | 226 |
16790524-DS-2 | 22,362,679 | Surgery
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet when out of bed at all times.
Please keep your sutures or staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | #TBI
Patient was admitted to ICU for close neurologic monitoring. 3%
hypertonic saline started for goal sodium of 138-150. Repeat CT
head showed worsening hemorrhage/contusion. He was taken
emergently to the OR for left decompressive hemicraniectomy on
___. Postop CT head showed expected postoperative changes and
slightly improved midline shift. Surgical drain left in place
postop. He was taken off hypertonic saline and remained at goal.
On POD#1, there was minimal output to his drain and drainage
from his incision, which stopped. His neurologic exam improved
postoperatively. He was extubated on POD#1 and neuro exam
improved. Subdural drain continued with low output and was
removed. He was given helmet for OOB. Alertness continued to
improve and he was transferred out of ICU. He remained
neurologically stable and was transferred to the floor.
#Seizures
Patient was started on Keppra and cEEG, and Neurology was
consulted for seizures. Keppra was uptitrated for seizure
control. No epileptiform discharges were seen on EEG, so this
was discontinued on ___.
#Left Temporal Bone Fracture
ENT was consulted for left temporal bone fracture and
recommended Ciprodex drops and CSF leak monitoring. After
extubation, the patient was noted to have a left ___ nerve
palsy; CT orbits & sella was concerning for small left petrous
bone fracture. CN6 palsy improved. If persists, he should follow
up with ophthalmology.
#Orthostatic hypotension
On ___, when working with ___, he became orthostatic and dizzy.
He was ordered for a 1L bolus, and orthostatics were rechecked,
which improved. On ___, he was again orthostatic with ___,
however was asymptomatic. He was given an additional 1L bolus
and placed on IV maintenance fluids which were eventually
discontinued.
#BLE/LBP
Patient complained of right lower extremity pain from hip to
knee while working with ___. On evaluation ___, the patient
endorse RLE pain with pain on palpation from hip to knee only.
XR of right hip was negative. Pain persisted and ___ started
uptrending, RLE US was negative for DVT. On ___, he began
complaining of low back pain that radiated down BLE to knees,
endorse pain to palpation on spine from mid thoracic thru
lumbar. CT L spine was negative. CT T spine showed compression
deformities, MRI T spine revealed that the compression
deformities were chronic. MRI L spine showed a subdural
collection from L2-S2 and and epidural collection at L2. After
review of images with spine attending, it was determined that no
surgical intervention was indicated at this time. Patient has
been instructed to follow up in spine clinic on discharge.
#Leukocytosis
Patient's WBC started increasing on ___. Patient was afebrile.
UA was negative and RLE ultrasound negative. Tylenol held to see
if it was masking fevers, patient remained afebrile and Tylenol
was restarted. WBC began to down trend.
#Thrombocythemia
Patient had continuously elevating platelet count. He was
started on IV fluids. Platelet count continued to up trend so
medicine team was consulted. Blood smear showed blood cells with
regular morphology and increased platelets. Merit was consulted
and after discussion with hematology determined this was likely
a reactive response secondary to trauma. Platelets continued to
be trended while in patient and patient instructed to follow up
with hematology on discharge.
#Hyperkalemia
On ___, patient's K was 5.5. EKG was normal. He was restarted
on telemetry. ___ K was 5.1. K continued to down trend and
remained within normal limits thru duration of stay.
#Dispo
___ and OT evaluated the patient. ___ cleared him for home with
___. OT initially recommended rehab, however due to the patient
not having rehab benefits, began progressing him to home with
24h supervision. Complex case management was involved. On ___,
a family meeting was held to discuss coordination of 24 hour
supervision. Patient was stable and cleared for discharge home
on ___. | 608 | 620 |
19429340-DS-3 | 23,363,681 | Dear Mr. ___,
You were admitted to the hospital with abdominal pain and
abnormal liver enzymes. An ERCP was performed and you were found
to have a condition called cholangitis. We treated you with
antibiotics and ultimately referred you to the surgical service
for removal of your gallbladder, which they will do in a few
weeks as an outpatient.
We wish you the best with your health.
Warm regards,
___ Medicine | BRIEF FICU COURSE:
=================
Mr. ___ is a ___ y/o man with coronary artery disease
and
hypertension who is presenting as a transfer from ___ for an ERCP in the setting of acute
cholangitis.
Patient was sent to the FICU in the setting of shock. His
hypotension is likely driven by a distributive physiology
secondary to sepsis and possibly pancreatitis, both of which are
likely triggered by an obstructed common bile duct. He was fluid
resuscitated and his MAPs were maintained with norepinephrine.
He was covered broadly with vancomycin and
piperacillin-tazobactam for the time being, follow up blood and
urine cultures. He was taken for ERCP on ___ where he was
found to have cholangitis. He had a sphincterotomy and a
plastic stent was placed after which he was transferred to the
hospital floor. | 71 | 133 |
15219741-DS-22 | 29,702,921 | Dear Ms. ___,
You were admitted to ___
because your kidneys were injured. This is because of worsening
of your cirrhosis, which caused not enough blood to flow to your
kidneys. (This is also known as hepatorenal syndrome.)
While you were here, we gave you medications to increase blood
flow to your kidneys. We also looked in your urine and blood to
make sure there was not any infection contributing to your
kidney injury.
At time of discharge, you were on the maximal medical treatment
that we could give you. Your creatinine (a number that we use to
look at kidney function) at discharge was 3.4; your baseline
creatinine is 1.1-1.6.
It was a pleasure taking care of you, and we wish you well.
Sincerely,
Your ___ care team | ___ year old woman with hepatitis C cirrhosis (MELD 36)
complicated by ascites, hepatocellular carcinoma (s/p TACE, RFA,
and CT guided fiducial placement), and hepatic hydrothorax s/p
pleurex placement, who presented with acute kidney injury
concerning for hepatorenal syndrome. Cr 3.4 on discharge despite
maximal midodrine, octreotide, and albumin, from baseline of
1.1-1.6. Thoracentesis and abdominal paracentesis are indicated
with palliative intent.
# Hepatorenal syndrome: Ms. ___ presented on ___ with acute
rise in Cr from baseline of 1.1-1.5 to 2.4, concern for
hepatorenal syndrome. All diuretics were discontinued, and she
was given octreotide, midodrine and albumin 1g/ kg from
___. As her Cr continued to rise, she was placed on maximal
octreotide and midodrine and 40g albumin/day from ___ onwards.
Cr peaked at at 3.4 on ___, downtrending thereafter.
Unfortunately, on day of discharge, her Cr was again 3.4. She
will be continued on maximal octreotide 200 mcg subQ Q8H and
midodrine 15 mg PO TID upon discharge. Of note, during her stay,
she remained afebrile. Her infectious work up has also been
unremarkable, with negative U/A ___, CXR ___, and no evidence
of SBP on ___ paracentesis.
# Hepatitic C Cirrhosis
1) Ascites: Ms. ___ received paracentesis ___ while at
home for diuretic resistant ascites. During her stay with us,
diuretics were held due to concern for hepatorenal syndrome. She
received diagnostic and therapeutic paracentesis on ___, for
total of 2.5 L removed; she received 25 g of albumin post
procedure. No evidence of SBP. She will continue to receive
weekly paracentesis after discharge, with albumin 25% ___ of
ascitic fluid removed for symptomatic management.
2) Hepatic encephalopathy: Infectious workup was negative as
above. She was continued on lactulose 30mL q4H, titrated to 3
bowel movements daily, and rifaximin 550mg BID.
3) Hepatocellular carcinoma: s/p TACE, RFA, and CT guided
fiducial placement
4) Heptaorenal syndrome: Management as above
5) Grade I varices: No evidence of GI bleeding throughout
admission, H/H remained stable.
# Recurrent hepatic hydrothorax: s/p R pleurex placement. 1 L of
fluid was drained by interventional pulmonology on ___ for
symptomatic management. She developed a small pneumothorax which
resolved on its own on ___.
# Goals of Care: After multiple discussions with the patient, it
was decided that given likely poor prognosis due to hepatorenal
syndrome, hospice care would be the correct option, as she
wishes to enjoy the rest of her life doing things that she
enjoys, such as playing with her grandchildren.
=========================
TRANSITIONAL ISSUES
=========================
[ ] DNR/DNI on discharge, given trial of maximal therapy will
not benefit from further inpatient management--should be
transitioned to comfort measures only. She is not a candidate
for CRRT.
[ ] Call to restart weekly paracenteses at ___- should
receive IV albumin 25% ___ of ascitic fluid removed with
paracentesis. The radiology nurses at ___ have a
standing order for paracenteses and IV albumin.
[ ] Monthly thoracentesis via pleurex catheter.
[ ] Octcreotide and Midodrine uptitrated maximally to 200 mcg
and 15 mg TID respectively.
# CODE: DNR/DNI
# CONTACT: ___, daughter. Cell: ___ | 124 | 496 |
17236865-DS-30 | 24,634,813 | Dear Ms. ___,
It was a pleasure participating in your care during your
admission to ___. You were
admitted for abdominal pain that was concerning for possible
vasculitis or infection. You were treated with antibiotics and
testing for infectious causes of your abdominal pain showed no
infection. Instead, you were determined to have an inflammatory
vasculitis of your bowels, likely related to your lupus, and
treated with prednisone. You have improved with that treatment.
You have completed your steroid course, which was a taper. You
will also taper your pain medication, oxycodone, as directed. We
also started a new pain medication, gabapentin. Finally, we
started two new medications, HCTZ and nadolol, for your high
blood pressure.
During your evaluation, you had a flexible sigmoidoscopy that
showed polyps in your colon. In 4 weeks, it is very important
that you have a colonoscopy with complete prep to better
evaluate the colon. You can follow up with Dr. ___. I have
ordered that colonoscopy. Please call ___ to schedule a
colonoscopy in about one month when it is convenient for your
schedule.
It was a pleasure being involved in your care, and best wishes.
Sincerely,
___, MD | ___ year old female with lupus, HTN, substance abuse, neuropathy,
s/p CVA, depression and anemia presenting to ED with lower
abdominal pain for 3 days found to have evidence of vasculitis
and lupus enteropathy on CT.
ACTIVE ISSUES:
1. Abdominal pain: Differential included vasculitis from lupus,
inflammatory bowel disease, and infectious enteropathy. Patient
did not have fevers or leukocytosis. She has a history of lupus
complicated by nephritis, pericarditis, and peritonitis so lupus
vasculitis was plausible, and CT abdomen findings were
concerning for lupus vasculitis. Rheumatology recommended
holding steroid therapy until infectious etiologies were ruled
out. She was started on cipro/flagyl. Paracentesis showed < 250
PMN. On ___, GI performed sigmoidoscopy which showed mild
edema and loss of vascularity in the rectum and sigmoid colon
(biopsy). Polyps in the colon.
Otherwise normal sigmoidoscopy to splenic flexure. Stool studies
were delayed due to patient not passing sufficient stool for
culture, but were sent on ___ and ___ and showed no ova and
parasites. Rheumatology recommended prednisone taper starting at
60mg. The patient improved on this taper over the next two days,
though her pain settled at a level still above her baseline. She
was discharged on a short course of oxycodone.
2. Rash: Started prior to hospitalization. It may be a
manifestation of vasculitis, other lupus symptoms, or allergy.
Patient was started on Sarna lotion. Over course of
hospitalization, rash resolved.
3. Hypertension - Patient was continued on home lisinopril but
had several episodes of hypertension in the setting of pain.
hydrochlorothiaze 25mg daily and nadolol 20mg daily were added
to control her pressures.
4. Substance abuse: c/b neuropathy due to alcoholism and poor
nutrition. On narcotics contract as outpatient. Patient required
hydromorphone for pain control during hospitalization, switched
to oxycodone and tapered on discharge to q6h for 4 days, q8h for
4 days, q12h for 3 days, q24h for 3 days.
CHRONIC ISSUES:
1. Hypothyroidism - Patient was continued on Synthroid.
2. Depression/Anxiety - Patient was continued on Paroxetine.
3. Migraine - Patient's fioricet was held because she was given
IV pain medication.
4. Nicotine dependence- Patient received a nicotine patch.
5. GERD - Patient was continued on omeprazole.
6. Lupus - Patient was continued on Hydroxychloroquine Sulfate
TRANSITIONAL ISSUES:
- Needs colonoscopy with complete prep as an outpatient in 4
weeks for more complete evaluation of colon
- Patient has understandable resistance to follow up with
rheumatology due to association of poor status in family members
while undergoing treatment | 192 | 408 |
14927129-DS-7 | 21,166,955 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for pneumonia and swelling
and pain in your hands
- You were also found to have elevated liver tests which will
need to be followed up by your doctor
- You were also found to have nodules in your lung which will
need to be followed up by your doctor
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were given antibiotics for the pneumonia
- You had blood tests drawn to check on your swollen joints,
most of which are still pending
- You were found to have nodules in the lung
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.
We wish you the best!
Sincerely,
Your ___ Team | Mr ___ in a ___ M with PMH of BPH s/p prostatectomy on no
medications at home who was admitted for pneumonia and MCP joint
swelling, found to have elevated LFTs and nodules within the
lungs. | 159 | 37 |
15185501-DS-25 | 21,739,672 | Dear Ms ___,
It was a pleasure to care for you at ___. You were admitted to
the hospital because you had a bad pneumonia causing 'septic
shock' (very low blood pressure). You went to the ICU, received
antibiotics, improved and came to the regular floor.
You developed an infection of your colon called colitis. You
will finish antibiotics on ___. After you finish your
ciprofloxacin and Flagyl, re-start your Bactrim therapy.
Also while you were here, you underwent sigmoidoscopy to
evaluate your abdominal pain. It revealed mild inflammation and
ulcers. It will be important to follow-up the biopsy results
with Dr. ___.
You need oxygen right now but as your pneumonia resolves and you
start opening your airways with physical therapy, we hope you
will be able to come off of oxygen.
All the best,
Your ___ Team | ___ yo F with MMP, significant for PSC and FMF who presented in
septic shock with a pulmonary source, who had a brief stay in
the MICU for pressor support. She completed an 7 day course of
antibiotics for pneumonia ___ Zosyn/azithromycin;
vancomycin discontinued after 2 days in ICU) but she continued
to be febrile on the floor and developed new abdominal pain.
Repeat CT abdomen on ___ showed new pan-colitis. Her antibiotic
coverage was augmented to Zosyn/Flagyl. Her abdominal pain
improved with antibiotic therapy and her fever curve trended
down. Flex sigmoidoscopy on ___ showed ulcers in sigmoid colon
and rectum. Planned for a 5 day course of GI antibiotic coverage
___ that her GI coverage overlaps with her PNA
coverage). Of note, she remained on supplemental ___ after
pneumonia treatment, with likely contribution from atelectasis,
given minimal incentive spirometry use and mobility.
# SEPTIC SHOCK SECONDARY TO PULMONARY SOURCE. She presented with
fever, hypotension, tachycardia, with vasopressor requirement
despite 4L NS in the ED and a potential source in the lungs with
a productive cough and chest xray findings. She was able to be
quickly weaned from low dose presors. She is known to be VRE+,
with CURB65 of 4. She only required low amounts of oxygen via
nasal cannula. Legionella and influenza were negative. Low
suspicion for MRSA pneumonia, so discontinued vancomycin. There
was perhaps a slight component of iatrogenesis as patient's home
dose of midodrine was delayed in the ED. She was also anemic,
though this was not thought to be due to hypovolemia from
bleeding for the reasons described below. She was treated with
vancomycin, Zosyn, and azithromycin given her known
immunocompromised state.
# ABDOMINAL PAIN. She developed abdominal pain on the general
medical floor and continued to have persistent fevers despite
broad pneumonia antibiotic coverage. Given the persistence and
severity of her pain, a repeat CT abdomen was obtained and
showed pan-colitis, which was thought to be the likely source of
her abdominal pain. She was augmented from Zosyn, with the
addition of Flagyl. Her fever curve trended down, and her
abdominal pain improved. Most likely etiology is intra-abdominal
infection, though C diff negative. Because of her known PSC, we
were also concerned for UC, as there is an association between
these diagnoses. Always of concern for her is recurrent
cholangitis and recurrent hepatic microabscesses. She had a
flexible sigmoidoscopy on ___ that showed ulcers and in the
sigmoid colon and rectum. She did not undergo MRCP as suspicion
for cholangitis was lower and she was clinically improving.
De-escalated antiobiotics from IV Zosyn, Flagyl to PO
Cipro/Flagyl, to complete 5 days (day 1 of GI coverage = ___,
final day ___. Rheumatology did NOT think her pain was due to
FMF.
# PNEUMONIA, HYPOXEMIA: Completed an 8 day course of antibiotics
for pneumonia (___) per above. By discharge was afebrile
with minimally productive cough, maintaining O2 saturation on
1L-2L NC. Persistent hypoxemia and slow recovery of pulmonary
status is likely secondary recent pneumonia but compounded by
atelectasis at this point. She continued to have poor air entry
over bilateral lower lobes, and was not compliant with incentive
spirometry, and rarely agreed to get up to chair with nursing or
___. Completed antibiotic coverage with Zosyn and azithromycin.
Continued supplemental O2 for SaO2 >94%. Encouraged incentive
spirometry, Acapella for expectoration
# MENTAL STATUS: Patient initially with poor attention,
difficulty word-finding after call out from the ICU. Low
suspicion for hepatic encephalopathy given her improvement, lack
of asterixis. ___ have also had a componenet of sedation from
narcotics, gabapentin as well as post-ICU delirium. Most likely
toxic-metabolic encephalopathy in the setting of systemic
infection and ICU course. By hospital day ___ her mental status
was improved and she was back to baseline. During this time we
minimized delirogenic medications, while still treating her back
and abdominal pain.
CHRONIC ISSUES:
===============
# IRON-DEFICIENCY ANEMIA: She was noted to have a drop in Hct
from 9.4-6.7 since arrival at ___. This likely represented
dilution from the liters of IVF she has received as well as
myelosuppression in the setting of severe systemic infection. CT
ruled out RP Bleed. Hemolysis labs unremarkable. No evidence of
GI bleed. Her retic count was inappropriately normal indicating
inappropriate bone marrow response. She received 1 unit PRBCs
and remained stable.
Patient with MCV <80 which began in ___, and anemia to Hgb
baseline of 10. Patient received 1 unit pRBC in MICU prior to
transfer to floor for Hgb 6.7. H/H remained stable on the
general medicine service without evidence of bleeding. Continued
home iron supplementation.
# LOWER BACK PAIN: Has been present for 1 month, in the setting
3 falls, localizing to coccyx, without motor or sensory
deficits. Also with normal hip XRs, and CT, at PCP. No evidence
of skin breakdown or cord compression. Continued APAP, lidoderm
patch, and tramadol PRN. Transiently held her gabapentin and
oxycodone in the setting of altered mental status. Restarted
gabapentin, did not require oxycodone for pain control on the
floor.
# PRIMARY SCLEROSING CHOLANGITIS, HEPATIC ABSCESS: Patient with
PSC and recurrent cholangitis s/p CBD excision with roux-en-Y
anastamosis complicated by h/o recurrent cholangitis. Patient
was on suppressive Bactrim at home, as well as Ursodiol. Biliary
duct did not look worse on CT ABD, lower suspicion for
cholanigitis given above differential and symptoms. Held home
suppressive Bactrim while on broad antibiotics and restarted on
discharge. Continued home ursodiol.
# FAMILIAL MEDITERRANEAN FEVER: Dx ___ - on colchicine at home.
Her flares are characterized by a particular abdominal pain,
distension, and fevers, which she denied on this admission.
Appreciate Rheum input, did not feel that patient was having a
FMF flare. Continued colchicine.
# PEPTIC ULCER DISEASE: continued home famotidine & sucralfate.
# HYPOTHYROIDISM: continued home levothyroxine.
# POLYMYALGIA RHEUMATICA: not on medication at this time - has
been off prednisone.
# ANXIETY: on clonazepam 0.5 mg TID at home, held during period
of altered mental status, and restarted prn on improvement.
# NEUROPATHY: continued Magic Mouthwash, Nystatin and home
gabapentin (though decreased dose of gabapentin in setting of
altered mental status). | 138 | 1,021 |
17836650-DS-9 | 25,137,236 | Dear ___,
___ was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
===========================
- you had abdominal and bilateral leg pain, and you were found
to be bleeding into your lower back; you also had blood clots in
both legs
WHAT HAPPENED IN THE HOSPITAL?
================================
- you were evaluated by our hematology team and neurology teams,
who recommended starting heparin drip for immediate
anticoagulation while monitoring you closely for ongoing bleed
into the retroperitoneum and the brain.
- you were also evaluated by our interventional radiology team,
who mechanically removed clots from your legs through a
procedure called thrombectomy
- you started receiving Lovenox injections after the heparin
drip was stopped, you then began the transition to long-term
anticoagulation on warfarin
- you were treated for your pain
- you received blood transfusions when your red blood cell
counts got low
- you were treated for your diarrhea, which was caused by a
bacterial called Salmonella, with an antibiotic called
ciprofloxacin
WHAT SHOULD I DO WHEN I GO HOME?
==================================
- finish your antibiotics: you last dose of ciprofloxacin is on
___
- You should establish care at an ___ clinic for
ongoing management of your warfarin after you leave rehab
- please attend your appointments as listed below
- please review your discharge medications and take them as
directed until you are instructed otherwise by your outpatient
providers
___ wish you the best!
-Your Care Team at ___ | =========================
BRIEF SUMMARY
=========================
Mrs. ___ is a ___ year old woman with a recent hemorrhagic
stroke, heterozygous prothrombin mutation, history of DVT/PE s/p
IVC filter (placed during recent hospitalization for stroke),
COPD, AAA s/p EVAR repair, Roux-en-Y gastric bypass, and
anxiety/depression, who presented from rehab with a
retroperitoneal hematoma and extensive bilateral lower extremity
DVTs.
=========================
PROBLEM-BASED SUMMARY
=========================
___ DVT
She was found to have extensive bilateral clot burden with
extension past level of the IVC filter. Hematology/Oncology was
consulted for hypercoagulability work-up
(anti-beta-2-glycoprotein-1 and anti-cardiolipins negative).
Neurology was consulted for timing of anticoagulation given
recent basal ganglia bleed. She was deemed not to be candidate
for long-term anticoagulation given recent stroke and ongoing
bleed. However, in discussing risks of intervention with
mechanical thrombectomy (including intra-procedural
anti-coagulation) it was thought that while risk of hematoma
expansion or intracerebral bleeding was increased, the risks
were not necessarily prohibitive toward a procedure. She was
initiated on heparin and transferred to the MICU for
neurovascular monitoring. While in the MICU, she was maintained
on the heparin drip and monitored closely for signs of bleeding
(see below). She underwent mechanical thrombectomy of bilateral
DVTs and IVC on ___ with Interventional Radiology. During the
mechanical thrombectomy, ___ was able to significantly reduce the
thrombus burden, however, they noted that there remained very
poor and persistent thrombus throughout the femoropopliteal and
iliac veins and IVC. Patient was transfused 1U PRBC on ___ and
___ for downtrending Hgb to mid 7. Once Hgb stabilized, the
patient transferred out of MICU to the floor. The patient was
consistently afebrile after the clot removal. She remained
neurologically and hemodynamically stable initially on the
heparin gtt (dosed to maintain PTT between 40 and 80) then
transitioned to Lovenox 90mg BID on ___ to continue bridge to
warfarin with ultimate INR goal of ___. Her ___ and groin pain
was initially controlled with standing acetaminophen, topical
lidocaine, PO oxycodone ___ mg q4h PRN, and IV morphine ___ mg
q3h PRN. Following clot removal, she did report improved ___ pain
so morphine was weaned. However, her ___ edema remained
impressive, and the patient could not bear weight without pain.
Given her consistently good kidney function, we started gentle
diuresis with PO Lasix (___) to help mobilize fluid from her
___.
# RETROPERITONEAL HEMATOMA
The hematoma measured 10x10x8 cm on ___ CTA at ___ prior
to transfer to ___ ED. The etiology is unclear. She was
evaluated by ___, who recommended conservative management with
serial CBCs and hemodynamic monitoring. While in the MICU, the
patient was tachycardic, hypotensive, and had Hgb drops
requiring intermittent transfusions of pRBCs (as above). She had
a repeat CT on ___ which showed that the RP hematoma was stable
in size. She was transferred to the floor once her Hgb
stabilized. Her abdominal pain also improved over the course of
this hospitalization.
# LUE PAIN
Patient complained of LUE pain on ___, noting that it began 5
days earlier during this admission. She had a reassuring exam
without notable UE asymmetry. LUE Doppler US was negative for
thrombosis. Given that she describes a neuropathic pattern of
intermittent sharp shooting pain from elbow to fingertips, she
was started on gabapentin 100mg TID and additional 200mg qhs.
she has a recorded allergy to gabapentin with unknown reaction,
she was monitored for adverse effect when this medication was
initiated inpatient without issue. We were also concerned her
pain may be MSK in etiology, related to contractions, so OT was
consulted and began an exercise program which should be
continued at Rehab.
# S/P R BASAL GANGLIA HEMORRHAGE
Patient had a hemorrhagic stroke while on vacation in ___, and
was hospitalized at ___ ___. Please see Discharge Summary
from this previous hospitalization for more detailed
information. The stroke was thought to be hypertension-induced
given its location, and because it was hemorrhagic not ischemic.
Workup for pheochromocytoma negative. She has residual left
sided symptoms (mild facial asymmetry, mild slurred speech,
weakness LUE > LLE). During this hospitalization, she maintained
SBP goal <150mmHg to prevent recurrent stroke without requiring
any medication. Her aspirin 81mg was held. Atorvastatin was also
held on admission but was restarted on ___ after her liver
enzymes normalized. She was monitored for signs and symptoms
with serial neuro exams. She had a NCHCT on ___ which showed no
new bleeds.
#DIARRHEA
In setting of increased diarrhea and fever on ___, patient had
cultures sent. Stool culture returned positive for salmonella.
She was started on ciprofloxacin 500mg q12h for a 7 day course
___ - projected end date ___.
#HEADACHE/HISTORY OF MIGRAINE
Patient complained of a severe headache which prompted a repeat
NCHCT on ___ which was negative for acute intracranial
processes. It was ultimately thought that the headache was
secondary to her known migraines. Her headache resolved with
Compazine. She was continued on Topamax daily for migraine
prophylaxis.
# ELEVATED LIVER ENZYMES
AST/ALT in low 100s on admission, with concurrently elevated
alkaline phosphatase but normal Tbili. Etiology unclear but
suspect secondary to compression from RP hematoma and possible
medication effect. Work-up was notable for RUQ U/S without PVT,
stable common bile duct dilation, negative
Hep serologies. Statin was held until her liver enzymes
normalized over the course of this hospitalizations.
# TWI/INFERIOR Q-WAVES
Noted on admission ECG, new from prior ECG. ___ have represented
demand ischemia. Multiple troponins negative. Will require
outpatient cardiac work-up.
#CHRONIC ISSUES
- HTN: goal SBP <150 as above, no medications were required.
- COPD: continued on home Advair.
- Depression: continued on home citalopram.
- Anxiety: continued on home lorazepam and buspirone.
- GERD: continued on home pantoprazole, received prn Zofran for
nausea
=========================
TRANSITIONAL ISSUES
=========================
- Last dose of ciprofloxacin on ___
- Administer Lovenox 90mg BID while bridging to warfarin
anticoagulation, check daily INR until therapeutic (goal INR
___ then discontinue Lovenox between ___ hours afterwards
- Pull back / discontinue furosemide once leg swelling has
improved
- ongoing titration of pain medications (may need to continue
gabapentin for arm pain but will likely be able to come off
oxycodone once leg swelling from clots improves)
- Follow up in ___: complete
hypercogulability work-up, consider protrombin gene mutation
testing to confirm history
- Follow up in Stroke Clinic: repeat MRI brain w/ and w/o
contrast + MRA within ___ months for follow-up
- Follow up with PCP: 1) cardiac work-up given new TWI and
inferior Q-waves on admission ECG; 2) continue to follow
incidental adnexal mass noted on CTA; 3) continue work-up of
incidental adrenal nodules as an outpatient (has negative
metanephrines in our records); 4) consider MRCP for further
evaluation of hepatic duct dilation
- CONTACT: ___ (daughter) ___
- CODE STATUS: Full code (attempt resuscitation) | 243 | 1,084 |
12307741-DS-3 | 23,212,654 | Ms. ___,
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you fell and hit your head.
- You also had low blood counts.
- You were found to have a bacterial infection in your blood
while you were here.
WHAT HAPPENED TO YOU WHILE YOU WERE IN THE HOSPITAL?
- You had imaging of your head done which showed a small bleed
in your head.
- Hematology doctors came to ___ you because your blood count
was low. They ordered tests to figure out why and had you stop
taking your Hydroxyurea.
- Infectious disease came to see you because you had bacteria in
your blood. We started you on antibiotics to treat your
infection.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
- You should go to rehabilitation.
- You should follow-up with Dr. ___ information
below).
- You should continue taking your antibiotics until ___.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team | Pt is a ___ y/o F with PMH polycythemia ___ and multiple CVAs
p/w fall. Patient fell backwards from a step on her driveway and
hit her head on the car. Her brother noticed that she looked
panicked and "dazed" before and after the fall so he brought her
to the ___ for a trauma/fall work-up. He is unsure as to
whether the patient lost consciousness. Per brother, the patient
is afraid to leave the home. She also has had a ___ year history
of numbness and pain in her feet that has not been worked-up
because the patient has canceled her appointments due to fear of
leaving the house. Of note, brother says that 4 days before the
fall, the patient had an episode of difficulty walking and
speaking which started in the afternoon and lasted until the
next morning.
====================== | 154 | 142 |
10777078-DS-5 | 24,828,086 | You have undergone the following operation: Laminotomies and
discectomy L3-4
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound. | Mr. ___ was admitted to the service of Dr. ___ for a
lumbar discectomy. He was informed and consented and elected to
proceed. Please see Operative Note for procedure in detail.
Post-operatively he was given antibiotics and pain medication.
His bladder catheter was removed POD 3 and his diet was advanced
without difficulty. He was able to work with physical therapy
for strength and balance. He was discharged in good condition
and will follow up in the Orthopaedic Spine clinic. | 343 | 85 |
11761593-DS-21 | 27,315,501 | Dear Mr. ___,
You came to the hospital because you were feeling very weak and
had a new cough.
While you were in the hospital, you were found to have
pneumonia. You were treated with antibiotics and cough medicine.
When you leave the hospital, you will take levofloxacin until
the bottle is empty.
It was a pleasure taking care of you!
Your ___ Team | Mr. ___ is a ___ w/ recently diagnosed aortic valve SBE i/s/o
strep viridans bacteremia, recent admission for splenic infarct,
papillary thyroid cancer, graves disease and HTN presenting with
weakness, fatigue, and dyspnea found to have pneumonia
ACTIVE ISSUES:
#Pneumonia: Bibasilar consolidations on CXR concerning for
pneumonia, with largest consolidation in right middle lobe.
Given his complicated history and multiple recent admissions,
hospital-acquired pneumonia was treated initially with IV
cefepime. He quickly defervesced, remained HD stable/afebrile
and was transitioned to levofloxacin on ___ to complete 5 days.
#Weakness
#Fatigue:
#Recent subacute bacterial endocarditis.
Pt had sudden onset of generalized weakness, fatigue, and brief
shortness of breath in the setting of recent hospitalization for
subacute bacterial endocarditis. His presenting symptoms were
most likely related to pneumonia. Other possible etiologies were
considered, including severe aortic valve insufficiency and
persistent SBE. He had no signs or sx of volume overload. He had
no fevers, chills, nightsweats, and no leukocytosis. He is s/p
adequate 4-week antibiotic course for his endocarditis, with
improved appearance of valvular vegetation seen on TEE on
___. Blood cultures were pending at the time of discharge but
at the time this discharge summary was signed, were final
negative. Patient was without evidence of heart failure or
volume overload and has excellent exercise tolerance, reassuring
against decompensated aortic insufficiency or recurrent
endocarditis.
#Erythema: diffuse. Reports has history of "ruddy complexion."
Does not appear to be burn. Perhaps drug rash? Though not
morbiliform. Reports history of red man syndrome to vancomycin,
though did not receive this during this hospitalization.
Asymptomatic. Resolved on discharge.
CHRONIC ISSUES:
#HTN: cont home HCTZ, atenolol
#Hyperlipidemia: cont home crestor
#Grave's Disease: continue home methimazole
================================
## TRANSITIONAL ISSUES ##
================================
## PNEUMONIA: will complete 5 day course of levofloxacin (day 1
= ___
## AORTIC INSUFFICIENCY: has follow up with ___ Cardiac
surgery on ___. | 62 | 309 |
15335612-DS-16 | 23,697,454 | Dear ___
___ was a pleasure being involved in your care.
Why you were her:
-you came in because you fainted
What we did while you were here:
-We got imaging of your brain, chest, abdomen and pelvis which
were normal. We gave you some fluids because we felt that you
were dehydrated.
Your next steps:
-please follow up with you doctor within 1 week
-please make sure to drink fluids, especially if you will be
outdoors
-you should have something called an echocardiogram as an
outpatient to look at your heart
-your may also need some more monitoring of your heart beat with
something called ___ of Hearts monitor
We wish you well,
Your ___ Care Team | ___ yo ___ speaking woman ___ hypothyroidism and
hypertension who p/w syncopal event. Patient had full syncope
workup including: EKG, CXR, CT head w/o contrast, CTA head/neck,
and CT Abdomen/pelvis all of which were within normal limits.
MRI head was unremarkable. She was given 1 liter of normal
saline, with resolution of symptoms. Of note, on the day of
discharge, pt mentioned that she had occasionally had
palpitations, including on the day of her syncopal episode. She
did not note any palpitations while hospitalized. She may
benefit from ___ monitoring as an outpatient.
#Syncope: Patient presented with episode of syncope, reportedly
___ min by husband, with no clear prodromal symptoms, no focal
neuro deficits, no obvious signs of infection, glucose wnl. Most
likely orthostatic. Patient had full syncope workup including:
EKG, CXR, CT head w/o contrast, CTA head/neck, and CT
Abdomen/pelvis all of which were within normal limits. MRI head
was unremarkable. She was given 1 liter of normal saline, with
resolution of symptoms. Of note, on the day of discharge, pt
mentioned that she had occasionally had palpitations, including
on the day of her syncopal episode. She did not note any
palpitations while hospitalized. She may benefit from ___
___ monitoring as an outpatient.
#HTN: well controlled throughout hospitalization. Continued home
amlodipine.
#Hypothyroidism: Continued home synthroid.
#Vitamin D deficiency: Continued home vitamin D.
======================================================
Transitional Issues
-encourage good PO intake, particularly when in sun
-patient should have a TTE as an outpatient
-consider ___ of ___ monitor as an outpatient
-consider downtitration of amlodipine (BPs were 100's-120's in
the hospital)
# CODE: FULL
# CONTACT: ___, ___ | 108 | 269 |
10690033-DS-4 | 26,306,810 | You were evaluated at ___ for
your chief complaint of lower extremity weakness with an
increase in back pain. At the time of your presentation to the
hospital, you were found to be short of breath and with a fever,
and as such we obtained a Chest X-Ray which did not reveal any
pneumonia or other lung or cardiac pathology. An Echocardiogram
further ruled out any cardiac issues; your heart function was
shown to be normal with no concern for infection. We also
obtained MRI studies of your spine which showed your T5/6 disk
herniation was unchanged from before. While a lumbar disk
herniation was observed on the study, no compression of the
nerve was identified.
Upon discharge, you will discharged with a 10 day course of
Clindamycin to treat your cellulitis; please complete this
course of medication even if your arm pain and swelling
improved.
We have made the following changes to your medications:
- Clindamycin 300mg every 8 hours
- Gabapentin 800mg every 8 hours
We have also given you a short course of medication to control
your pain.
- Oxycodone 20mg every 4 hours as necessary for pain
For any additional medical management, please contact your
primary care physician.
Upon discharge please follow up with the appointments listed
below.
It was a pleasure taken care of you, and we wish you all the
best. | Mr. ___ is a ___ year old man with a history of IVDU and T5-6
disc protrusion s/p rehab who was evaluated for lower extremity
weakness and worsening lower back pain.
# Neurologic:
Mr. ___ complained of weakness and sensory changes in his
lower extremities, and back pain over his lumbar spine. He was
found on MRI to have a stable T5-T6 posterior disc herniation
with cord compression and a small L5-S1 disc protrusion that did
not deform or compress bilateral S1 nerve roots. He was
evaluated by the orthopedic spine service who believed his discs
were stable and there was no necessary surgical intervention.
Over the course of his stay, Mr. ___ weakness has
completely resolved. He continues to experience sensory of
deficit to pain and temperature in his right leg and right torso
up to T6, consistent with his cord compression.
Due to his fever and elevated ESR and CRP on admission there was
concern for an epidural abscess. No evidence of abscess or
infection was seen on MRI of the thoracic or lumbar spine. A
lumbar puncture was attempted but could not be completed due the
patient's exquisite sensitivity to pain. A lumber puncture was
performed under fluoroscopy with general anesthesia. The CSF
showed no evidence of infection; WBC, protein and glucose within
normal limits. The patient's subjective report of pain was
likely elevated somewhat due to withdrawal demonstrated by
elevated ___ scores in the setting of known opiate addiction.
# Infectious Disease:
Mr. ___ spiked intermittent fevers as high as 101.8 during
his hospitalization. To determine if he had an active infection
a chest X-ray and urinalysis were preformed. They showed no
evidence of pneumonia or UTI, respectively. Due to his history
of IVDU an echocardiogram was also preformed that showed no
vegetation worrisome for bacterial endocarditis present on his
heart valves. The patient picked out a peripheral IV from his
left arm with a fork. He subsequently developed an erythematous,
hot, swollen rash over his forearm consistent with cellulitis.
He is currently being treated with Clindamycin.
HIV Ab tests were negative.
# Psych
Mr. ___ had a urine tox screen positive for opiates on
admission and admits to using heroin in the last month. He
experienced withdrawal symptoms during his hospitalization and
was severely agitated at times requiring restraints. There was
concern for substance abuse within the hospital; the patient
endorsed taking PO opiates that he brought with him. He was
evaluated by psychiatry and social work for opiate addiction. He
was advised to follow up with his out patient psychiatrist and
provided a list of resources including addiction day treatment
centers, crisis centers, and methadone clinics.
In order to adequately treat his pain per chronic pain
consultation, we decided to prescribe 5 days (30 pills) of
Oxycodone 20mg to control his pain. He was recommended to
follow up with his primary care physician, with whom we made
three attempts to contact to no avail prior to discharge, for
any additional medications.
# GI/ Hepatic
The patient had elevated AST and ALT on admission, and has a
history of IVDU. He tested positive for hepatitis C virus
antibodies. His hepatitis B serologies showed that he has active
hep B immunity.
# CV
Mr. ___ had a transthoracic echocardiogram preformed to
evaluate for valvular vegetation and bacterial endocarditis. He
was found to have no cardiac dysfunction with a LVEF of 70-75%,
no pulmonary hypertension or right heard strain, no valvular
disease, and no vegetations.
# Transitions of care
- Will follow up with out patient psychiatrist / primary care
physician for renewal of medications and discussion of substance
abuse therapy.
- Will follow up with primary care physician ___ 4 weeks
- Will complete a 10 day course of clindamycin for cellulitis
- CNS HSV PCR still pending at time of discharge
- Provided with a list of resources to seek aide with substance
abuse when the patient decides to pursue this course of action.
List of resources includes crisis centers, methadone clinics,
and addiction day treatment programs. | 222 | 663 |
18123738-DS-26 | 26,835,965 | You were admitted because you had fevers in the setting of
treatment for a MRSA infected port. The Infectious Disease
doctors recommended removal of the port, but you declined. You
are being discharged home on IV antibiotics and plans to
follow-up with Infectious Disease (appointments listed below).
We made the following changes to your medications:
-START Daptomycin (planned duration 4 weeks from ___
-STOP Vancomycin | This is the brief hospital course of a ___ year-old female with a
past medical history significant for medically-refractory Crohns
disease with multiple prior surgical resections and resultant
short-gut syndrome with osteoporosis and secondary
hyperparathyroidism who presented this admission with fevers.
The patient was admitted to Medicine on ___ for 2-days of
fevers. The fevers began on ___ and ___ in the setting of the
patient completing one month of Vancomycin for an MRSA line
infection in her left port-a-cath. The vancomycin was completed
___ so she essentially spiked through vancomycin treatment. She
also noted some sore throat and cough with rhinorrhea the week
before this admission making a viral URI a possible cause of her
fever. She denied worsening abdominal pain. She had no dysuria
or urinary symptoms. Her port-A-cath was placed in ___ ___. She has required multiple ports given that she is
difficult to access.
Surgery and ID were consulted and despite ID and primary team
informing her of preference for removal of line to assure
clearance of infection the patient opted to maintain the line.
Given the concern that fever represented a breakthrough
infection on vancomycin (particularly given unclear dosing and
monitoring) she was started on a course of IV Daptomycin of four
weeks to treat for another episode of potential transient
bacteremia. She has had no leukocytosis, all cultures were
negative in house, and she was afebrile the entire stay on the
floor. Several studies were completed to rule out sites which
the patient's persistent MRSA line infection could have seeded
as a source of the fevers from ___. These included UE
venograms, TEE, CT abd/pelv, and others. No seeded sites were
noted.
In terms of her osteoporosis, she has been on calcium carbonate,
calcitriol and vitamin D supplementation and has had low calcium
levels in the past with elevated PTHs. She was started on
vitamin D 50,000 units PO BID four times daily. Her calcium
regimen includes 2 tums Ultra TID daily with meals and a MVI.
She is also on Calcitriol 0.25 mcg 8 times weekly and maintains
1.5 servings of dairy daily.
Her GI issues (Crohns) were completely inactive during this stay
with the exception of Daptomycin causing increased ostomy
gaseous output.
She will complete 4 weeks of IV Daptomycin with help from ___
infusions. | 64 | 385 |
13213017-DS-14 | 26,307,591 | * Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Do not use non-steroidal anti-inflammatory drugs ( ie,
Ibuprofen, Motrin, Advil, Aleve, Naprosyn) because of your
reported history of gastrointestinal bleeding while using them
before.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
* Use your incentive spirometer often, ideally 10 times per hour
while awake | Ms. ___ was admitted to the ACS service with HPI as stated
above and diagnosed on imaging in the ED with right ___ and ___
posterior rib fractures as well as UTI on UA; it was
incidentally noted on CT that she has diverticulosis without
evidence of diverticulitis as well as cholelithiasis,
asymptomatic per ROS.
Her pain was treated with low-dose narcotic pain meds PRN as
well as scheduled acetaminophen; she stated that she tolerated
this regimen well with markedly reduced pain. Her UTI, while
asymptomatic, was treated by initiating ciprofloxacin, 500mg
BID. NSAIDs for pain were avoided due to reported history of GI
bleed while on NSAIDs and Ultram was avoided due to very mildly
prolonged QT interval with brief course of cipro used for UTI
treatment.
She did well overnight and was evaluated by physical therapy on
hospital day 2; for full evaluation please see the full physical
therapy note. In brief, it was stated that she was considered
appropriate for discharge to home with home physical therapy.
She did well and is discharged to home on the afternoon of ___,
her second hospital day. She is discharged with pain medicine
as stated above as well as with completion of a 3-day-total
course of ciprofloxacin. She will also be discharged with an
incentive spirometer and plans for continued home physical
therapy.
She is discharge with appropriate information, warnings,
prescriptions, and plans to follow up with her primary care
doctor; she does not require follow up with Surgery unless new
concerns develop. | 236 | 263 |
19080882-DS-11 | 26,132,793 | Dear Ms. ___,
___ were admitted to the hospital with a bowel obstruction due
to an incarcerated hernia. ___ have since undergone repair of
the hernia and are now preparing for discharge to home with the
following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until ___ 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 ___ have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
___ may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If ___ have staples, they will be removed at your follow-up
appointment.
*If ___ have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Colostomy:
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
Additionally, your CT scan showed a partially obstructing stone
in your urinary system, which will require that ___ follow-up
with a urologist; this appointment has been scheduled for ___.
Please seek immediate medical attention should ___ develop
fevers, burning with urinary, back pain,
flank pain,
dysuria, hematuria, history of nephrolithiasis, recent UTI, or
previous GU surgery. | The patient presented on ___ due to an incarcerated
parastomal hernia. On ___ patient was taken to the OR and
underwent a parastomal hernia repair with mesh. There were no
adverse events in the operating room; please see the operative
note for details. Post-operatively the patient was taken to the
PACU until stable and then transferred to the wards until stable
to go home.
NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with Dilaudid PCA.
Pain was very well controlled.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient had a foley placed intra-operatively,
which was removed post-surgery on ___ with autonomous
return of voiding. The patient was tolerating a regular diet
prior to discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
OTHER: Of note, on admission CT patient was found to have a
focal
dissection of the infra-renal aorta and vascular surgery was
consulted. CTA was ordered and showed no dissection, chronic
left CIA occlusion, right iliac stenosis
and diffuse atherosclerosis. Follow up was suggest as outpatient
in a month with vascular surgery and aspirin was started.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating diet as
above per oral, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 523 | 304 |
12746688-DS-20 | 28,568,280 | Ms. ___,
- ___ were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing in the left lower extremity
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 ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 2 weeks
WOUND CARE:
- Twice daily pin site care.
- Skin check will be performed at your first follow up
appointment.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ 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:
Activity as tolerated
Left lower extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Pin site care twice per day for LLE ex-fix. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left trimalleolar ankle fracture-dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for placement of a L
ankle-spanning external fixator, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with services was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weightbearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with ___ per 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. | 252 | 259 |
19438264-DS-48 | 25,827,683 | Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to ___
___ for weakness, dizziness, and chest pain.
For chest pain, we checked labs that confirmed there you were
not having a heart attack and did not have damage to your heart
muscles. A stress test was conducted and was normal.
For you weakness and dizziness, we check your blood pressure
lying, sitting, and standing up and found that you were
dehydrated. This is likely due to taking too much torsemide at
home. You were given IV fluids with improvement in your
symptoms. When you get home, do NOT take Torsemide. You are
scheduled to see your PCP this ___ and the Heart Failure
team next ___ and they will decide when/if to restart
your torsemide.
Urine tests were concerning for a urinary tract infection.
Because a urinary tract infection could cause you to feel foggy,
we decided treated you with an antibiotic called
"Ciprofloxacin." We changed your foley ___ on ___.
You are now safe to leave the hospital. Please ___ with
your health care team as scheduled and take your medications as
prescribed. | ___ with a history of coronary artery disease, type 2 diabetes,
chronic kidney disease, peripheral vascular disease, and
diastolic heart failure who presented with weakness, dizziness,
and chest pain.
# Chronic diastolic heart failure: Diagnosed on ___ ECHO. On
admission, there was initially concern in the emergency room
for acute heart failure exacerbation. However, patient did not
appeared volume overloaded on exam. Labs (BNP 595 significantly
lower than prior and CBC hemoconcentrated), clinical signs (no
jugular venous distenting, lungs clear bilaterally, and no
significant lower extremity edema), imaging (CXR without
significant pulmonary edema) not consistent with heart failure
exacerbation. Instead, patient appeared volume deplete, with
symptoms of weakness/dizziness likely related to orthostasis as
orthostatic vital signs were positive in the setting of active
diuresis with home PO torsemide. During this admission,
patient's diuresis was held and he was administered gentle IV
fluids with improvement in orthostasis. Attempts to restart
diuresis at home dose and decreased dose resulted in subsequent
orthostasis so all diuretics were held beginning ___ and at the
time of discharge. At discharge, patient was not orthostatic
and weight was 254lb. Patient has scheduled PCP ___ on
___ and Heart Failure ___ on ___ where diuresis
will be re-considered. Patient was continued on home statin and
beta-blocker regimen without complications.
# Positive urinalysis: Urinalysis on admission positive with
urine culture growing Klebsiella sensitive to ciprofloxacion.
Given patient's chronic indwelling foley, it was unclear whether
this represented a true urinary tract infection especially
without fevers, chills, leukocytosis. However, given confusion
he was treated with 5 days of ciprofloxacin for UTI (further
antibiotics not recommended by outpatient Urologist). 18 ___
coude catheter was changed on ___,
# Coronary artery disease with chest pain: Patient reported
chest pain on admission that resolved the day of admission. Two
sets of cardiac biomarkers were sent and notable for flat CK-MB
and troponin stable at 0.03 in the setting of chronic kidney
disease. Nuclear stress test was conducted ___ and normal.
# Type 2 Diabetes Mellitus: Patient was continued on his home
insulin regimen with gentle insuline sliding scale without
complications.
# Hypertension: Given limited blood pressure effect of
metoprolol, patient was continued on his home dose of metoprolol
without complications.
# Anemia of Chronic Disease: Patient's baseline Hgb is 12. On
admission, his CBC was suggestive of hemoconcentration with Hgb
14. Subsequent CBC remained within patient's baseline. He was
continued on his home iron supplementation.
# Chronic Kidney Disease: Renal function was monitored adn
remained stable within his baseline of creatinine 1.8-2.2.
# Benign Prostatic Hypertrophy: Remained stable, continued on
home regimen.
# Spinal Stenosis: Remained stable, continued on home pain
regimen.
# Obstructive Sleep Apnea: Remained stable, continued on home
CPAP at night.
# Glaucoma: Remained stable, continued on home eye drops .
====================================
TRANSITIONAL ISSUES
====================================
- STOPPED torsemide in the setting of orthostasis.
- Discharge weight 254lb (115.6kg)
- PCP appointment scheduled for ___. Please check weight and
orthostatic VS. If it weight increases and he is not
orthostatic, please restart torsemide to be restarted.
- Cardiology ___ scheduled for ___ and ___. | 195 | 509 |
13632470-DS-18 | 26,265,637 | Dear ___,
___ was an absolute pleasure taking care of you during your
admission to the ___. You were
admitted for loss of conciousness and falling down.
You were found to have a small bleed in your brain that had no
neurological manifestations. You were seen by the neurosurgeons
who did not think you needed further evaluation or assessment.
You will follow up with them in 1 month to have another CAT scan
of your head to make sure the bleed is stable.
You likely had a bleed from your gut that caused you to feel
dizzy and fall. We gave you blood products and your blood counts
improved. The gut doctors saw ___ and performed an endoscopy
which showed small erosions in the stomach (small cuts that are
of no consequence) but nothing to explain the bleed. We
recommend you get a colonoscopy outpatient at some point in the
future to assess your lower gut. | Ms ___ is a ___ with history of CHF, cirrhosis ___ right
heart failure, Afib on ___ transferred from an OSH after
being found down at home for unknown duration by a neighbor on
day of presentation (___) found to have a new anemia, ___
and concern for GI bleed as well as subarachnoid hemorrhage.
# GI bleed: On arrival HCT 18 down from 30 during ___
hospitalization with report of guaiac positive maroon stools at
both OSH as well as ___ ED. Patient reported about a few days
of dark loose stools. She was admitted to the MICU, GI was
consulted. She was initialy given PPI gtt and octreotide gtt
along with ceftriaxone given her history of ? cirrhosis. She was
supported with transfusions of pRBCs (3 total between both
hospitalis) and given FFP and vitamin K for supratherapeutic
INR. EGD showed erosions but no sign of acute GI bleed. HCT
stabilized at 26 for several days. GI team felt that she did not
need any further studies or imaging to workup the GI bleed and
recommended outpatient elective colonoscopy.
# Anemia: Baseline hematocrit appears to be ___ per records,
presented with hematocrit of 18, with elevated reticulocyte
count, negative hemolysis labs. She was supported with blood
and FFP transfusions as discussed above. HCT stabilized.
#Subarachnoid Hemorrhage: Found to have small SAH on CT without
any neurological sequelae. Neurosurgery evaluated patient and
did not think any intervention was warranted at this time. They
recommended follow up CT in 4 weeks to trend SAH. Neurosurgery
did explain that they did not think it was appropriate to resume
coumadin in this patient.
# Acute on chronic kidney injury: Baseline Cr 1.4-1.9. She
presented with creatinine of 2.0. Urine electrolytes showed
likely prerenal etiology. Cr improved with PRBC and holding her
home lasix, lisinopril and spironolactone.
# Demand ischemia: Presented with ST depressions in V3-V6 with
mildly elevated trop but neg CK-MB. EKG improved to baseline
after PRBC transfusion.
# Atrial fibrillation: coumadin was initialy held and patient
was reversed with Vit K and FFP. Decision was made not to
continue coumadin. Neurosurgery did not feel that coumadin was
appropriate after a SAH. In addition, primary medical team had
discussion with patient and daughters reviewing the risks and
benefits of coumadin and the patient ultimately declined
coumadin therapy and instead start aspiring 325mg. She expressed
full understanding of risk of ischemic stroke, especially given
her high CHADS score. Primary care physician was notified. Pt
was discharged on ASA 325mg.
# Chronic Right heart failure: Known history of severe right
heart failure, repeat echo this admission showed EF 55%, severe
TR, moderate pulmonary artery systolic hypertension and right
ventricular dilation. Furosemide, spironolactone, metoprolol
lisinopril all initially held for concern for acute GI bleed
(and lisinopril for ___. She may resume these medications at
discharge.
# Cirrhosis: Normal LFTs, albumin. Ultrasound and CT did not
reveal signs of cirrhotic liver. Hepatology was consulted and
recommended liver u/s which showed congestive hepatopathy. | 153 | 493 |
19341622-DS-18 | 27,845,656 | You were admitted for evaluation of rectal pain and found to
have a rectal abscess a drain was placed and you were started on
antibiotics with good effect you will need to continue this
drain until you see your colorectal surgeon in clinic and to
take your antibiotics through ___.
You had some electrolyte abnormalities which corrected during
admission. You had some leg swelling which is likely due to
getting IV fluids and not eating enough protein in your diet.
Please continue to work on your nutrition after discharge.
Please continue to follow up with your outpatient psychiatrist
to further discussion your depression. | This is a ___ with severe chronic constipation with
proctocolitis, pruritis ani, pelvic floor dyssynergy, fatty
liver
disease (on US/MRI, prior fibroscan without fibrosis), anxiety,
depression, possible PTSD, insomnia, glaucoma, endometriosis
(prev on hormonal therapy), who presented ___ with worsening
rectal pain, tachycardia, hypotension, and leukocytosis, found
to
have perirectal supralevator abscess s/p drain placement on
___.
Patient has remained inpatient for anemia, electrolyte
abnormalities, psychosocial situation and was transferred to
medicine.
#supralevator abscess s/p EUA and I&D on ___
continued on PO Augmentin
CRS recs- continue Augmentin with last day ___, keep drain in
place, flush drain with 10cc BID, should be left in place until
postop check which should be in ___ weeks from discharge. Pain
control with Tylenol and prn oxycodone. Goal to wean asap.
#Depressive disorder
Appreciate psychiatry recommendations. Per Dr. ___: "No
clear evidence FOR primary eating disorder, however the
patient's beliefs and behaviors around food, nutrition and body
habitus may be affected by her depression as well as trauma.
There are no acute safety concerns."
Psychiatry follow up with Dr ___ - ongoing management of
depression, and would continue to explore issues related to
nutrition/weight in outpatient setting
Social work involvement, referral to psychotherapist
Continued bupropion, olanzapine, clonazepam
# Anemia of Chronic DIsease
No evidence of acute bleeding, no hematoma on exam or MRI pelvis
done ___. Most likely due to suppressed bone marrow production
of RBC from malnutrition and infection as consistent with iron
studies.
#Euthyroid sick syndrome
TSH is 14, while free T4 is 1.0. Endocrine consulted, did not
think pt needed supplementation and recommended anti TPO and
repeat TFTs in 1 wk with endo f/u.
# Severe protein calorie malnutrition
# hypoalbuminemia and anasarca with ___ edema.
Urine protein not suggestive of nephrotic syndrome. Nutrition
consulted. Ensure supplements TID.Vitamin D, Folate, MVI. ___
negative for DVT. Likely due to hypoalbuminemia from
malnutrition and IVF resuscitation due to infection.
# Leukocytosis
Likely related to known ongoing supralevator abscess. C. diff
negative. U/A not suggestive of infection and
CXR without pneumonia.
# ___ - resolved
# Acidosis - resolved
# Hypomagnesemia - resolved | 105 | 316 |
10491477-DS-14 | 20,042,822 | Dear Mr. ___,
You were admitted for administration of intravenous antifungal
medications due to your pulmonary cryptococcus infection. We did
an LP and blood work which did not show any evidence of
cryptococcal meningitis or other disseminated infection. You
will need to take oral antifungal medications for the next
several months and follow up with the infectious disease and
pulmonology doctors. You may want to see a neurologist about
your chronic headaches. It has been a pleasure taking care of
you. | PRINCIPAL REASON FOR ADMISSION:
___ with Hashimoto thyroiditis, chronic back pain s/p MVA in
___ who presents per his PCP's recommendations with pulmonary
biopsy results demonstrating cryptococcus and with ___ months of
headache, fever, night sweats, fatigue, and neck soreness which
was initially concerning for meningitis, but unlikely after
further diagnostic work-up in ED
. | 81 | 53 |
11286349-DS-6 | 22,864,173 | Please follow up with a physician to have your wounds looked at
and to make sure that you are recovering well.
Please avoid heavy lifting greater than ___ pounds for the next
few weeks.
Please avoid baths for the next few weeks. Shower and keep your
wounds clean and dry. | ___ with hx gastric bypass in ___ transferred from ___
___ with findings of high grade small bowel obstruction on
CT. The patient was stable on arrival, describing a few day
history of sharp, left-sided abdominal pain with associated
obstipation, nausea, and vomiting. She had an NGT in place and
her exam was nonperitoneal, although a high clinical suspicion
for an internal hernia, the findings of high grade obstruction
on CT, and her history of gastric bypass prompted OR planning
for diagnostic laparoscopy for definitive diagnosis. The patient
was taken to the OR on ___ and underwent an exploratory
laparoscopy, lysis of adhesions,
internal hernia reduction, and mesenteric defect closure. Her
NGT was removed on ___ in the morning. She quickly advanced
from sips to clears to regular throughout the day, was passing a
small amount of flatus and was out of bed ambulating and feeling
well. The patient attempted to leave AMA in the late afternoon,
stressing that she was well, did not require monitoring, pain
medication, or further hospitalization and describing that she
wanted to return to ___ with her husband as soon as possible.
I was able to reach the patient prior to her departure and
review appropriate discharge instructions and provide her with a
prescription for pain medication. The patient verbalized
understanding and stated that she would be following up in 2
weeks with her bariatric surgeon in ___ to haver her surgical
incisions looked at. She was provided with the ___ clinic phone
number should she need further follow up with us, and to
facilitate communication between her bariatric surgeon and ACS,
should the need arise. | 48 | 271 |
15345843-DS-8 | 29,647,503 | It was a pleasure taking care of you at ___
___. You were admitted to the hospital after surgery
on your leg. This surgery was done to improve blood flow to
your leg. 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.
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes within
a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will receive a visit from a Visiting
Nurse ___. Members of your health care team will discuss
this with you before you go home.
Medications:
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!
Your Aspirin has been held while you are on Plavix, and
warfarin with Lovenox bridge. Please discuss this with Dr.
___ at your followup visit.
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not lift >10 pounds for 1 week.
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight undergarments/pants.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the staples. This is
normal.
It is normal to have a small amount of clear or light red
fluid coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
Please keep a dry sterile dressing on the site.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician. | This patient presented ___ years after undergoing a left fem-pop
bypass using PTFE. with a 12-hour history of worsening left
foot pain and tenderness. He presented to our emergency room
with acute ischemia. Preoperative evaluation by CT angiography
demonstrated occlusion of the common femoral artery as well as
profunda femoris. There was occlusion of the fem-pop bypass
graft with reconstitution of flow at the popliteal artery at the
level of the knee. We elected to take him to the operating
room urgently for graft thrombectomy.
He underwent thrombectomy of the left fem-pop bypass graft and
placement of left popliteal stent across anastomosis on ___.
Please see operative report for details. He tolerated the
procedure well and was ultimately transferred to the floor where
he remained hemodynamically stable. Systemic anticoagulation
with intravenous heparin as initiated and eventually
transitioned to warfarin with Lovenox bridge at discharge to be
managed as an outpatient by PCP. ___ was consulted for
glycemic control and recommendations instituted with PCP
followup as an outpatient. His diet was gradually advanced and
at the time of discharge he is tolerating a diet, voiding
without issue, passing gas and independently ambulatory with a
walker. He worked with physical therapy who recommended home
___. He was discharged to home on POD #2 in stable condition
with ___ nursing and ___ services. Follow-up staple removal has
been arranged with Dr. ___ in 3 weeks with surveillance
imaging in 4 weeks. ___ will draw ___ on ___ to be
communicated to PCP, who has verified they will provide
anticoagulation oversight moving forward. In order to avoid
triple therapy, ASA has been discontinued while pt remains
systemically anticoagulated and on Plavix. This will be
discussed further with Dr. ___ at followup. | 844 | 294 |
18991862-DS-16 | 27,179,992 | You were admitted to the hospital after a fall down stairs.
Upon imaging you were found to have a small bleed in your head
and a fracture to your upper neck. You were seen by the Spine
service who recommended a collar for 6 weeks. You were placed
on a week course of dilantin. Your vital signs have been stable
and you have not had a fever. You are preparing for discharge
home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Because you hit your head, please follow up if you develop:
*severe headache
*facial droop
*difficulty speaking
*weakness one side of your body
*double vision or change in your vision
*increased sleepiness
Report the following:
*increased numbness arms, fingers
*decreased strength in upper extremities
Please wear the ___ J collar as recommended, ___ weeks. | Ms. ___ is a ___ year old female who presented to
___ ED as a transfer from an outside hospital after a fall
down 12 stairs after 4 glasses of wine. CT scan at outside
hospital demonstrated a C6 fracture and a SAH and subgaleal
hematoma. Neurosurgery was consulted and frequent neurochecks
and siezurer prophylaxis. Orthospine was consulted for the C6
fracture and reccommended MRI to evaluate for discoligamentous
structures integrity. Final Orthospine reccomendations were for
___ collar and f/u in clinic. Patient was kept NPO and
monitored on the floor until all studies were perfomed and
reccomendations from consulting services were communicated. At
that time diet was advanced and pain control was transitioned
from iv to po with good control. ___ evaluated the patient and
she was cleared for home. At time of discharge patient was
ambulating without assistance, voiding, had stable labs and
vital signs and was AAOx3. Appropriate f/u was provided to
patient at time of discharge and she was discharged to home with
7 days dilantin and po pain control with instructions to
follow-up sooner if neurological symptoms develop. | 291 | 192 |
19287139-DS-5 | 22,404,224 | You were seen and evaluated for nausea and abdominal pain with
eating, and found to have acute on chronic iron deficiency
anemia. Your blood counts were also monitored to make sure you
did not have any major bleeding from an ulcer. You were given a
dose of IV iron to supplement your iron deficiency, and
discharged on Iron supplements which you should continue to take
until you are seen in clinic at your ___ appointment on ___. | Ms. ___ was seen and evaluated for nausea and abdominal
pain with eating leading to decreased PO intake. She was
admitted from the ED to the floor for hydration and work-up.
Labs were drawn, and she was given a banana bag for vitamin
repletion. The patient was seen by the hematology-oncology team,
and thought to have acute on chronic iron deficiency anemia.
After hydration, nutrition supplementation and sequential
advancement of her Bariatric diet to stage 3, she was given a
loading dose of Iron Dextran 1000 mg IV and discharged on the
morning of hospital day 3 on Iron supplementation along with
colace, for iron deficiency anemia consistent with short-gut
syndrome as the etiology. Her clinical picture was also thought
to be consistent with an ulcer and she may require an outpatient
EGD, although throughout her stay she was hemodynamically stable
with a stable hematocrit and guaiac negative stools (x 2). She
is already scheduled for an appointment with the bariatric team
at ___ on ___, and was encouraged to follow up at that
appointment. | 77 | 176 |
12676624-DS-18 | 23,077,692 | You were admitted to the surgery service at ___ for treatment
of pancreatitis. You have done well and are now safe to return
home to complete your recovery with the following instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | The patient with the history of necrotizing pancreatitis was
admitted to the General Surgical Service with increased
abdominal pain. The CT scan revealed acute on chronic
pancreatitis. Admission amylase and lipase were 289 and 8166.
The patient was started on IV Meropenem, IV fluids, was made
NPO, and she was given IV Morphine for pain control. The patient
was hemodynamically stable.
The patient's abdominal pain started to improve on HD # 2,
amylase/lipase tranded down. Patient's diet was advanced to sips
on HD # 3, her antibiotics were stopped.
Diet was progressively advanced as tolerated to a regular diet
by HD # 6. During hospitalization patient, who has a long
history of smoking and COPD, desaturated to low ___ several
times. Pulmonary emboli work up was negative. The patient
received nebulizer treatment with Ipratropium/Albuterol and O2
Sat improved prior discharge. The patient was discharged on HD #
6, her lipase/amylase prior discharge were 51/39.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 182 | 201 |
19105125-DS-23 | 23,478,635 | Dear Mr. ___,
You were admitted to ___ for
symptoms of facial warmth/tingling. We performed an MRI, which
showed that there was no stroke. We saw small areas of bleeding
from your hemorrhage a few years ago. We are still not sure what
caused your symptoms, but they may be related to anxiety or a
viral syndrome affecting a peripheral nerve. You will follow up
with the stroke department, Dr. ___, as described below. | Mr. ___ was admitted to the stroke service, floor with
telemetry, for further workup of facial paresthesias as
described in the HPI above. His symptoms remained unchanged
while admitted here.
MRI of the brain was performed, which showed evidence of an old
hemorrhage in the right occipital/temporal lobe, there were no
acute changes. TTE showed a moderately dilated right ventricle,
and a mildly left atrium, but was otherwise normal. Telemetry
showed normal sinus rhythm. Lipid panel was wnl and HbA1c was
5.8%, TSH was wnl. His symptoms were thought to be somatoform in
nature, related to anxiety, or to a mild peripheral nerve
syndrome. He was discharged to home with follow up in stroke
clinic and with his primary care physician.
OUTSTANDING ISSUES
[ ] Stroke follow up
[ ] PCP follow up
[ ] TTE report was pending at time of discharge, patient will
need update regarding this. | 73 | 144 |
17682234-DS-22 | 26,657,824 | Dear Ms. ___,
You were admitted for a broken hip. You underwent surgery, and
developed confusion, kidney injury and blood loss. You received
hydration and a transfusion of blood. Your blood counts were
stable after this and your kidneys were improving by the time of
discharge.
Please see the directions below regarding care of your hip.
It was a pleasure taking care of you at ___. We wish you well.
Sincerely,
Your Team at ___
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 (start date
___
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
ACTIVITY AND WEIGHT BEARING:
- WBAT BLE
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | This is a ___ with ___ speaking a history of DHS on
right,HTN, CAD s/p DES to the LAD in ___, Afib (not
on coumadin), ischemic cardiomyopathy (EF 30% in ___
diabetes who presents with a mechanical fall off toilet and
found to have left intertrochanteric hip fracture.
BRIEF HOSPITAL COURSE
======================
ACTIVE ISSUES
---------------
#L COMMINUTED HIP FRACTURE: The patient presented to the
emergency department and was evaluated by the orthopedic surgery
team. The patient was found to have a left hip fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for L hip DHS, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was complicated by delirium and acute
kidney injury, which have improved to baseline. It was also
complicated by NSTEMI, please see below.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE extremity, and
will be discharged on enoxaparin for DVT prophylaxis. The
patient will follow up in two weeks per routine.
# NSTEMI: She was noted to have new V4-V6 depressions on
___ EKG, and rising troponins. Cardiology evaluated, most
likely demand ischemia in setting of anemia and acute kidney
injury. Family approached regarding management if it had been a
Type I NSTEMI. Patient and daughter defer invasive procedures
including catherization and repeat stenting. Patient optimally
medically management for coronary artery disease. Statins
deferred due to rising CPK. Losartan was initially deferred due
to ___, but started when Cr improved.
# HyperCPK: Most likely secondary to surgery and limited
mobility. improved with IVF. CPK steadily trended down to normal
range prior to discharge.
# Acute blood loss anemia: Hct trended down from 34.9 on
admission to 29.8 post surgery to now 23.7. Surgical wound
appeared intact with no signs of active bleeding into hip,
however most likely related to hematoma development. Patient
given 1 U pRBCs with appropriate incrementation and stable H/H
thereafter.
# Acute Kidney Injury: Most likely secondary to hypovolemia in
setting of surgery, acute blood loss and poor po intake. Given 1
L LR and pRBCs with downtrending Cr. Voiding independently
without Foley.
# Delirium: In setting of surgery and pain, post operative
course complicated by excessive somnolence, disorientation, and
confusion. Her age and language barrier are major risk factors.
Infectious workup negative. Cardiac workup consistent with
demand induced ischemia. Patient placed on ___ geriatric
precautions, frequently reoriented by daughter; pain controlled
with ATC Tyelenol. IV opioids held and noted to have improved to
baseline A&Ox3 prior to discharge.
# Coronary artery disease: s/p ___, known significant
coronary artery disease. From the cath at the time of the LAD
STEMI in ___, she had residual disease with the LCx small and
diffusely diseased in proximal and mid level about 70%. The RCA
was a large dominant vessel with diffuse irregularities with
proximal eccentric 80%, 50% mid disease with diffuse severe
disease in the PDA and PL branch with mid 70% disease.
Troponinemia consistent with NSTEMI (see above). Patient managed
with aspirin, isosorbide mononitrate, metoprolol. Losartan held
in setting of ___. Further invasive intervention was discussed
with and declined by the patient and family, including
catheterization and stenting.
# Atrial fibrillation: CHADS 4. Rate controlled with metoprolol
and amiodarone. The patient is not on anticoagulation as she has
refused in the past given risk for falls.
# CHRONIC SYSTOLIC HEART FAILURE: EF of 30%. Patient with
dynamic volume status due to surgery. Patient managed
clinically. Resumed torsemide 30 prior to discharge. Admit
weight: 67.13 kgs. Discharge weight : 65kg (bed weight, unable
to stand)
# Diabetes Mellitus, type 2: Metformin held while inpatient,
patient managed with insulin sliding scale while hospitalized
# GERD: switched ranitidine to PPI to minimize deleiium-inducing
medication
TRANSITIONAL ISSUES
--------------------
[] REHAB: Continue enoxaparin for 14 day course (start date
___
[] volume status and weights will need to be monitored closely
(previous home dose of torsemide 40 daily, currently on 30
daily)
[] please check a CBC within ___ days after discharge | 227 | 777 |
17455506-DS-10 | 29,508,731 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why were you here?
- You were here for treatment and monitoring of your eating
disorder
What did we do?
- You were placed on the eating disorder protocol
- You were started on fluoxetine
- You were treated for a skin infection
What should you do after you leave?
- Continue to take the fluoxetine every day
- Continue participating in treatment
We wish you all the best!
Sincerely,
Your ___ team | Mr. ___ is a ___ year old man with a history of anorexia
nervosa who presents with dyspnea on exertion, lightheadedness,
and presycnopal symptoms and has had a course complicated by
electrolyte deficiencies, bradycardia, and pancytopenia. Now
gaining weight and medically stable for discharge to eating
disorder program.
# Anorexia nervosa: Patient presented to ED with symptoms of
weakness and DOE requesting admission for management of eating
disorder. He has had multiple previous admission. He was found
to be pancytopenic and bradycardic on admission, which was
consistent with previous admissions. His admission weight was 94
lbs (IBW is 144). He was started on eating disorder protocol and
generally did well with it. At discharge his weight is 115.6 lbs
(52.4 kg). Psychiatry was involved with his care and started him
on fluoxetine. He was told that if he refused the medication
that they will file for ___ guardianship for his father, and
was willing to take fluoxetine after that point.
# Right arm cellulitis: from IV site, completed 1 week course of
clinda with resolution of infection.
# Cytopenias: From malnutrition. Consistent previous. Improving
at discahrge. His discharge Hb was 10.5.
#Court Date: Noted to have a court-date for trespassing on the
date of admission ___. SW sent a letter to the court
explaining the circumstances. This was rescheduled to ___. | 75 | 223 |
13695905-DS-17 | 20,304,122 | Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
___ because with shortness of breath. Testing showed that you
had a pneumonia, and possible progression of your cancer.
You were treated with antibiotics and improved.
You were also found to have low oxygen levels that did not
improve after treatment of pneumonia. This may be a result of
your cancer. We arranged for home oxygen therapy for you.
You are now ready for discharge home.
Note: when using oxygen at home, you CANNOT have anyone near you
who is smoking--this can cause life threatening fire/explosion.
We discussed this and you verbalized your understanding.
It will be important for you to follow-up with Dr ___ Dr.
___. | This is a ___ year old female with past medical history of type 2
diabetes, hypertension, COPD, DCIS status post lumpectomy and
radiation, metastatic lung adenocarcinoma, with brain metastases
status post SRS/SRT admitted ___ with dyspnea found to
have acute bacterial pneumonia and concern for progression of
lung cancer, course complicated by persistent hypoxia thought to
be from underlying COPD and possible lung cancer progression,
able to be discharged home with ___ and home oxygen therapy:
# Acute hypoxic respiratory failure secondary to
# Acute bacterial pneumonia
# RUL Lung Cancer, metastatic
Patient presented with dyspnea on exertion and cough, found to
be hypoxic with CT scan showing "Interval increase/new bilateral
lower lobe ground-glass opacities, most prominently at the right
lower lung may represent infection and/or disease progression of
known metastatic lung cancer." Patient was started on
antibiotics for possible community acquired organisms, with
subsequent improvement in respiratory symptoms. Following
completion of 5 day course of antiobiotics, cough resolved, and
was able to be weaned to room air at rest; however, she would
become hypoxic with ambulation. Despite attempts to optimize
with bronchodilators and incentive spirometry, patient remained
hypoxic with ambulation. Suspected that remainder of hypoxia
related to her underlying malignancy and impaired lung
parenchyma from chronic COPD. Arranged for home O2 for patient.
Continued umeclidinium-vilanterol, flovent. Continued folate,
Tylenol, gabapentin, and oxycodone. Discharged with oncology
follow-up on ___. Of note, Patient reported her husband
still smokes at home; discussed with patient regarding risks of
using oxygen in the presence of someone smoking; advised her
that husband should not smoke in the house with her, given
danger for fire/explosion; patient was able to verbalize
understanding of this risk, reported an action plan for safe
home oxygen use--husband plans to smoke on the porch, outside
the house, and has an appointment with his PCP to discuss
assistance with cessation later this week
# Secondary malignancy of bone
Of note, CT incidentally showed "Interval increase in size/new
of sclerotic and lucent osseous foci at the vertebral body of
T12, worrisome for osseous metastatic disease." Patient was
without localizing pain. Would consider whether additional
imaging and or management is indicated as outpatient.
# Hyperlipidemia
# Hypertension
Continued ASA, statin, Metoprolol
# Diabetes type 2
Held home sitaglipitin, acarbose, metformin while inpatient,
then restarted at discharge.
# Anxiety
Continued home LORazepam prn. | 127 | 393 |
19068326-DS-21 | 20,358,402 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You came to us because of shortness of breath and coughing up
blood.
While you were here, we discovered that you had yet another
pneumonia. Because you were very sick when you first came in
requiring 6 liters of oxygen, we initially treated you with
multiple antibiotics as well as steroids for a total of 5 days.
We were able to de-escalate your antibiotics, and you continued
to improve, to the extent that you could walk around the
hallways without using oxygen!
As for episodes of coughing up blood, we initially held your
warfarin because it thins your blood. We think that this is in
the setting of an infection and inflammation. You should restart
your warfarin once you stop coughing up blood, or once you
discuss it with your primary care doctor.
Overall, we find it curious that you have had so many repeated
episodes of pneumonia (at least 4 in the past year), typically
in your right lower lobe. We wonder if there is an anatomical
abnormality there contributing to recurrent infections. Hence,
we would recommend follow up chest X ray within ___ weeks of
discharge to make sure that everything has cleared up.
Please take care, we wish you (and ___ the very best!
Sincerely,
Your ___ Care Team | ___ year old gentleman with past medical history of recurrent
pneumonias, atrial fibrillation on warfarin, CKD, CAD, DM, who
presents with small volume hemoptysis and dyspnea, found to have
acute on chronic anemia and sepsis from multifocal PNA.
# Multifocal Pneumonia
# Sepsis = tachycardia, tachypnea, pulmonary source
# Hypoxia
Patient presented with dyspnea and bilateral opacities on CXR
concerning for multifocal pneumonia. PSI score at least 118,
risk class IV for age, renal disease, BUN, and Hct. Initially
patient presented with significant hypoxia despite 6L NC,
increased work of breathing. Given severe presentation, recent
hospitalizations, hence at risk for resistant organisms, we
initially covered him broadly with vancomycin + cefepime +
levofloxacin ___ narrowed to cefepime + levofloxacin ___
when MRSA swab returned as negative -> narrowed to levofloxacin
___ to complete 5 day course. He also receive 5 days of
prednisone 50 mg daily based on recent data concerning CAP.
Other work up notable for: negative urinary legionella serotype
1, negative S. pneumo, sputum culture unfortunately
contaminated.
Of note, patient reports recurrent episodes of pneumonia
(4x/year). Brief review of imaging reveals bibasilar patchy
opacities ___, bilateral lower lobe opacities ___, right
lower lobe consolidation ___, right lower lung opacity
___. Would consider further imaging within ___ weeks to
ensure resolution of pneumonia, and consider CT chest to
evaluate for anatomic abnormality as an outpatient. Whilst in
house, we also r/o HIV in the setting of low absolute lymphocyte
count. Review of prior work up reveals that he has had negative
evaluation for MM (SPEP negative ___, UPEP negative ___
which we briefly considered in the setting of known CKD and
recurrent pneumonias. He does not have history of
sinusitis/otitis media/bronchitis in association with recurrent
pneumonia at this time, hence we did not send immunoglobulin
levels.
He is s/p PCV ___ and ___.
# Acute on chronic anemia
# Hemoptysis
Baseline Hgb ___ likely in setting of CKD. Etiology of
hemoptysis thought secondary to hemoptysis as above. Home
warfarin was held on discharge to be resumed once hemoptysis
completely resolves. It was substantially improved upon
discharge.
# Hyperglycemia/DM: Hyperglycemia worsening in setting of
prednisone use. 20U Glargine + ___ Humalog + SSI started ___
with FSBG 109 and pre-meal 120s, tightly controlled, hence
decreased to 3U with meals ___ ___. He was discharged on his
home insulin regimen.
CHRONIC
# CAD. Initially held ASA and metoprolol but restarted prior to
discharge. Continued home atorvastatin.
# HLD. Continue atorvastatin, hold fenofibrate
# Afib on warfarin. INR 2.9 on admission. Held warfarin as
above. Discussed risk of stroke with patient versus risk of
ongoing bleeding.
# HTN. At home on amlodipine, furosemide, metoprolol. Initially
held all in the setting of concern for sepsis; restarted prior
to discharge.
# CKD. Baseline Cr ___. Admission Cr 5.5 at baseline. Continued
calcitriol. Renally dosed medications and avoid nephrotoxic
agents.
# BPH. Continue home doxazosin | 217 | 473 |
19401821-DS-17 | 20,507,152 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You had dizziness, abdominal distension and leg swelling.
WHAT HAPPENED IN THE HOSPITAL?
-You were evaluated for the cause of your abdominal and leg
swelling.
-You underwent a procedure to evaluate the fluid in your
abdomen.
-You had an echocardiogram of your heart, for which you should
follow-up with cardiology.
-You were seen by the hepatologists who recommended a low dose
diuretic (lasix) to decrease fluid in your abdomen and legs.
-You tolerated the new medications well and no longer had
unsteadiness with walking.
WHAT SHOULD YOU DO AT HOME?
-You should continue to take your medications as directed.
-You should follow-up with your primary care physician and
hepatologist as below.
-You were scheduled for a cardiology appointment to follow-up
the results of your echocardiogram. You will be contacted for an
appointment.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | ___ y/o F with PMH significant for stage II L breast
adenosquamous cancer (ER+/PR+) s/p lumpectomy and XRT, DM2, HTN
presenting with thrombocytopenia, ascites, and abnormal LFTs,
and nodularity on liver concerning for cirrhosis. | 161 | 34 |
10067859-DS-22 | 23,598,978 | Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
MEDICATIONS:
Take Aspirin 325mg (enteric coated) once daily
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room. | ___ is a ___ w/ hx of Crohn's disease and AAA who is
presenting as a txf'r from ___ w/ 3day hx of LLQ pain radiating
to back and found to have interval increase in size of AAA as
well as dissection of the aneurysm. Per report, 4 mo ago a
surveillance scan showed diameter to be 4.5 cm. He presented to
his GI doctor who obtained a CT A/P, which showed AAA diameter
to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had
LLQ in the past that he associates w/ his Crohn's flares, but
this pain is of a different quality. ROS is o/w -ve except as
noted above. He was hypertensive at ___ and was started on an
esmolol gtt. Patient was taken urgently to OR for EVAR procedure
for symptomatic/dissected infrarenal AAA.
For the details of the procedure, please see the surgeon's
operative note. He received ___ antibiotics. He was
admitted to the ___ on
___ post-operatively. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where he remained through the rest of the hospitalization.
Post-operatively, he did well. He was able to tolerate a regular
diet, get out of bed and ambulate without assistance, void
without issues, and pain was controlled on oral medications
alone. Patient did have a little burning on urination that
resolved spontaneously and some tenderness to his left groin
incision site. Patient had a urinalysis sent and an ultrasound
taken of his left groin. Both tests came back negative for any
concerning findings. He was deemed ready for discharge, and was
given the appropriate discharge and follow-up instructions. He
will follow up with Dr. ___ in 1 month with a CTA. | 350 | 306 |
13030167-DS-20 | 21,900,067 | Dear Mr. ___,
It was a pleasure caring for you during your recent admission.
You came to the hospital with flu-like symptoms and chest pain,
and unfortunately we found a mass in your chest that's
responsible for these symtpoms. This mass is concerning for
cancer. We did some studies to see if the cancer has spread, and
there is concern that it may have spread to your brain. A PET
scan was done on ___ which also looks for any spread of the
possible cancer; the results from this study were not known at
the time of your discharge. We also biopsied part of the mass in
your lung, which will help determine what kind of treatment you
will need going forward.
While we're waiting for the biopsy results to return, you were
discharged home with close follow-up in place. We talked about
the importance of coming back to the hospital if you have
increased chest pain, feel dizzy/lightheaded, or feel short of
breath. Please follow-up with your doctors as ___ below.
Sincerely,
Your ___ Care Team | ___ year old male with PMH of HTN and HLD as well as 30+
pack-year smoking hx who presented with flu-like symptoms,
cough, and chest pain, found to have mediastinal mass concerning
for malignancy.
# Mediastinal mass: pathology pending at time of discharge. CT
chest, MRI brain, and PET scan all consistent with diffuse
metastatic disease, most likely lung primary. Pt has 30+
pack-year smoking hx, and several months of weight loss. While
the mediastinal mass surrounds the SVC with radiographic
evidence of SVC syndrome, and clinically there was only mild
facial fullness on exam initially, which resolved prior to
discharge and the SVC was patent and his VS remained stable.
Heme-Onc and Interventional Pulm were consulted. A bronchoscopy
with paratracheal lymph node biopsy was done on ___, path
pending at time of discharge. Pt and family wished to obtain
second medical opinion prior to initiation of treatment, and he
was discharged him on ___ with Heme-Onc and IP follow-up in
place. He plans to seek a second opinion at ___ and will most
likely seek treatment there as well.
# Pericarditis: chest pain for several weeks prior to
presentation, and admission EKG with diffuse mild ST elevation.
Pericarditis likely secondary to irritation from mediastinal
mass on pericardium. No NSAIDS were prescribed, as pain was
minimal. Small pericardial effusion seen on admission bedside
U/S, but no evidence of tamponade physiology during admission .
# Hypertension: Continued on home BP medications
# Chronic back pain: Continued on home tramadol prn
TRANSITIONAL ISSUES:
=========================
# Pathology results and PET scan results pending at discharge
# Has Heme-Onc follow-up in place on ___
# Pt understands to return to ED if he becomes SOB, develops
worsening chest pain, or for any other symptoms that concern him
# He should have TFT's to f/u the thyroid findings seen on PET
scan | 173 | 302 |
13736848-DS-19 | 29,084,513 | Dear Mr ___,
You were hospitalized due to symptoms of confusion resulting
from a TRANSIENT ISCHEMIC ATTACK, a condition where a blood
vessel providing oxygen and nutrients to the brain is
temporarily blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Transient ischemic attacks 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: atrial
fibrillation and hypertrophic cardiomyopathy. You were started
on a blood thinner, Rivaroxaban 20mg by mouth daily, to prevent
clots.
You were found to have a bacterial infection in your blood,
likely related to a desmoid tumor in your abdomen. You will need
to continue antibiotics for two weeks and follow up with your
PCP for repeat abdominal imaging. | ___ yo M with HOCM, VF s/p ICD placement, paroxysmal Afib not on
anticoagulation, Gardners syndrome s/p abd surgeries (last
___, desmoid tumors on sulindac p/w confusion and fever and
later found to have GNR sepsis. Patient was initially admitted
to the Neurology service as there was concern for CVA/TIA or
meningitis. He was transferred to medicine when GNR bacteremia
found.
# Fevers: Patient presented with rigors that improved with
Tylenol. He had a HIV viral load test sent due to concern about
possible exposure via sexual contact 2 weeks ago, that was
negative. On ___ he spiked a fever of 103, he had a lumbar
puncture done that was unremarkable. He was started on
vancomycin, ampicillin, acyclovir, and ceftriaxone. He grew out
gram negative rods from his blood culture. After he was found to
have an abdominal abscess he was started on Flagyl and his
vancomycin and ampicillin were discontinued. His ceftriaxone was
changed to cefepime and he was transferred to medicine. His
antiotic regimen was changed to PO ciprofloxacin and
metronidazole (see below). He remained afebrile x 24hours prior
to discharge.
# GNR bacteremia
Patient with pansensitive E. coli from two sets of blood
cultures ___. Abdominal source suspected given CT finding of:
New 3.6 x 2.5cm fluid and ___ collection c/f
localized perforation of the encased small bowel. UA WNL. No e/o
vegetations on valves or pacer lead on Echo and no e/o septic
emboli. Patient treated initially with Cefepime and
Metronidazole, then transitioned to oral Ciprofloxacin and
Metronidazole with continued improvement. Of note, no abdominal
pain or other localizing symptoms. Patient was evaluated by
surgery who recommended conservative management with
antibiotics. Infectious disease was consulted and recommended 14
days of PO antibiotics with repeat abdominal imaging in two
weeks.
#Paroxysmal atrial fibrillation:
SR throughout most of course. ICD interrogation inpatient showed
two episodes of Afib: 31s on ___ at 129bpm and ___ on
___ at 135bpm. Patient also had an episode of Afib with RVR
for which he received an ICD shock on ___. EP was consulted
and changed parameters. Given concern for TIA on presentation,
patient started on anticoagulation with Rivaroxaban. He was
continued on Diltiazem ___ 240 mg PO DAILY.
Atenolol was changed to Metoprolol XL 50mg BID. He had an
echocardiogram done that showed echogenicity concerning for
possible thrombus. He therefore had an echo with contrast done
on ___ that revealed no thrombus.
# AMS
Initial concern for CVA in ED as patient presented with AMS and
focal deficits. Deficits resolved while patient in ED and CT
head negative. Neuro exam WNL and stable throughout course.
Given h/o Afib, neurology concerned for TIA. He was briefly
placed on heparin drip, then later started on Rivaroxaban (see
above). In setting of high fevers, there was also concern early
in patient's course for meningitis. His LP was unremarkeable and
HSV PCR was ultimately negative. ___ encephalopathy
in setting of sepsis likely.
# Transaminitis
He had a liver US to evaluate his elevated LFTs which showed
evidence of fatty liver disease and splenomegaly that was seen
on past abdominal CTs. His hepatitis serologies did not show
evidence of active or chronic disease. He is s/p transduodenal
ampullary resection in ___, but no concern for obstruction
given improvement in LFTs on repeat labs.
#Hypertrophic cardiomyopathy
HOCM, diagnosed in ___ w/ detection of heart murmur, now s/p
AICD and ethanol ablation of interventricular septum (___).
Echo this admission with minimal resting left ventricular
outflow tract obstruction unchanged with Valsalva maneuver;
___ gradient new compared to ___. He was continued on
Diltiazem and Atenolol was changed to Metoprolol. Patient will
___ with cardiology outpatient.
# Desmoid tumors
Patient with ___ syndrome, confirmed APC gene mutation c/b
colonic polyps s/p subtotal colectomy ___, soft tissue fibromas
and desmoid tumors requiring multiple surgeries. His Sulindac
was held inpatient and upon discharge. Patient will follow up
with Dr ___ for ongoing management.
# GERD
Continued protonix.
# Chronic loose stools
___ colectomy, has been chronic and unchanged. No abd pain.
Continued home loperamide. | 171 | 671 |
10781468-DS-27 | 23,523,775 | Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of
shortness of breath, abdominal pain and nausea. You were found
to have significant fluid in your lungs. You underwent multiple
sessions of dialysis to remove some of this fluid.
Additionally, your blood pressure medications were increased to
better control your blood pressure. Please continue to attend
your regular ___ dialysis sessions and
follow up with the appointments as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the very best.
Sincerely,
Your ___ Team | Mr. ___ is a ___ yo male with a history of CAD, sCHF (EF
35-40%), COPD, DM2, ESRD on HD (___) who is presenting from home
after he developed N/V and abdominal pain as well as hypoxia and
O2 requirement. | 103 | 40 |
16209892-DS-16 | 21,106,039 | Ms. ___,
You were admitted to ___ for the workup of left lower leg
weakness. We were concerned for a TIA which is a mini-stroke,
the MRI of the brain was normal. You were started on aspirin to
prevent strokes. On the imaging, it was noted that your left arm
vessel was narrowed which could be related to your prior
episodes of intermittent fevers and elevated inflammatory
markers. Thus, repeat imaging was obtained, but this showed no
evidence of inflammation in the blood vessels (at least on
preliminary read - the final read is still pending). We suggest
you follow-up with your primary care doctor for further
management of these conditions. In addition, please call the
number listed below to arrange for a rheumatology appointment.
We made the following changes to your medications:
- We STARTED you on ASPIRIN 81mg once a day.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization. | Ms. ___ was admitted to ___ for the workup of left lower
leg weakness. We were concerned for a TIA. The MRI of the brain
was normal. She was started on aspirin to prevent strokes. On
the imaging, it was noted that her left subclavian artery was
narrowed which could be related to the prior episodes of
intermittent fevers and elevated inflammatory markers. Thus,
repeat imaging was obtained showing no evidence of vasculitis.
She will follow with her PCP Dr ___ to continue the
workup for her unexplained fevers and weight loss. Whether the
mild narrowing of her subclavian artery is related to the event
that lead to her hospitalization. | 180 | 110 |
13340997-DS-5 | 23,100,190 | You were admitted after a friend found you in your apartment
covered in blood. You likely fell due to alcohol intoxication.
You stabilized in the hospital. You were found to have a T-11
fracture. The neurosurgical service was consulted and
recommended a "TLSO" spinal brace and physical therapy with
neurosurgical follow up. You will need to wear the brace at all
times that you are out of bed. | ___ yo M presents with thoracic compression fracture due to fall.
T-11 Vertebral Compression Fracture: Patient was evaluated by
neurosurgery and they recommended non-operative management with
a TLSO brace. He was fitted for the brace which he was
instructed to wear at all times when he is out of bed. His
friend ___ will take him to her house until his house has been
cleaned and made safer (right now there are many boxes, etc
making it difficult to walk around). He will have home ___ and
nursing.
Alcohol use: His friend ___, who found him, was concerned about
recent heavy alcohol use. She noted that vodka bottles were
found through out the apartment. Of note, on the day of
admission the patient wanted to leave and a ___ was
ordered in the ED. He was subsequently pleasant and did not
request to leave. His friend felt that he does have some
cognitive decline/possible sundowning in the evenings, as well
as heavy drinking in the afternoons. Of discharge he was clear
and coherent, but still intermittently confused, not remembering
that he was found in the apartment covered in blood, etc. | 68 | 191 |
11671223-DS-4 | 21,777,933 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were transferred
her from ___ after a CT of your head showed a new bleed in
your head. The CT of your head was repeated and appeared stable,
so our neurosurgeons said there was no need for surgery, but you
should follow up with them as listed below.
Your low blood pressure and low oxygen level at rehab may have
been from food and/or saliva going into your lungs, an event
called "aspiration". Please continue to eat slowly and tuck your
chin to your chest when swallowing. We do not believe you had a
pneumonia.
If you would still like the ear/nose/throat doctors to ___
the lumps in your neck, please call them to reschedule your
biopsy that was planned for ___. | ___ man with history of paroxysmal Afib, CKD, cervical
adenopathy (currently undergoing work up at ___), multiple falls
and recent SDH presenting with headache, found to have acute on
chronic SDH.
#Acute on chronic subdural hematoma: Due to multiple falls, most
recent fall in ___ per HCP/daughter. CT head at ___ showed
acute on chronic bleed, repeat head CT here about 12 hours later
was stable. Q4H neuro checks were stable, though he did have
very subtle left deviation of the tongue from midline, unclear
if present in the past. Held prophylactic heparin as discussed
below.
#Hypoxic episode: Patient reported to have desaturation, cough
and consolidation on CXR at OSH, however, when film here
compared to prior, no significant change. No signs of sepsis.
Clinical picture could be due to recurrent aspiration (known to
be at risk and non-compliant with tucking chin). Stopped
vanc/cefepime after one day.
#Dysphagia: Patient with main complaint of being unable to
taste his food and feeling like food is getting "stuck." It
appears he has had some work up of this through ___
___, which he should continue, as it appears to be having
great negative effect on his quality of life. Flexible
laryngoscopy and modified barium swallow have been unrevealing
thus far.
# Cervical lymphadenopthy: Has been seen by ENT at ___
___. Was planning for biopsy in early ___
before diagnosed with SDH and admitted to rehab. Per discussion
with daughter, unclear whether or not patient would want
chemo/surgery/radiation if indicated, but he had expressed
interest in getting the biopsy. She says they were also planning
on a PET scan at some point.
- Follow up with CHA ENT depending on patients goals of care | 134 | 282 |
14290095-DS-8 | 21,075,581 | You were admitted to the hospital with an infection of your
blood and your peripherally inserted central catheter (PICC),
which was being used to provide nutrition directly into your
blood (total parental nutrition or TPN). Because your PICC was
infected and bacteria were likely stuck to it, it was removed.
You will have to be treated with IV antibiotics given directly
into your blood because we are unsure if any oral antibiotics
would be absorbed well enough. These IV antibiotics are being
admistered through another similar PICC line that is freshly
inserted and free of bacteria. You will need to be on a total
course of antibiotics for two weeks. You will have nurses come
visit you at your home to help administer these antibiotics.
Please return to the ED immediately if you have any concerning
symptoms, especially if you develop chills agian. | Ms ___ was admitted to the bariatric service on ___ with
PICC related sepsis which ultimately cultured pan-sensitive
Klebsiella and she was ultimately sent home on a 14day course of
IV ceftriaxone for poor enteral absorption.
She underwent an open roux en Y gastric bypass in ___
which was complicated by wound infection/dehiscence. She was on
TPN for poor enteral nutrition in the setting of a slow to heal
wound, although it has been granulating. She initially
presented with one day of shaking chills of unclear etiology.
She was given a 1L NS bolus in the ED and stat CBC/Chem10/LFT
labs were drawn which revealed leukopenic white count to 3.0,
and a mild transaminitis consistent with her TPN use. A stat
AXR revealed no abdominal perforation, and a stat CT abd
revealed no acute intra-abdominal process such as a leak,
perforation, or abscess. There was cirrhosis, sigmoid
diverticulosis, and interval partial closure of her open wound.
Given her chills a CXR and UA were also ordered which were
unrevealing. A blood culture was taken which initially stained
positive for only GPRs and vancomycin/fluconazole was started.
Mycolytic cultures were also taken. Her PICC was removed and
sent for culture. She was started on IVF @ 125cc/hr with 1mg
Folic Acid/100mg Thiamine per day ("banana bag") and made NPO.
She was additionally started on BID IV protonix. The following
morning, she was advanced to bariatric stage I which she
tolerated well. Her blood culture in the morning also stained
positive for GNRs, so zosyn was added to her antibiotic regimen
at 1200 on HD2. She was started on SQH and her diet was
advanced to regular which she tolerated and her IV was
heplocked. Repeat blood cultures were drawn on HD4 which were
negative for growth. Calorie counts were initiated on HD4,
however they were reported after her discharge at 673 kCal for
HD5. Fluconazole was discontinued on HD4 for lack of mycolytic
growth. On HD5, her GNR was speciated with pan-sensitive
klebsiella. ID was consulted and they recommended a two week
course of ceftriaxone given poor PO intake and her prior RNY
gastric bypass. They also determined that the bacillus was
likely a contaminant and that klebsiella was likely the cause of
her sepsis. Vanc/Zosyn was discontinued and ceftriaxone was
started prior to discharge. On HD6 a PICC line was inserted for
a two week course of ceftriaxone. She will receive ___ care to
assist with home midline PICC care.
On the day of her discharge, she was tolerating a stage V diet.
She was voiding freely and she had no abdominal pain. Her
initial presenting condition, PICC bacteremia, had now resolved.
She was ambulating freely without assistance. She will follow
up in the ___ clinic in one week. | 147 | 485 |
10956506-DS-14 | 25,204,535 | Dear Ms. ___,
You were admitted to ___ and
underwent an open appendectomy and wedge cecectomy for acute
appendicitis. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Ms. ___ is a ___ year old female, with a PMH significant
for HTN, Grave's disease, pAfib(on Eliquis), OSA, recently
diagnosed vaginal clear cell adenocarcinoma. She presented to
the ED with N/V/abdominal pain on ___. She had an
abdominal/pelvic CT which was concerning for acute uncomplicated
appendicitis. She was started on antibiotics. On ___ informed
consent was obtained and she was taken to the operating room and
underwent laparoscopic converted to open appendectomy as well as
a cecectomy. Please see operative report for details. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating regular, on IV fluids, and acetaminophen and
ketorlac for pain control. The patient was hemodynamically
stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. She was
prescribed a 4 day course of augmentin post op. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
___ restarted eliquis, +gas, d/c tomorrow
___ augmentin started, toradol. holding eliquis tolerating
reg diet
___ OR for lap->open appy and cecectomy, CLD->reg, d/c
dPCA, CTX/Flagyl, d/c foley
___ non-op management. Zosyn not approved, change to
CTX/flagyl
___ added on for OR for appy | 440 | 293 |
14630440-DS-17 | 27,806,177 | Dear Mr. ___,
You were admitted to the hospital because of malnutrition and
abdominal/testicular pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- Your abdominal pain and testicular pain resolved on their own.
- You were evaluated by nutrition and were determined to have
severe malnutrition. It was recommended that you have a feeding
tube placed if you are unable to take in enough nutrition by
mouth.
- You were found to have iron deficiency and were given IV iron.
- You elected to leave the hospital against medical advice
(AMA).
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please contact your gastroenterologist (GI doctor) to arrange
an endoscopy as soon as you leave the hospital
- Please continue to eat more protein and drink ensures
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- You must never drink alcohol again
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed
- Keep your follow up appointments with your doctors
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY STATEMENT:
===================
___ male ___ HCV/EtOH cirrhosis decompensated by
ascites,
HE, opioid use disorder, alcohol use disorder (in remission),
COPD presenting with intermittent RUQ abdominal pain,
progressive
weight loss, and malnutrition. Patient was determined to have
severe malnutrition and was recommended to remain in the
hospital for monitoring of PO intake and likely initiation of
tube feeds, however patient declined and decided to leave AMA.
TRANSITIONAL ISSUES
=====================
[] Repeat RUQ U/S in 12 months to evaluate 0.3 cm gallbladder
polyp v. adherent gallstone- standard ___ surveillance US will
suffice and due in 6 mos.
[] Repeat HBV serologies after HBV vaccine series (___) to
assess immunity
[] Received IV iron while inpatient for ___. Switched ferrous
sulfate dosing from TID to every other day
[] Endoscopy soon after discharge for work-up of iron deficiency
anemia. Additionally due for annual variceal screening ___.
[] Patient is reported to have received colonoscopy at ___
however no records are available. Consider colonoscopy as part
of anemic work up if records can be obtained. | 239 | 163 |
10000980-DS-21 | 26,913,865 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. As you recall, you were admitted for shortness
of breath. This was because one of your heart valves was weak,
which caused fluid to build up in your lungs. Your heart valve
was weak because there was a blockage in one of your heart
arteries. You underwent a procedure, called cardiac
catheterization, which opened up the blocked arteries. Your
valve and heart are pumping much more efficiently now. We are
glad you are feeling better. Please weigh yourself every
morning, and call your MD if your weight goes up more than 3 lbs
over 24 hours. | ___ female with ___, HTN, diabetes, CKD presented with
increased dyspnea and non-productive cough without fevers or
elevated white count, initially admitted to ___ with concern
for pneumonia. However, was found to have ST-changes, enzyme
leak, new wall motion abnormality consistent with a recent
cardiac event and had no evidence of pneumonia (no fevers, wbc,
lactate, normal vitals, CXR with likely one sided pulmonary
edema from mitral regurgitation). She was seen by cardiology who
transferred the patient to cardiology floor.
# Acute systolic CHF exacerbation/mitral regurgitation:
Likely secondary to ischemic valvular disease resulting in
worsening mitral regurgitation. ECHO also with akinetic inferior
wall segments, which also supports an ischemic event. Cardiac
cath revealed 3 vessel disease. Patient was managed medically
with lasix, lisinopril, and metoprolol. Cardiac surgery was
consulted for possible CABG and mitral valve repair/replacement.
However, given her multiple comorbidities, she is extremely high
risk and surgery was deferred. Therefore, the decision was made
to revascularize the patient with PCI to see if the patient
would regain function of her mitral valve. Patient received a
bare metal stent in the LCx and plain old balloon angioplasty in
the diagonal artery. Repeat echo showed improvement of her
mitral regurgitation.
# NSTEMI/CAD:
As evidenced by EKG changes and troponin leak. Patient was
briefly started on a heparin drip prior to her first cardiac
catheterization. As above, cardiac catheterization revealed
3-vessel disease. Patient was initially medically managed with
aspirin, plavix, metoprolol, lisinopril, and atorvastatin. As
the patient would be too high risk for CABG, patient returned to
the cath lab and had a bare metal stent and POBA. She will
require plavix for at least 1 month.
# Hypertension: Patient remained normotensive. Continued
nifedipine at half of her home dose. Continued on lisinopril.
She was also started on metoprolol as above for CHF.
# Diabetes: Continued home insulin regime.
# CKD stage IV: Baseline Cr 2.5-2.8 per renal notes. Currently
at baseline.
# History of CVA: Continued home aspirin and clopidogrel.
# GERD: Continued home ranitidine.
TRANSITIONAL ISSUES:
* Will need follow up with a cardiologist. Patient will be
scheduled to follow up with the first available CMED
cardiologist.
* Will need plavix for at least one month (day of bare metal
stent placement = ___.
* Atorvastatin dose increased to 80mg (per pharmacy, her
insurance will cover. Her co-pay will be $10/month).
* Consider titrating nifedipine dose back to 120mg if still
hypertensive.
* Please recheck Chem7 at next appointment to evaluate for ___
secondary to dye received during cardiac catheterization. | 108 | 414 |
18216436-DS-28 | 20,140,574 | Dear Ms. ___,
You were admitted to the hospital with difficulty breathing and
found to have the flu and pneumonia. We treated you with Tamiflu
for the flu and antibiotics for the pneumonia and you improved.
You also seemed a little dehydrated and we gave you fluids.
During your stay we also discovered you have new atrial
fibrillation and you are placed on new medications to control
the rhythm.
It was a pleasure taking care of you!
Your ___ team | Ms. ___ is a ___ ___ speaking only female with
history of advanced dementia, CAD, CKD stage 3, thoracic aortic
aneurysm (7.7 cm in ___ and history of DVT (no longer
anticoagulated) who was admitted on ___ for fever and found
to
have influenza B infection and bacterial pneumonia. She
completed
Tamiflu and cefepime -> CTX/azithromycin treatment. She was also
found to have ___ with hypernatremia due to poor oral intake.
Then, she had new onset afib on ___ and was transferred to
___ ___ for IV diltiazem and IV amiodarone drips. She
converted to sinus rhythm and transferred back to medical
floor on ___. Since transfer, she has been in sinus rhythm,
and her sodium was 144 on ___ after D5W infusion to bring it
down from 149 on ___.
THe patient has had persistent problems with taking medications,
and constantly spits them out even with her son to coax her over
the phone.
#New onset afib
-Amiodarone PO to maintain rhythm/rate control, as well as
metoprolol.
-Patient in sinus currently
-Can consider repeat TTE (last was ___ for workup of new afib.
-Not currently on anticoagulation, it will be tough to provide
this if she is not cooperative with taking medications.
-TSH was normal
#Poor oral intake
#Advanced dementia
#Goals of care
-At baseline, per rehab: I spoke to ___ who cares for the
patient
at ___). The patient at baseline
has not refused meds with ___ specifically but often will do
that with
unfamiliar providers. She often does not recognize her own son
in
person, and mistakenly thinks other people are her son there.
She
also doesn't recognize her daughter in law too. The patient is
wheelchair/bed bound and doesn't ambulate. She has been
typically
eating 40% of her meals there, and they often have to encourage
fluid intake as she usually doesn't drink enough. The patient
typically makes zero sense when conversing, for example if you
ask her if she wants to eat something, she will immediately talk
about something else tangentially.
-Here in the hospital, she is at her baseline self. She has been
very resistant to taking any oral medications
or food or drink. As such, hypernatremia has also been a
problem,
and D5W infusions were needed constantly during this admission.
-The son has made it clear to ___ and prior HMED team as well
as
myself, that during this stay that she is DNR/DNI with no
artificial nutrition allowed, except ICU transfers or central
line placement is acceptable.
-I had spoken directly to HCP by phone.
-Patient has essentially end stage dementia and I told him this.
However he is still opposed to hospice or palliative care
involvement. He believes discharging to her ___ with the
predominantly ___ speaking staff would result in her taking
more PO. He agrees with reducing med list to only the
essentials.
-Appreciate gerontology consult. Have pared down medications to
only the critical meds (amiodarone, metoprolol, amlodipine).
___ on CKD stage 3 (resolved)
#Hypernatremia (resolved)
#Chronic diastolic heart failure
-Largely due to poor oral intake and hypovolemia.
-IV Lasix as needed for volume control but was stopped,
her BUN/Cr got worse with diuretics given last on ___, suspect
she was somewhat hypovolemic from lack of PO intake and that the
___ is prerenal from that. This is likely true as her ___
resolved to baseline Cr, without diuretics, on ___.
-Stopped losartan.
#CAD
-Stop aspirin/statin as above per ___ consult.
#Pneumonia
#Influenza B infection
-Resolved. Finished full Tamiflu course. | 77 | 521 |
10805203-DS-3 | 22,054,032 | Dear Ms. ___ and ___,
You were admitted to the hospital with confusion. We found a
mass in the brain. We had a family meeting and it was decided
that treatment of this mass with chemotherapy, radiation, or
surgery would not be within your goals of care. We did treat the
swelling around the mass in the brain with some steroids, as we
discussed in the goals of care meeting. Additionally, we found
evidence of seizure activity in the brain. The seizure activity
was treated with anti-epileptic medications. While in the
hospital, you had difficulty swallowing. Although the risk of
aspiration is high, it was decided in another family meeting
that part of optimizing comfort would include allowing you to
eat a regular diet and take medications by mouth rather than by
IV.
You are now being discharged to ___ to focus on
spending time with your family.
It was a pleasure taking care of you.
- Your ___ Care team | SUMMARY:
___ is a ___ year old woman with a history of dementia,
and multiple malignancies (including melanoma) admitted with
acute AMS, found to have likely new intracranial malignancy c/b
focal seizures. Surgical, radiation, and medical management of
mass were not within ___ and patient was managed conservatively
with focus on seizure suppression and improvement in mental
status. Pt discharged with all PO meds and regular diet despite
high aspiration risk, per ___. Pt discharged on hospice to
___. | 160 | 79 |
11273499-DS-7 | 29,551,065 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 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 change your dressing every 3 days or as needed for
drainage.
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
Please call the ___ if you
experience any further changes in your blurry vision.
___.
Physical Therapy:
Weight bearing as tolerated
Treatments Frequency:
- Dressing changes only as needed for soiled dressing
- Please draw weekly antibiotic surveillance labs:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
CBC with differential, BUN, Cr, AST, ALT, TB, ALK PHOS, vanco
trough, ESR/CRP
- Patient's vanco was recently increased due to subtherapeutic
trough. Please draw first vanco trough on day of admission to
rehab. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left native septic knee and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a knee I&D 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.
ID service was consulted regarding management. Given her high
cell count and diff, she was empirically treated for native
septic knee arthritis despite negative cultures.
The patient also complained of worsening vision in her left eye.
She was evaluated by the neurology team in the context of her
recent stroke and they did not feel that her symptoms were
consistent with new stroke. She was also seen by the
ophthalmology service regarding this visual loss and underwent a
dilated eye exam. They recommended close outpatient follow up
for her diabetic macular edema and cataracts. Although her
vision was getting slightly blurrier upon discharge, the ophtho
service reported that it would be expected if her vision were to
slightly worsen given her macular edema and that close
outpatient follow up was appropriate. We made appointments for
her for a comprehensive diabetic eye exam as well as with a
cataract specialist. Those appointments are listed in her
discharge instructions.
The patient also 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
weight bearing as tolerated, and will be discharged on aspirin
for DVT prophylaxis. The patient will follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 327 | 389 |
19668080-DS-16 | 24,329,411 | Dear Ms. ___,
It was a pleasure taking care of you here at ___. You
were found to have high fast rates and an abnormal heart rhythm
for which you were started on a medication called metoprolol and
diltiazem. you were also started on a blood thinner called
apixiban to prevent blood clots from forming in your heart.
We wish you all the best in your recovery.
Sincerely,
Your ___ team | Ms. ___ is a ___ female with breast cancer
(s/p mastectomy ___, on exemastane), MGUS (not treated),
hypertension, and hyperlipidemia who presents with dizziness,
nausea, and new atrial fibrillation.
# New atrial Fibrillation: No prior history. CHADS2 = 3, TTE
___ wnl. TSH wnl as
well. Patient does report ongoing stressors since the start of
the year in the setting of recent mastectomy. Life stressors and
decreased po intake were thought to have acted as possible
triggers of atrial fibrillation. Patient was trialed on various
doses of metoprolol and diltiazem and ultimately achieved rate
control on metop 50mg BID and dilt ER 240mg daily. Metoprolol
was maintained as fractionated on discharge given concern for
hypotension with AM dosing of both metoprolol and diltiazem.
Patient was also started on apixiban and counseled on
risks/benefits of anticoagulation for atrial fibrillation.
# Breast Cancer s/p mastectomy ___: no evidence of infection on
skin exam. Pain was well controlled with Tylenol. She was
maintained on xemestane.
# Positive u/a. Patient asymptomatic and urine culture was
contaminated. Antibiotics were not thought to be indicated as
UTI unlikely.
# Hypertension: Home amlodopine, atenolol, and losartan-hctz
were discontinued given adequate blood pressure control with
metop/dilt.
# Hyperlipidemia: Continued simvastatin.
TRANSITIONAL ISSUES
- please consider referral to social work given numerous
multiple recent life stressors
- please follow-up heart rate control on po diltiazem and
metoprolol
- amlodopine, atenolol, and losartan-hctz were discontinued
given adequate blood pressure control with metop/dilt
- simvastatin was held due to interaction with apixiban
- CONTACT: ___ (husband) ___
- CODE STATUS: Full Code | 67 | 253 |
10229264-DS-13 | 25,809,401 | Dear ___,
___ were admitted to the hospital because ___ had a seizure and
suffered a head injury. Your seizure was because ___ missed two
doses of your anti-seizure medication (LEVETIRACTAM). It is very
important that ___ continue to take your seizure medication
EVERY SINGLE MORNING AND EVERY SINGLE EVENING. If ___ miss ___
dose of your medication, ___ are at risk of suffering from
another seizure.
When ___ had a seizure this time, we were concerned that ___ may
be going into episodes of multiple frequent seizures (PROLONGED
CONVULSIVE SEIZURES). For this reason, ___ were first admitted
to the INTENSIVE CARE UNIT because we were worried that ___ may
not be able to breathe by yourself. We placed a tube in your
lungs to help your breathing for one day while we gave ___ high
doses of seizure medication.
___ had no further problems after we started your seizure
medication. ___ were stable on your home seizure medication and
did not have any additional seizures while on this dose.
We sent for several lab tests during your hospital stay, which
showed that all of your HIV medications are working very well to
keep the virus level low.
It is VERY IMPORTANT that ___ TAKE ALL OF YOUR MEDICATIONS AS
DIRECTED. PLEASE NEVER MISS ___ MEDICATION DOSE.
We made no medication changes on your hospital admission.
Follow up with your Primary Care Physician ___
___ within ___ weeks.
Thank ___ for allowing us to participate in your care.
___ Neurology | Ms. ___ is a ___ woman with a history of HIV, stroke,
and epilepsy who was admitted for management of a prolonged
convulsive seizure requiring intubation. Etiology for her
seizure was in the setting of non-adherence to keppra. She was
extubated within one day without complications. Her EEG showed
right posterior quadrant focal slowing with epileptiform
discharges in the right parietal and right temporal regions,
suggesting that her seizure likely originates from this region.
No electrographic seizures were detected. Her hospital course
was complicated by a transient fever (<24hrs) that
self-resolved. Infectious work-up, including lumbar puncture,
blood cultures, HIV viral load, EBV PCR, and HSV PCR was
negative. Her CD4 count was 232, CD4/CD8 ratio was 0.24. We
resumed her home dose of 1000 mg keppra twice a day and she had
no further seizures.
During her admission, she complained of right shoulder stiffness
and pain (paretic from her prior stroke). XRAY of her shoulder
was negative for subluxation. She was stable for discharge to
home with ___ care from her husband and daughter and with home
___. Her exam on discharge was at her baseline prior to her
hospital admission, with right upper and lower extremity
paresis. We provided counseling and education on medication
compliance during her stay and confirmed that all of her
medications are delivered to her home pre-packaged.
#Seizures:
Patient was not taking her home keppra 1000 mg BID and this is
what is thought to have caused her seizure. Patient on CVEEG
with persistent focal slowing in the right posterior quadrant,
with interictal epileptiform discharges in the right parietal
and right temporal regions independently. Background slowing
consistent with a mild encephalopathy. She was treated with
keppra, at her home dose. MRI with signs of previous
toxoplasmosis in right occipital region, as well as small area
of restricted diffusion in the right temporal lobe likely
reflecting recent seizure. Per review of prior hospital records,
history of toxoplasmosis, but no malignancy. LP was within
normal limits. HSV PCR pending.
#Acute respiratory failure requiring intubation:
Patient was intubated after becoming somnolent with concern for
maintaining airway after receiving lorazepam 2mg. Patient
extubated ___ hours later and was weaned to room air.
#HIV/AIDS
Patient was restarted on home anti retroviral medication. Her
CD4 count this admission was 232. Per prior records, her CD4
count in ___ was reportedly 8. | 246 | 393 |
13702880-DS-17 | 20,917,137 | Dear ___:
You were admitted for weakness and fatigue. We drew blood
cultures and found that you had an infection in the blood. This
happened twice, and you also had 2 urinary tract infections. We
treated these with IV antibiotics.
While you were here, you had back pain. This turned out to be a
fracture of the bones in your back. You have a brace that you
can wear for comfort, and we will recheck imaging of your back
in ___.
We will arrange for you to be seen weekly in the clinic at
first, and then hopefully as you do better, you can be seen
every other week.
Please work hard with therapy to get stronger! | ___ year old female with CML who is ___ year s/p MUD reduced
intensity allo, admitted ___ with weakness/back pain
subsequently dx w/MSSA Sepsis & T11/T12 compression fx with
course c/b VRE UTI x 2, second episode of MSSA sepsis and CMV
viremia now on ganciclovir with ongoing malnutrition and poor PO
intake. | 114 | 48 |
19401446-DS-5 | 22,385,563 | Dear ___,
You were hospitalized due to symptoms of confusion and
exhaustion 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, high blood pressure, high cholesterol
We are changing your medications as follows:
START Clopidogrel (Plavix) 75mg by mouth daily
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. ___ is a ___ year old left handed woman with
hypertension hyperlipidemia and insulin dependent type 2
diabetes on insulin pump who is admitted to the Neurology stroke
service with confusion and progressive lethargy secondary to an
acute ischemic stroke in the bilateral basal ganglia. Her stroke
was most likely secondary to a small vessel ischemic event given
her poorly controlled vascular risk factors and the location and
appearance of the infarcts. She remains confused but is oriented
to self, name of hospital, and month of year. She will continue
rehab at a rehab center. | 240 | 96 |
17813402-DS-11 | 27,411,956 | You were admitted with a possible overdose which may have caused
a seizure and some hypoxic brain injury. This resulted in
injury to your kidney, liver, and muscle. This improved with
treatment. You also were found to have an infection which will
require treatment.
let your doctor know if you develop sharp pain in your tendons
as the antibiotic can sometimes cause injury to tendon if you
exercise strongly.
We provided you w Rx for narcan and discussed options for
substance use treatment.
For sleep you can use melatonin over the counter and use it as
directed if you have insomnia. | ___ y/o M with PMHx of polysubstance abuse (cocaine, opioids), as
well as bipolar d/o with prior SI, who was found down with
subsequent witnessed seizure activity, intubated, and
hospitalized for further care. Working diagnosis is drug
overdose causing seizure, rhabdomyolysis, ARF, and now found to
have bacillus bloodstream infection. He received ICU care and
then was extubated. He injects into buttocks w anabolic
steroids and possible myositis seen in this region on MRI.
Ultimately oral antibiotic chosen to treat bacillus rather than
placing PICC and sending him to a ___ as ID felt
there was sufficient data in literature to treat bacillus w PO
given lack of endocarditis.
# ACUTE TOXIC ENCEPHALOPAPTHY
# SEIZURE
# POLYSUBSTANCE ABUSE
# Hypoxic Brain Injury
The patient endorsed recent ingestion of cocaine and heroin.
However, he did not recall the events leading up to his
unresponsive episode, so he may have ingested other substances
as well. Mental status improved since presentation, and the
patient has been successfully extubated. Given overall
presentation, ingestion seemed to be most likely cause of the
patient's seizure (perhaps ___ cocaine or other ingestion).
Given lack of fever or meningeal signs, CNS infectious process
was unlikely. MRI brain performed to look for other CNS
processes. Of note, the patient did have possibly evidence of
mild opioid withdrawal. monitored on neuro precautions and
treated with thiamine and folate. MRI head evidence of
Intracranial hypoxic injury evidenced by DWI hyperintensities in
the globi pallidi and possibly also in the hippocampi
bilaterally.
[]Cognitive neurology contacted to assess patient as outpatient
given MRI evidence of hypoxic injury
[]OT evaluated patient: no needs for immediate rehab
#Bacillus Blood stream infection.
Per ICU notes, "WBC 30 on admission. Per girlfriend has been
having several days of headache, N/V, abd pain, subjective
fevers although afebrile at ED and urgent care on ___ and ___.
Started on vanc/zosyn in the ED." He denied any headache or
abdominal symptoms in house. Blood cultures grew GPRs (in 2
sets) and GPCs (in 1 set), ultimately speciated as bacillus (non
anthracis species) in multiple bottles and a coag neg staph
bottle.
Patient received IV vancomycin as his antibiotic regimen through
___ when ID advised that oral levofloxacin be used to treat his
bacillus. He was started on levofloxacin 750mg PO daily to
complete a 14d course of antibiotics w d1 being the first day of
negative cultures on ___ to end on ___. His significant
leukocytosis to 30 on admission improved prior to discharge.
TTE did not show evidence of endocarditis and TEE not felt to be
required by ID.
He was cautioned on risk of tendinopathy. EKG w QTC <420 on
admission
# ___: resolved creat 2.9 on admit, 1.1 on discharge
# RHABDOMYOLYSIS: CK peaked at 10K and then improved with IVF
and supportive care
There was evidence of possible myositis in his pelvic muscles.
See MRI report: Increased STIR signal and expansion of the right
gemellus, obturator
internus, piriformis, gluteus minimus, medius and maximus,
compatible with
nonspecific myositis, including infectious or inflammatory
etiologies.
Assessment for a rim-enhancing fluid collection is limited
without intravenous
contrast. IT was a limited study as patient could not tolerate
full study. CK 604 from peak of 10,000
# HEPATITIS C: HCV positive with moderate transaminitis, HCV VL
negative.
# DEPRESSION
# H/O SA
# Substance Use disorder
With possible recent SI per girlfriend. ___ consulted.
Continued fluoxetine. Not on ___. Has outpatient psych
team. He received SW consult and counseling on harm reduction
and team oferred MAT, but patient declined use of pharmacologic
or structured treatment programs. Given Rx for narcan.
>30min on discharge activities and coordination
medically stable for discharge on ___ | 103 | 616 |
11775739-DS-17 | 28,052,837 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for weight gain and
swelling consistent with a flare of you heart failure. You had
severe shortness of breath and required a brief time on
something called BiPAP to help you breath. We removed the excess
fluids with intravenous diuretics. Your breathing and swelling
improved. You will go home with a different diuretic called
torsemide.
You will also go home with an antibiotic for a new urinary tract
infection.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
On behalf of your ___ team,
We wish you all the best | ___ male with a significant past medical history of
metastatic osteosarcoma and sCHF (EF in ___ 29%) who presented
with decompensated systolic heart failure.
# CORONARIES: unknown
# PUMP: 29% EF in ___
# RHYTHM: NSR | 111 | 36 |
12966187-DS-7 | 27,223,466 | Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted to the hospital after you developed chest pain
while getting your CT scan to look at your heart. You had a
catheterization procedure which showed a blockage in one of the
arteries of your heart for which you received 2 drug eluting
stents. If will be extremely important for you to take your
aspirin and Plavix every day to prevent the stents from becoming
blocked.
The CT scan also showed incidentally several small nodules in
your lungs. It is unclear what these are, and it is important
that you have repeat imaging with your primary doctor for
follow-up of this.
You should discuss with your cardiologist when you should
restart your atenolol. We stopped this medication because your
heart rate was slow.
The following medications were changed during this admission:
- Please START to take aspirin 81mg daily
- Please START to take Plavix 75mg daily
- Please STOP atenolol
- Please CONTINUE to take the rest of your medication.
We also made the following appointments (see below).
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery. | ___ w/ h/o HTN, HLD, DM2, who had one year of exertional chest
pain and underwent outpatient coronary CTA, and was found to
have 99% RCA stenosis.
.
ACTIVE ISSUES
# Unstable angina: Pt had one year stable angina symptoms, and
presented for scheduled CTA per PCP ___. Her CTA
showed 99% RCA, 85-90% LCx disease. More importantly, she
complained of worsening chest pain after the CT. Of note, her
EKG is unchanged and her cardiac enzymes were flat. Pt was
loaded with plavix and admitted for catheterization. She was
found to have a 75% stenosis in LAD and 70% lesion in diagonal.
Both lesions were intervened with ___. Post
catheterization, pt was treated with aspirin 81 mg, plavix 75 mg
daily. We held her atenolol given the bradycardia. Her
hemoglobin A1c and lipid panel were both at goal. Pt also
underwent a post-cath ECHO, which reviewed a preserved EF at
55%, with no ASD or VSD.
.
CHRONIC ISSUES.
# Diabetes: mild DM2 with A1c 6.5. We held her metformin and
started her on sliding scale insulin, which she tolerated well.
.
# gastritis: stable condition, we continued her omeprazole
.
# liver disease: Pt showed evidence of liver disease, including
thrombocytopenia, and coagulopathy.
.
TRANSITIONAL ISSUES
# CODE STATUS full
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES:
- STOPPED atenolol (as BP on lower end)
- STARTED aspirin 81 mg qd
- STARTED plavix 75 mg qd
# FOLLOWUP PLAN:
- Pt need cardiology and PCP ___.
- Consider repeat CT scan in 6 month for multiple small
nodules ranging in size from 3.4 to 5.9 mm in diameter, largely
in the lingula and left lower lobe. | 195 | 284 |
16457455-DS-4 | 23,801,562 | 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:
- 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
ACTIVITY AND WEIGHT BEARING:
- Left lower extrmity: weight bearing as tolerated
Physical Therapy:
Left lower extremity: weight bearing as tolerated
Treatments Frequency:
# DAILY CHEM to monitor Na
# Free water restriction to 1.5L
Site: L hip
Wound: Surgical incisions
Description: Dry gauze and tape dressing
Care: Change dressing every other day or as needed to keep clean
and dry. If incision remains non-draining, OK to leave open to
air.
Follow-up: Pt is to follow-up in ___ days for removal of
staples. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a left hip hemiarthroplasty,
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 with primary
management by the orthopedic team and medicine consultation. In
the ___ period, the patient had atrial fibrillation,
which was self-limited with no need for
rate control of anticoagulation during hospitalization. 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. POD#2, the patient's was noted to
be hyponatremic to 120, likely secondary to administration of
hypotonic IVF (___) in the setting of taking HCTZ with a
high ADH state. She was asymptomatic. Her HCTZ was held, she was
fluid restricted to 1.5 L and hyponatremia improved and remained
stable. It is recommended that she does not re-start HCTZ. Other
than HCTZ, the patients home medications were continued
throughout this hospitalization. Mutlivitamin, Vit B12, Calcium.
Vit D, and Folate were also added to the patient's medications
in order to optimize her nutrion status, which was felt to be
sub-optimal. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 230 | 360 |
17976112-DS-4 | 27,999,468 | You were admitted to the ___ surgery service for surgical
incision and drainage of your multiple left breast abscesses.
You have done well in the post operative period and are now safe
to return home to complete your recovery with the following
instructions:
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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. | Patient presented to the emergency department on ___ for
evaluation and treatment. The patient was found to have multiple
left breast/axillary abscesses. The patient was admitted to the
hospital, labs were drawn, and the patient was placed on empiric
IV antibiotics. Pharmacy was consulted regarding medication use,
given the patient is ___ weeks pregnant. The patient was
initially placed on IV-morphine for pain control, but was
changed to IV-dilaudid secondary to nausea with morphine. The
patient's vital signs were routinely monitored, and fever curves
were closely followed. The patient remained afebrile while on
the floor.
The patient was taken to the operating room on ___ for
incision and drainage of the left breast/axillary abscesses. The
operation went well without complications (please refer to
operative note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor. Postoperatively, the
patient's diet was advanced when appropriate, which the patient
tolerated well. She was able to void independently. The
patient's wound was packed daily, and she was premedicated with
pain medications prior to packing. The patient will continue to
re-pack the wound once daily with the help of ___. The patient's
antibiotic regimen was scaled back to zosyn alone on ___
(vancomycin was discontinued), as per the recommendations of the
Infectious Diseases service. The patient will complete a 2-week
course of zosyn (last dose ___, to be administered through
her PICC line. The patient will follow-up in Infectious Diseases
clinic. On ___, patient had some blood loss when repacking
the wound, which self resolved. The patient's hemotocrit was
monitored, and remained stable. The will follow-up with Dr.
___ surgery) in clinic.
The patient received 1 unit of packed red blood cells secondary
to Hct<20. The patient remained hemodynamically stable. No
transfusion reactions were observed.
The patient received subcutaneous heparin and SCD boots for
prophylaxis.
At the time of discharge, the patient was alert, voiding
independently, ambulating independently, and able to verbalize
understanding with the discharge plan. | 172 | 325 |
12405234-DS-11 | 27,442,171 | It was a pleasure to participate in your care.
You were admitted after a fall. You reported neck pain. A CT
scan of your neck did not show a fracture. Your pain is likely
due to musculoskeletal strain. You were seen by physical therapy
and they recommended that you use a cane when you walk.
You were found to have a pneumonia. Please complete an
additional five days of the antibiotic augmentin. Also, we have
prescribed acamprosate, a medication that will help curb your
cravings for alcohol. Please take this three times a day. You
have some neuropathy (nerve damage) in your feet, likely
secondary to your alcohol use. You are experiencing pins and
needles sensations in your feet. I have prescribed neurontin
for this.
ALL OF YOUR PRESCRIPTIONS HAVE BEEN FAXED TO THE ___ AT
___ IN ___ SO YOUR MEDICATIONS SHOULD BE
READY WHEN YOU GO THERE. | The patient is a ___ year old male with a medical history of
alcohol abuse who presents after a fall found to have fever,
bandemia, hypoxemia concerning for sepsis due to pneumonia also
with alcohol withdrawal and suicidal ideation
#SEPSIS / PNEUMONIA: The patient met SIRS criteria
(tachycardia, fever, white blood cell count) with presumed
pulmonary source. The patient reported cough and was found to
be febrile with hypoxemia with exam concerning for pneumonia.
Labs notable for leukocytosis and bandemia. CXR was notable for
left lower lobe opacity consistent with pneumonia. There was
concern for aspiration pneumonia in the setting of alcohol use
and fall so he was started on levofloxacin (___) and flagyl
(___). Blood cultures showed no growth at the time of
discharge. Patient was converted to augmentin the day before
discharge and tolerated the medication well. ___ normalized at
7.7.
#ETOH WITHDRAW: Patient with history of heavy alcohol use and
seziures in the setting of withdrawal. He was at risk for severe
withdrawal given history of seizure in the past and concomitant
infection. He was started on symptom based scoring scale
initially with IV ativan and then transitioned to oral valium.
He was given thiamine, folate, and multivitamin. Patient did
not end up exhibiting severe withdrawal and only scored enough
on the CIWA scale a few times to receive diazepam. He was
discharged with a prescription for acamprosate.
.
#SUICIDAL IDEATION: Per psychiatry notes, he has a history of
suicidal ideation in the setting of alcohol use. Per ED notes,
the patient reported that he wanted to stab himself. He was
evaluated by psychiatry and initially maintained on a 1:1
sitter. When the patient was no longer intoxicated he no longer
reported SI, and was deemed competent by psychiatry.
# NECK PAIN: Most likely musculoskeletal from fall. He had a
non-focal neurological exam. CT neck showed no evidence of
acute fracture but noted enlarged paraspinal muscles.
Neuroradiology was contacted and did not feel MRI was needed at
this time.
.
#MECHANICAL FALL: Reports several recent falls in setting of
alcohol use. Physical therapy was consulted.
.
#TRANSAMINITIS: This was likely due to alcohol use (AST>ALT).
Hepatitis serologies were checked and were negative.
Transaminitis improved over the course of his hospital stay, but
were still elevated on discharge, and should be rechecked when
he is followed up as an outpatient.
.
#BIPOLAR DISORDER: He was continued on his home trileptal.
.
#ASTHMA: He was continued on albuterol and flovent.
.
#BPH: Terazosin was initially held in the setting of systemic
infection, but resumed on discharge.
.
#Tobacco dependence: Discharged with nicotene patch.
# Neuropathy: Complained of paresthesias on the plantar surface
of both feet. Has good DP pulses, but diminished sensation on
plantar surfaces. Also had some erythema at tips of toes -
possibly evidence of past mild frostbite. His paresthesias are
likely from alcoholic neuropathy, and he was given a
prescription for neurontin to take at night. | 157 | 504 |
11459825-DS-5 | 26,711,086 | Dear Ms. ___,
You were admitted to the ___
with shortness of breath. You were found to have a low
hemoglobin and you were transfused a unit of blood. You were
also found to be fluid overloaded and so you had several
sessions of hemodialysis which improved your shortness of
breath.
Your medicines have been changed-- you should take amlodipine 5
mg daily (half of the dose you were taking before). You were
also started back on EPO and you should get this with dialysis.
You should follow up with your PCP and with your nephrologist.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | Ms. ___ is a ___ F with ESRD on HD, dCHF and chronic anemia
presenting with shortness of breath, found to have Hbg of 6.5.
# Shortness of breath: Etiologies include symptomatic anemia and
fluid overload. Pt's Hb was 6.5 on admission and she received 1
u pRBCs. She also underwent hemodialysis with removal of 1.5 L
fluid with improvement in her symptoms. EPO was also given
during HD and should be continued upon discharge.
# Anemia: Patient presented with Hbg of 6.5 (baseline high
6s-low 8s). Etiology of anemia is likely ACD given ESRD,
elevated ferritin, and normal haptoglobin. Patient reported not
having received EPO recently at HD. On admission she was
transfused 1 u pRBC with adequate response. EPO was given during
HD and should be continued (6,000 qHD session). She demonstrated
no signs of active bleeding.
# HTN: During hospitalization patient had labile blood
pressures, with SBP ranging up to 190s and dropping as low as
___ during HD. She had been told to stop taking amlodipine 10 mg
prior to this hospital stay. She was maintained on home
labetalol 400 mg TID and ISDN 10 mg TID. Amlodipine was
restarted at a lower dose (5 mg daily). She remained
asymptomatic during hypertensive episodes.
# ESRD on HD: Patient with ___ schedule. She underwent HD
prior to admission and last HD was received on ___ with
removal of 1.5 L as above. EPO also started, as above. Patient
was continued on home calcitriol. Calcium acetate temporarily
stopped due to low phos but restarted given normalization after
receiving 1-time phosphorus repletion.
# dCHF (last EF >60% ___: Patient's last TTE last admission
notable for normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Moderate
pulmonary artery systolic hypertension. Mild-moderate mitral
regurgitation. She also had a stress test last admission that
was normal. However, BNP this admission elevated to ___. Fluid
balance was maintained with HD, as above.
# Thrombocytopenia: Patient noted to have a mild
thrombocytopenia (also noted last amission). No known
cirrhosis, INR normal, albumin slightly low, intermittently
elevated liver enzymes. Not an active inpatient issues; should
be worked up as an outpatient.
# Hypothyroidism: Continued home levothyroxine.
# DMII: recently stopped home POs given hypoglycemia. Patient
maintained on ISS in-house. Also kept on home aspirin and
gabapentin.
# GERD: Continued home ranitidine.
# CODE: Full
# CONTACT: ___ (daughter, ___) ___ | 105 | 401 |
10577868-DS-20 | 27,272,884 | You were admitted after you injured your hand. You underwent
surgery. After surgery you had some trouble breathing and were
also found to have a pneumonia. You were started on antibiotics
and you improved. You also had slow down of your gut motility
called "ileus" due to pain medications (narcotics), but this
resolved.
Discharge Instructions:
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 in left upper extremity in splint
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.
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.
- 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 | ___ year old woman with RA on abatacept and methylprednisolone,
bipolar disorder, chronic back pain and spinal stenosis, GERD,
HTN, hypothyroidism (post-thyroidectomy for benign nodule),
hypocalcemia due to
hypoparathyroidism after thyroidectomy, obesity s/p gastric
bypass in ___, OA s/p knee replacement, neuropathy who
presented
to the ED after falling onto glass and
sustained a deep laceration to the left arm with incomplete
median nerve injury and potential injury to the extrinsic
flexors, now s/p operative repair on ___, but course
complicated by sepsis, ___, respiratory failure due to narcotic
overuse. Transferred to ___ on ___ from surgery.
#Sepsis (resolved)
#Pneumonia (resolving)
-likely was from pneumonia and now rapidly improved.
-levofloxacin for 7 day course (last day to be ___
___ (resolved) - likely was prerenal from sepsis, improved with
IVF.
#Acute hypoxic respiratory failure with somnolence, narcotic
toxicity (resolved)
#Nausea (resolved)
#Vomiting (resolved)
#Ileus (resolved)
-KUB on ___ revealed ileus. Probably due to narcotic overuse
earlier in
her stay.
-She then had daily bowel movements as it resolved.
-Tolerated her diet without emesis for 48 hours prior to
discharge.
#Left forearm laceration and incomplete median nerve injury
#Left toe fracture, suspected
- Post-op shoe to LLE, WBAT
- NWB LUE, maintain elevation
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
#HTN
-Initiated losartan 100 mg once daily, this is new medication
for BP.
#hypocalcemia due to
hypoparathyroidism after thyroidectomy
-Ca is stable with albumin correction.
#RA on Orencia/methylprednisolone
-Stable, on home methylprednisolone.
-Hold abatacept for 4 weeks at minimum.
#Hypothyroidism
-Continue home synthroid
#Bipolar disorder
-Continue home lamotrigine, wellbutrin | 326 | 262 |
12525991-DS-17 | 20,519,715 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in with abdominal pain at the site your
LVAD driver enters your body. We believe this pain was most
likely related to trauma after a staff memeber accidentally
tripped over the cord at rehab. There were no signs of
infection. You will complete a 7 day course of antiboitics to
prevent infection of your LVAD following the traumatic event. | ___ with end stage non-ischemic cardiomyopathy, h/o afib, s/p
CVA who s/p HeartMate II LVAD implantation ___ as BTT),
now presenting with abdominal pain @ LVAD insertion site.
#RUQ Abd pain: Patient presented with a day of ___ RUQ pain
overlying area of percutaneous LVAD driver entry. The pain was
most likely secondary to trauma at ___ battery site after staff
at rehab mistakenly tripped over cord. Infectious etiology was
less likely as he denied any constitutional symptoms (initially
promoted subjective fevers which he later denied), he was
afebrile, and had no leukocyctosis above baseline. A CT abdomen
and pelvis showed a stable sub xiphoid fluid collection without
concern for infection. He was noted to have a small pleural
effusion at base of right lung with low concern for underlying
pneumonia. He was initially covered with with vanc/cefepime but
this was held after 48hrs with low concern for infection. Blood
cultures remain no growth at time of discharge. His LVAD was
functioning normal this admission and there was no concern for
thrombus. Mr. ___ does have chronic constipation which may
have also contributed to abdominal pain. He had a well formed
bowel movement following lactulose dose. His abdominal pain is
improved at the time of discharge. His will complete a 7 day
course of doxycycline for prophylaxis following trauma to LVAD
driver site.
# RLL opacity: Patient was found to have a right pleural
effusion on CT abd/pelvis with RLL changes more consistent with
atelectasis vs. pneumonia. As noted above, he had no clinical
evidence of infection and vanc/cefepime were held after 48
hours. Blood cultures remain NGTD.
# Non-ischemic cardiomyopathy status post LVAD: LVAD was
functioning properly during admission. His goal INR is now ___.
His dose of warfarin was decreased to 1mg daily. He was
continued on ASA 325mg and dipyridamole. His hydralazine was
increased from 25mg to 30mg TID.
#Eosinophilia: Pt has long history of eosinophilia, but only
mild to moderate elevation based on absolute counts which may be
related to medications. Hematology evaluated patient this
admission and did not have concern for hypereosinophilic
syndrome (concern has heart biopsy previously showed eosinophils
in myocardium). Peripheral smear was reassuring. Strongyloides
and stool O&P were negative in ___. His allegra was made
standing and added fluticasone as phe has a hx of rhinitis.
==================== | 74 | 387 |
18258934-DS-21 | 27,978,041 | Mr ___, you were hospitalized at ___ following a fall. You
were found to have low blood sugar and throughout your hospital
stay had worsening liver failure. Unfortunately this prohibits
any treatment of pancreatic cancer at this point as it would
cause more harm from the side effects of chemotherapy. You and
your family were discharged home with hospice services to assist
with managing your symptoms related the pancreatic cancer. | Mr ___ is a ___ yr old male with hx HTN, ETOH use and recently
diagnosed pancreatic cancer admitted following a fall and
initially found to have hypoglycemia, home oral diabetic
medications were stopped and not resumed. There was no LOC. Head
CT negative on admission, no fracture in ankle. He also
developed progressive liver failure including worsening
hyperbilirubinemia and hyperammonemia with encephalopathy. He
was evaluated for a reversible cause for his liver failure, but
RUQ did not show any obstruction or thrombosis. His liver
failure continued to worsen during this hospitalization and was
felt to be related to progressive infiltrative malignancy in the
setting of alcoholic cirrhosis. Plan initially was to pursue
chemotherapy as an outpatient, but he declined quickly during
this hospitalization to the point that it was not felt safe or
effective to give chemotherapy after discussion with his
outpatient oncologist. He transitioned to comfort care and will
be going home with hospice.
His hospital stay was marked by fluctuations in his mental
status. On ___ he was more confused than on admission and was
felt to have hepatic encephalopathy. He was started on rifaximin
and lactulose with improvement. He had diarrhea and severe
hypokalemia so dose was reduced to 2 times daily which resulted
in ___ soft stools daily. He was monitored on CIWA protocol due
to history of drinking, but his score remained low and he
reportedly had not had a drink in several weeks prior to
admission. Plans were being made on ___ for discharge but he
was found to be very deconditioned and rehab stay was
recommended. The following morning, he had an outburst of
violence and attacked his nurse including grabbing her neck. He
fell on the ground and was unable to get up until helped back by
public safety. He remained on public safety supervision for the
rest of his stay, though he had no further outbursts. There were
thought to be several possible factors: hepatic encephalopathy,
reduction in psych meds on admission due to concern for
decreased liver function, psychological stress of cancer
diagnosis. He was seen in consultation by psychiatry. His
seroquel was increased to home dose of 300mg BID. He was
continued on wellbutrin, clonazepam, lamictal and adderall
At time of discharge he was calm and becoming more and more
deconditioned and confused to the point his physical ability for
violence had reduced greatly, he was largely bed bound but able
to get up with assistance. | 73 | 408 |
13505524-DS-26 | 29,752,307 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for fever and sinus pain.
What was done for me while I was in the hospital?
- You were treated with antibiotics for a chronic sinus
infection.
- You were given medications to help mobilize the material in
your sinuses.
- Your blood pressure dropped and you were given IV fluids and
steroids. Your blood pressure returned to normal.
- You were evaluated for a severe headache. The imaging did not
show any bleeding or evidence of a stroke.
What should I do when I leave the hospital?
- Continue taking your medications as prescribed.
- Keep all of your follow-up appointments.
- Please schedule a follow up with your endocrinologist.
- Please call Dr. ___ specialist) for an
appointment.
ph. ___.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female with AML s/p allo-SCT
in
___ with post transplant course complicated by extensive
chronic
GVDH (skin, eyes, lungs, liver, mucous membranes) and multiple
pulmonary infections including invasive pulmonary aspergillosis,
hypogammaglobulinemia on monthly IVIG, and DVT/PE on Eliquis who
was admitted with fevers, cough, and sinus pain concerning for
acute
on chronic sinusitis.
# Chronic Sinusitis: Patient presented with progressive fevers
and continued cough with sinus pain. Of note, she has had
multiple prior admissions for various pulmonary infections
including a recent discharge after a viral and E. Coli pneumonia
in addition to bilateral sinusitis. She is s/p a 10 day course
of
meropenem for her MDR E. coli pneumonia from prior admission.
Possible that the patient's antibiotic course was not long
enough
to clear her infection or that she has developed another viral
infection (recently with enterovirus and rhinovirus) given her
symptoms. Fungal sinusitis is less likely given her recent
negative galactomannan and B-glucan. Viral culture showed +
rhinovirus and +enterovirus. Likely viral with +/- superimposed
bacterial infection. ENT scoped and found active purulent
drainage from left maxillary sinus, cultures and showed rare
coag
neg staph. Discussed with ID and felt to be contaminant. Will
need to mobilize sinus secretions.
- meropenem ___ - ___ transitioned to doxy ___
- nasal saline spray qid
- Flonase 2 sprays qd
- ENT consulted, appreciate recs
- ID consulted, appreciate recs
- sinus aspirate with coag neg staph. Discussed with ID and
___ likely contaminate.
- ___ blood cultures NGTD.
- follow up with ENT as outpatient.
#hypotension:
___ p.m. BP of 78/58. HR 90. 02 sat 96%. T 98.1. Repeat BP
80/55. No chills. Afebrile. Cough stable. No new localizing
symptoms. Labs were sent
(cultures, lactate, CBC). She was given one L NS and blood
pressure remain low, 88/56, despite fluids. She has been on
chronic steroids and was given dose of steroids and BP improved.
No obvious signs of bleeding and repeat CBC with stable H/H. No
EKG changes. Also obtained echo to eval any cardiogenic cause,
however, concern re: adrenal insufficiency and repeated dose of
methylpred ___
___ consulted endocrine d/t concern adrenal insufficiency
causing episode of hypotension. Endocrinology felt unlikely
that
her current hypotension/orthostatic hypotension is caused by
adrenal insufficiency. Causes of HPA axis
suppression that could result in secondary adrenal insufficiency
including exogenous steroids (prednisone 7.5 mg daily, recent
sick dose steroids, clobetasol topical cream, dexamethasone
swish
and spit) and opioids (guifenesin-codeine and oxycodone). On
review of her MRI brain there does not appear to be a mass
lesion
that would raise concern for hypopituitarism from a mass effect.
TSH of 2.8 and free T4 of 0.9 appears within range of prior
values in setting of known hypothyroidism but would
endocrinology
recommended adding on a total T4.
-Add on serum free cortisol and total T4 to morning labs
-Continue with 7.5 mg prednisone daily while inpatient.
-follow up next week. Per endocrine consider decreasing
prednisone
to 5 mg daily. (due to concern
for side effects including worsening of osteoporosis)
-Repeat thyroid function tests in 4 weeks prior to follow-up
with
Dr. ___
-___ with
guiafenesin-dextromethorphan
- outpatient follow-up with Dr. ___ in 4 weeks
re: low cortisol level a.m. cortisol level, T4
#HA accompanied by mild disorientation
Report severe HA this ___ which was reported different in
quality and severity than prior sinus HA. Given she is on
apixaban non-contrast CT head ordered to r/o bleed. CT
concerning for possible hypodensity right frontal lobe. Code
stroke was called. Neuro exam reassuring with no focal changes.
CTA head, neck with perfusion did not show any abnormal
perfusion. No evidence of large vessel occlusion, aneurysm, or
dissection.
# MRI Brain completed and reviewed with neuro. It does not show
any evidence
of acute infarction and CT Head
findings felt to be artifactual.
Most likely diagnosis remains headache related to sinus.
# mild transaminitis: ? related to antibiotics. Continue to
monitor.
# Hyponatremia: Likely hypovolemic in the setting of acute
illness, poor intake.
- Trend Na
- IVF prn
# CMV Viremia: On valganciclovir during last admit, currently on
acyclovir,
- Follow CMV VL
- Follow up with ID as an outpatient scheduled.
# Cough
- Continue home regimen of guaifenesin-codeine and benzonatate
PRN
# AML s/p allo SCT
- Continue home valganciclovir, Bactrim, and Cresemba
# Invasive Pulmonary Aspergillosis
- Continue home Cresemba
# Chronic Extensive GHVD: Known extensive GVHD of the eyes,
liver, skin, mucous membranes (mouth, vagina) and lungs. Given
current infection, is at risk for exacerbation. CBC and LFTs are
at baseline.
- Continue home prednisone 7.5mg daily and CellCept 500mg BID
- Continue home eye drops
- Continue Singulair and inhalers
- Dexamethasone oral solution PRN
# Anemia
- Trend daily and transfuse prn Hb<7
# ___ Esophagus/Gastritis
- Omeprazole in place of esomeprazole as non-formulary inhouse.
Resume esomeprazole as outpatient.
# Hypogammaglobulinemia: Patient has had multiple various
infections and is treated with monthly IVIG. Last received on
___.
- Continue to monitor
- continue monthly IVIG as outpatient.
# DVT/PE
# History of PVT
- Continued home Eliquis
# Secondary Hemochromatosis
- Continue to monitor
# Hypothyroidism
- Continue home levothyroxine
# Anxiety
- Continue home clonazepam and Zoloft
[] Consider treatment of her ___, but has been deferred in the
past due to heavy macrolide exposure with risk of resistance,
rifampin interactions and potential for ethambutol ocular
toxicity.
[] will require ENT follow up with Dr. ___
specialist), ID follow up, endocrinology follow up.
[] follow up cmv, blood cultures. | 163 | 837 |
13351753-DS-14 | 20,601,128 | It was a pleasure being involved in your care during your stay
at ___. You were admitted for
abdominal pain and a change in your bowel habits, which we
believe was due to your chronic Crohn's disease. While you were
in the hospital, you were given intravenous (IV) steroids to
help decrease the activity of your condition. You should
continue Prednisone 60mg by mouth daily when you leave the
hospital, and continue to take your ___ to keep your condition
under control. You were also seen by our GI doctors who further
___ your case, as well as our social worker who helped
make proper arrangements for your future housing and coping with
your current pregnancy. We were sure to give you medications
that were compatible with the current timing of your pregnancy.
START prednisone 60mg by mouth Daily
CONTINUE ___ (mercaptopurine)
CONTINUE prenatal | ___ year-old female G2P1 with a past medical history of Crohn's
disease who now presents with apparent Crohn's flare-up.
.
1. Crohn's Disease Flare-Up: The patient presented with a 1-week
history of increased bowel movements, nausea and vomiting. As
her bowel movements had been bloody, and she had not been taking
her home medications (___) recently this was thought to most
likely be a flare-up of her Crohn's. She was given solumedrol 20
mg IV TID for 3 days with marked improvement in her symptoms on
a daily basis, and put on prednisone 60mg PO Daily upon
discharge. Furthermore, she was restarted on her mercaptopurine
75 mg PO DAILY to continue her remission; she was also advised
to continue taking this medication at home and seen by a social
worker to discuss her difficulties in renewing her prescription
(as the patient had explained she could not afford to refill her
prescriptions). She was kept on a clear liquid diet until her
symptoms had mostly resolved, then advanced to regular liquids
and a regular diet, with no complications. Other underlying
etiologies of her symptoms that were considered were infection
and pregnancy complications/side-effects. Her symptoms were
unlikely to be a process of her pregnancy (e.g. hyperemeis
gravidarum) as her diarrhea had been bloody in nature. Full
infectious work-up was started, with stool cultures for
ova/parasites negative and a flexible sigmoidoscopy performed
for biopsies to help rule out CMV colitis were negative. Of
note, she had associated back pain which was treated with
lidocaine patch (x2), which resolved and did not require further
management.
.
2. Hypokalemia: The patient presented with hypokalemia (K=3.2)
and received a total of 120 mEq Potassium Chloride PO during her
stay (40 mEq in the ED, 80 mEq on the floor) with complete
resolution (K=4.1). This hypokalemia, in addition to her
decreased bicarbonate on admission, was most likely secondary to
her diarrhea, and thus improved with resolution of her flare-up.
Also, she had decreased chloride on admission, most likely
secondary to her vomiting, which also resolved with resolution
of her symptoms.
.
3. Pregnancy: The patient is G2P1 and underwent an ultrasound in
the ED which confirmed an intrauterine pregnancy of
approximately 5.5 weeks. She had no complications of her
pregnancy both prior and during her admission, with no vaginal
bleeding reported. She was informed that her Crohn's disease is
more likely to be active throughout pregnancy, as she had
already had a flare-up, but that continuing to take her
medications should help to keep her in remission. Also, she was
continued on her pre-admission medications (multivitamins
w/minerals and folic acid DAILY), and seen by a social worker
that discussed her future plans for coping with her pregnancy,
and began a re-evaluation of her healthcare in light of her
financial difficulties and current pregnancy. Her healthcare
plan was extended to allow proper coverage with regards to her
medications.
.
4. Leukocytosis: The patient presented with a WBC count of 12.8,
which was concerning for infection in light of her flare-up.
Urinalysis revealed >10 WBCs, but urine cultures showed no
bacturia, with mixed flora consistent with contamination.
Furthermore, stool cultures were sent and biopsies taken during
the patient's flexible sigmoidoscopy to rule out CMV colitis. As
the patient was afebrile, did not have symptoms of infection
(e.g. cough, dysuria, shortness of breath), this elevation in
her white count was most likely an acute phase reaction during
her current flare-up. Her leukocytosis resolved with resolution
of her symptoms (WBC=5.0). | 141 | 571 |
19248822-DS-18 | 24,288,962 | You were admitted with a knee infection. You had a surgery
called incision and drainage and you tolerated this well. You
were started on IV antibiotics which you will take for 6 weeks,
and a ___ line was placed for antibiotics.
The staples and sutures on your knee will be removed when you
follow up with orthopedic surgery in several weeks.
You also had an echocardiogram while you were hospitalized that
showed that your heart was pumping "hyperdynamically" and all of
your heart valves are normal. | ___ with complex PMH including multiple revisions and infections
of L TKA who presents with left knee pain, fevers, and evidence
of left knee septic arthritis.
# Septic arthritis: Pt. with GPCs in pairs/clusters on ___ of
joint fluid, WBC 25.5, febrile to 103 in ED, all c/w septic
arthritis. Also concern for sepsis and bacteremia given high
grade fevers, SIRS criteria. She was started on daptomycin after
BCx had been drawn. She remained afebrile and hemodynamically
stable and pain had resolved by day 1. ID was consulted and
recommended a 6 week course of daptomycin. On ___ the patient
had an incision and drainage with liner exchange by orthopedic
surgery. She tolerated the procedure well. A PICC line was
placed for antibiotics and the ID team scheduled ID follow up.
She will receive daptomycin for 6 weeks, and likely start
suppressive antibiotics after that. Orthopedics plans to remove
her sutures and staples in follow up in 3 weeks. She is
non-weightbearing on left leg, even with transfers and should
have a knee immobilizer on when she is being transferred or
participating in physical therapy. Daily dressing changes are
appropriate, and if an dampness, pus, or erythema develops at
the site of the incision the covering MD should be notified.
# Diarrhea: Pt. with multiple bowel meds on list from rehab for
both constipation and diarrhea. On admission lactulose was
stopped.
# HCP: Pt. has HCP (daughter ___ who she is now estranged
from. SW was consulted to make sisters ___.
# Chest xray abnormalities: On ___: "Increased density
obscuring the left hemidiaphragm as well as a new nodular
opacity overlapping the inferior margin of the right scapula,
both of unclear etiology. Conventional lateral view would be
helpful for further evaluation." This will need follow up with a
lateral view in the next few weeks. This was not pursued today
as moving causes the patient significant pain due to recent knee
surgery. No fevers, cough or leukocytosis to raise concern for
pneumonia.
# Childhood seizure history: The patient's phenobarbital was
stopped after discussion with her PCP ___. She has not
had seizures in many years and this was felt appropriate, as she
might be starting rifampin in a few weeks to help treat the
joint infection.
# Systolic heart murmur: Echocardiogram did not reveal any
evidence of valvular abnormalities, just a hyperdynamic left
ventricle.
# Chronic diastolic Congestive Heart Failure: Continued on home
lasix, statin, and lisinopril.
# Psychiatric: Patient was continued on her home lorazepam
regimen. She was noted to have persistent delusions about having
surgery on her arms and breasts. She was otherwise pleasant,
oriented to person, place and time each day and had fluent
speech.
# GU: Patient refused discontinuation of the foley placed for
pre-op purposes for several days. The foley was discontinued on
___ at 11am and the patient will be due to void between 5 and
7pm. If not able to void, foley should be replaced. | 85 | 485 |
10949577-DS-19 | 28,628,042 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weight bearing as tolerated
Treatments Frequency:
You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right intertrochanteric fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right trochanteric fixation nail,
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 <<>> 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
weight bearing as tolerated in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 345 | 255 |
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