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13744239-DS-11 | 26,601,398 | You came to the hospital with sepsis, most likely due to
recurrent cellulitis of your left leg. You improved markedly
with antibiotics. Please take KEFLEX to complete a seven day
total course of treatment. After that, go back to taking your
suppressive penicillin.
We also found you are losing a lot of phosphate in your urine. I
suspect you have FANCONI SYNDROME, which is a minor kidney
damage you can get from certain HIV meds and chemo meds. Please
take vitamin D supplements (one giant ergocalciferol pill per
week) and follow up with the kidney specialist to get the labs
re-checked. | ___ w/ HIV/AIDS on HAART (last CD4 326, VL UD), chronic LLE
lymphedema from ___'s sarcoma, recurrent LLE cellulitis (on
suppressive penicillin), admitted with sepsis of unclear source.
On vanc/cefepime azithro; cultures pending.
#Sepsis
#Recurrent LLE cellulitis
The patient initially presented with sepsis without any clear
source, but after extensive workup he eventually developed
redness on the leg consistent with cellulitis. This is presumed
to be the source of his sepsis.
Presenting symptoms/findings were leukocytosis, tachycardia,
fever, and chills/body aches. Flu negative. Urine without
inflammation. CXR potentially c/w an infiltrate, but CT scan did
not show any pneumonia. More unusual OIs seemed unlikely given
his reasonable CD4 count on last check.
He was started on vanco/cefepime/azithro and fluids originally
and defervesced, then was narrowed to Ancef when his leg started
to show inflammation. He is discharged on Keflex to complete a
seven day course and will resume his suppressive PNC thereafter.
#HIV/AIDS
Last CD4 326 with VL undetectable. He was continued on his home
___
#Suspected Fanconi syndrome
The patient was noted to have marked hypophosphatemia and
history of having a mild non-gap acidosis. Urine lytes were
collected, which showed significant renal phosphate wasting
(fractional excretion of phosphate 53%). He was started on
vitamin D supplementation for a vitamin D of 7. He will follow
up with renal in clinic for further management. Since this can
be a side effect of HAART medications, he may need his HIV meds
switched if renal is concerned. | 102 | 241 |
15384065-DS-8 | 22,718,783 | Ms. ___
___ was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you were having abdominal pain, nausea
and vomiting. There was some concern there might be a blockage
in your intestine but an Xray did not show this. You had several
bowel movements and your distension improved. There was some
inflammation in your lung caused by choking when you were
vomiting. However this was not felt to represent a pneumonia and
therefore you were not given antibiotics. In speaking with your
guardian the decision was made to allow you to eat through there
is some risk you may aspirate again. | Ms. ___ is a ___ year old woman with severe dementia who
presented from nursing home with constipation, nausea, vomiting,
and presumed aspiration event.
# Pseudo-obstruction: Patient with nausea, vomiting and
constipation which is likely ___ colonic pseudo-obstruction
secondary to underlying dementia. Patient was on heavy bowel
regimen at baseline indicating that this is likely acute on
chronic constipation. Unclear what initiated worsening
pseudoobstruction, but resulted in nausea, vomiting and presumed
aspiration (below). Her labs were notable for elevated lactate
on admission that resolved by discharge. She also note to have
___ with elevated BUN/Cr (below). KUB revealed markedly
distended loops of small and large bowel, but no transition
point or evidence of mechanical obstruction. She was made NPO
and started on IV fluids on arrival to the hospital. She
proceeded to have multiple large bowel movements in the ED and
on the floor with resolution of her abdominal distension and
abdominal pain. Repeat KUB revealed resolution of obstruction
consistent with physical exam findings.
# Aspiration pneumonitis: Patient presented with likely
aspiration event given nausea and vomiting from obstruction
(above) along with decreased oxygen saturations in the ED. She
was initially on a nonrebreather, but was weaned to 2L NC with
saturations in the high ___. She had leukocytosis with left
shift, but remained afebrile without obvious consolidation on
CXR and was read as atelectasis vs aspiration. No antibiotics
were given as she did not have clinical or radiologic signs of
pneumonia. On the floor, respiratory function and leukocytosis
improved and she remained afebrile. Speech and swallow saw
patient who deemed that she was at a high risk for aspiration so
was kept NPO. Patient's legal guardian (___) was
contacted to discuss the risks of aspiration if the patient was
allowed to eat for comfort. She agreed that it would be in the
best interests of the patient's quality of life to avoid feeding
tube and continue with thick liquids, despite the risk of
aspiration which could ultimately lead to pneumonia or even
death. Patient was sent back to nursing home with instructions
to continue honey thick liquids to minimize aspiration risk, but
with the understanding that aspiration may be inevitable.
# ___: Patient with Cr of 1 on admission and BUN of 28 which
likely represents pre-renal etiology of ___. Her baseline is
unclear, but she resolved to a Cr 0.6 by discharge follwoing IV
fluid repletion. Lactate was initially elevated on admission,
which is consistent with this, and resolved to 1.1 by discharge.
# Dementia: Discussed mental status with legal guardian ___
___ (___) and patient is non-communicative at
baseline. There was discussion prior to this episode of
possible hospice care for patient, but this was not going to be
done until ___. On further discussion with ___, she
will try to initiate discussion of transition to hospice care
shortly after return to nursing home.
# Hypothyroid: Patient was euthyroid on exam and was continued
on home levothyroxine. TSH was normal as were T4 and free T4.
# PPX: heparin SQ, bowel regimen
# CODE STATUS: DNR/DNI per legal guardian
# EMERGENCY CONTACT: legal guardian - ___ ___
# Transitional issues:
- Spoke with ___ on phone multiple times throughout
admission and she would like to initiate discussion of
transition to hospice care. She would like to have the hospice
team evaluate Ms. ___ at her nursing home.
- Patient can eat honey thick liquids for comfort with the
understanding that she may aspirate
- Elevated blood pressures in the hospital, but did not initiate
anti-hypertensive regimen in order to simplify medicine regimen
after discussion with legal guardian | 112 | 621 |
12140267-DS-14 | 22,954,436 | Mr. ___,
You were admitted to the hospital for high blood sugars and DKA,
likely from issues surrounding insulin dispensing from your
pump. You were seen by diabetes (___) team while admitted,
and were temporarily switched to a different insulin regimen.
You will need to ___ very closely with your usual diabetes
doctor after discharge to discuss going back to pump, and how to
use your new insulin pump.
It was a pleasure taking care of you!
Sincerely, your ___ Team | SUMMARY:
=========
Mr. ___ is a ___ man with end-stage renal disease ___
T1DM status post kidney transplant, as well as type 1 diabetes
with an insulin pump, HTN, HLD, BPH, who receives his renal care
at ___, who presents with
DKA and ___, infectious w/u negative. | 78 | 44 |
17581511-DS-18 | 20,062,457 | Ms. ___,
You were admitted to the surgery service at ___ for evaluation
of possible wound infection. Your wound was opened ___ ED and you
were started on IV antibiotics. CT demonstrated peritoneal
abscess, and you underwent US-guided drainage. You are now safe
to return home to complete your recovery with the following
instructions:
.
Please call Dr. ___ office at ___ if you have
any questions or concerns. During off hours: Please call
Operator at ___ and ask to ___ team.
.
*Please change your wound dressing daily and prn. Pack wound
loose with packing strip twice a day. ___ nurses ___ help you
with dressing change.
.
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 ___ the drain.
Call the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*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 ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | The patient s/p open cholecystectomy was admitted to the General
Surgical Service for evaluation of a purulent leak from her
wound. Patient was afebrile on admission with elevated WBCs. She
underwent CT scan, which demonstrated abscess containing air ___
the region of the gallbladder fossa, and residual complex
collection containing multiple locules of air within the
subcutaneous soft tissues right lower quadrant anterior
abdominal wall. Patient's wound was partially opened, fluid was
dtrained and sent for microlab. ___ was consulted for poosible
gallbladder fossa collection drainage. Patient also was started
on broad spectrum antibiotics. On HD 2, patient underwent
US-guided drainage of the peritoneal abscess and fluid was sent
for microbiology eval. Fluid originally was purulent, and on HD
3 turned into bilious, but remained with low output. Patient's
LFTs were within normal, and her WBC returned back to normal
limits. Patient was advanced to regular diet, which was well
tolerated. Wound cultures return positive for E. coli, and wound
drainage subsided with dressing changes and became serous.
Abscess cultures grew polymicrobial organisms, and were negative
for MRSA. On HD 5, patient was transitioned to oral
Cipro/Flagyl. She was discharged home with ___ serviced to
continue dressing change and drain care at home. Patient will
continue on current antibiotics for additional 10 days.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic 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. | 218 | 266 |
17037515-DS-25 | 25,469,701 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You came in for scrotal pain and discharge and found to have a
scrotal abscess. The urologist removed the abscess and packed it
with a dressing. You were started on antibiotics for the
bacterial infection. Your scrotal pain improved following
removal of the abscess. | ___ with asthma, scleroderma, and pulm HTN who presents with
scrotal pain and discharge since ___.
#Scrotal Abscess: Patient was seen as an outpatient by PCP
earlier in the week complaining up a lump in scrotum. His PCP
sent him for an US of the lump. Patient states after the
procedure he developed worsening pain at the site and noted a
white discharge. The following day, he noticed the lump had
grown and it was causing him more pain. In the ED, patient was
seen by Urology and a pelvis CT confirmed an abscess. It was I&D
by Urology. The pain in scrotum was most consistent with
scrotal abscess in setting of visualized scrotal drainage and
relief in pain following I&D. US findings also most consistent
with a scrotal wall abscess vs an epididymo-orchitis. His pain
was treated with oxycodone. Patient remained afebrile and
Urology changed packing prior to discharge. He was started on a
7 day course of Bactrim. He will follow up with Urology as an
outpt.
#SOB: Patient was found to have SOB in ED. It was most likely
secondary to scleroderma w/ secondary pulm htn and COPD. Patient
says this has been his current baseline over last several
months. He recently finished a course of levaquin and had no
infiltrates/consolidation on CXR, and was afebrile throughout
admission so infection was unlikely. He has been on a Prednisone
taper from previous COPD exacerbation and was continued on
scheduled taper. He was kept on his home O2 at 2L NC with
saturations above 95%. He received one neb treatment with
albuterol and ipratropium.
#Scleroderma: Pt seen at ___. Recently increased dose of
mycophenolate from 500 to 1000mg.
-Pt not on treatment for pulm htn | 59 | 284 |
13251065-DS-37 | 26,664,911 | Dear Mr. ___,
Thank you for coming to the ___
___. You were in the hospital because you had another episode
of cholangitis. You were treated with IV antibiotics. An ERCP
was performed which showed a narrowing of your bile duct with
infection. A stent was placed to relieve the obstruction. You
will need to continue the antibiotics for at least 1 month and
will be reassessed at that time. You will need to follow up with
the infectious disease doctors as ___ outpatient to decide on the
duration of antibiotics and the need for suppressive
antibiotics. You should also follow up with your liver doctor
and your primary care doctor.
Medication Recommendations
Please START
-ertapenem IV 1 gram daily for 3 weeks or until instructed to
stop by your infectious disease or liver doctor
-___ 5 mg every ___ hours as needed for pain
-Acetaminophen
No medications were stopped
Please continue taking all other medications as you have been | Mr. ___ is a ___ M with history of alcoholic liver disease
and HCC s/p liver transplant complicated by recurrent ESBL E.
coli bilomas and recurrent pleural effusion who presents with
fevers, chills and abdominal pain from cholangitis.
.
ACTIVE ISSUES
# Recurrent cholangitis: His symptoms are consistent with his
prior episodes of cholangitis. He was treated with IV meropenem
based on his previous cultures andhe rapidly improved
clinically. He underwent ERCP which showed stricture of a bile
duct and pus formation. One stent was placed. Id was consulted
who recommended PICC line placement and ___ weeks of ertapenem
therapy as an outpatient. Suppressive antibiotics after this
course of IV antibiotics will be at the discretion of his
outpatient infectious disease doctor and liver doctor. He will
also need to have the stent removed in ___ weeks.
.
# Acute renal failure: He had mild increase in his creatinine on
presentation that resolved the following day with IV fluids.
.
# EtOH cirrhosis and ___ s/p transplant: Current presentation
not consistent with rejection. Currently on list for
re-transplantation consideration, given that he has developed
complications of hepatic artery stenosis and biliary strictures.
We continued his home rifaximin, ___, urosdiol and bactrim. His
diuretics were initially held then restarted on discharge. His
rapamycin level remained at goal throughout the admission.
.
# R pleural effusion: He has a h/o of this in the past which was
felt to be exudative and reactive with negative work-up x 2.
Currently asymptomatic, and not impressive on imaging.
TRANSITIONAL ISSUES
-PICC line removal
-Decision on suppressive antibiotics
-Stent removal
-Three sets of blood cultures are pending at discharge | 153 | 267 |
14097415-DS-15 | 27,968,751 | You came to the hospital because you had abdominal pain, nausea,
and some blood in your vomit. While here we did a pregnancy test
which showed you were pregnant and an ultrasound which showed
you are 17 weeks pregnant. We feel that you most likely have
heartburn which is common in pregnancy and because you took lots
of advil lately that may have caused some inflammation of your
stomach. We did a rectal exam and it showed microscopic amount
of blood in your stool likely from the inflammation of your
stomach or from when you vomitted blood the other day which
could have been from a small tear in the tube that leads from
your mouth to your stomach.
Please STOP taking advil
please START prenatal vitamins daily
please START pantoprazole twice a day
Please follow up with your OBGYN and take your prenatals
please follow up with your PCP about your stomach pains
If you continue to feel these symptoms please call your primary
care doctor | Ms. ___ is a ___ G3P2 with hx of depression who presented
with abdominal pain and vomiting and was found to be 17 weeks
pregnant.
# Abdominal Pain / Vomiting: The patient was admitted with right
and left lower quadrant pain and vomiting, and found to be
pregnant. She also endorsed NSAID use recently for headache. She
was started on a PPI twice daily and felt better. Initially in
the ED her stool was guaiac negative, but on the floor it was
faintly guaiac positive. Her hematocrit remained stable and
similar to her past hematocrits in the ___ records. She was
given clear liquid diet and tylenol and oxycodone for pain and
her pain improved and her diet was advanced. On discharge she
was able to tolerate a bland diet. The PPI was continued on
discharge.
# Pregnancy: Per ultrasound, intrauterine pregnancy at 17 weeks.
Pt notes that she had continued to menstruate (as recently as
one week prior to admission), so the pregnancy was a surprise.
She was seen by social work and encouraged to follow up with
___ OB.
TRANSITIONAL ISSUES
-f/u H pylori
- OB f/u
- f/u abd pain | 162 | 189 |
12418395-DS-11 | 25,256,076 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house. | Mr. ___ was admitted to Dr. ___
service with bilateral obstructing ureteral stones and acute
renal injury and underwent urgent cystoscopy, incision of right
ureteral orifice, extraction of right ureteral stone, and
bilateral ureteral stent placement. He tolerated the procedures
well and was recovered in the PACU before transfer to the
general surgical floor. Bilateral indwelling 6 x 26 double-J
ureteral stents and an ___ coude tipped Foley
catheter were in place post procedure and the right ureteral
stone fragments were sent to pathology for analysis. See the
dictated operative note for full details. Mr. ___
was hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics. His postoperative course
was unombolicated but he remained until trending imrovement in
acute renal injury. His Foley was removed and he voided without
difficulty and after an aggressive bowel regimen, he evacuated
his bowels which also improved his general discomfort. At
discharge Mr. ___ pain was controlled with oral
pain medications, he was tolerating regular diet, ambulating
without assistance, and voiding without difficulty. All of his
questions were answered and he was explicitly advised to follow
up as directed as the indwelling ureteral stents must be removed
and or exchanged. | 424 | 199 |
13730972-DS-14 | 23,906,332 | Dear Ms ___,
You were admitted to ___ with chest pain and were found to
have a collection of fluid around your heart, called a
pericardial effusion. The fluid was drained with a catheter and
follow up images showed that the collection had resolved. We
pulled the catheter and checked again, confirming that the fluid
was almost completely gone. Unfortunately, we are not certain
what caused this fluid to build up, but we have ruled out any
issue that would require additional urgent intervention. We have
started you on medications to treat your condition, which you
will continue until you follow up with a cardiologist. You
should see your PCP ___ ___ as scheduled (details below). On
___, you should call your PCP's office and request a referral
for your cardiology follow up, and call ___ to schedule
a 2 week follow up appointment and echocardiogram.
Best Wishes,
Your ___ Care Team | Ms. ___ presented to ___ for chest pain. She
was found to have a pericardial effusion on Echo and transferred
to ___ for management. She was taken to the cath lab and had a
pericardial drain placed. 250cc of serous fluid was removed.
Follow up echo showed resolution of the effusion and the drain
was removed. The following day, a post-pull echo showed minimal
effusion. She was discharged home on colchicine and ibuprophen
with PCP and cardiology follow up.
#Pericardial effusion:
Exudative effusion c/w inflammation and possible infection.
Possible post-viral infection vs. parasitic infection from
travel outside country ___ in ___, ___ in ___. Other etiologies include traumatic (less likely given
details of MVC and no other reported tramua), malignancy (no
coloscopy this year, regularly sees PCP, no 'b' sx), autoimmune
(hx of psorasis, no arthritis, no family hx of autoimmune dx).
Known hx of thyroid disease. TSH 5.7, CRP 191.1. Ambulatory O2
sat 99% on day of discharge. Will follow-up with ECHOCARDIOGRAM
and cardiology outpatient appointment in 2 weeks.
-F/u ___
-F/u Pleural fluid ___, f/u cultures
-Colcichine 0.6 mg PO BID + Ibuprofen 600 mg PO TID
#Sinus tachycardia
Tachy on admission to 130s, improved during CCU course. Likely
stress reaction/pain response.
#Hypothyroidism
-Continued home levothyroxine 50 mcg PO daily
TRANSITIONAL ISSUES
___ is pending at the time of discharge. Follow up result.
#Patient should have cardiology follow up in 2 weeks and an
echocardiogram at that time
#Colchicine should be continued for 3 months. Ibuprophen may be
continued for 2 weeks. If she needs NSAIDS for longer than this,
consider GI prophylaxis. | 151 | 254 |
17967695-DS-18 | 24,607,931 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___.
Why was I admitted?
--------------------
- You were admitted to the hospital for excess fluid in your
abdomen and excess fluid in your legs.
What happened to me in the hospital?
- The fluid in your belly was drained and you were found to have
an infection of your abdomen. You were given antibiotics to
treat this infection.
- You will continue to take antibiotics when you leave the
hospital, to prevent any future infection.
- You also were given medications through the IV (Furosemide) to
help get rid of the extra fluid in your body. This extra fluid
is likely from your liver disease, heart disease, and also from
the high amount of salt you were eating.
- You were started on a medication called lactulose, to help
prevent confusion caused by liver disease.
What should I do at home?
- You should weigh yourself every day, and keep track of these
weights.
- You should keep taking lactulose every day, so that you have
___ bowel movements every day. This is important so that your
body doesn't accumulate toxins and get confused.
- You should eat a LOW SALT DIET. This means not adding ANY salt
(or low salt alternative mix) to your foods. You should also NOT
eat processed meats, frozen meals, or any other foods high in
salt.
- You should STOP DRINKING ALL ALCOHOL. If you do not stop
drinking, your liver function will continue to get worse and you
could become very sick.
- You should continue trying to quit smoking.
- Please go to your follow up appointments (below). You should
have your doctor to review your diuretics and get lab tests at
these follow up appointments.
When should I come back to the hospital?
- You should return to the hospital if you experience severe
pain in your belly, if fluid returns to your legs, if you become
short of breath, if you have a fever/chills, if you gain 3
pounds in one day or 5 pounds in three days.
It was a pleasure taking part in your care!
Your ___ team | PATIENT SUMMARY
___ man with Child's B HCV/EtOH cirrhosis, decompensated
by variceal bleeding s/p TIPS in ___, active alcohol use
disorder, atrial fibrillation not on AC given bleed risk, and
COPD without home O2, who presented with volume overload, found
to have SBP, for which he was treated with with CTX and
transitioned to prophylactic Ciprofloxacin. His course was
complicated by hepatic encephalopathy and orthostatic
hypotension. Offending agents were removed, his portal system
and TIPS were interrogated on ultrasound, and encephalopathy
resolved with lactulose and rifaximin, and holding opiates. His
course was also complicated by fluid overload, likely secondary
to diastolic HF exacerbation (TTE with diastolic dysfunction and
elevated JVP), treated with aggressive prolonged diuresis and
Lasix gtt.
ACUTE ISSUES
==============
#Hepatic Encephalopathy
#Spontaneous bacterial peritonitis
#Acute decompensated HCV/EtOH cirrhosis w varices (s/p TIPS
___
Child's class B, MELD-Na 24 on admission with volume overload
___ decompensated cirrhosis and high sodium diet. He was found
to have ascites with SBP on a diagnostic paracentesis at ___
___, for which he was treated with CTX for five days and was
transitioned to prophylactic Ciprofloxacin. Asterixis was found
to be present on exam on ___, and the patient did not remember
getting morning labs. His trigger was most likely oxycodone, as
US was negative for portal vein thrombosis, TIPS patent, no
ascites, CXR negative and cultures were negative for infection.
He was given lactulose and rifaximin, and oxycodone was stopped,
and his encephalopathy improved. Of note, the patient had a
positive HCV viral load this admission with no history of
treatment. He will follow up with outpatient liver team
(appointment scheduled for him) for this.
#Acute on chronic diastolic heart failure exacerbation
He had 3+ pitting edema bilaterally to his thighs and sacrum,
and he had JVP elevated to jaw. He was diuresed with IV Lasix
boluses and gtt, and was started on midodrine for hypotension in
setting of diuresis. He was transitioned to furosemide PO 80mg
daily and spironolactone 100mg daily, with goal of continuing to
be even to mildly negative at discharge. He is scheduled for
follow up with PCP and hepatology and should get repeat labs and
diuretic adjustment at this appointment.
#Hypoxemia
The patient's O2 saturations were in the low ___ on admission,
likely secondary to volume overload vs baseline COPD hypoxemia.
There was no evidence COPD exacerbation this admission and this
improved with diuresis.
#Tailbone Pain
Had underwent a mechanical fall on his behind when getting up,
and losing his balance. Oxycodone was discontinued, as it was a
likely contributor to hepatic encephalopathy. Managed with
Tylenol, less than 2.5g/day.
#Atrial fibrillation
Patient reports that he has about ___ year history of atrial
fibrillation. He is usually rate-controlled on Diltiazem,
however not anticoagulated due to variceal bleed history and
CHADSVASC score of 1. He was placed on fractionated Metoprolol
after an episode of RVR on ___. He remained rate-controlled,
and was switched back to Diltiazem, fractionated, on ___. | 354 | 476 |
19030887-DS-3 | 29,135,617 | Mr. ___, it was a pleasure taking care of your during
your stay at ___. You were admitted for pneumonia, influenza
and a lung mass. You were evaluated by the pulmonary team. They
recommended treatment of your pneumonia and influenza, then
outpatient follow up.
Please follow up with your PCP next week.
Please follow up with listed appointments. | # Dyspnea
# Subjective fever
# Acute hypoxic respiratory failure
# Apparent bilateral pneumonia with lung mass:
Mr. ___ like presented with acute influenza with
superimposed bacterial pneumonia. He was evluated by the
pulmonary team who recommended treatment for his acute process.
He was treated with Vanc/Unasyn/Azithromycin, then narrowed to
Levofloxacin for 7 day course. He was also started on Tamiflu.
Notably, he also had a lung mass which is concerning for
malignancy. Per pulm, he will need further work up, but they
would repeat CT in 6 weeks and follow up with pulm and IP at
___. Galactomannan negative. Notably, he had concerning
findings on PET scan early this month. He was set up with
appointment with IP and pulm and ___. He was also set up with
PCP appointment to ensure follow up for his mass. By discharge,
he was off oxygen and back to baseline breathing.
# N/V
Initialy presented with nausea and vomiting likely due to
influenza, it quickly resolved.
#Transaminitis
Mild in nature. Likely due to acute infection. Hep serologies
negative.
# Chronic diarrhea:
He has had diarrhe since cholecystectomy. C. diff was negative. | 58 | 184 |
19479023-DS-12 | 20,657,812 | Surgery:
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity:
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications:
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | Ms. ___ was transferred from ___ after
work-up for two weeks of word finding difficulty led to findings
of a left frontal brain lesion on CT head. She was transferred
to ___ for neurosurgical evaluation.
#Left temporal brain lesion with cerebral edema and cerebral
compression
The patient underwent an MRI which showed a 6.1cm mass in the
left temporal lobe with surrounding edema likely representative
of high-grade glioma vs solitary metastasis. She was started on
keppra for seizure prophylaxis and decadron with GI prophylaxis
and a RISS for blood glucose control while on steroids. Neuro
oncology and radiation oncology were consulted and she was added
to Brain Tumor Conference. A CT torso was without evidence of
intrathoracic/intrabominal malignancy, however multiple small
pulmonary nodules in bilateral upper lobes of indeterminate
origin, measuring up to 3mm, were noted. Radiology recommended
follow up. MRI Wand was ordered. On ___ she went to the OR for a
left craniotomy for tumor resection. The case was uncomplicated
and she tolerated the procedure well. Please see OMR for
additional intraoperative details. The patient was extubated in
the OR and recovered in the PACU. She was transferred to the
step down unit postoperatively for close neurologic monitoring.
She remained neurologically and hemodynamically stable
postoperatively. She was started on sq heparin for DVT
prophylaxis. Her hemovac came disconnected accidentally and was
cleaned and a the collection container was replaced overnight.
STAT NCHCT to evaluate for bleeding was stable. The drain was
removed without complication the following morning. Her pain was
well controlled and she was on a bowel regimen with good effect.
Social work was consulted for coping with her new prognosis.
Neuro oncology and radiation oncology were consulted. Post-op
MRI showed some residual tumor. She will need radiation planning
after discharge and her and her husband preferred she be treated
at ___ for radiation treatments. Neuro oncology
recommended she get a portacath so ___ was consulted. Portacath
was placed on ___, the procedure was uncomplicated, please
see OMR for the separate procedure note.
#Visual deficits
Patient reported blurred and slanted vision after surgery. She
was evaluated by OT and ophthalmology for her visual complaints
and it was recommended she patch either eye as needed for
symptomatic relief of double vision. It was anticipated her
double vision would improve or resolved in about 6 weeks. She
was instructed to call ___ ophthalmology if her symptoms did
not improve in ___ weeks and ask for clinic appointment with
neuro-ophthalmology for repeat evaluation.
#Aphasia
She continued with fluid aphasia after surgery. She was
evaluated by SLP who recommended ongoing speech therapy.
#Dispo
___, OT, and SLP evaluated the patient and recommended home with
home ___. | 485 | 442 |
15336428-DS-12 | 27,406,291 | Dear Mr. ___,
It was a pleasure to care for you during your hospitalization.
You were admitted to the hospital on ___ to evaluate painful
oral ulcers and a skin rash. You were seen by the Dermatology
consult service. Your symptoms are due to a condition called
Erythema Multiforme - this most likely developed as a result of
a recent viral infection. It is possible, though, that your
recent antibiotic use could have contributed, so you should
avoid taking azithromycin in the future.
This condition should begin to improve in the next days to
weeks. It is very important to keep up with you nutrition and
intake. It is also important to ensure you do not develop a lot
of secretions in your mouth or throat that make it difficult to
breath.
If you develop any shortness of breath, worsening oral swelling,
lots of oral secretions, eye pain, rash/crusting around your
eyes, blisters on your skin, areas of skin falling off, fevers,
chills, or any other worrisome symptoms, call your doctor right
away or go to the Emergency Department. | ___ male with a past medical history of non-Hodgkin's
lymphoma ___, s/p auto-SCT) who presents with new rash and
intra-oral lesions following a recent ILI and cold sore, likely
Erythema Multiforme. | 176 | 31 |
11521280-DS-9 | 25,294,354 | Dear Mr. ___,
You are admitted for symptoms of slurred speech and word finding
difficulties. These symptoms may be secondary to a stroke, but
as you refused an MRI, we were unable to rule out a stroke.
More likely your symptoms are secondary to deconditioning, and
possibly poor oral intake in the setting of your achalasia,
given your profound orthostatic hypotension. You were found to
have achalasia and had an EGD with botox injection. Your
swallowing and speech improved. You are still having difficulty
ambulating, for which rehabilitation will help you
significantly.
==================================================
A 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:
-Obesity, testosterone use, hypertension, diabetes, atrial
fibrillation, steroid use.
We are changing your medications as follows:
-No significant changes were made to your medications at this
time, discuss concerns of polypharmacy with your primary care
provider, we are recommending holding testosterone cream until
you have further discussion with your primary care provider.
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 ___ Team
====================================== | Mr. ___ is a ___ RHD M w/ PMH afib on warfarin, T2DM, prostate
Ca s/p XRT/HT also on testosterone, tobacco dependence ,DM, PVD,
peripheral neuropathy, multifactorial gait disorder, CAD,
esophageal achalasia, HTN who initially presented with slurred
speech, word finding difficulties for several days. He was
initially admitted to neurology service for work-up of slurred
speech with subtle right arm pronation and generalized weakness.
On further history taking, symptom onset was subacute. Notably,
he has afib and is maintained on warfarin with therapeutic INRs
leading up to event. He refused MRI brain due to severe
claustrophobia. Per stroke service, there is low suspicion for
stroke given optimized from stroke risk factor perspective,
including therapeutic INR for atrial fibrillation. Hospital
course complicated by findings of severe esophageal achalasia,
ultimately prompting GI consult with EGD on ___ with botox
injection. | 348 | 139 |
11211608-DS-5 | 24,914,340 | 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:
- Touch-down weight bearing right lower extremity in an unlocked
___ brace
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-op
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.
- Daily dressing changes over skin graft
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
TDWB RLE in an unlocked ___ hinged knee brace
Treatments Frequency:
Daily Xeroform/ABD/Kerlix dressing changes
Staples will be removed at two-week post-op visit | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a bicondylar tibial plateau fracture and compartment
syndrome and was admitted to the orthopedic surgery service. The
patient was taken to the operating room emergently on ___ for
external fixation and 4-compartment leg fasciotomies, which the
patient tolerated well. For full details of the procedures
please see the separately dictated operative reports. Each time,
the patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. Early in his course the patient was
hypertensive and tremulous and so was treated for alcohol
withdrawal with a CIWA scale and PO diazepam. His withdrawal was
uncomplicated and easily treated. The patient's pain was quite
difficult to control, particularly early in his course. Acute
Pain was consulted and placed him on a ketamine guttae and
Dilaudid PCA. These were transitioned to oral medications. He
suffers from anxiety and was started on PRN lorazepam which had
good effect. The patient was given ___ antibiotics
and anticoagulation per routine. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the right lower extremity, and will be discharged on
enoxaparin 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. | 274 | 309 |
16592679-DS-7 | 22,248,979 | Ms. ___,
You were admitted for further management and work-up of your new
decreased speech, weakness, and confusion. Your imaging
demonstrated that the collection of blood around your brain was
stable in size although there was some mild swelling, for which
steroids were started. Your speech and confusion improved on
steroids and remained improved after tapering off steroids. You
were monitored on EEG, and although seizures were not noted,
there were some areas of increased activity. However, further
improvement was not noted with restarting anti-seizure
medication given at the outside hospital (Levetirecetam), which
was subsequently tapered off.
Due to continued difficulty swallowing, you required a
nasogastric tube for nutrition. As the speech therapist felt
your recovery would be prolonged, you had a percutaneous gastric
tube placed by general surgery.
You were discharged back to your rehab facility in improved
condition to continue your recovery and therapy.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ neurology team | This is a ___ woman with a recent admission for left
epidural hematoma, C3 and T1 fracture after a fall with a
history of hypertension, hyperlipidemia, diabetes who presented
from her
rehab with newly noted difficulty speaking. Initial differential
included new ischemic stroke from possible local compression
from the epidural hematoma versus new ischemic infarct from
patient's notable vascular risk factors versus local cortical
irritation from the epidural hematoma causing focal seizures
(initial MRI with improving post-traumatic findings, EEG without
seizure) versus hydrocephalus (no increased ventricular size on
imaging). No clear toxic metabolic etiology. Had concerning
decline from nonfluent speech to akinetic mutism on ___ AM.
Repeat NCHCT unchanged, cvEEG with diffuse background slowing,
focal left hemisphere attenuation consistent with known
hematoma, and multifocal discharges over left hemisphere
concerning for increased cortical irritability. Did not improve
with a trial 1mg IV ativan ___. LP deferred for further
evaluation of increased ICP as not ventriculostomy candidate at
this time per neurosurgery consult. Did have improvement in
ability to follow commands & attend to exam after initiation of
low dose steroids ___ ___, which have been tapered off with
sustained improvement. Started on levetirecetam with concern for
increased cortical activity and increased seizure risk. Repeat
___ brain MRI w/ small subacute left thalamic infarct, which
would not explain patient's symptoms. Nasogastric tube in place
for oral medications and tube feeding initiated per nutrition
recs due to continued dysphagia despite improvement in mental
status. SLP eval notable for oral/verbal/limb apraxia and
significant dysphagia, PEG placement ___ with prolonged
recovery expected. ___ recs for rehab when medically ready for
discharge.
# acute onset akinetic mutism
# recent traumatic epidural hemorrhage
-off Keppra and low dose steroids
-systolic blood pressure goal <160 per neurosurgery
-activity as tolerated
# significant oropharyngeal dysphagia, c/f high aspiration risk
# odynophagia
# oral thrush
-strict NPO per SLP eval
-meds per tube
-TFs per nutrition recs
-oral nystatin for thrush
-PRN chloraseptic spray for mouth/throat pain
# T2DM
-restart home metformin on discharge
-continue SSI as needed
-switch TFs to glucerna
# HTN
-continue home lisinopril and amlodipine | 158 | 333 |
16207152-DS-7 | 23,317,869 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for altered mental status and low sodium. Your low
sodium improved with fluids and you likely have a syndrome
called cerebral salt wasting which causes you to lose salt.
This will go away on its own over the next few weeks, but you
should be sure to stay hydrated with fluids and good oral
intake. You should have your electrolytes rechecked next week
either at your PCP's office or at the nearest lab and have the
results faxed to your PCP. If you are unable to maintain good
oral intake and your sodium decreases below 130, please speak to
your doctor about starting salt tabs. | ___ with history of recent left orbital fracture, anxiety p/w
worsening confusion and vomiting and was found to be hyonatremic
to 113, responsive to fluids.
# hyponatremia: Pt's urine electrolytes c/w cerebral salt
wasting versus SIADH. Pt with positive orthostatics and marked
improvement with hydration; thus, patient likely with cerebral
salt wasting and also hypovolemic state. Fluid restriction was
trialed at one point in her hospitalization and her sodium
decreased. The pt was hydrated and demonstrated good PO intake.
I discussed with the pt's daughter the need to draw labs early
this week to ensure stabilization of sodium. If the patient's
sodium drops<130, she will likely need salt tabs to augment her
PO intake until the CSW resolves.
# Delirium: Patient with waxing and waning and marked sundowning
at night with resolution during day time. This was likely a
result of recent surgery, being in unfamiliar hospital setting,
and hyponatremia. Head CT showed no acute process. Infectious
workup negative. The patient should improve in home setting.
#Recent globe rupture s/p repair: Seen by ophtho as inpatient
who noted no acute issues and recommended continuation of
topical abx/steroid/atropine. She has follow up scheduled with
ophtho.
#Constipation: Patient continued on colace/senna/miralax
#Hypertension: Pt was continued on her home propanolol
#Pulmonary nodule: Seen on CXRay. Pt will need to follow up
with CT scan if not previously done and if within goals of care
of pt.
#LFT abnormalities: Pt with elevated bili to 2.1 on admission
which self resolved with hydration. Unclear etiology
# CODE: Full Code
# CONTACT: ___: ___ | 125 | 266 |
15285530-DS-15 | 27,563,294 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You were hospitalized because of dizziness. There was concern
that you may have had a stroke. You had an MRI of your brain
which fortunately showed no evidence of a stroke.
We think that you likely had inflammation of your inner ear and
this is what made you feel dizzy.
After leaving the hospital, you should take all of your
medications as prescribed and follow up with your primary care
doctor within the next ___ weeks.
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with PMH of HLD who presented
with 1 day of acute onset persistent vertigo. The patients
symptoms of vertigo resolved over night with residual dizziness
with sitting up from a supine position or ambulating. This
dizziness is now more described as unsteady rather than the room
spinning. He still has difficulties with tandem gait, but
horizontal nystagmus in right eye and torsional nystagmus in
left eye resolved.
MRI was negative for acute stroke.
Etiology likely vestibular neuritis in the setting of recent URI
symptoms. Recommended outpatient vestibular therapy. | 92 | 97 |
11645608-DS-17 | 29,070,858 | Dear Mr. ___,
You came into the hospital because you had an episode of your
evaluated for a neurologic cause of these strange behavior and
memory problems. Issues. Your brain MRI which was negative.
Lumbar puncture which was normal. You had an EEG to look for
seizures, which was also negative.
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- Please follow-up with psychiatry
It was a pleasure taking care of you,
Your ___ Care Team | ___ is a ___ year-old male who presents with an
acute change in behavior and memory lapses.
Initial differential diagnosis was broad, including complex
seizures, infectious/inflammatory/autoimmune encephalitides, and
primary psychiatric or drug-induced dissociative episode.
His exam was notable only for deficits in attention and
short-term memory with intermittent paranoid thoughts. Outside
hospital non-contrast CT head and CSF were unremarkable. MRI of
the brain was unremarkable. Greater than 24 hours of EEG
monitoring did not demonstrate any epileptiform activity.
Patient was evaluated by psychiatry. Patient noted that he had
been using anabolic steroids, and recently increased his dose of
testosterone up to 400 mg weekly. It was felt that this may have
precipitated a dissociative episode.
TRANSITIONAL ISSUES
-Please ensure follow-up with psychiatry.
-No primary neurologic issue, so no need for neurology follow-up | 85 | 127 |
12176259-DS-7 | 23,601,385 | Dear Mr ___,
WHY DID I COME TO THE HOSPITAL?
- You were having weight loss and trouble breathing.
WHAT HAPPENED AT THE HOSPITAL?
- We discovered you had lung cancer ("small cell" type).
- Your cancer is "extensive stage," which means it has spread
widely to other organs (including your liver, abdomen, and
brain).
- Your cancer was also causing pneumonia, an infection in your
lungs. We treated this with antibiotics and your breathing
improved.
- You received one cycle of chemotherapy in the hospital
- Your daughter-in-law is your active health care proxy.
- You had your teeth pulled because they were infected
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You will receive hospice care to help manage any discomfort
It was a pleasure taking care of you!
Your ___ Team | Mr. ___ is a ___ with PMHx of a known RUL lung mass (with no
prior workup/therapy on admission), prior DVT (not on
anticoagulation), and T2DM who p/w shortness of breath,
anorexia, severe weight loss and was found to have extensive
stage small cell lung cancer s/p Interventional Pulm
bronchoscopy with biopsy. He was treated with chest radiation
his first cycle of carboplatin/etoposide C1D1 ___. His
course was complicated by significant depressive symptoms; he
did not participate in rehabilitation services or goals of care
conversations, and as a result became profoundly deconditioned
and weak. Given his general debility, he was not deemed a
candidate for a second cycle of chemoradiation in the hospital.
While awaiting SNF placement, patient underwent complete teeth
extraction with OMFS due to multiple necrotic teeth. He was
discharged to home with hospice for end of life care given his
severe debility from advanced metastatic cancer, poor functional
status, and decline in cognitive status and motivation to
participate in rehabilitation. | 127 | 168 |
14023270-DS-14 | 21,556,007 | Dear Mr. ___,
You were admitted because of redness and swelling of your right
foot after recent discharge for the same problem. We had
originally discharged you with antibiotic pills to treat a
possible skin infection involving your foot. Your visiting nurse
thought that the redness of your shin and foot required
evaluation. We do not think that you had an antibiotic failure,
but rather your swelling and chronic venous stasis of your legs
may have led to an appearance of infection. Your foot will need
to heal on its own, which will take time. The cultures that were
obtained from the fluid that drained from a pocket of your skin
was cultured and the bacteria identified can be treated with the
antibiotics we chose to send you home with. It is important to
finish this prescription.
Thankfully, your pain was well controlled. You can continue
taking the medications you were recently discharged with, though
you should stop the antibiotic (clindamycin) ___ favor of the new
antibiotic (cephalexin).
It is important that you follow up with your podiatrist within 7
days. You should NOT put weight on your right foot until that
appointment. Continue elevating your foot, using ice, and
wrapping ___ with ACE bandage for mild compression. Continue with
Naproxen (similar to Ibuprofen), Tylenol, and Oxycodone to
control your pain until these doctors ___. You should take
the naproxen with food and should not take this medication for
more than 1 week as it can be toxic to your kidneys. You will be
evaluated by ___ Dr. ___ ___.
Also, because of your heart failure you should weigh yourself
every morning and call MD if weight goes up more than 3 lbs.
Your weight at discharge was 347 lbs. You also need to take a
baby aspirin (81mg) every day for the rest of your life.
It was a pleasure to take care of you, and we hope that you feel
better soon.
Your ___ team! | Mr. ___ is a ___ with type 2 diabetes, chronic diastolic
heart failure, COPD, morbid obesity, and chronic venous stasis
recently discharged on ___ for RLE cellulitis who returns to
___ with worsening edema and erythema. | 324 | 36 |
19618753-DS-6 | 21,298,114 | Orthopedic Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin.
8. ANTICOAGULATION: Anticoagulation is needed for four (4) weeks
after surgery to help prevent deep vein thrombosis (blood
clots). If you were given aspirin, continue the 81mg twice daily
x 4 wks.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after surgery while wearing your aquacel
dressing, but no tub baths, swimming, or submerging your
incision until after your first checkup and cleared by your
surgeon. After the aquacel dressing is removed 7 days after your
surgery, you may leave the wound open to air. Check the wound
regularly for signs of infection such as redness or thick yellow
drainage and promptly notify your surgeon of any such findings
immediately.
10. ___ (once at home): Home ___, Aquacel removal POD#7, and
wound checks.
11. ACTIVITY: Weight bearing as tolerated with two crutches or
walker for as long as you need. The physical therapist will help
guide you until you are safe to wean from assistive devices.
Posterior hip precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
You were admitted for worsening hip pain and found to have
likely infection of your hip. You were seen by orthopedics and
underwent repeat surgery to clear out the infection. You were
resumed on antibiotics with improvement of symptoms. Given your
pain you were started back on opiates that were weaned down
prior to discharge. These should be continued to be down
titrated as your pain improves.
New medications:
1) Aspirin is a medication as noted above to prevent blood clots
2) Oxycodone is a narcotic medication to help control your pain.
PLease take as prescribed and wean off as your pain improves by
decreasing frequency and amount.
3) Naproxen is a medication to help control your pain. Please
take as prescribed.
4) Protonix is a medication to help prevent stomach damage while
you are on aspirin and naproxen.
5) Ferrous sulfate is a medication to help replete your low iron
stores.
6)Daptomycin is an antibiotic to treat your infection. Please
take as prescribed through ___.
7) Your home medication of gabapentin was increased. Please take
at increased dose as prescribed.
8) senna, colace, miralax are medications to help prevent
constipation. Please take as prescribed as needed.
Best of luck in your recovery,
Your ___ care team | Mr. ___ is a ___ male with history of opiate use
disorder with heroin and recent complicated admission for septic
arthritis of the left hip, Infective
Endocarditis and gluteal abscess who presents now with 2 days of
worsening left hip pain. | 646 | 40 |
16984077-DS-9 | 26,797,547 | Dear ___,
.
As you and your family are aware, you came to ___
because you had belly pain, most likely because of constipation.
Some testing initially was concerning for a clot or an abscess
in your kidney, but after more testing, both of those seem
unlikely. You may still have some residual infection from
before, so we will give you some antibiotics to take by mouth.
.
Please be sure to follow up with your primary care doctor Dr.
___ and to keep your original appointment with Dr. ___
to take out your stents.
.
It was a pleasure to take care of you during your stay here, and
we wish you the very best at home.
.
Warmest wishes,
Your ___ care team | Ms. ___ is a ___ woman with a h/o Hirshprung's
disease s/p two reversed colostomies with chronic constipation;
___ nephrolithiasis c/b urosepsis treated with nephrostomy
tube placement and s/p laser lithotripsy, bilateral ureteral
stent placement, and nephrostomy tube removal on ___
PICC-associated DVT from the ___ hospitalization for the
urosepsis; cerebral palsy c/b epilepsy and mental retardation;
and stroke w/L hemiparesis. She presented from ___ to
___ with abdominal pain and was transferred to ___
after CT showed new wedge-shaped areas in upper pole of both
kidneys and lower pole of left kidney concerning for possible
renal infarcts which were determined to most likely be
post-nephrostomy tube / pyelo changes.
.
Aside from her chronic issues, we actively managed the
following:
# Abdominal pain, likely due to combination of severe
constipation (large stool burden) and mild dysmenorrhea. This
improved with rectal bisacodyl and oral docusate/miralax/senna,
as well as occasional tylenol.
.
# CT renal findings of possible Renal infarcts. Given absence of
leukocytosis, absence of SIRS, relatively well appearance, and
supratherapeutic INR (4.4) at presentation, as well as
discussions with urology, renal, interventional radiology, and
radiology services, the CT findings seemed more likely to be due
to her recent urological procedures and resolving
pyelonephritis. She did however get vancomycin/ceftriaxone,
which were changed over to a 7-day outpatient course of
amoxicillin which will complete a total of 14 days given history
of ureteral stents / possible pyelo. Urine cultures from ___
returned at 36 hours with <10,000 gram positive cocci (possibly
residual enterococcus) and <10,000 mixed gram negatives.
.
### TRANSITIONAL ISSUES ###:
- Bowel regimen (docusate, bisacodyl, senna, miralax) will need
to be continued indefinitely; severe constipation history
- consider follow up with congenital heart service for enlarged
aortic root diameter 3.8 cm (normal less than 3.6cm)
- Planned followup with urology (Dr. ___ for flexible
cystoscopy and ureteral stent removal scheduled with her
urologist ___
- Warfarin may need to be redosed based on INR (to be drawn
___ given new dose of 2 from prior 3), to complete 3 months
from PICC associated DVT (ending ___. Will need to
be checked 3x per week until stablized. | 116 | 348 |
11472206-DS-17 | 27,965,458 | Dear Mr. ___,
You were admitted to ___ for shortness of breath. It appears
that you had an exacerbation of your congestive heart failure
and anemia. You were given higher doses of lasix to help reduce
extra fluid from your lungs as well as 1 unit of blood. You also
had an endoscopy which showed continued oozing from your stomach
blood vessels. The gastroenterologists performed a procedure to
help stop the bleeding. We now feel it is safe for you to leave
the hospital.
When you leave the hospital, you will need to have your blood
work checked on ___. A prescription for this is
attached. You will also need to have a repeat endoscopy in ___
wks. This will be arranged by your gastroenterologists.
While you were here, you were seen by the pulmonary team for
your breathing issues. They recommended you continue to wear
your CPAP and repeat a sleep study. They also recommend you do
pulmonary function tests and follow up with them in clinic in 2
weeks.
Lastly, you had an abnormality in your liver seen on your cat
scan. We tested you for hepatitis. These results will need to be
followed up by your PCP and gastroenterologist also.
We made the following changes to your medications:
STOP lisinopril
**It is very important that you weigh yourself daily and call
your doctor if your weight increases by more than 3 lbs in less
that one week.** | Patient is a ___ year old male with a history of coronary artery
disease with a CABG in ___, atrial fibrillation (off coumadin
for ___ yr), chronic kidney disease, long-standing iron deficiency
anemia, gastritis and chronic slow gastrointestinal bleed from
GAVE who presented with dyspnea, found to have fluid overload,
anemia, hyperkalemia, worsening renal function, and CT findings
of esophagitis.
.
# Acute on Chronic Diastolic Heart Failure: He reported weight
gain and was found to have signs of fluid overload consistent
with CHF exacerbation. No known obvious cause of exacerbation.
Cardiac enzyme levels did not indicate ischemic event. No change
in lasix regimen or diet recently. Appeared to be slow
progression possibly worsened by anemia causing increased
demand. He was diuresed with IV lasix boluses with good effect.
He was discharged on his home dose of lasix.
OSA/Pulmonary Hypertension: Respiratory was consulted to set the
pt up with nightly CPAP. He reported not using his own CPAP
machine at home because it was broken and could not be returned
because the sleep facility he went to was shut down. Therefore,
has an appointment set up for outpatient sleep clinic. The
pulmonary team was consulted, who recommended outpatient PFTs
for diagnosis of COPD, optimization of heart failure and OSA
therapy, and eventually repeating his TTE or considering right
heart catheterization to evaluate pulmonary hypertension. On
discharge, he continued to have oxygen saturations in the high
___ despite adequate diuresis, so he was sent home with home
oxygen. He was also written for outpatient ___ rehab.
.
# Upper GI Bleed: Pt has been previously diagnosed with
gastritis and GAVE. Baseline Hct ___ per prior
hospitalizations. He received 1 unit pRBCs on admission, and his
hct remained stable. He had an EGD on ___ which showed
recurrent GAVE. Bleeding vessels were cauterized with APC. He
will need a repeat EGD in ___ wks with APC to control his
bleeding. He was continued on home PPI, started on iron
supplementation, and will follow up with his outpatient GI
doctor on ___.
.
# Acute on chronic kidney injury: Cr at last discharge was
1.7-1.8, and pt presented at 2.3. Likely prerenal in setting of
poor forward flow secondary to heart failure exacerbation. Home
lasix dose was held. Improved with diuresis. Cr on discharge was
1.5. His lisinopril can be restarted as needed fr HTN.
.
# Hyperkalemia: Likely secondary to autodigestion of lysed blood
in the GI tract in the setting of upper GI hemorrhage. His K
came down with administration of insulin and dextrose in the ED
as well as lasix throughout his admission.
.
# Cirrhosis on CT chest: no known history of cirrhosis, LFTs
normal. GI was aware and recommended getting a hepatitis panel,
which was negative. Of note, he reports greater than moderate
alcohol use, approx 3 glasses wine per day and history of
heavier drinking. This should be further worked up as an
outpatient. | 233 | 481 |
19459342-DS-16 | 24,121,084 | Dear Ms. ___
You were admitted to the ___ for a stress test to
examine how your heart is functioning. Your stress test showed
that your heart is functioning normally.
When you went to Dr. ___ office on ___ your blood
pressure was low (100/60). We adjusted your blood pressure
medications, which are now: labetalol 200 mg twice a day and
amlodipine 5 mg daily. If you measure your blood pressure at
home and the top number (systolic) pressure is higher than 180,
call Dr. ___.
Additionally, it was found that your blood sugar is very low.
You told us about your poor appetite. We decreased your long
acting insulin (lantus) from 50 at night to 25 at night. It is
important to keep your appointment with Dr. ___ to adjust
your insulin as your appetite improves.
Many of your symptoms were likely due to side effects from your
statin. We stopped this medication for now, but expect that you
will be able to take a different version of this medication in
the future to help with your heart disease.
Thank you for allowing us to participate in your care.
___ Care team | Mr. ___ is a ___ year old female with history of DM2, CKD, and
PVD who presents with 1 months of fatigue and multiple
complaints. Seen at ___'s office and found to be hypotensive.
Admitted for ACS rule out and ___.
# Chest Pain/Hypertension: Patient presented to PCP ___ ___ with
symptoms of lightheadness, profound fatigue, chest pain at rest
and with exertion in the past few weeks that was not active in
the office, shortness of breath with ambulation especially up
stairs, loss of appetite, loss of interest in daily activities
and watery diarrhea after eating that has lasted two weeks in
duration. At the PCP's office her blood pressure was lower than
baseline at 100/60 baseline (130/60), she was told to hold her
labetalol in anticipation for a cardiac stress test and report
to the emergency department to be admitted. In the emergency
department, BP was 129/50 mmHg. Initial ECG showed T wave
inversions in lateral leads V4-V6 that resolved on subsequent
ECG. Patient remained chest pain free. Trops 2X <0.01 and MB was
elevated to 16 with CK elevated to 1897. White count was mildly
elevated to 10.7K, patient remained afebrile. On transfer to the
floor, the patient remained normotensive with a BP of
130's/60___s. Her home blood pressure medications were held
(labetaolol, lisinopril, HCTZ). She was made NPO for stress
perfusion study. She underwent pharm stress perfusion study with
dipyridamole, no anginal symptoms were observed, no ST changes
were observed during infusion or recovery and there was no
evidence of myocardial perfusion defect with normal wall motion
and LVEF of 68%. After the cardiac stress/perfusion study,
patient was restarted on labetalol 200 mg BID as well as
amlodpidine 5 mg per Atrius cardiology recommendations. Patient
was discharged on labetalol 200 mg BID and 5 mg amlodipine
daily. BP on discharge was 150-160/50-60. Lisinopril/HCTZ were
held in the setting ___ on CKD.
# Elevated CK: CK 1897/MB ___ 0.8/Trop-T <0.01. On high dose
atorvastatin 80 mg. Atrovstatin 80 mg was held due to elevated
CK and question of statin myopathy.
# ___ on CKD Stage IV: Patient with known CKD Stage IV ___ to
diabetic nephropathy with baseline Cr of 2.0. Cr on admission
2.5, likely pre-renal in the setting of hypotension, poor PO
intake, and diarrhea. UA lytes show a pre-renal pattern. She
received 1L NS in the ED. Her HCTZ and lisinopril were held. Cr
downtrended and was 1.7 on day of discharge. HCTZ/lisinopril
were held upon discharge.
# DIARRHEA: Patient reports several episodes of diarrhea per
day, which occur almost immediately after eating. She denies
fevers, chills, nausea, and vomiting. Finished 10 day course of
amoxicillin on ___ for sinusitis. She denies recent
travel. Given chronicity of symptoms, infectious etiology less
likely. Furthermore, abdominal exam is benign. Could consider
malabsorption syndrome given the association with eating.
Patient did not experience diarrhea while inpatient and
therefore stool studies were not send. Patient had one small,
soft bowel movement with no episodes of diarrhea.
# HYPOGLYCEMIA: Patient was on 50U lantus at home, with Humalog
sliding scale. First morning of admission, patient was found to
be hypoglycemic with BS ___ in AM before breakfast likely due
to decreased PO intake after receiving half of her home dose,
25U Lantus. Hypoglycemia recovered to 95 after juice and ___
crackers. Her evening dose lantus was further decreased from 25U
to 15U to avoid AM hypoglycemia. On the night prior to
discharge, she was trialed on 20U evening lantus with good AM
control of her blood glucose and was discharged home on 20U
lantus in the evening with instructions to continue her HISS and
to check her AM glucose.
# LEUKOCYTOSIS: Patient afebrile. Only complains of diarrhea.
CXR showed no effusions or consolidations concerning for
pneumonia. The patient did not experience any episodes of
diarrhea while in the ED or while inpatient. Leukocytosis
resolved on day two of admission without antibiotics. Patient
remained afebrile with normal white count for remainder of
hospitalization.
# FATIGUE: Patient presents with 1 month of fatigue associated
with nonspecific symptoms as described as above. Admission labs
only concerning for ___. Patient reports feeling depressed,
which likely contributes to her symptoms. She was tried on
sertraline, which was discontinued after 1.5 weeks due to lack
of affect and concern for side effects. Patient also on
zolpidem, which may contribute to symptoms. However, she reports
being on this medication for several years. She also reports bug
bites, but no reported ticks or rashes. TSH normal at 1.5 B12
normal in 800's. CK was elevated while taking high dose
atorvastatin concerning for a statin myopathy that could also be
contributing to her fatigue.
# Depression: Meeting criteria for a major depression episode:
>4 weeks of lost of interest in daily activities i.e. no longer
wants to walk her dog, sleeps multiple hours a day, loss of
appetite accompanying weight loss. Discussed with outpatient
provider who recommended starting wellbutrin. We deferred
starting an antidepressant while inpatient and advised the
patient to discuss further with PCP.
OF NOTE:
On discharge, the following medication adjustments were made:
- Lantus decreased from 50U nightly to 20U nightly
- Labetalol decreased from 400 mg BID to ___ mg BID
- Amlodipine 5 mg daily started
- Lisinopril/HCTZ held in the setting ___ on CKD
- Atorvastatin 80 mg held in the setting of statin myopathy with
elevated CK to 1800.
=====================================
Transitional Issues:
=====================================
- Insulin Management: due to hypoglycemia, discharged on 20U
Lantus at night. Please continue to adjust as patient's appetite
improves.
- Blood Pressure Management: Patient was discharged on labetalol
200 mg BID and 5 mg amlodipine daily. BP on discharge was
150-160/50-60. Lisinopril/HCTZ were held in the setting ___
on CKD. Please consider restarting if needed.
- Depression: meeting criteria for major depression disorder. No
active SI. Please follow up CBT/pharm management
- Elevated CK: ?statin myopathy; holding statin on discharge but
would benefit from a statin: consider restarting different
statin/lower dose in the future
- Amyloidosis work-up pending at discharge; results to be
followed up by PCP
>30 minutes spent coordinating discharge | 193 | 1,021 |
11994050-DS-3 | 26,633,666 | You were admitted with biliary obstruction caused by tumor(s)
blocking your bile ducts. You were taken for ERCP with stent
placement to relieve the obstruction and you had biopsies done
for diagnosis. You did well after the procedure.
You were incidentally discovered to have pulmonary embolism and
bilateral deep vein thrombosis. You were treated with blood
thinners. | Brief summary:
This is a ___ with minimal past medical history who presented
with jaundice, elevated LFTs, and abnormal CT with concern for
pancreatic cancer with malignant biliary obstruction. She was
admitted and the ERCP team was consulted. She underwent ERCP
with stent placement and biopsy. LFTs/bilirubin steadily
improved. She was incidentally found to have pulmonary embolism
on her CT scan and had LENIs confirming bilateral DVT, so she
was treated with heparin gtt and subsequently therapeutic
Lovenox. She was discharged with plans for followup with PCP,
___, and the ___ clinic pending biopsy results. | 56 | 96 |
16214116-DS-13 | 22,745,089 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were treated for a right scrotal cellulitis and abcess with
antibiotics. General surgery decided to do an incision and
drainage of the abcess. They packed the wound. The culture of
the abcess fluid grew Group B Streptococcus. We treated you with
the appropriate antibiotics and you improved. You did not have
fevers and pain was controlled with medications. You will have a
visitng nurse change the dressing daily.
You were also found to have high blood sugars. The Diabetes is
not controlled at this time and we started you on insulin (18
units of Lantus). You need to follow-up with your
Endocrinologist in the next ___ days. Your hemoglobin A1C was
11.1% (should be below 5.5%).
Please see your primary care doctor in the next ___ days.
Please see your Urologist who saw you for your previous abcess
in the next ___ days.
You will need a referral to a general surgeon via the primary
care doctor in order to assess the wound and make sure it is
healing well. | ___ hx DM2, HTN, ___ pw 3d of scrotal pain and erythema c/w
scrotal cellulitis.
#Scrotal Cellulitis: H/o scrotal cellulitis that resolved about
3 months ago. Initially concerned for ___ at OSH so
transferred. CT without gas or signs of gangrene and no crepitus
on exam. Surgery was consulted who felt that he did not have
___ and recommended IV abx. Afebrile, +leukocytosis, mild
lactate elevation. Started on Vancomycin, Zosyn, and Clindamycin
initially. S/p I&D of R perineal abcess by surgery, recommended
BID dressing changes. Gram stain showed gram positive cocci in
pairs, disconinued Clindamycin (no evidence of sepsis, stable
VS), and switched Zosyn to Unasyn (no GNR on stain, less concern
for pseudomonas). Continued to improve. Fluid culture of abcess
fluid eventually grew Group B Strep. Vancomycin was discontinued
and Unasyn IV was switched to Augmentin PO. After 24 hours on PO
antibiotics, pt continued to improve, stable VS and improving
cellulitis. At this time, patient was found to be safe to
discharge to home with appropriate follow-up. Pt discharged with
a Augementin PO for 6 more days (total of 10days of
antibiotics). Pain was controlled with Percocet. ___ was
arranged for daily wound dressing changes until healed. Patient
also instructed to ask for referral to a general surgery when he
visits his PCP in order to have his wound checked.
.
#DM2: Sugars uncontrolled, just on metformin at home (also
10units Lantus at night if blood sugar was high at night, but pt
was not checking blood sugars at home). Risk factor for
fourniers and infection. Has a DM specialist, Dr. ___. Hgb
A1C was 11. Pt started on insulin sliding scale and Lantus
18units at bedtime because blood suagrs were above 300.
Eventually, they decreased to below 200. Pt was discharged with
an appointment to see Dr. ___ a week and Lantus
18units at bedtime (while checking blood sugars in the morning).
It was stressed to pt the importance of taking control of his
DMII.
.
#Morbid Obesity: Has been losing weight over the past year, as
per pt. Again, stressed the importance of losing weight. We
discuseed the options of bypass surgery and possible plastic
surgery consult to remove abdominal pannus. Removing abdominal
pannus may help with his chronic skin fold fungal infections.
.
#HTN: Stable, continued Lisinopril and HCTZ.
. | 183 | 378 |
17976484-DS-20 | 27,423,471 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ were sent to the hospital for concern of worsening left foot
infection and redness and swelling of your leg. ___ were started
on IV antibiotics and your redness and swelling improved.
However, the swelling and redness did not improve as much as we
would have hoped. It was recommended that ___ go home with IV
antibiotics, or stay in the hospital for 24 hours after
switching to oral antibiotics. Because ___ needed to go home,
___ decided to leave against medical advice on oral antibiotics
without being monitored.
Your blood sugar was elevated throughout hospitalization. Please
follow up with your new endocrinologist.
Please follow up with your outpatient providers. Please keep
pressure off your foot.
Sincerely,
Your medical team at ___ | ___ woman with hx RCC s/p left nephrectomy ___, NIDDM, HTN,
chronic left hallux ulcer followed closely by podiatry, sent in
from wound care clinic at ___ for worsening left hallux
ulcer with erythema.
# Left Hallux Ulcer with overlying cellulitis: Patient with
chronic left hallux ulcer that is debrided frequently. She has
failed multiple outpatient oral regimens. At clinic she had
spreading erythema, warmth, swelling and tenderness over left
mid foot and toes. Sent to ___ for IV antibiotics. She was
started on vanc/zosyn and erythema improved significantly. Exam
significant for left foot with swelling of big toe, erythema
from toes to midfoot, minimal erythema spreading up the leg to
ankle. Ulcer clean s/p debridement, no purulence, 1.5cm x1.5cm
x-0.5cm on the left base of foot. Minimal drainage. She had a
mild leukocytosis to 10 and CRP 140 ESR 79, which is concerning
for osteo, even though XRAYs do not show evidence of bone
involvement. MRI negative for osteo or abscess. Erythema shrunk
down to midfoot and midcalf, but not completely resolved. Plan
was for either IV antiotics or transition to oral cipro/clinda
with 24 hours monitoring, but patient decided to leave on
cipro/clinda AMA.
# DM type 2: On glipizide, metformin and invokana at home.
Patient does not check blood sugars regularly because she hates
needles. As BS >300 and active infection, and started lantus
while inpatient, and uptitrated HISS. Patient declined starting
lantus while inpatient. Instead she will be referred by her PCP
to an outpatient endocrinologist at ___.
# HLD: on simvastatin and amlodipine at home which have
interactions. Simvastatin stopped in the hospital. Transitional
issue will be to switch to atorvastatin.
# Tobacco Abuse: Counseled patient on avoiding tobacco
particularly for wound healing. Started nicotine gum prn
cravings in addition to nicotine patch.
# Depression: Continued Paroxetine 20mg daily
# Insomnia: Continued TraZODoned 50-100 mg PO QHS:PRN insomnia
# Pain: Pain contract with new PCP. confirmed with pharmacy.
continued oxycontin 10mg BID and oxycodone 5mg TID prn. No extra
pain medications given.
======================= | 135 | 340 |
18981355-DS-14 | 20,409,711 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- Because your blood was thin and you had low blood pressure.
What did you receive in the hospital?
- We held your warfarin (blood thinner) until your INR came
down. We then restarted you on your home doses of warfarin.
What should you do once you leave the hospital?
- Keep all of your appointments and take all you medication as
prescribed
- Weigh yourself every morning, and call your doctor if your
weight goes up more than 3 lbs in 1 day or 5 lbs in 3 days.
- Please continue to work with the ___ clinic to
closely monitor your INR. Your goal INR is 2.5-3.5. A higher INR
means that your blood is too thin.
We wish you the best!
Your ___ Care Team | Ms. ___ is a ___ female with h/o mechanical MVR on
Coumadin with INR goal of 2.5-3.5, CAD andHFrEF (LVEF 38%)
referred from ___ clinic w/ INR > 8.0 and concerns for BRBPR.
The patients warfarin was held as INR downtrend. It was 3.1 at
discharge. At that time ___ clinic was contacted and
the patient resumed home regimen of 7.5mg on ___ and 10mg on the
other 6 days. The patients h/H was stable and she did not have
BRBPR during hospitalization.
#Supratherapeutic INR
Unfortunately patient had poor understanding of warfarin dosing
and exceeded recommended amount. She was found to have INR of 8
and was admitted for inpatient monitoring. It was 3.1 at
discharge. At that time ___ clinic was contacted and
the patient resumed home regimen of 7.5 W and 10mg 6 days. The
patients h/H was stable and she did not have BRBPR during this
hospitalization. She was set up with ___ for assistance with her
medications and enrolled in PACT. She will follow up with
___ clinic for further management.
#Pain management:
#Anxiety
Patient with chronic pain. She has a contract to receive
Percocet ___ TID and will follow with pain clinic. During
hospitalization she had exacerbation of her pain. Pain was
generalized to back, kidneys, chest. Infectious workup was
unremarkable. EKG and troponins unremarkable. While
hospitalized she was treated with oxycodone ___ Q4, Tylenol
___ Q8, Tizanidine 2mg TID home Lorazepam ___ BID. She was
discharged on home regime of Lorazepam ___ BID and Percocet
___ TID.
#Hypotension:
#Concern for blood loss anemia
#Concern for Infection
On review of outpatient records patient SBP typically 90's-120s.
Her blood pressure was transiently low to the 80's systolic
while in the ED. Infection workup was unremarkable. CT abdomen
to evaluate for possible nephrolithiasis demonstrated incidental
finding of colitis, though she had no GI symptoms while
hospitalized. The patient's H/H was stable during
hospitalization. She remained afebrile. The patient has not had
any new episodes of diarrhea or dark stool to suggest infection
or ongoing bleed. She was discharged on on her home metoprolol
and lisinopril. | 159 | 345 |
14921998-DS-21 | 26,558,571 | Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. You were admitted for a
single episode of fainting and low blood counts.
While you were in the hospital, you received intravenous fluids
and esophagogastroduodenoscopy, a type of procedure that allows
visualization of your gastrointestinal track for signs of
bleeding. Bleeding vessels were found in your stomach and were
burned, successfully halting further bleeding.
We expect that this procedure will decrease the amount of blood
you are losing and help halt your rapid drop in blood counts.
Your care facility will monitor your blood levels after
discharge to make sure you are not continuing to bleed.
You should continue taking your regular iron supplementation and
increase your omeprazole intake from 20mg once per day to twice
per day. Also, because of the bleeding in your stomach, you
should stop taking clopidogrel and aspirin for now, which
increase your bleeding tendency. On your next visit to your
gastroenterologist and/or neurologist, you should ask about
restarting clopidogrel and aspirin because although these agents
can cause bleeding, they also may be beneficial for preventing
further strokes. | Mr. ___ is a ___ with history of multiple sclerosis,
cerebrovascular accident, iron deficiency anemia, and atrial
fibrillation who presented following a witnessed syncopal
episode with progressive anemia and was found to have bleeding
gastric arteriovenous malformations. | 190 | 37 |
16522692-DS-20 | 27,652,514 | Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to ___
___ for coughing up blood. This was found to be due
to bleeding from your lung vessels caused by "bronchiectasis,"
damage to your airways that cause it to stretched and widened.
We tested you for tuberculosis and you were negative.
For the bleeding, our interventional radiology team conducted
two procedures to close the bleeding blood vessels in your lungs
on ___ and ___. After these procedures, the amount of
blood you coughed up decreased. We also started you on
medications to treat your cough to help prevent further
bleeding. We expect you to have a little bit of blood mixed in
with mucous when you cough because of the old blood in your
lungs. However, if you discover that you have a lot MORE blood
when you cough or cough up only blood you should come into the
hospital.
You are now safe to leave the hospital. We have arranged for
you to ___ with your PCP ___ ___, the Thoracic Surgery
Team on ___. ___ with the Pulmonary doctors is being
arranged. Please take all your medications as prescribed. | Mr. ___ is a ___ with remote history of active tuberculosis
treated in ___ and 30 pack-year smoking history with residual
left upper lobe scarring and persistent bronchiectasis who
presented ___ with hemoptysis.
# Massive hemoptysis: Patient presented with ___ days of
progressive small-volume hemotypsis. In the setting of prior
tuberculosis and smoking history, there was initial concern for
active tuberculosis or malignancy. However, beyond hemoptysis,
patient was otherwise negative for systemic complaints (fevers,
chills, weight loss, night sweats) that would suggest either.
CTA chest was conducted and without suggestion of malignancy,
and patient had 3 induced sputums that were preliminary AFB
negative on concentrated smear. As such, etiology of hemoptysis
was thought secondary to worsening of known chronic
bronchiectasis. Regarding management, patient was intubated for
airway protection in the setting of massive hemoptysis on
___. The Interventional Radiology team attempted but was
unsuccessful at embolization on ___, instead creating a
dissection that thrombosed. In the setting of recurrent
hemoptysis, they took the patient for another procedure on
___ where they were able to embolize left bronchial artery.
Post procedure, the patient remained well-appearing and was
managed with anti-tussive agents. At the time of discharge, he
had blood-tinged mucous but no overt hemoptysis. He has
scheduled PCP and ___. Pulmonary
___ is being arranged.
# Hypertension: Was hypotensive in MICU in the setting of
volume depletion and being made NPO. Patient was fluid
responsive and never require vasopressor support. In this
setting, home lisinopril was held with improvement in blood
pressure to sBP 100-110s. At the time of discharge, lisinopril
continued to be held pending ___ blood pressures.
# Noninsulin-dependent diabetes mellitus: Pateint home glipizide
was held and restarted at the time of discharge. He was briefly
placed on an insulin sliding scale that was discontinued because
patient did not require insulin.
# Hyperlipidemia: Remained stable, continued home simvastatin.
# GERD: Remained stable, continued home dose omprazole.
========================================
TRANSITIONAL ISSUES
========================================
- STARTED on Tessalon Perles and guaifenisin with codeine to
suppress cough
- STOPPED lisinopril because of low blood pressure. Please
consider restarting pending ___ blood pressures
- PCP ___ scheduled for ___
- Thoracic surgery ___ scheduled for ___
- Pulmonary ___ is being arranged | 202 | 363 |
10611631-DS-15 | 23,730,280 | Dear. Ms. ___,
It was a pleasure taking care of you at ___
___.
You initially came to the hospital because of abdominal pain and
because you were having blood in your stools.
What happened during her hospitalization?
-You continued to have bloody stools and you had several
episodes of vomiting blood
-You were evaluated by the gastroenterology team and underwent
an upper EGD or scope and colonoscopy
-The scope showed that you had some areas of inflammation in
your stomach and biopsies were taken
-Your bloody stools were thought to be from anal fissures
-You were treated with an antibiotic for a urinary tract
infection
-We were also evaluated by the pain management team due to your
severe abdominal pain
-You decided to leave against medical advice
What should you do when you leave the hospital?
-Continue to take all of your medications as prescribed
-Follow-up with your primary care physician ___ 1 week
-Please keep all of your other scheduled healthcare appointments
as listed below
Sincerely,
Your BIMDC Care Team | ***PATIENT LEFT AGAINST MEDICAL ADVICE. SHE WAS ABLE TO STATE
THE RISKS OF LEAVING AND HAD CAPACITY TO LEAVE THE HOSPITAL.
PLEASE SEE BELOW REGARDING AMA DISCHARGE***
Ms. ___ is a ___ female with history of PE and DVT,
Fe deficiency anemia, menorrhagia status post hysterectomy on
___, recurrent UTI with previously ESBL E. Coli, ischemic
colitis with prior GI bleeds requiring PRBC transfusions, who
presented with a 2 day history of severe abdominal pain with
hematochezia, hospital course complicated by moderate volume
hematemesis, now status post EGD and colonoscopy showing small
patches of erythema in the stomach body, but without any
evidence of bleeding lesions with overall improvement of
hematochezia. Patient had ongoing episodes of hematemesis with
stable vital signs and hemoglobin. She refused to stay for
further monitoring or testing as she did not feel like her pain
was being adequately addressed. Of note, there is significant
concern for opiate use disorder as patient has filled 14
prescriptions for narcotics with 14 different providers over the
past year with several occurring in the past several months.
When confronted about our concern for her opiate use and pain
control, the patient became very tearful and angry and demanded
to leave against medical advice when we refused to offer IV
dilaudid. She declined oxycodone, Tylenol, or other PO
alternatives. She declined seeing an addiction specialist. The
patient ultimately signed out AMA.
ACUTE ISSUES
==============
#Hematemesis
#Hematocheiza - Patient initially presented with a 2 day history
of severe lower abdominal pain and hematochezia. Hospital course
was complicated by moderate volume hematemesis with clots.
Hemoglobin on admission was 10.9, down from recent baseline of
___, however patient also with severe iron deficiency anemia
with L sided port for IV Fe infusions, and is also status post
hysterectomy on ___. At times patient had brief episodes of
hypotension with SBPs in the ___, received intermittent IVF
boluses. She remained asymptomatic, otherwise hemodynamically
stable, with stable hemoglobin throughout hospital course.
Initial CT A/P demonstrated trace pelvic free fluid within
physiologic range or possibly related to recent hysterectomy.
There was no otherwise no acute intra-abdominal or pelvic
findings. Hematemesis and hematochezia was initially thought to
be secondary to possible PUD vs. ischemic colitis, and of note,
patient was restarted on Lovenox due to prior PE/DVT at time of
hysterectomy, with plan for 10 day duration of therapy, however
patient had continued to take lovenox beyond 10 days prior to
admission. Lovenox was subsequently held on admission.
GI was consulted and patient underwent EGD and colonoscopy,
revealing small patches of mild erythema in the stomach body
with biopsies taken, showing corpus type gastric mucosa without
abnormalities on pathology report. Otherwise normal mucosa and
no obvious source of bleeding on EGD or colonoscopy. Per GI,
hematochezia thought to be secondary to anal fissures. Patient
was initially placed on pantoprazole 40 mg IV BID, however later
switched to omeprazole 40 mg PO BID. Patient did not require any
blood products during hospitalization. Per GI, no indication for
any additional diagnostic workup at this time. Given pattern of
bleeding with hematemesis with blood clots, unlikely to be small
bowel bleed. Per GI, if patient continues to have hematemesis,
would pursue repeat EGD and possible colonoscopy at that time.
Diet was advanced to regular time of discharge. Patient left AMA
and refused to stay for further monitoring of her CBC.
#Abdominal Pain
#Possible Opioid Use Disorder
#AMA Discharge- Patient continued to have at times severe
subjective abdominal pain, which was inconsistent with physical
exam and diagnostic imaing findings. Patient also demonstrated
drug-seeking behavior. ___ PMP demonstrated
patient had filled 14 different prescriptions by 14 different
providers over the last year concerning for risky opioid use and
dependence. Pain management was consulted. Patient was
descalated from IV opioids to oxycodone 10 mg Q4H:PRN. Patient
became very upset when she was no longer able to get IV dilaudid
and refused alternative PO medications. When confronted about
her opiate use and our overall concerns about her usage over the
past year, the patient became angry, tearful and demanded to
leave AMA. She declined seeing an addiction specialist or
alternative pain medications or PO narcotics.
#UTI - Patient has a history of ESBL E. coli UTI, with initial
UA on admission consistent with UTI. Given history of ESBL E.
coli, she was initially started on meropenem. Urine cultures
eventually grew pansensitive E. coli, and antibiotics were
de-escalated to ciprofloxacin. Plan for 7 day course of
ciprofloxacin given history of urethral diverticulum status post
excision with suburethral sling. End date ___.
#Transaminitis - Patient presented with new transaminitis on
admission with AST/ALT 100/111, which down trended during
hospitalization. She is status post cholecystectomy. Was found
to be hepatitis B immune, HCV antibody negative, ferritin within
normal limits. CT abdomen/pelvis demonstrated no intra-hepatic
pathology. ___ consider outpatient workup of mild transaminitis
if LFTs persistently elevated.
CHRONIC ISSUES
===============
#DVT/PE - Patient has a history of ischemic colitis placing
patient at high risk for DVT, with DVT in ___ thought to be
secondary to ischemic colitis. Patient subsequently had PE which
occurred in the postoperative setting. Patient is followed by
Dr. ___ Hematology. She was initially treated with
warfarin and Eliquis, and was previously off anticoagulation
since ___. Hypercoagulability workup was subsequently
negative. Per above, patient was restarted on Lovenox prior to
hysterectomy which was stopped on admission. After improvement
of hematemesis, patient was restarted on subcutaneous heparin
for DVT prophylaxis given that she is at high risk for VTE.
#Menorrhagia s/p hysterectomy - Patient underwent hysterectomy
on ___ secondary to menorrhagia. CT A/P findings per above
were consistent with post-operative changes. OB/GYN was
consulted in the emergency department, and there was no blood in
the vaginal vault on physical exam.
#Anxiety/Depression - Patient was continued on home clonazepam,
citalopram, and hydroxyzine.
TRANSITIONAL ISSUES
===================
[ ] NEW/CHANGED Medications
-Cipro 500mg BID (end ___
-Omeprazole 40mg BID | 158 | 962 |
12585131-DS-11 | 24,002,060 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to begin treatment for your
newly diagnosed MPNST - a type of cancer in your chest. We
attempted to place a stent in your SVC (a large vein that drains
into the heart) to help relieve obstruction from the cancer -
the stent could not stay in place, and ultimately was put lower
down in your IVC.
We also started you on chemotherapy and radiation therapy after
placing a port-a-cath. You tolerated the chemotherapy and
radiation well with only some expected nausea and mild diarrhea.
You will need to follow up on ___ in clinic for your
Neulasta shot and with the radiation doctors to complete your
radiation treatment. Drs. ___ be in touch
to help coordinate your next clinic appointment (likely next
___, or the next) round of chemotherapy (likely ___
We have started you on a number of medications for nausea and to
reduce swelling (dexamethasone). Please take the ondansetron
(Zofran) every 8 hours for the next three days, then you can
take it as needed. Please taper the dexamethasone as described.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female with history of
Hodgkin's lymphoma and recently found to have large mediastinal
___ and diagnosed MPNST with heterologous rhabdo
differentiation. She was admitted with shortness of breath and
concern for SVC syndrome.
___ attempted to place SVC stent ___ however migrated into RA
and re-positioned into IVC; subsequently had angioplasty of SVC
and right brachiocephalic veins and left single lumen port
placement. She initiated chemotherapy with ifosfamide/mesna with
5-day protocol on ___ with concurrent radiation. She tolerated
treatment well with moderate nausea controlled with antiemetics.
We will taper he dexamethasone, which was started on admission,
and she will follow up in clinic on ___ for Neulasta. Her next
chemotherapy is tentatively planned for ___. She will also
continue to follow up with radiation oncology to complete her
planned radiation course.
# SVC Syndrome:
# MPNST with Heterologous Rhabdo Differentiation: Diagnosed on
mediastinal biopsy from ___. Admitted with concern for SVC
syndrome due to increased facial swelling and imaging at OSH.
Started on high dose dexamethaseone and underwent CT torso on
admission and attempted SVC stenting on ___. Initiated
ifosfamide and Mesna with concurrent radiation on ___. IVF
were provided to ensure 4L UOP daily and she was monitored for
hemorrhagic cystitis. She tolerate treatment well with mild
nausea and diarrhea. She will follow up in clinic on ___ for
Neulasta. She will also continue to follow up with radiation
oncology to complete her planned radiation course. Next
chemotherapy tentatively planned for ___. She was discharged
with ondansetron and Compazine for nausea, along with RX for
viscous lidocaine in case she develops radiation esophagitis.
# Leukocytosis: Noted early in course. Likely secondary to
steroids. No signs/symptoms of infection. Stable/downtrending on
discharge.
# Hypothyroidism: Continued home levothyroxine
# GERD: Continued home protonix
# Concern for ___: TTE prior to chemo showed possible
intracardiac ___ or thrombus, however was poor quality.
Cardiology and TEE were consulted who recommended cardiac MRI.
Cardiac MRI on ___ was negative for ___.
# Billing: >30 minutes spent coordinating and executing this
discharge plan | 193 | 336 |
13714536-DS-11 | 23,086,253 | You were admitted to the hospital with abdominal pain and
vomiting thought to be secondary to gallstone pancreatitis. You
underwent ERCP with sphincterotomy with improvement in your
pain. You were able to tolerate a regular diet prior to
discharge. Please do not take any ibuprofen, naproxen, Motrin,
Alleve, aspirin, or similar medications for one week.
You were also found on abdominal CT scan to have a lesion in
your left kidney concerning for cancer. You will need to
follow-up with ___ in the renal cell ___ clinic for
further evaluation. If you have not heard from ___
___ about that appointment by ___ please call his
office. | 1. ?Gallstone pancreatitis: Abrupt onset of abdominal pain,
nausea and vomiting c/w cholecystitis, and concomitant elevation
of lipase concerning for gallstone pancreatitis. Patient
responded well to supportive care with NPO, IV fluids,
anti-emetics and pain medications. He underwent ERCP with
sphincterotomy with subsequent normalization of his bilirubin.
He will follow-up with ___ in ___ as previously
scheduled.
2. Likely RCC: Incidentally noted on abdominal CT. Urology
notified and patient will follow-up with ___ in the Renal
Cell Clinic in ___ weeks.
3. DMII, controlled, without complications: Home metformin held
while in the hospital and patient covered with a sliding scale.
He experienced several episodes of hypoglycemia while NPO
despite not receiving insulin; this resolved with resumption of
his diet.
4. Hypertension: Home nadolol and lisinopril held on admission
given concern for infection and resumed at discharge.
Code Status: Full Code, confirmed on admission | 106 | 144 |
18377456-DS-7 | 25,650,133 | Dear Ms. ___,
You were admitted to ___ for
evaluation of abdominal pain following removal of your
gallbladder on ___. You were evaluated by the acute care
surgeons, and underwent a cat scan which demonstrated a small
fluid collection. This was thought to be post-operative in
nature and did not require drainage. Your labs were trended and
a gallbladder scan was done which ruled out bile leak. You have
since been able to tolerate a regular diet and your pain has
improved. 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. | Patient is a ___ year old female with past medical history of
acute cholecystitis s/p lap cholecystectomy on ___. Patient
presented to the emergency department with complaints of
abdominal pain. Acute Care Surgery was consulted and CT was
obtained which demonstrated nonspecific small amount of fluid in
GB fossa, most likely post-surgical in nature. She was then
admitted to the inpatient unit for serial abdominal exams, lab
monitoring, and plan for HIDA scan.
On HD2, her LFTS were grossly normal with down trending WBC.
HIDA scan was obtained and was negative, therefore she was given
clear liquid diet to advance to regular which she tolerated
well. She was then cleared for discharge after work up was
negative.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and incentive spirometry and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well. She was
afebrile and her vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and her pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed, and follow up appointments were scheduled and
reviewed with reported understanding and agreement. | 392 | 219 |
18931099-DS-22 | 25,083,041 | You were admitted to ___ after a fall, and were found to have
a fractured rib, bleeding in your right lung and abnormal kidney
electrolytes indicative of an acute kidney injury. You required
a chest tube be placed to drain the blood from the pleural space
of the lung, and you were given IV fluids to help correct your
kidney function. You were monitored closely and eventually
required surgery to clean out your chest and help re expand your
lung. Please note the following discharge instructions:
* Your injury caused a rib fracture which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
* Continue your Coumadin and the ___ clinic here
will continue to regulate your dose. | The patient presented to ___ Emergency Department on ___. Pt
was evaluated by
the acute care surgery team. Imaginge found the following: | 523 | 22 |
15048306-DS-13 | 29,880,108 | Dear Mr. ___,
You were admitted to ___ for
evaluation of abdominal pain and diarrhea. You were found to
have a large right sided inguinal hernia that requires surgical
intervention. You have refused surgical repair of your hernia
and requested transfer to ___ which we have
facilitated for you. As you near discharge from ___, 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. | Patient is a ___ year old male with ___ significant for GERD,
IBD, anxiety and asthma. Patient presented to the emergency
department with complaints of persistent diarrhea and abdominal
pain. Imaging was completed which demonstrated large right
inguinal bowel containing hernia extending into the scrotum with
new thickening of the distal ileum just beyond the hernia neck,
concerning for bowel ischemia. Therefore acute care surgery was
consulted for evaluation and surgical management.
The patient was then admitted to inpatient unit where surgical
intervention was discussed and he was made NPO with IV fluids
for plan of going to the OR on ___. However the patient was
unwilling to proceed with plan for surgical repair. He was then
offered surgery again in the following days and the OR was
booked multiple times, however the patient again refused to
proceed each time. He then requested transfer to ___
___, ___, where he reports he had a recent hospital
admission and feels he 'is better known at their facility' and
stated 'the surgeons are better'. The bed facilitator at ___ was
then contacted to arrange transfer to the patients requested
hospital. The plan of care was discussed with chief of acute
care surgery, Dr. ___ at ___ and the patient was accepted
for transfer.
The patient was screened by their bed facilitator and it was
determined a private room would not be available for him for at
least ___ days (pt with contact precautions requiring single
room). Therefore at the request of Dr. ___ outpatient
visit was arranged with him on ___. On ___, following
evaluation by social work, as requested by the patient, he was
cleared for discharge to home with plan for follow up at ___ as
scheduled. Once discharged, the patient began to make
threatening statements and comments that acute care surgery was
'kicking him out against his will'. It was discussed with him
that he was offered surgery but declined and had requested
transfer therefore it was arranged at his request.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and incentive spirometry and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient was discharged to home with follow up at ___
___ scheduled. Transfer was reviewed with reported
understanding. However again, following completion of his
discharge, the patient was refusing to leave the hospital. He
refused to put on street clothes and although an ___ car
was arranged, he refused to get into the car. The plan for
discharge and ___ clinic follow up was again discussed and the
patient walked out of the hospital while still dressed in his
hospital gown and socks, his belongings in a bag in his hand. | 280 | 468 |
15618507-DS-19 | 20,913,543 | Ms. ___, it was a pleasure to take part in your care at
___. You were admitted to the hospital after a fall and loss
of consciousness at home. In the hospital, we tested your blood
and tested your urine. We did not find any evidence that this
fall was due to your heart. This is your first episode of fall
and loss of consciousness. Given how you felt right before the
fall, this was probably due to a temporary shortage of blood
supply to the brain. Please monitor for any more similar or
additional symptoms (listed below). Please also monitor for any
unusual headaches or frequent morning headaches. | PRIMARY REASON FOR HOSPITALIZATION
___ y/o ___ female w h/o CAD, MI s/p catherizations
2x ___, HTN, HLD, breast cancer, and CLL who p/w a first
syncopal event with chest pain.
ACUTE DIAGNOSES
# SYNCOPE: first syncope, unwitnessed, unclear prodromal history
but pt mentioned acutely decreased hearing and vision prior to
falling. Unclear etiology. Troponin negative x 2, no abnormal
EKG findings or telemetry recordings. Vasovagal was thought to
be the most likely given the fall happened shortly after rising
out of bed to go to the bathroom; patient is also on HCTZ at
home. Brain mets also a possibility given prior h/o breast
cancer but patient without symptoms to suggest seizure (no
tongue biting, no incontinence). Pt advised to rise from bed
slowly to monitor for symptoms of dizziness in the future. Some
volume depleting medications were lowered on discharge.
# UTI: U/A concerning for infection, although patient without
symptoms. Treated empirically with bactrim. Culture pending at
discharge.
CHRONIC DIAGNOSES
# CAD: s/p MI in ___ w/ catherization x 2. Troponins negative.
TRANSITIONAL ISSUES
Pt lives alone and loves her independence. She has a Health Aid
who spends 7 hours per week with her. She is ambulatory and does
not need ___. She has a caring daughter who can serve as her
___. | 109 | 214 |
19404265-DS-2 | 26,466,590 | Mr ___ was admitted to ___ for management of a large brain
bleed. See discharge summary for details regarding the hospital
course.
On ___, the patient died in the neurology ICU. | ___ is ___ with history of OSA on CPAP, HTN, and
atrial fibrillation on warfarin who presented with left thalamic
intraparenchymal hemorrhage with intraventricular extension s/p
VPS, trach, and PEG. Etiology of hemorrhage is likely
hypertension, worsened by coagulopathy. Course complicated by
PNA, fevers, C. diff colitis. He died on ___.
#Left thalamic intraparenchymal hemorrhage with intraventricular
extension
Patient was intubated at OSH and given Kcentra and Vitamin K in
addition to 3% HTS. Upon arrival to ___ his INR was 1.3. EVD
was placed in the ED ___. MRI brain showed a small amount of
contrast extravasation in the acute parenchymal hematoma
centered in the left thalamus with intraventricular extension,
mild hydrocephalus, and acute punctate infarctions in the left
temporoparietal lobes. Additionally, there were findings
consistent with amyloid angiopathy. His home aspirin and
warfarin were held and blood pressure paramaters were set to
maintain systolics less than 150. He was unable to be weaned off
ventilator and a trach and PEG were placed ___ in accordance
with his and his family's wishes. Patient failed multiple
episodes of EVD clamping due to sustained ICPs >30 and required
ventriculoperitoneal shunt to be placed on ___ ___
strata set at ___. Post-op head CT showed expected post op
changes and resolving hemorrhage. Fluoxetine was started in
accordance to ___ trial for motor recovery, but was
discontinued after no effect was seen. Anticoagulation was not
restarted given degree of already sustained disability and
evidence of amyloidopathy on MRI. This decision was made after
discussion with his family. He continued ___ with plans to be
discharged to rehab.
#Fever
#Diarrhea
#C diff colitis:
Developed watery diarrhea ___ and persistent fevers. GI
consulted for assistance. Highest suspicion for norovirus versus
effect from tube feeds. Treated with fluid repletion, holding of
tube feeds, and immodium with slight improvement. Initial
testing for C difficile was negative, but due to recurrence of
diarrhea this was retested and was positive (for colonization,
though toxin assay was negative). Still, given leukocytosis and
fevers, he was treated for C diff colitis based on clinical
suspicion. Plan is to continue treatment with PO Vancomycin for
14 days, with last dose on ___. Treated previous Citrobacter
PNA as below.
#Shunt hardware infection
#Sepsis
On ___, he again developed hypotension (requiring pressors),
fevers concerning for sepsis. Infectious work-up, including
blood, urine, sputum, and stool culture was sent. Stool culture
was notable for C diff, as above. LP was also performed, and was
notable for 72 WBCs (with 317 RBCs, likely traumatic). CSF
culture did not show any organisms. Still, given concern for
shunt infection, he was started on Vancomycin and Meropenem.
Meropenem was stopped after CSF culture was negative. He
completed a 14 day course of IV vancomycin, last dose on ___.
#Acute respiratory distress syndrome:
On ___, he developed worsening hypoxia requiring increased PEEP
and FiO2 on the ventilator. Chest x-ray showed moderate
pulmonary edema. He was managed per the ARDSnet protocol, with
improvement in his oxygenation over the next few days.
#Pulmonary Embolism
___ CTA showed left lower lobe subsegmental pulmonary embolism.
No anticoagulation was started per patient family wishes.
#Hypervolemia
Patient is on standing furosemide 20 mg PO twice daily at home.
Furosemide held in the setting of contraction alkalosis and
hypotension. This led to vascular congestion and lower extremity
edema. He received Diamox until contraction alkalosis improved
and was then restarted on his home dose of furosemide. Increased
furosemide on ___ to 40mg BID.
#Left arm tremor:
Per family left arm tremor has been there for some time prior to
admission and there was question of ___ disease. On
admission to Neuro ICU he was noted to
have high frequency low amplitude tremor of left arm. He was
started on keppra and hooked up to EEG which showed left
frontocentral discharges but no seizures. Keppra was
discontinued.
#Essential (primary) hypertension
Systolic blood pressure goal of less than 150 given IPH.
Required a nicradipine gtt until ___. His home losartan of
100mg daily was started as well as amlodipine 2.5 mg daily. He
occasionally required IV medications PRN to maintain blood
pressure goal. He then became hypotensive in setting of c. diff
colitis and possible shunt infection and his home losartan and
amlodipine have been held.
# Chronic Atrial fibrillation, Right bundle branch block,
frequent ectopy, prolonged QTc (507)
Patient was started on metoprolol 12.5 mg q6h. ASA and warfarin
held as above. His electrolytes were monitored and repleted as
necessary. EKG monitored.
# Hyperlipidemia
LDL of 81. Restarted simvastatin at 20mg po qhs (max dose given
interaction with amlodipine). If amlodipine remains held, his
simvastatin can be increased as an outpatient.
# HFrEF (40-45%)
Weight of 115 kg on on admission. Monitored I/Os and daily
weights. His home Lasix 20 mg PO BID was started and he was
given additional Lasix PRN to maintain euvolemia. On ___
increased lasix 40mg PO in AM, 20mg in ___ based on additional
PRN Lasix requirements. Reduced back down to home dose when
hypervolemia resolved. He became hypotensive in setting of
sepsis ( c. diff and possible VPS infection) and Lasix was held.
He developed a contraction alkalosis leading to 2 days of Diamox
before transitioning back to furosemide 20mg BID. Furosemide was
increased to 40mg BID on ___
# Acute respiratory insufficiency now s/p tracheostomy
Continued difficulties weaning from ventilator to trach collar
with tachypnea and desaturations. Had thick secretions had
mucous plugging. Mucomyst, duonebs, and frequent suctioning
required. Diureses to help with weaning as above.
# Hypernatremia
Intermittently hypernatremia with Na max of 152. Free water
flushes adjusted accordingly.
# Citrobacter ___ PNA
___ with fever, tachypnea, and increasing ventilator needs.
Mini-BAL obtain ___ grew CITROBACTER KOSERI. He was started
on ceftriaxone before switching to cefepime to complete a 9 day
course of antibiotics.
#Folliculitis on back
Improving with Miconazole Powder 2% 1 Appl TP TID
# History of gout, not an active issue
Continued home allopurinol.
# Endocrine, no active issues
# HbA1c ___ 5.7 and SSI discontinued as not needed to maintain
euglycemia.
# TSH normal at 2.8
# Death
Patient died on ___. | 31 | 983 |
16173452-DS-10 | 20,317,887 | Dear Ms. ___,
You came to ___ because you had leg swelling.
You were found to have a excess fluid and an irregular heart
rhythm. Please see more details listed below about what happened
while you were in the hospital and your instructions for what to
do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
___!
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were given medications to help remove the excess fluid.
- You were given medications to help prevent stroke.
- You were given medications to control the heart rate.
- You improved considerably and were ready to leave the
hospital.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have chest pain, palpitations or
other symptoms of concern.
Sincerely,
Your ___ Care Team | PATIENT SUMMARY
===================
___ year old female with PMH most significant for hypertension,
uterine cancer s/p TAH-SBO in ___, anxiety, pancreatic
insufficiency and h/o SBO in ___ s/p repair and most recently
SBO s/p repair ___ p/w new onset ___ edema x 2 days after
recent SBO repair 1 week ago, found to be in asymptomatic a fib
with RVR in clinic today. History and exam c/w acute CHF
exacerbation ___ A fib with RVR in the setting of recent
surgery.
ACUTE ISSUES
===================
#Volume overload
#Acute on chronic heart failure with preserved ejection fraction
exacerbation Evidence of volume overload with lower extremity
edema with elevated BNP on admission suggestive of heart failure
exaserbation. Trop negative x1 and no EKG changes suggesting ACS
as the underlying cuause of CHF exaserbation. Mostly likely
secondary to new onset pa.fib (see below). She had adequate
urine output on 20 IV Lasix, with improvement in her volume
exam. She was transitioned to po Lasix and urine output remained
adequate and her volume exam continued to improve. She was
discharged on amlodipine, metoprolol and 20mg Lasix po.
#pAfib
Presented to clinic in ___ without symptoms. Found to be in
a.fib with rates in the 100's on arrival here. She was started
on metoprolol for rate control and on anticoagulation for a
CHADsVasc 4 with apixaban. She had recently undergone surgery
for SBO and this was seen as her inciting event as TSH was nml
and no signs of infection were noted. She remained asymptomatic
from her a.fib during her stay although this was likely the
precipitant for her CHF exacerbation. She converted to sinus
rhythm. She was discharged on metoprolol and apixaban.
#SBO
ACS consulted in ED, no acute surgical need. Patient with benign
abdominal exam and passing loose stool and flatus. Chronic loose
stools in the setting of recent abdominal surgery and abx use,
c-diff negative.
CHRONIC ISSUES
#GERD - Pantoprazole 40 mg PO Q24H
#IBS - DICYCLOMine 10 mg PO BID
#HTN - amLODIPine 5 mg PO DAILY, stopped Triamterene-HCTZ
(37.5/25) 1 CAP PO DAILY given starting lasix
#hld - Atorvastatin 10 mg PO QPM
#Insomnia/Anxiety - trazadone QHS
#Muscle spasms - holding home lorazapam unless patient requires
TRANSITIONAL ISSUES
====================
[] stopped Triamterene-HCTZ (37.5/25) because now on Lasix | 164 | 360 |
18779774-DS-9 | 23,098,161 | Please keep splint on until your follow-up appointment. Any
stitches or staples that need to be removed will be taken out at
your 2-week follow up appointment.
******WEIGHT-BEARING*******
touch down weight bearing left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Physical Therapy:
touchdown weight bearing left lower extremity
Treatments Frequency:
Please keep splint on until your follow-up appointment. Elevate
the lower left extremity to help decrease swelling when you are
sitting or in bed. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left trimalleolar ankle fracture. The patient was
taken to the OR and underwent an uncomplicated ORIF left
trimalleolar ankle fracture. The patient tolerated the procedure
without complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status: touchdown weight bearing left lower
extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 143 | 170 |
13152015-DS-11 | 29,797,038 | You were admitted to ___ after having sudden onset shortness
of breath and chest pain at rehab. You did not have evidence of
a heart attack. You had a CT scan of your chest and were found
to have a blood clot in your lungs. These clots often come from
clots in the legs, and your left leg was more swollen than your
right, but you were not found to have a clot in the veins of
your left leg. You were put on a blood thinner called heparin to
immediately thin your blood and prevent the clot from getting
bigger. You will need to take another blood thinner called
warfarin for at least 3 months. You will require blood tests
routinely to monitor how thin your blood is. | Ms. ___ was admitted with an acute PE. There was no evidence
of right heart strain or lower extremity DVT. She was started on
a heparin drip while bridging to warfarin and discharged on
enoxaparin to continue bridging. She was discharged stable to
home with ___.
ACTIVE ISSUES
# Provoked Subsegmental PE
No evidence of right heart strain on EKG or CTA, blood pressure
stable. Although she was using enoxaparin, she was at increased
risk of DVT/PE s/p orthopedic surgery. Was stared on a heparin
drip and warfarin, transitioned to enoxaparin to continue when
discharged while completing bridging to an INR goal of ___. She
will require 3 months of anticoagulation, to be managed by her
PCP and ___ ___ clinic. Her chest pain and shortness
of breath resolved at discharge.
# S/P left THA
Doing well in rehab, minimal pain. Per discharge summary dated
___, patient to have staples out 2 weeks after surgery. Her
staples were removed prior to discharge on ___. She has
follow-up in orthopedic surgery clinic on ___.
CHRONIC ISSUES
# HTN
Stable, continued HCTZ.
# Reflux
Stable, continued omeprazole.
# Depression
Stable, continued sertraline.
# HepC, h/o HCC
Not currently on treatment, followed in liver clinic.
TRANSITIONAL ISSUES
- Incidental finding on CTA - "Partially imaged thyroid
demonstrates a rounded hypodensity in the right lobe which can
be further evaluated with a thyroid ultrasound on a non urgent
basis if it has not been performed already."
- Full code | 129 | 234 |
16497072-DS-21 | 24,166,268 | Mr. ___:
It was a pleasure to take care of you. You were admitted to the
___ because of abdominal pain and shortness of breath. You
were found to have very high blood pressures (hypertensive
emergency) leading to fluid build up in your lungs (pulmonary
edema due to congestive heart failure). In the context of this
emergency, your oxygen levels dropped (hypoxia) and you
developed a Non-ST Elevation Myocardial Infarction (MI), a type
of heart attack. This heart attack was triggered by an increased
metabolic rate. Our cardiologists saw you and you and your
family declined further aggressive intervention such as a
cardiac catheterization. Hence, we have been treating you with
medications to optimize your cardiac function.
Please follow up with your doctors as ___ below.
Please review your medication list closely. | ___ M with h/o CAD, PVD (s/p bilateral SFA stents) and HTN who
presented to the ED initially with abdominal pain (anginal
equivalent) who developed hypoxia, demand ischemia in setting of
hypertensive emergency, admitted to the MICU with flash
pulmonary edema, diuresed successfully and was admitted to ___
service for further treatment of CHF.
.
# Acute on chronic CHF: Chronic systolic CHF admitted in acute
CHF exacerbation related to hypertensive emergency and demand
related ischemia. Patient presented with hypoxia. Initially
concern for pneumonia, and patient was started on antibiotics
for empiric coverage for CAP. On arrival to ICU, he flashed and
developed worsening respiratory distress. He was placed on a
non-rebreather and treated for flash pulmonary edema with lasix
and nitro gtt. The ABX were discontinued. With diuresis,
however, he developed acute renal failure. When the nitro
dripped was stopped, the patient was transtioned to BP control
and afterload reduction with isosorbide and hydralazine. CHF and
pulmonary edema improved with control of BP and aggressive
diuresis. TTE showing LVEF of 35-40% with severe hypokinesis of
the mid to distal anterior wall, anterior septum and apex. On
discharge, patient euvolemic on exam without JVD, ___ or sacral
edema. Patient continued, however, to sat low ___ on 3L NC. Not
on home O2, but according to notes from prior admission ___,
patient had widely variable room air sat low ___. Hence,
patient is being discharged to rehab with plan for further O2 as
needed as well as on a optimal medical regimen (see below).
.
# CAD/NSTEMI: The patient's pulmonary edema and decompensated
CHF were felt to be due to ischemia versus hypertension. This
was thought to be the catalyst for his acute pulmonary edema.
Given his age and goals of care (as voiced by his sons), this
was treated medically with heparin gtt, aspirin, nitro,
beta-blockade. The heparin was stopped after 48 hours. The
patient was continued on metoprolol, aspirin, and statin.
Losartan was initially held due to ARF. Troponin peaked at 0.18.
Echo showed moderate regional left ventricular systolic
dysfunction with severe hypokinesis of the mid to distal
anterior wall, anterior septum and apex. Cardiology consulted,
and reviewed patient's history, including chronic CAD with prior
coronary stenting (unknown anatomy) and recent history of demand
related cardiac ischemia in setting of hypertensive emergency
and hypoxia. Felt this presentation was likely secondary to a
fixed defect overcome by increasing myocardial oxygen demand.
Case discussed with family and patient, and plan for medically
optimizing regimen as patient/family do not seek additional
invasive procedures. Patient discharged on medically optimized
regimen including Plavix (new this admission), aspirin,
amlodipine 10mg daily, metoprolol succinate 100mg daily, Imdur
120mg daily, losartan 100mg daily.
.
# ABDOMINAL PAIN: This was initially felt to be due to coronary
angina. Lactate not significantly elevated. Resolved on
admission to ICU. Patient's symptoms recurred thereafter on the
medical floor, but was without any EKG changes or troponin
elevations. Felt to be likely gastrointestinal in origin.
.
# HYPERNATREMIA: Sodium noted to be 148 on admission, which was
similar to prior levels, upon reviewing laboratory studies.
This remained stable during the admission.
.
# HTN: Chronic and in poor control with multiple episodes of
hypertensive emergency during this admission with systolics to
180s. Home metoprolol was increased, hydralazine was added, home
HCTZ was discontinued in favor of lasix. Antihypertensive
regimen on discharge was amlodipine 10mg daily, Lasix 20mg
daily, hydralazine 50mg q8h, Imdur 120mg daily, losartan 100mg
daily, metoprolol succinate 100mg daily.
.
# T2DM: Chronic Diabetes Mellitus Type II, non-insulin
dependent, currently in good control though complicated by
peripheral vascular disease. Held glipizide while in house.
Maintained on ISS.
.
# BPH: Chronic, stable. Continued finasteride
.
# GERD: Chronic, stable. Omeprazole was changed to famotidine
due to concern for potential interaction with clopidogrel.
.
# Depression: Chronic, stable. Continued paxil
. | 129 | 636 |
11884747-DS-16 | 21,005,012 | Mr. ___,
You came to the hospital because you had shortness of breath.
You were found to have low blood levels ("anemia") and you had
blood in your stool. While you were in the hospital, you
developed atrial fibrillation (irregular heart rhythm), which
you have had before.
What was done while I was in the hospital?
==========================================
- You were given blood transfusions to increase your blood
levels
- You were given medicine to slow your heart rate
- You had a procedure to look at your stomach and intestines
which showed inflammation of the esophagus and stomach and 2
colonic polyps.
What should I do now that I am leaving the hospital?
====================================================
- Continue to take warfarin and lovenox and follow-up with
___ clinic
- Please take all your medicines exactly as prescribed.
- Please call your doctor if you develop blood in your stools,
shortness of breath or chest pain
- Make an appointment with your PCP ___ ___
weeks of discharge.
- Discuss duration of colchicine with your cardiologist.
- Follow-up with Dr. ___ ___.
- Follow up with Dr. ___ to discuss repeat colonoscopy to
remove polyps and to plan for surveillance of ___
esophagus
Thank you for allowing us to participate in your care!
- Your ___ Team | ___ with PMH pAF on warfarin s/p PVI ablation ___, mod AS, HTN,
presenting with SOB found to have Hgb 4.7, INR 4.6, guaic pos,
no RPB on CT abd/pelvis.
# Anemia
# GI bleed
Patient has a history of anemia with prior work-up including
___ showing only grade 1 internal hemorrhoids. Now with new
progressive DOE and lower than baseline HCT concerning for new
process. He received 4 units pRBC on admission and H/H remained
stable. His warfarin was held and he was placed on a heparin
drip for ___, which showed esophagitis (Bx c/w ___,
gastritis, duodenal polyp and 2 colonic polyps. Polyps not
removed due to recent bleeding. High dose PPI started BID and
recommend continuing for 8 weeks and following up with GI. Hgb
8.6 on discharge.
# pAF s/p PVI ablation recent
# Supratherapeutic INR on warfarin
Patient developed atrial fibrillation w/ HR up to 140-160s while
getting MoviPrep for ___. Patient was never hemodynamically
unstable or symptomatic other than feeling palpitations.
Metoprolol 12.5 mg BID increased to Metoprolol 12.5 mg Q6H.
Patient converted back to sinus rhythm with episodes of sinus
bradycardia during hospitalization. For anti-coagulation,
initially stopped Coumadin and placed on heparin ggt. Coumadin
restarted at 5 mg daily after ___. Then patient
transitioned to lovenox bridge. INR 1.2 at time of discharge.
Patient was discharged on metoprolol 12.5 mg BID.
---------------
CHRONIC ISSUES:
---------------
# Aortic Stenosis: moderate as of most recent echo. Discontinued
Lasix iso GI bleed and not restarted.
# HTN: Losartan held in the setting of GI bleed. Metoprolol
continued for pAF.
# Pulmonary/thyroid sarcoid: stable.
--------------------
TRANSITIONAL ISSUES:
--------------------
# NEW MEDICATIONS: lovenox (bridging), colchicine, ferrous
sulfate, pantoprazole
# STOPPED MEDICATIONS: furosemide 20 mg daily, omeprazole
[] Appropriate dosing of warfarin. Patient on 6.25 mg warfarin
with INR of 4.6. Dose changed to 5 mg daily on admission. Check
INR ___.
[] EGD with biopsy c/w ___ esophagus. Started high dose
PPI. Please re-evaluate long term need of PPI. f/u with GI for
long term surveillance of ___
[] Discuss duration of colchicine for post ablation inflammation
[] Colonic polyps on biopsy were not removed in the setting of
recent GIB. Please consider further intervention as outpatient.
[] Continue to monitor anemia. Primary concern now is Fe
deficiency from chronic GI bleed, but recommend trending to
ensure anemia not related to a proliferative process. | 202 | 386 |
14407325-DS-13 | 27,615,264 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for an enlarging lump in your neck that
ended up being cancer of your tonsils
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had your airways and esophagus visualized by a scope to
see if you had any cancer spread
- You received a tube that connected to your stomach to give you
nutrition
- You also received a tracheostomy to help you breathe, since
the lump in your neck posed a high risk of obstructing your
airway
- You received a port on your chest to help give you
chemotherapy, which you began and completed in the hospital
- We did a video scan of how you swallowed to help advance your
diet, and you were gradually advanced to a regular diet
- The lump in your neck started to get more painful and larger,
so we drained some of the pus inside and put in two drains that
helped it drain completely
- We started you on several antibiotics to treat the neck lump
- We removed the drains from your neck and started you on only
one antibiotic after your neck stopped draining pus
- Your blood sugars were not well controlled on the oral
medication which you were taking. We started you on insulin,
twice a day as well as with meals.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your appointments
- Your tube feeds were stopped in the hospital because you were
able to eat more and more through your mouth. It's important to
try to eat as much as possible to keep your weights up while you
are healing from your neck infection and getting treatment for
your cancer. If you find yourself losing weight while still
trying to eat as much as you can, you'll need to call the cancer
nutritionist to help with your dietary needs. They gave you the
phone number for the Head and Neck cancer nutritionist.
- Make sure you change the dressings for your neck.
- It's important to follow up with your PCP to control your
diabetes- be sure to talk to your doctor about this.
- Please follow up with Dr. ___ 6 weeks after treatment is
completed or you may follow-up with your local ENT Dr. ___. To
schedule at ___ with Dr. ___ call ___.
- Please make sure to keep track of how much you are eating, and
to weigh yourself daily. If you note that you are not eating
enough or are losing weight, please reach out to the
nutritionist to determine what the next steps are.
- Please check your OPAT labs on ___. Any questions
please call ID at ___.
- Your blood sugars were very high during your stay, and we
started you on insulin. At home, please make sure you measure
your sugars after each meal, and follow the directions to give
yourself the proper amount of insulin.
- It's important to give yourself your scheduled insulin in the
morning and night. This type of insulin is different than the
insulin you give yourself at meals, so please be careful!
- Since you are giving yourself insulin, it's important to know
the symptoms of low blood sugar. You may feel dizzy,
lightheaded, weak, shaky, irritable/anxious, clammy, have
sweatiness/chills, or feel hungry. Check your blood sugars
immediately if you feel any of these symptoms, and if they are
low, drink some juice or use the glucose gel we included in your
supplies for insulin.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with medical history only
notable
for diabetes and prior history of tobacco use, presenting with
an
approximately 4 week history of rapidly enlarging neck mass, now
s/p trach and G-tube during panendoscopy on ___, with
preliminary pathology demonstrating new squamous cell cancer of
right palatine tonsil, now s/p D1 of ___.
Hospital course complicated by development of a large abscess on
the right side of the neck, drained by ENT. The patient was
discharged on a 4 week course of ceftriaxone, end date ___
pending ID input.
TRANSITIONAL ISSUES
===================
[] 6 weeks after chemotherapy, will need to see Dr. ___
follow up with local ENT Dr. ___. To schedule, please call
___
[] Found to have A1C 13.9, insulin management was challenging
inpatient. Recommend intensive management of diabetes, likely
with insulin initiation and uptitration as an outpatient.
[] Pt was on salt tabs throughout the hospitalization from
likely tumor related SIADH. As his sodium normalized, the salt
tabs were downtitrated.
Discharge regimen: 24 units glargine qAM, 36 units qPM, SSI
OPAT: CEFTRIAXONE: WEEKLY: CBC with differential, BUN, Cr, AST,
ALT,
Total Bili, ALK PHOS
ACUTE ISSUES
=============
# Neck Mass
# Squamous Cell Ca of soft palatine tonsil
Patient had a 4 week history of rapidly expanding neck mass.
Rush
pathology from OR panendoscopy and biopsy on ___ demonstrated
squamous cell carcinoma of his right palatine tonsil. This was
possibly due to longstanding tobacco use history. CT chest ___
did not show evidence of metastatic spread. He started inpatient
chemotherapy with docetaxel, cisplatin, and ___. ___.
Neupogen given from ___ to ___. His discharge ANC was 19.56.
# SIADH
Noted to be hyponatremic as low as 129 during admission. Workup
revealed SIADH, most likely i.s.o cisplatin chemotherapy. CXR
was negative for pulmonary etiology of SIADH. He was given salt
tablets and had his fluids restricted. His sodium levels
gradually increased after he finished his chemotherapy and on
discharge were wnl. His salt tablets were downtitrated on the
last few days of admission, and were discontinued upon
discharge.
# Neck Mass
The patient was noted to have a large neck mass which was
believed to be secondary to involuting tumor. On ___, a CT scan
was done of the neck which showed a "large, centrally
cystic/necrotic, peripherally enhancing septated right neck mass
with minimal interval increase in size from ___, now
measuring 7.7 x 6.1 x 12.4 cm (previously 7.0 x 5.7 x 11.5 cm).
___ was consulted and performed a bedside drainage of the
collection, which ultimately grew pansensitive STREPTOCOCCUS
ANGINOSUS (MILLERI) GROUP. He was then started on broad
intravenous antibiotics, vanc/cipro/flagyl on ___. On ___, ENT
performed additional drainage of the abscess with placement of
two pemrose drains, and over 250cc of purulent material was
drained. On ___ the drains were removed, and the patient was
initiated on IV CTX for a 4 week course (end date ___.
# EKG abnormality
EKG on admission ___ showed right bundle branch block. New EKG
prior
to ___ administration on ___ showed new EKG with ventricular
beats. Cardiology was informally consulted and did not recommend
any additional evaluation as an inpatient. Rather, the patient
will follow-up with them as an outpatient after discharge,
scheduled for ___.
#Diabetes
His diabetes was difficult to manage during admission, thought
to be exacerbated by steroids required for chemotherapy, and
then by tube feeds and the reintroduction of food by mouth. His
glimepride was held and was started on an insulin sliding scale.
His A1c was 13.9. He originally received insulin every 6 hours
and a morning and nighttime basal dose during admission, and
after tolerating PO intake, continued the basal doses and
switched from Q6h insulin to meal time administrations. His
glucose remained quite high throughout admission, but were
improved as we uptitrated his insulin. Discharge regimen:
glargine 24 units qAM, 36 units ___, SSI
# Dysphagia
# Weight loss
He received a tracheostomy due to concern for airway compromise
due to distorted anatomy. He received a PEG for dysphagia and
poor
PO intake, both on ___. The tracheostomy was managed by ENT,
who downsized his trach a few days post-op, which the patient
did very well after. Respiratory therapy provided artificial
airway assessments during admission, and he used a humidified
trach mask and was on continuous O2. SLP evaluation with video
swallow initially cleared him for thin liquids/pureed solids,
and he received meds and TFs through his PEG. Over the course of
the hospitalization, the patient was able to advance his diet so
that he did not need to supplement with any artificial
nutrition, and was solely obtaining nutrition by mouth. He was
visited by the Oncology Head and Neck nutritionsist and he will
see them as part of his follow-up care. He was instructed to
keep track of his oral intake and to weight himself daily to
ensure adequate nutrition.
# Severe malnutrition
Per nutrition, PO intake was meeting <75% estimated needs for >1
month. There was significant unintended weight loss of 6.8 kg
(7%) x1
month. He received tube feeds through his PEG to meet his
nutritional goals. He was better able to tolerate PO intake and
his tube feeds were gradually titrated down and was discontinued
after upgrade to a regular diet.
CHRONIC ISSUES
==============
#Tobacco use disorder, resolved
Quit in ___ after 50 pack year history.
# HCP/CONTACT: ___ (wife) / ___
# CODE STATUS: Full (verified with patient) | 608 | 868 |
17846223-DS-19 | 22,664,344 | Dear Mr. ___,
You were admitted to the hospital after you had recurrence of
fevers, chills, and fatigue. You had a CT scan of your lungs
which showed worsening of prior lesions with a few ones. We
believe you have an infection of your lungs and treated you with
IV antibiotics. We performed a bronchoscopy as well and results
of that test are pending.
Here are your new medications:
- cefpodoxime (antibiotic) 200mg every 12 hours: last day ___
- vancomycin 125mg every 6 hours: last day ___
- Advair: 1 puff inhaled twice a day
- duonebs: use with your nebulizer machine as needed for
shortness of breath
Please follow-up with your doctors as listed below.
Take care,
Your ___ Team | Impression:
Mr. ___ is a ___ yo man with history of IVDU (last use ___,
asthma, anxiety, prostatic enlargement, and recent pneumonia who
presents with fever, chills, weight loss and increasing cough
found to have cavitary lesions on chest CT concerning for
recurrent pneumonia vs septic emboli.
#Recurrent PNA vs Septic emboli: CT showed several of the
lesions are ___ the same areas as prior chest CT ___ ___ although
appears to be some ___ new locations. He was ruled out several
times for TB including three recent AFB smears ___ ___ but given
the cavitary lesions will rule him out again. He had a TEE on
last admit which did not show vegetation. He was treated
empirically with vanc/zosyn which was narrowed to zosyn. He had
a bronchoscopy with lavage performed on ___ which yielded a
blood sample. As all testing was negative, he was transitioned
to cefpodoxime to finish a 14 day course (end date: ___.
#C. diff colitis: Patient with recent c.diff infection and
treatment, now with recurrent diarrhea and + c. diff. Given
diarrhea, most likely presentative of recurrent infection and
thus, he was started on PO vancomycin and should continue a
course of 7 days past duration of cefpodoxime (end date: ___
#Asthma: Patient with wheezing on exam and improvement ___
respiratory status with nebulizers. He was started on Advair and
will f/u with pulmonary as an outpatient.
#Polysubstance use disorder: Patient states he has not used
benzos or heroine since last admission, but per ___ filled a
prescription ___ ___. He has only filled prescriptions from 1
provider during this past year. He was not discharged with any
benzodiazepines.
#Weight Loss: Likely from above infectious process, nutrition
recommended supplements, which were provided.
#Thyroid Issue: Patient convinced he has hyperthyroidism. Labs
with TSH 0.28 and
free t4 0.8, not consistent with hyperthyroid. FSH also low.
Endocrine consulted and recommended random urine iodine level,
which was pending at discharge. Additionally, brain MRI from
___ was discussed with radiology and no pituitary
abnormalities were found. | 116 | 333 |
11132535-DS-24 | 26,344,028 | Dear Ms. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You fell while at home and came to the emergency room.
- You were feeling short of breath when you arrived in the
emergency room which we thought was because of your heart
failure, so you were admitted to the hospital to remove the
extra fluid in your body.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given Lasix through your IV to help get the fluid
out.
- We did an MRI of your spine which did not show any fractures.
The spine doctors saw ___ and thought it would be fine for you
to remove the neck brace.
- You improved considerably and were ready to leave the
hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below).
- Please follow up with your doctors as listed below.
- Please weight yourself when you get home from the hospital. If
that weight is different from your weight on discharge (224
pounds), please use that weight as your dry weight.
- Weigh yourself every morning. Your weight on discharge is 224
lbs. Call your doctor or seek medical attention if your weight
goes up more than 3 lbs in one day (227 lbs) or 5 lbs total (229
lbs).
- Call your doctor or seek medical attention if you have new or
concerning symptoms or you develop swelling in your legs,
abdominal distention, or shortness of breath at night.
- Any questions, call ___ Cardiology ___
We wish you the best!
-Your ___ Care Team | TRANSITIONAL ISSUES:
====================
[ ] She will need outpatient sleep follow-up for her OSA.
Scheduled for sleep study ___ at 11:40 AM as
above | 281 | 22 |
11083240-DS-15 | 20,130,019 | You were admitted with a gastrointestinal bleed. This was
related to your recent procedure to remove a polyp. You had a
repeat colonoscopy and they were able to stop the bleeding by
placing clips. Your blood counts fell but are stable and you
had no further bleeding. You were given IV iron and are being
discharged on iron pills, this may make your stool dark. If you
have more bleeding please return to the emergency room as you
may need another colonoscopy. Please have your PCP repeat your
blood counts at your scheduled visit. | Ms ___ is a lovely ___ with h/o granular cell tumor
of the colon, tobacco abuse, HTN, depression, who recently had a
colonoscopic procedure to remove a sub-mucosal lesion, who now
p/w lower GI bleed.
#) GI bleed: related to procedure to removal colonic polyp on
___, now w/ bleeding from operative site, now s/p clips x4 and
epinephrine injection on ___. Colonoscopy showed significant
amount of old blood in colon, given that H/H now stabilizing the
blood that she is now passing is likely old blood. Her
hemoglobin stabilized and she had no BM for nearly 24 hours
prior to discharge. She wished to avoid transfusion and was
given IV iron for 2 doses.
- F/u with PCP, recommend repeat CBC check
- Started ferrous sulfate BID and bowel regimen
- Counselled to return to ED if she rebleeds, would need repeat
colonoscopy.
#) Transaminitis: may be related to ~3 drinks/night. CT showed
diffuse hepatic steatosis. Thus likely has NASH vs alcoholic
inflammation. Ongoing discussion RE cutting EtOH back as
probably not a healthy level. Slight improvement prior to
discharge.
-Repeat LFTs with PCP
#) HTN: held lisinopril initially, restarted on discharge.
#) Depression: continue bupropion
FEN: clears, IVF, replete electrolytes
PPX:
-DVT: mechanical
ACCESS: PIV
CODE: Full
EMERGENCY CONTACT HCP: Husband ___ ___
DISPO: home | 98 | 215 |
17210469-DS-4 | 20,998,207 | Dear, Mr. ___,
You were admitted to the hospital because you were vomiting
blood.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You underwent a procedure to identify the source of your
bleeding.
- You were managed without the need for blood transfusion.
- You were started on medications to help prevent further
bleeding.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or you will die
- 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 (listed below)
- Keep your follow up appointments with your doctors
- 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.
- 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 | TRANSITIONAL ISSUES:
====================
[] Esophageal/Gastric varices:
[] Uptitrate nadolol (discharged with 40 mg QD) for goal vitals
for goal HR 50-60s, SBP>90
[] Repeat EGD within ___ weeks of discharge, consider banding
of esophageal varices if red ___ signs and able, reassessment
of gastric varices. If improved synthetic function patient will
benefit from BRTO/TIPS as soon as Bilirubin <2 which he should
achieve with sobriety. If re-bleeds he will need emergent TIPS.
[] Continue BID PPI for 6 weeks. Then transition back to PPI
QD.
[] Decompensated cirrhosis: consider TIPS evaluation if patient
is able to maintain sobriety and upon improvement of his current
liver labs/liver inflammation. Should be qualify, patient would
benefit from TTE to evaluate right heart.
[] FYI: patient started on baclofen 5mg TID for alcohol use
disorder. Consider uptitration as tolerated or as needed ( max
30 mg/day)
- Post-Discharge Follow-up Labs Needed within 7 days: CBC, LFTs,
BMP
# CODE: Full Code presumed
# CONTACT:
___
Relationship: PARTNER
Phone: ___
BRIEF HOSPITAL SUMMARY
=======================
Mr. ___ is a ___ with history of alcoholic cirrhosis
complicated variceal bleeding (most recently 4mo. ago, s/p
banding), who presents as a transfer from ___
___ with hematemesis. Patient required ICU admission and
intubation for airway protection prior to EGD which revealed
portal hypertensive gastropathy and distal esophageal as well as
gastric varices (non-bleeding, non-band-able) and no
intervention was deemed necessary. Acute blood loss likely
related to PHG without need for transfusion, and patient managed
with IV octreotide, ceftriaxone, and PPI. Patient seen by social
worker for ongoing need for relapse prevention and provided
resources. Team recommended patient undergo repeat EGD while
inpatient due to high risk, but patient preferred outpatient
follow up. He was discharged home without services. | 192 | 285 |
15202900-DS-4 | 28,654,128 | Ms. ___, You were admitted with a GI bleed that was found
to be caused by a mass in your jejunum. That mass was removed
along with a small part of your small bowel on ___. You have
recovered well and are now ready for discharge.
*** NO Aspirin or NSAIDs (Ibuprofe) until allowed by PCP ***
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.
.
General Discharge 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.
*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. | ___ presenting with UGIB with extensive work-up found to have a
GIST
# GI bleed with melena secondary to likely GIST: GI and surgery
were involved in the management of her case. She had multiple
procedures, including EGD, colonoscopy, capsule endoscopy, CTA
of her abdomen, and push enteroscopy. Results as above. There
was a possible lesion in her mid-jejunum, visualized in CTA and
in capsule endoscopy as a polyp with several associated ulcers.
However, push enteroscopy was unable to locate this lesion. She
had an MRE, which showed revealed a likely GIST. The patient was
subsequently referred to Dr. ___ from surgical
oncology
.
# Acute Blood Loss Anemia: She had anemia from her GI bleed. She
did not require transfusions prior to surgery. She did not have
sufficiently rapid bleeding to on CTA to be treated with ___
embolization.
----
After transfer to the surgical service, the patient was taken
for an exploratory laparoscopy converted to laparotomy, lysis of
adhesions, small bowel resection and placement of fiducials on
___. Please see operative report for details. She was given
1 unit of pRBC intra-operatively for a Hct of 24.2 with a rise
in Hct to 26.1 post-op.
On the night of surgery, she was given ice chips and IVF. She
had an epidural for pain. On POD 1, she was advanced to sips
then clears. She had an episode of emesis after drinking two
cups of tea rapidly. Nausea resolved after self-regulation of
intake. She continued on clears through POD 2. On POD 3, her
epidural and foley were removed. She was transitioned to PO
pain medication with good pain control and voided without
difficulty. She tolerated a regular diet and was transitioned
to Pantoprazole 40 mg PO Q12, which she will continue upon
discharge. Her aspirin was held due to recent GI bleed. On POD
4, she was passing flatus but had not had a bowel movement, so
she was given a bowel regimen and milk of magnesia.
Half of her staples were removed prior to discharge and
steri-strips were placed.
On discharge, she was tolerating a regular diet, her pain was
well-controlled on PO pain medication, and she was voiding,
passing flatus, and ambulating independently. She has follow-up
with her PCP, ___, and Surgical Oncology. | 371 | 382 |
12617506-DS-14 | 24,030,323 | You were admitted to ___ after being struck by a car. You
fractured your right leg and right ribs, plus suffered facial
lacerations. You were taken to the operating room with the
Orthopedic Surgery team and underwent an intramedullary nailing
of the right tibial fracture. You tolerated this procedure well.
The ___ diabetes specialists saw you in regards to your
diabetes. You have been started on medications to control your
blood sugars. You should follow-up with the ___ doctors for
___ as an outpatient.
You have been cleared by Physical Therapy for discharge home
with home ___. Please note the following:
* Your injury caused 3 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | ___ year old pedestrian stuck admitted to the Trauma service for
management of polytrauma. Imaging revealed an acute comminuted
fractures of the proximal right fibula and tibia shafts along
with right rib fractures ___ and facial lacerations. Orthopedics
was consulted, and the patient was taken to the operating room
for an intramedullary nailing, right tibial fracture. He
tolerated the procedure well. Post-operatively, the patient
worked with Physical Therapy. He was noted to have a foot drop,
for which Ortho recommended Ankle-Foot Orthosis (AFO).
The ___ diabetes team was consulted for management of the
patient's untreated diabetes. The patient states he self
diagnosed himself ___ years ago and has not seen a doctor. ___
started the patient on oral antidiabetic drugs and an insulin
sliding scale.
Pain was well controlled. 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 lovenox for DVT prophylaxis 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 to bathroom independantly, voiding without
assistance, and pain was well controlled. The patient was
discharged home with ___ services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 343 | 234 |
18689476-DS-20 | 26,910,239 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had nausea, vertigo, and chest tightness for several
days. Neurology evaluated you and determined that you have
Benign Positional Paroxysmal Vertigo (BPPV), which causes nausea
and vertigo when you move. This is benign and not due to
something bad happening in the nervous system. For therapy and
to improve and resolve symptoms, please do the Epley maneuver at
least once a day (recommend at bedtime, on your bed), as you
were shown how to do it in the hospital.
Please follow up with your PCP on ___, and discuss
improvement and resolution of BPPV, as well as continuation of
iron supplement for iron deficiency anemia. Your cholesterol
(LDL) was a bit high, and we recommend that you also discuss
this with your PCP.
We also recommend outpatient physical therapy for your gait
imbalance (you will receive a prescription for this).
We wish you the best,
Your ___ team | ___ presents with multiple complaints including vertigo,
paresthesias, chest pressure, and SOB, with brain MRI showing
abnormal bone marrow enhancement and mildly enlarged pituitary,
found to have benign positional paroxysmal vertigo. | 161 | 31 |
13092910-DS-16 | 28,347,089 | 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:
- You should continue taking warfarin, and your INR should be
between 2 and 3. The rehab will monitor your INR. Please follow
up with your PCP about how long you should be on warfarin for.
WOUND CARE:
- You must the splint on your right leg on at all times. Do NOT
get the splint wet. Wear the CAM walking boot over top of the
splint.
- You may get your right arm wet. No baths or swimming for at
least 4 weeks.
- No dressing is needed for your right arm wound if continues to
be non-draining.
ACTIVITY AND WEIGHT BEARING:
- You may bear weight as tolerated with the right leg in the
splint AND CAM walking boot but do not point your toes down
(plantar flex).
- You may NOT bear weight with the right arm but may use the
right arm to use a platform crutch, as you were taught by the
physical therapists.
- Please change dressing QOD with adaptic over skin graft and
covered with ABDs kerlix and ace.
- CAM boot when OOB
- Donor Site: ok to wash with soapy water.
Physical Therapy:
WBAT RLE in posterior splint & CAM boot over top (no plantar
flexion)
NWB RUE but okay to load through forearm for platform crutch
Treatments Frequency:
- You must the splint on your right leg on at all times. Do NOT
get the splint wet. Wear the CAM walking boot over top of the
splint.
- You may get your right arm wet. No baths or swimming for at
least 4 weeks.
- No dressing is needed for your right arm wound if continues to
be non-draining.
- Please change dressing QOD with adaptic over skin graft and
covered with ABDs kerlix and ace.
- Donor Site: ok to wash with soapy water. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femoral shaft fracture, right open distal third
tibia/fibula fracture, and right midshaft ulna fracture. The
patient was admitted to the orthopedic surgery service under the
care of the trauma ICU. The patient was taken to the operating
room on ___ for open reduction and internal fixation of
right ulna, intramedullary nail for right femur, intramedullary
nail for right tibia, and fasciotomies of right thigh and leg.
For full details please see the separately dictated operative
report. The patient was taken from the OR to the ICU. He was
transfused 2 U pRBCs post-operatively. Of note, the patient was
on warfarin for history of pulmonary embolus approximately 8
months prior to admission. He underwent CT-PE to evaluate for
the presence of PE on ___, which was negative. He was
kept on prophylactic enoxaparin 40 mg sc qhs, and his warfarin
was restarted, though his INR remained subtherapeutic.
The patient subsequently returned to the OR on ___ for
I&D, vac change over fasciotomy wounds, and primary closure of
the right lateral leg fasciotomy wound. For full details please
see the separately dictated operative report. The patient was
taken fom the OR to the ICU. He was transfused 1 U pRBCs
post-operatively.
On ___, the patient was transferred to the orthopaedic
floor for further care. He returned to the OR on ___ for
I&D, vac change over right leg medial fasciotomy wound, and
primary closure of thigh fasciotomy wound. For full details
please see the separately dictated operative report. After
recovery from anesthesia, the patient was transferred from the
PACU to the orthopaedic floor.
On ___, the patient returned to the OR with the plastic
surgery service for rotational muscle flap to cover the medial
tibia in addition to split thickness skin graft. Please see the
separately dictated operative report for full details. After
recovery from anesthesia, the patient was transferred from the
PACU to the orthopaedic floor. The patient was kept on bed rest
for 48 hours post op and then was returned to weight bearing as
tolerated with no plantar flexion.
The patient was initially given IV fluids and IV pain
medications post-operatively, and progressed to a regular diet
and oral medications. The patient was given perioperative
antibiotics. On ___, the patient was tachycardic to
heart rate 130s with fever to 102; CT-PE was repeated that was
again negative for PE. He remained on prophylactic enoxaparin 40
mg sc qhs while warfarin was titrated to therapeutic range. A
fever work up was also performed which was negative for
infection. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity (no planta flexion), and will be
discharged on warfarin for DVT prophylaxis with INR goal of ___.
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. | 357 | 555 |
15849338-DS-4 | 27,951,184 | Dear Mr. ___,
You were admitted to the hospital with a large hematoma
(collection of blood) which caused very high pressures in your
leg. You had to undergo urgent surgery to release the pressure
in the leg and several procedures to finish the surgery. You
were monitored closely after the surgery and did not have any
further bleeding.
You were restarted on your Coumadin on ___ and until your INR
is back within your goal (2.5-3.5) you will be on Lovenox as
well.
We wish you the best!
Your ___ medical team | This is an ___ year old male with past medical history of mitral
regurgitation and tricuspid regurgitation status post mechanical
mitral valve replacement and tricuspid anuloplasty, atrial
fibrillation, DM type 2, admitted ___ with spontaneous LLE
hematoma and acute left lower extremity DVT complicated by
compartment syndrome, status post fasciotomy and subsequent
wound closure, on anticoagulation without signs of bleeding,
course complicated by mild delirium, able to be discharged to
rehab
# LLE Hematoma with compartment syndrome: Presented to ___
___ with spontaneous expanding LLE hematoma (no prior
trauma) and concern for compartment syndrome. He was transferred
to ___ and evaluated by orthopedics who performed emergent
left lower leg fasciotomy ___. He then underwent
irrigation and debridement with hematoma evacuation ___.
He underwent closure of left lower extremity fasciotomy
___. Perioperatively, he was anticoagulated with heparin.
Aspirin was held given bleeding risk. His pain was
well-controlled, and was comfortable with Tylenol by time of
discharge. His weight bearing status per orthopedics
recommendation on discharge: touch-down weight bearing; with
planned suture removal assessment ___ appointment.
# LLE Popliteal DVT: Presentation notable for identification of
DVT in setting of hematoma and compartment syndrome.
Anticoagulated as below.
# Mechanical MV: In setting of surgical intervention and
presentation above, warfarin was held initially, and once
surgically stable he was started on IV heparin drip given his
mechanical valve and DVT. He had no evidence of further
bleeding complications. He was transitioned to weight based
lovenox 90 BID ___ to bridge to warfarin, which was restarted
___ at 5mg. He will need to continue bridge until warfarin is
therapeutic (INR 2.5-3.5). For reference, his home warfarin
regimen was 10 mg daily except for 15 mg ___.
# Dementia with behavioral disturbance
# Toxic encephalopathy secondary to opiates
Had intermittent mild confusion through hospital stay, thought
to be delirium, which worsened when placed on on opiate for leg
pain control. He had no focal neurologic symptoms, infectious
signs or symptoms, and no electrolyte abnormalities. Improved
with delirium precautions and avoidance of sedating medications.
His pain was well controlled with Tylenol and low dose flexiril
at discharge.
# Acute Blood Loss Anemia: Perioperatively and due to continued
blood loss into hematoma. He required a total of 6 units pRBC
from ___. He remained hemodynamically stable.
# Peripheral edema: He was diuresed perioperatively with IV
Lasix given peripheral edema and concern for tension on closed
wound, then successfully transitioned to home Lasix 20 mg po.
# Diabetes mellitus 2: Fasting sugars remained <180 during the
hospitalization on 15 units lantus nightly and sliding scale
insulin.
# Left lower extremity cramps: He complained of short, ___
left calf cramps that have been occurring chronically. They
were thought to be muscule cramps, and were improved with
flexiril. Not consistent PVD and electrolytes were within normal
limits. Would consider further work up as outpatient if
persists.
CHRONIC
=====================
# H/O Transient amnesia and aphasia - continued phenytoin 200mg
daily, 300mg HS
# AFib - continued home digoxin 0.25 and metoprolol was
increased to 25mg BID and tolerated well
# CAD - Continued home metoprolol, atorvastatin. Held ASA
perioperatively. Will need to resume.
# BPH - continued BPH and tamulosin
# Dementia - continued Donepezil | 88 | 525 |
13231278-DS-2 | 25,553,591 | -Please also reference the instructions provided by nursing on
Foley catheter care, hygiene and waste elimination.
-ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from
ALL sources) PER DAY.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Do NOT drive while Foley catheter is in place.
-AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up. Do not vacuum.
-No DRIVING for TWO WEEKS or until you are cleared by your
Urologist
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
allow anyone that is outside of the urology team remove your
Foley for any reason.
-Wear Large Foley bag for majority of time; the leg bag is only
for short-term when leaving the house, etc. | Ms. ___ was admitted to the Urology Service from the ED with
hematuria as described in the HPI. She was restarted on home
medications, basic metabolic panel and complete blood count were
checked, pain control was with oral analgesics and her diet was
advanced to a regular one. Foley catheter care and leg bag
teaching was provided by nursing. Ms. ___ was discharged to
home on HD2 in stable condition, eating well, ambulating
independently, and with pain control on oral analgesics. On
exam, incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up in next week for definitive surgery. | 314 | 112 |
11971405-DS-17 | 27,282,316 | Weigh yourself every morning, call cardiologist or pcp if weight
goes up more than 3 lbs.
This information is designed as a guideline to assist you in 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.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are to partially bear weight on your heel only
for ___ weeks. You should keep this amputation site elevated
when ever possible.
You may use the heel of your amputation site for transfer and
pivots. But try not to exert to much pressure on the site when
transferring and or pivoting. 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.
Do not drive a car unless cleared by your Surgeon.
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. No bathing. A
dressing may cover youre amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your ___ appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
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 in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
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 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.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected 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 in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in 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 in 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.
___ 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. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a ___ visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | Mr. ___ was admitted to the vascular service and started on
iv antibiotics. Transplant nephrology was consulted, and
followed him closely throughout his admission. Podiatry was also
consulted and followed along. They ultimately took him for a
right ___ metatarsal head resection on ___. He did well and
continued on iv antibiotics. Xrays showed no evidence of
osetomyelitis, and the ID team was consulted and ultimately
recommended oral antibiotics for 2 weeks as an outpatient. He
was monitored closely and deemed stable for discharge on ___. He will follow up with his pcp for INR monitoring. He will
see Dr. ___ at ___ in the next 2 weeks, and
see Dr. ___ back in the office in a few weeks as well.
He is partial heel weight bearing on the right side, and is
compliant in ___ shoe. At the time of discharge he is
tolerating a regular diet, ambulating independently and voiding
without difficulty. | 882 | 157 |
10731439-DS-9 | 25,997,628 | Dear Ms. ___,
You were seen in the hospital for loss of vision in your left
eye. You were evaluated with an MRI of your brain and an MRI of
your orbits, which were both essentially normal. You began to
improve during this hospitalization and we hope that you will
continue to improve with time. You will follow-up with
opthalmology for further eye tests as well as with the EEG lab
here for better testing of your optic nerve function. Please
bring your ___ records to your neurology follow-up appointment.
It is very important that we also get this information. In
addition, you should not drive until your eye doctor tells you
it is alright to do so.
We made no changes to your medications.
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. | ___ is a ___ year-old right handed woman with prior
episode of vision loss who presented to ___ in the setting of
an acute loss of vision in her
left eye persisted but improved on this admission.
# NEURO: patient was taking pradaxa prior to admission, but her
PTT on admission was not elevated, which may be suggestive of
some non-compliance with her pradaxa. In addition, patient
stopped taking her pradaxa for 2 weeks 1 week prior to admission
for an "H. Pylori diagnosis", which could have also contributed
to her unelevated PTT. We continued patient's ASA 81mg QD.
Opthalmology came to see that patient and recommended MRI of the
orbits, which were done, but showed no abnormality. The patient
will get visual evoked potentials and will follow up with optho
and neuro.
# CARDS: patient was found to have a PFO on her TTE, which may
be a possible source of embolism. While here, we monitored her
on telemetry and noted no events. We held her HCTZ while an
inpatient and only gave her a ___ dose of labetalol. We
continued her home dose clonidine to prevent reflex
hypertension, but on discharge she was restarted on her prior
home meds.
# ENDO: we continued pt on her home dose atorvastatin 80mg QD.
While here she was put on an ISS which was stopped at discharge. | 168 | 235 |
18589167-DS-34 | 22,155,741 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization.
WHY WERE YOU ADMITTED?
- You had altered mental status.
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- Your mental status improved.
- You were found to have an infection in your urine and were
treated for this.
- You had your insulin adjusted by the diabetes doctors.
- You had imaging of your kidney which showed that it was
functioning well.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- You should continue to take all of your medications as
prescribed.
- You should follow up with your doctors as ___ below.
Again, it was a pleasure taking care of you.
All the best,
Your ___ Team | ___ male with HIV on HAART, s/p LRRT, insulin dependent
diabetes, who presents from SNF after a high risk sexual
encounter.
# Sexual encounter:
Patient was involved in a sexual encounter with a resident at
his facility. Per ED documentation, "patient states that a
neighbor backed into him into a room and offered oral sex. He
performed penetrative oral sex, which he states was consensual."
However, other male resident is reportedly non-verbal,
post-stroke, and has a history of HepC. Details of event are
unclear but police have been involved and patient was taken to
court on ___ for trial. He was given hepatitis B booster given
encounter. Although there were no charges, the patient remained
in the hospital for difficult disposition, since he could not be
accepted to any nursing homes due to the allegation of assault,
yet his family was not able to take care of him at home.
Ultimately he was transferred to the ___ on
___ for evaluation by the court psychologist after which he
was reportedly then transferred to the ___
___ for further care.
#Pyuria
#Yeast in urine
#Coagulase negative staph UTI
Patient was noted to have pyuria during his hospitalization.
Urine culture was performed which grew yeast x2. Patient has
history of ___ UTIs in the past for which he was
treated with fluconazole. Urine culture was sent to ___ for
speciation and grew ___. ID was consulted and
patient was started on fluconazole 400mg daily for yeast and
completed a 21 day course with last day of therapy on ___.
Coagulase negative staph was later growing in the urine, which
was treated with ceftriaxone and doxycycline for a 5 day total
course
# Major neurocognitive disorder ___ to HIV.
# Dementia with Behavioral Disturbance
# Adjustment Disorder with Mood Disturbance
Patient demonstrated impaired memory (retrieval > storage),
abstraction, comportment, judgment, and significant executive
dysfunction, consistent with HIV dementia. Psychiatry was
consulted during hospitalization and felt that patient was at
baseline and did not meet inpatient psychiatry needs. OT was
consulted and recommended need for 24 hour care/supervision.
# ESRD ___ diabetic nephropathy s/p LRRT in ___
# hydronephorosis
Baseline Cr is 1.4-1.6. Post transplant course complicated by
transplant ureteral stenosis requiring PCNU, ligation of native
R ureter. Patient had renal US performed during hospitalization
which demonstrated moderate hydronephrosis. CT scan was
performed which showed improvement. His outpatient transplant
surgeon was consulted and felt that there was nothing to be done
regarding his hydronephrosis other than monitoring. His Cr
remained stable during hospitalization. His tacrolimus dosing
was adjusted after initiation of fluconazole per above, with it
being decreased to 1.5mg BID which was transitioned to 3.5mg BID
after completion of fluconazole. He will need weekly tacro
levels checked. He remained on prednisone 5mg and azathioprine
50mg daily for immunosuppression. He also remained on at___
1500mg daily for PCP ___.
# Subcutaneous mass
Patient complained of RLQ pain around subcutaneous mass. Renal
u/s demonstraed 2.9 x 2.8 x 0.7 cm hypoechoic mass. Per
radiology, mass has been present on prior imaging in early
___. CT scan was performed to evaluate if mass was infected
and imaging showed no evidence of this. Patient was given
acetaminophen for pain though he continued to report the
symptoms nearly every day.
# T1DM:
Patient has a history of T1DM. ___ was consulted for
assistance in BG management. He was discharged on glargine 21u
QAM, Humalog ___ with meals, and ISS.
# Right testicular pain
Patient was complaining of pain in his right testicle.
Ultrasound showed a hyperechoic lesions possibly related to
trauma. Recommended a repeat US in ___ weeks. | 107 | 592 |
17425595-DS-15 | 27,520,164 | Dear Mr. ___,
You were admitted after multiple episodes concerning for
seizure. You underwent a broad work up including MRI, EEG (to
monitor brain waves), spinal tap. None of these diagnostic tests
showed a clear cause or trigger for your episodes. Sometimes,
patients may experience a dissociative reaction to significant
stressors, which are not seizures from abnormal brain activity.
However, you should follow up with your scheduled neurology
visit with Dr. ___. Should you have any new neurologic
symptoms, please go to the nearest ED.
Per ___ law, you may not drive for 6 months following
the most recent episode of loss of awareness. Please also avoid
any activities that may endanger you if you lose awareness, such
as swimming by yourself, climbing heights, etc.
It was a pleasure taking care of you.
___ Neurology | The patient is a ___ man with a history of migraine
headaches and prior concussions who presented to the ED as a
transfer for possible seizure activity. His parents state that
he developed 1 of his typical migraines last ___.
The next day, his headache was more severe so he went to a
___ clinic in ___. He was prescribed Fioricet and told
to take ibuprofen as well. His parents state that he did not
take more than 1 or 2 tabs of Fioricet. Later that night, he
developed a more sharp, severe pain on the sides of his head. He
went to the ___ ED on ___. Apparently, while
there, he had several brief episodes of shaking. His mother
describes these as very fast, low amplitude shaking of all
limbs, lasting not more than 1 or 2 seconds. His eyes were
closed during the episode but he would wake up quickly right
after and follow commands. A head CT was obtained and was
apparently normal. His mother reports that no one ever told him
that they thought the shaking episodes were seizures. He was
discharged with recommendations to take Tylenol and Motrin as
needed. Over the next few days, his headache slowly improved.
His father notes that over the last few days he was very sleepy
and spent most of the day in his room with the lights off. When
he did awake and eat or speak to his family and friends, he
appeared to be normal and was not acting strangely. As of
___, his headache had completely resolved. However, later in
the day he did complain of feelings of lightheadedness
and nausea. In the evening he was speaking with his father when
he told him "I think I am having a panic attack". His father
states that he was breathing fast and taking shallow breaths, he
seemed somewhat shaky and scared, and complained of feeling weak
all over. They therefore decided to return to the ___ on
___ in ___. On the way to the ED while trying to call his
girlfriend, his father notes that he was unable to perform the
correct words. He was able to only say 1 or 2 words at a time,
for instance
"hospital". Shortly thereafter, he developed abnormal shaking
movements. His father describes these as large amplitude,
violent movements of any one limited time. All 4 limbs were
involved and he would have these movements in an asynchronous,
non-rhythmic manner in about a frequency of one every second.
His father also notes that his head was "snapping" back and
forth. He is unsure what his eyes were doing. There was no
incontinence or tongue bite. He was not talking or able to
follow instructions during this time. In the ___, he
continued to have this abnormal movement. His parents report
that in the hospital that he was repeatedly lifting his head off
the bed and his eyes regarding all over.
Because of concern for seizure he was given 2 mg Ativan IV
followed shortly thereafter by another 2 mg IV. His mother notes
that afterwards he was able to look at her and possibly follow
some basic commands. Lab work was obtained and he was sent for
head CT. In the CT scanner, he had another episode of the
abnormal movement. He received an additional 2 mg of Ativan and
the decision was made to intubate him. After intubation, the
head CT and lumbar puncture were performed and he was
transferred to ___.
AT ___, he was briefly admitted to the NeuroICU. Broad workup
including repeat LP, MRI/MRA, scrotal ultrasound, was
unremarkable. CSF studies pending for esoteric causes of
encephalitidies, including paraneoplastic panel, though negative
for HSV or pleocytosis. EEG with occasional slowing but no
epileptiform activity. He was subsequently extubated to room
air, and transferred to the floor. No additional seizure
activity. The non-rhythmic nature of the initial description
appeared to be more consistent with non-epileptic spells, though
no definitive psycho-social stressor was identified. Given the
unclear nature of these events, with a normal EEG we elected not
to treat him with AEDs at this time, pending evaluation by
neurology as an outpatient.
He was reminded not to drive for 6 months following the episode
of impaired awareness. Seizure safety plan reviewed.
Transitional issues
[ ] follow up with neurology (Dr. ___ at ___
___
[ ] follow up labs (CSF)
[ ] consider referral to neuropsychiatry for anxiety/PNES | 131 | 740 |
19076882-DS-15 | 22,541,358 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
fast heart rates and chest pain. You were found to have an
abnormal heart rhythm called atrial flutter, for which you were
treated with cardioversion. Your heart rhythm returned to a
normal rhythm. You were started on a medication called
rivaroxaban, which you should take daily.
Please follow up with your outpatient provider.
Wishing you well,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
___ year old woman with sCHF (EF 20%), pulmonary HTN, OSA who
presents from clinic with complaint of intermittent chest
tightness.
#CHEST PAIN/ATRIAL FLUTTER: Patient presented to ED with
intermittent chest tightness, and palpitations. She was found to
be in atrial flutter with HR 150s. Troponin (-) x 2, no ST
changes on EKG. Cardiology was consulted in the ED and
recommended diltiazem and admission for cardioversion. She
received IV diltiazem in the ED and was maintained on diltiazem
30 mg q6h until her cardioversion. She was also started on
rivaroxaban. Trigger for atrial flutter may be secondary to
recent stressor of death of sister. She underwent cardioversion
on ___ with return to sinus rhythm. Post-cardioversion, she
had resolution of chest pain/palpitations.
#CHRONIC SYSTOLIC HEART FAILURE: LVEF of 40-45% in ___.
Euvolemic on exam. Continued on home lisinopril, Lasix,
spironolaction, carvedilol
#OSA: Recent positive sleep study per patient, CPAP while in
house
#Chronic Pain: Continue home tramadol, cyclobenzaprine,
oxycodone. Discharged on home pain regimen.
#PAH: Continue home albuterol, fluticasone
#ADD: Held during admission in setting of atrial fibrillation.
Resumed on discharge
#GERD: Continue home omeprazole
TRANSITIONAL ISSUES
- Started on rivaroxaban 20 mg qD before cardioversion
- Pt given prescription for metoprolol tartrate 25 mg PRN for
palpitations or HR > 100 and instructions to call cardiologist
if she feels she requires this medication
#CODE STATUS: Full
#WEIGHT ON DISCHARGE: 136.1 kg | 74 | 235 |
13199946-DS-17 | 20,207,381 | Dear Ms. ___,
You were admitted to ___ after having a seizure.
We started you on Keppra to prevent seizures.
Please take all your other home medications as prescribed.
Sincerely,
Your ___ Team | ------SUMMARY/ACUTE ISSUES----
In summary, ___ is a ___ woman with metastatic
lung cancer, prior PE on lovenox, renal impairment and anemia,
who presented after being found by family members with R arm
stiffening and confusion and difficulty producing speech,
symptoms which resolved over the period of several hours. She
was taken to OSH due to concern for stroke but was not a TPA
candidate due to lovenox. She was transferred to ___. The
presentation was felt to be consistent with seizures with
prolonged post-ictal state. An MRI was performed with and
without contrast which did not show any brain metastasis (bony
metastatic lesions were noted.The etiology of seizures is most
likely multifactorial and she was started on keppra 750mg BID.
She did not have further seizures during admission.
In summary, ___ is a ___ woman with metastatic
lung cancer now on the neurology service with mild inattention,
poor verbal recall, renal failure, severe anemia and mild
asterixis. She had presented with seizures. The etiology of
his
seizures is most likely multifactorial and she remains on renal
doses of Keppra. Her other medical issues include diffuse bony
metastases and a massive pulmonary embolus on Lovenox. She has
had no further events, though she remains somewhat
encephalopathic.
She has also been on immunotherapy for her lung cancer and
remains on high-dose steroids which are being weaned down to her
current dose of 100 mg daily of prednisone. She is also anemic
with a crit that fell to as low as 6.7 and now slightly higher.
She has not had any blood transfusions. Most likely the
high-dose steroids are used for immune reactions to her
immunotherapy and fortunately is being weaned, but it places her
at risk for gastrointestinal bleeding. We will change her
hematocrit and look for occult blood in her stool.
From a pain perspective she denies any significant bony
metastatic pain although she does take oxycodone.
Pertinent features of examination this morning with again the
poor verbal recall, asterixis and she has more proximal weakness
as noted above which may be either steroid myopathy or cervical
spondylotic myelopathy in her neck.
Given that she is on hospice care, the plan will be to make sure
that her crit is stable and hopefully will send her home today. | 28 | 360 |
18879912-DS-13 | 29,816,737 | Dear Mr. ___,
You were admitted to the hospital because of shortness of breath
and your recent fall. You were thought to be short of breath
because of your chronic obstructive pulmonary disease (COPD),
for which you are on oxygen at home. You were treated with
antibiotics and a short course of prednisone which should help
you feel better. You still have a few days left of both of these
medicines, please take the rest of them at home. Please continue
to use oxygen at home around the clock to prevent
lightheadedness/dizziness and falls.
In regards to your fall, extensive workup showed that you did
not suffer any fractures or head injury. However, it did show
that you had a lesion of your left skull that is concerning for
possible cancer. Given your history of prostate and bladder
cancer, it is very important for you to follow up with your
oncologist for further evaluation. Please be careful when you
walk around at home, being especially mindful of steps and
ledges that might cause you to trip. | ___ w/ COPD, dementia, and known bladder and prostate cancer,
p/w multiple complaints including SOB, fatigue, and recent fall.
# COPD: Patient on 1L at home, using only for sleep as of one
week prior to admission; had previously had been on 1L O2 at all
times. Daughter notes that O2 sats are typically in 90-94% range
at home. Patient up to 2L at admission. Patient denies SOB,
but lung exam in ED c/f exacerbation given wheezes; patient
started on IV solumedrol in ED then continued on 40mg pred x 4
days. Z-pak started ___. Received albuterol and ipra nebs
q6hr with good effect. Continued home loratadine. Ambulatory
sats down to high ___, 97% on 2L and eventually weaned to home
1L at 95%
# ?Pulm edema: Some pulmonary congestion on CXR. C/f CHF with
elevated BNP on labs. However, patient appeared dry on exam, so
was not diuresed despite persistent O2 requirement.
# Prostate Cancer: s/p TURP in ___, found to have high
grade prostate cancer with intraductal component. Currently
receiving q12wk leupron, with improved PSA. Previous bone scans
had shown 6mm focus in L proximal tibia but did not note any
spinal or cranial lesions; CT head on admission ___ showing
lytic lesion of L occipital bone. Patient denies back pain
currently, but had reported multiple foci of tenderness along
spine in ED and had reported back soreness to daughter, c/f
possibility for more extensive metastatic involvement. No red
flags for acute cord compression.
# thrombocytopenia: Present and roughly stable since ___.
Possibly due to AVR which was done at that time. Remained stable
throughout hospitalization.
# recurrent falls: ___ be related to dementia. No h/o LOC or
prodromal symptoms. No palpitations or CP. Per report, likely
mechanical. Consider hypoxic events. Patient is a poor historian
himself. Trauma survey negative for acute fractures. No events
on tele. ___ felt patient was safe to continue home ___. Will
require O2 at all times when ambulating. Deferred echo given
recent clearance from cards.
# CAD: s/p CABG. Denies CP now, but found to have positive
troponin. EKG on admission appearing similar to prior EKG
without e/o acute ischemic event. Denies angina on exertion. Per
cards note, no need for ACEI and BB. Repeat trop negative. No
events on tele.
# GERD: no complaints. Continued home omeprazole .
# UC: No complaints. Continued mesalamine.
# BPH: No complaints. No changes in recent bowel habits.
Continued home tamsulosin
# Dementia: AOx2-3 throughout hospitalization, although poor
historian. Approximately baseline per daughter. Continued home
donepezil.
# Aortic stenosis, s/p AVR: no issues at this time. Asx. Next
scheduled echo in ___. Continued baby aspirin.
# HL: stable. Continued home simvastatin. | 178 | 453 |
15044918-DS-8 | 27,973,205 | Dear Mr. ___,
You were admitted for repeated falling. Though the source of
these falls is unclear, your evaluation has demonstrated that
you do not have a flare of MS, your electrolytes are normal, and
you do not have signs of heart disease or infection. These falls
can be improved with consistent physical therapy. | Mr. ___ was admitted and monitored on telemetry, he was
found to have no rhythm abnormalities. Labs resulted and
demonstrated no infectious or electrolyte etiology of his
unsteadiness. MRI showed no new lesions in the brain or spinal
cord. His exam was consistent with full strength but motor
inattentiveness which was worse in the proximal muscles than in
the distal muscles. He is stable for discharge with follow up
with Dr. ___ and with physical therapy services. Regarding his
home situation, he was given many resources for shelters by
social worker and he has the option of living with his
girlfriend's mother in ___. | 53 | 105 |
11707304-DS-9 | 29,592,027 | Dear Mr. ___,
You presented to ___ because you had a fall.
-You had imaging of your head and neck which showed a mass in
your neck with an adjoining small fracture
-You were seen by the Neurosurgery team, who determined that you
do not need surgery right now and do not need
After you leave the hospital, it is important that you follow up
with your doctors ___ that they can obtain a sample of the neck
mass. This will be important to find out what the mass is. You
should hear tomorrow from the interventional radiology team, who
will schedule you to biopsy the mass. If you do not, please
We wish you the best,
Your ___ medicine team | ___ PMH gout, hypothyroidism, BPH, bladder cancer s/p resection
___ in remission, depression/anxiety, with left hip fracture
status post repair, who presents after a trip and fall to
outside hospital was found to have a C1 fracture, transferred to
___ for further evaluation and management.
#Neck mass
Patient with newly discovered neck mass at C1, with report of
intentional weight loss but no other B symptoms reported. MRI
C-spine showed no cord signal abnormality or evidence of acute
fracture. Concerning for possible malignancy. Seen by
neurosurgery in ED, no indication for surgical intervention or
c-spine collar at present. The patient was admitted for ___
biopsy of the neck mass to rule out cancer; however, ___ decided
that the biopsy should happen on ___ instead on an
outpatient basis, and that the patient did not need to be in the
hospital until then. The plan is for the patient to return for
biopsy of neck mass and cytology. Plan was formulated entirely
by ___ and neurosurgery, as the patient should never have been
hospitalized on the medicine service.
#Fall
Per report is mechanical. 2 falls in past year. Injuries to
head, knee, hip appear superficial. Xrays were reassuring (no
fracture). Pain was treated with Tylenol and lidocaine patch.
#HTN
Patient with elevated BP ISO pain, anxiety. He has no history
chronic HTN. His pain was treated as above.
#Gout: continued allopurinol
#BPH: continued finasteride/tamsulosin
#Depression/anxiety: continued citalopram
TRANSITIONAL ISSUES
[] patient requires biopsy - order will be placed following
discharge, and ___ will plan to biopsy early next week; results
should be followed up by neurosurgery attending who formulated
the plan for biopsy.
[] home safety evaluation arranged through ___ to minimize fall
risk as an outpatient
# CODE: DNR/DNI
# CONTACT: Son ___ ___ | 117 | 283 |
11823634-DS-10 | 23,090,479 | Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted for symptoms of dizziness and difficulty speaking. Your
symptoms were caused by an ACUTE HEMORRHAGIC STROKE. This means
you suffered a small bleed from one of the blood vessels in your
brain. This is most often caused by high blood pressure.
It is very important that you continue to take your medications
as your doctors ___. This will help control your blood
pressure and cholesterol levels. Given your muscle aches with
your previous use of simvastatin, we have switched this
medication to one called atorvastatin. Please call your doctor
if you continue to experience muscle aches.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | ___ w hx of HLD and depression who developed acute onset of
vertigo, ataxia, dysarthria on ___ leading to presentation to
___ where CT revealed 1.5cm hemorrhage in left
basal ganglia. Hospital course, by system, as follows:
1) Neuro: Presented with left basal ganglia 1.5cm hemorrhage
presumably leading to vertiginous symptoms which progressed to
mild dysarthria, hypophonia, and left arm/leg parasthesias.
MRI/MRA on ___ did not identify vascular abnormalities,
though was confirmatory of recent hemorrhage in left basal
ganglia. Suspect this subcortical bleed is secondary to chronic
HTN. Speech and swallow evaluation on ___ revealed mild
dysphagia to thin liquids, thus initially started diet of
regular food plus nectar-thickened liquids. He recovered from
this transient dysphagia, and was formally evaluated and found
to be tolerant of all liquids by HD2 (day of discharge).
Neurologic risk factors were assessed, including HbA1c and lipid
panel. His A1c was 5.3. His LDL was elevated at 155. He had
previously been prescribed simvastatin 10mg daily for his
hyperlipidemia, but had stopped this medication secondary to
muscle aches. He was restarted on a statin, using atorvastatin
20mg daily. He will follow-up in the neurology clinic on ___.
2) CV: History of HTN, though not adherent to his home regimen
of lisinopril and HCTZ. During hospital stay, his BP was allowed
BP to autoregulate to goal systolic less than 160. Upon
discharge, he was provided with prescriptions for 30 day supply
of HCTZ and lisinopril. | 277 | 237 |
14737220-DS-5 | 27,753,871 | Ms. ___, it was a pleasure taking care of you during your
stay at ___. You were admitted for confusion and a urinary
tract infection. We treated your infection with antibiotics. You
should complete the course of antibiotics as prescribed. Your
confusion should continue to improve. Please follow up with your
primary care provider. | # UTI: Grossly positive UA with sxs, despite recent outpatient
treatment with PO cipro. Likely driving recent confusional state
in this elderly patient. Her urine culture grew Lactobacillus.
Despite this being usual flora, given large growth and symptoms
proceeded with treatment. She was treated with CTX and
transitioned to Cefpodoxime on discharge.
# ___: Baseline Cr 0.5-0.6. This peaked at 1.7 and was 1.4 on
discharge. This was likely pre-renal in nature. She will need to
continue fluid hydration. I discussed this with her family and
caretaker and they understood the importance of hydration. We
held Lisinopril wiht stable blood pressures.
- Outpatient BMP for improvement in Cr
- Consideration of when to restart Lisinopril
# Delirium: Presents with inattention, poor short term memory
and waxing and waning level of orientation in the setting of
untreated UTI. Otherwise there is no evidence of electrolyte
abnormalties (none on labs here), no evidence of uremia, no head
trauma. Unlikely this is a primary psych process, although there
is strong component of anxiety. This improved on discharge. Her
family noted she was improving everyday and would benefit from
being in her home surrounding. At discharge, her family felt
comfortable taking her home and monitoring for continued
improvement in her mental status. We held her home Ativan given
potential contribution to delirium.
#Anemia/Thrombocytopenia
Noted on admission and remained stable. RI: 0.8 c/w
hypoprliferative process. Low transferrin saturation with low
iron suggestive of ___.
- She will need outpatient work up with consideration of
colonoscopy
# Weakness prior CVA
They recommend home with 24hr care. Per discussion with pt and
RN, she has home support 24 hours a day. She was discharged with
plan for home ___.
#N/V
She had several episodes of nausea and vomiting after trialing
Ferrous Sulfate. She became hypotensive during this episode as
well. This improved with fluids and cessation of ferrous
sulfate. By discharge, she was tolerating oral intake. | 54 | 314 |
11771778-DS-17 | 26,754,873 | You were admitted with weight loss and diarrhea. You were
treated with steroids for your Crohns disease and your diarrhea
improved. You had a CT scan that showed a nodule in the lung,
and you were seen by the interventional pulmonologists. They
will contact you with an appointment to discuss biopsy.
It is important that you continue to eat, and drink supplements
as you have been losing weight. | ___ yo F with ___ disease recently admitted with weight loss
and continued diarrhea, infectious workup (including cdiff,
stool studies, biopsy with stain for CMV) negative but pt
continuing to loose weight and severe colitis seen on imaging
and recent flex sig. also with incidentally noted pulmonary
process
worrisome for malignancy.
# ___ flare, severe colitis:
The patient was followed by GI. She was treated with Prednisone
and cholestyramine with good effect on stool output. Patient
put on refeeding protocol with calorie counts, close monitoring
of electrolytes and I/O's; encouraged adherence to supplements.
Her diarrhea improved to where she was having ___ formed stools
daily. The patient's weight did increase while hospitalized. She
expressed that she was not interested in either TPN or tube
feeds (please see Dr. ___ note dated ___. The patient
was discharged on 20mg of prednisone with plans to taper by 5mg
every 2 weeks. She has follow up scheduled with
gastroenterology. If she continues on steroids, would benefit
from calcium and vitamin d supplements, consideration of PPI and
PCP ___.
# Lung nodule:
As part of her work up, the patient underwent a chest CT which
revealed a lung nodule. She was seen by interventional pulmonary
while hospitalized and they recommended bronchoscopy with linear
EBUS lymph node staging. They are currently arrainging follow up
on discharge.
# Anemia, stable:
The patient has likely anemia of chronic disease. HCT on
discharge was 32.2.
# Hypothyroidism
The patient has history of hypothyroid, TSH was checked and is
normal. Continued on same dose of levothyroxine.
# CKD
The patient has CKD- creatinine on discharge 1.5 at baseline. | 68 | 265 |
17192431-DS-19 | 29,827,262 | You were admitted to the hospital after a CT scan for diarrhea
showed evidence of metastatic cancer in your abdomen with an
unclear primary source. During your stay, you were seen by
Gastroenterology, who performed a sigmoidoscopy to further
evaluate an abnormal area in your rectum seen on the CT scan.
The results were concerning for tumor in that area causing
compression of the rectum and obstruction of your large bowel.
A Nasogastric tube was placed for decompression. Unfortunately,
you are not a candidate for surgery and we were unable to do a
surgical G-tube so we had to leave the Nasogastric tube in
place. You did receive a partial cycle of FOLFOX chemotherapy
(oxaliplatin and ___ bolus), however this had to be stopped due
to decreased urine output and altered mental status. You will
have to discuss the option of further chemotherapy with your
outpatient oncologist.
.
Several changes were made to your medication regimen as shown
below. You will continue on the medication regimen listed
below:
.
Chloraseptic Throat Spray 1 SPRY PO Q2:PRN dry mouth/sore throat
Dexamethasone 4 mg IV Q12H
Metoprolol Tartrate 5 mg IV Q6H
Miconazole Powder 2% 1 Appl TP TID:PRN perineal soreness/itching
Morphine Sulfate ___ mg IV Q4H:PRN pain
Ondansetron 8 mg IV Q6:PRN nausea
Octreotide Acetate 300 mcg SC Q8H
Prochlorperazine 10 mg PO Q6H:PRN nausea
clamp NG tube for 30 min after giving
Promethazine 6.25 mg IV Q6H:PRN nausea
Alendronate 70 mg weekly
.
We stopped your anastrozole as it was felt to not be effective.
We are holding your lovastatin and aspirin as well as you are
not able to take pills by mouth at this time. | The patient is a ___ year old female with h/o breast cancer s/p
mastectomy and hypertension who presented with one week of
watery, non-bloody diarrhea and abdominal pain. She was found to
have diffuse abdominal and pelvic metastatic disease with
unclear primary - a sigmoidoscopy with biopsies showed cancer of
presumed Gastric origin.
.
# Large bowel obstruction: The patient was noted to have rectal
stricturing during her flex sig. This was felt to be secondary
to malignant invasion of the colonic wall. She was evalauted by
___ surgery and felt to not be a candidate for a
diverting ostomy. She was also evaluated by GI and felt to not
be a candidate for a venting G-tube secondary to her large
ascites. She was decompressed with an NG tube. She failed a
clamping trial on ___ with increased symptoms of nausea and
pain. She was passing gas on the day of discharge, but did not
have a bowel movement. She was kept NPO. Octreotide was started
and it relieved her nausea and decrease NG output. Although it
did not entirely relieve all symptoms it did reduce secretions
and discomfort. As her NG tube output decreases, another
clamping trial could be considered. Paitent can be allowed to
have clear sips for comfort. If she develops increased pain,
then this should be d/c'd and NG tube kept to suction.
.
# Metastatic carcinoma: Biopsy results showed presumed
gastrointestinal etiology of her malignancy. The decision was
made to treat with FOLFOX - she received her oxaliplatin and the
bolus dose of ___, however after that she had an acute change
in mental status and further chemo was held during the
admission. She will have to discuss with her outpatient
oncologist further chemotherapy. Palliative care was consulted
and after family meetings, decision was made to make patient
DNR/DNI. She also indicated that she would not want to be
transferred to the ICU if her medical condition further
deteriorated.
.
# Atrial Fibrillation: She had an episode of AFib with RVR the
evening of ___, likely in the setting of volume depletion
from her diarrhea. She spontaneously converted back to sinus
rhythm after receiving 2500 ml IV fluids. She does not have a
known history of AFib. Her CHADS2 score is 2 for age and
hypertension, suggesting a likely benefit from anticoagulation
for stroke prophylaxis, but she may be at increased risk for GI
bleeding given her diffuse abdominal malignancy. At home, she
was on Atenolol 25 mg PO daily and Aspirin 81 mg PO daily which
were held on admission. She was started on Metoprolol 25 mg PO
BID on ___, which was converted to metoprolol 5mg IV every
6 hours. She had no further episodes of Afib with RVR.
.
# Heart Block: She was noted on review of telemetry to have had
several episodes of heart block with multiple dropped QRS
complexes in a row ___ dropped beats, P waves marching out
unchanged). The episodes occurred around noon on ___.
Prior EKG from ___ showed intermittent LBBB. The episodes were
most likely vagally mediated given her ongoing GI issues. She
had no further episodes on telemetry.
.
# Volume Status: The patient is volume overloaded secondary to
increased fluid input from chemotherapy, TPN, and decreased
urine output; a renal U/S showed stable hydronephrosis. The
patient was given lasix prn volume overload and tolerated this
well.
.
# Bile duct stone: Prior cholecystectomy for biliary stones. CT
and US showed abnormal enlargement of the intrahepatic and
extrahepatic bile ducts. No fevers or other evidence of
cholangitis during her stay.
.
# Breast Cancer - stopped anastrazole as patient was not
tolerating POs.
.
# Anemia: Stable as an inpatient
.
# Hyperlipidemia: Lovastatin held during stay given initial
transaminitis and not taking POs.
.
# Hypertension: Controlled on metoprolol IV.
.
# DVT Prophylaxis: Pneumoboots.
Pt was maintained as DNR/DNI throughout this hospital stay. | 279 | 657 |
12373624-DS-14 | 27,732,694 | Dear ___,
___ were admitted to ___ after ___ had a fever in clinic and
looked unwell. We ran several tests to determine the cause of
your fever and were started on strong antibiotics to treat
infections. Our Infectious Disease and Urology teams helped in
determining your treatment plan. ___ improved significantly once
___ were in the hospital and were treated with a medicine called
"fluconazole" to treat a urinary infection caused by yeast. ___
will continue this medication until ___. At this time, we
believe this is the most likely cause for your symptoms.
We had our Port team examine your port and evaluated it with a
CT scan and ultrasound- the discomfort ___ are experiencing is
likely due to irritation of a nerve and we recommend that ___
keep the port in at this time after speaking with Dr. ___.
It is now safe for ___ to return home. ___ will follow-up with
Dr. ___ Dr. ___ further care.
It was a pleasure taking care of ___ during your stay- we wish
___ all the best!
-Your ___ Team | Ms. ___ is a ___ year old woman with history of
intravascular lymphoma who is being admitted with fever and
hypotension.
# Fungal cystitis: increased risk for infection given
immunocompromised status and diabetes mellitus with glycosuria.
CT torso showed evidence of cystitis which would fit with her
clinical symptoms and prior culture. Fever workup otherwise with
no localizing sources (port considered by evaluated multiple
times without significant findings), negative culture data and
negative CT Torso (other than previously described). No further
hypotension after admission with persistent SBP >110s. Initially
started on cefepime which was discontinued after ID consulted.
Started on fluconazole 400mg daily, then dose adjusted to 200mg
daily to complete at 4 week course Urology consulted and agreed
with ID recommendations with additional recommendations to send
viral studies which were pending at time of discharge. Given
lack of gross hematuria (15 RBCs on U/A), there was no need for
acute management of this did indeed represent hemorrhagic
cystitis- they recommended outpatient follow-up with Dr. ___
cystoscopy and urodynamic testing.
# Intravascular B-cell lymphoma: confirmed by bone marrow
biopsy, s/p recent R-CHOP, has required transfusion support
after most recent cycle. Continued on VZV prophylaxis with
acyclovir. Patient evaluated by Port team for a sensation of a
"needle" sensation at port site. No change of sensation with
accessing vs. deaccessing. Physical exam and CT failed to show
any specific abnormality. Ultrasound showed some nonspecific
surrounding soft tissue swelling but no contained fluid
collection or foreign body. Discussed possible removal of port
but after discussion with primary oncologist this was deferred
given her high risk for disease relapse and possible need for
additional treatment. Patient will follow-up with Dr. ___ as
an outpatient for further care.
# Anemia: chronic normocytic anemia slightly patient's baseline
on presentation (baseline ___ in the setting of recent
chemotherapy. Hemolysis labs negative. No evidence of active
bleed with the exception of microscopic hematuria. Received 1U
pRBCs with good response and stable counts thereafter.
# Diabetes mellitus, type II: home metformin held, titrated ISS
and glargine for target blood glucose <180. Early in admission,
she had labile blood sugars with occasional symptomatic episodes
of hypoglycemia (50s) prompting a more conservative sliding
scale with no further events.
# History SVT (AVNRT): continued on sotalol and monitored QTc
while on fluoconazole (and home quetiapine) with daily EKGs
(460s).
Transitional Issues
===================
[ ] continue fluconazole 200mg daily until ___ per ID, f/u yeast
speciation
[ ] f/u urine infectious studies (BK, culture, histoplasma)
[ ] check magnesium at next visit (discharge Mg 1.4 and received
4g IV), discontinued home magnesium oxide due to patient
complaint of loose stools since starting
[ ] monitor QTc with EKG while on fluconazole and sotalol,
recommend avoiding additional QT-prolonging agents (discharge
QTc 460s)
[ ] patient discontinued on Pyridium given absence of relief and
risks associated with medication after discussion with Pharmacy
[ ] obtain nonemergent pelvic ultrasound to characterize
findings on CT Torso | 177 | 478 |
18591903-DS-16 | 26,545,435 | Dear Ms. ___,
You were admitted to the ___
for an exacerbation of your COPD. You had an x-ray of your chest
which showed that there was no infection in your lungs. You were
started on several medications to treat your COPD including
breathing treatments called nebulizers containing albuterol and
ipratropium, a pill steroid (prednisone), an inhaled steroid
(fluticasone), and antibiotics.
You also underwent more detailed imaging of your lungs in a
study called a "CT." This study showed that you had mucus
plugging in your airways, lymph node enlargement, signs of
infection, mild emphysema, and a spiculated (irregularly
bordered) lung nodule. You will need to have additional imaging
in 3 months to follow this nodule and make sure that it is not
cancerous. The medical team thought that you would benefit from
a pulmonary (lung) consult. The pulmonologists (lung doctors)
assessed you and recommended that you have lung function test
performed. You had these tests done on ___ and will discuss the
results with your primary care doctor on ___.
Because you described a history of choking, difficulty
swallowing solid foods, and feeling full soon after starting to
eat, you underwent a swallow study. This showed a small amount
of gastro-esophageal reflux which can cause chest discomfort,
nausea, and burping. We started you on a medication to reduce
the acid production in your stomach called ranitidine.
Because of your family history of heart disease in your mother,
sister, and brother, and your description that the "blood flow
through your heart is not good," there was initially concern
that your symptoms may have been related to underlying heart
disease. All imaging and markers showed that there were not any
problems with your heart that would be causing your symptoms of
shortness of breath, cough, or chest pressure.
Your breathing improved over the course of your hospitalization
and your chest pressure improved with the breathing treatments.
By the time of discharge, you were maintaining good levels of
oxygen in your blood without supplemental oxygen therapy, were
able to walk without becoming too short of breath, and were able
to tolerate oral intake and the medical team felt you were in
good condition to return home with follow-up with a primary care
physician.
We have given you prescriptions for the ___ equivalents of the
medications you brought from ___. Please take all your
medications as perscribed (listed in your discharge paperwork).
It is very important that you attend the appointments listed
below (Recommended Follow-up). It was a pleasure taking part in
your care.
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with a history of diabetes,
hypertension, and COPD who presents with 2 weeks of increasing
shortness of breath and chest tightness with exertion, most
consistent with a sub-acute exacerbation of her known COPD, with
some concern for other pulmonary pathology.
#RESPIRATORY DISTRESS: On presentation, Ms. ___ reported that she
had noticed a decline in her respiratory status over the past 4
months, from being able to walk for ___ hours without shortness
of breath, to being unable to walk at all without shortness of
breath. She also described chest pressure/tightness, wheeze, and
cough consistent with exacerbation of her known COPD. She did
not have leukocytosis, fever, or concerning findings on CXR,
which was reassuring against pneumonia. However, given her
respiratory distress necessitating hospitalization, the patient
was started on azithromycin (start ___ end ___, given its
presumed anti-inflammatory properties. Given concern for pan
bronchiolitis, obliterative bronchiolitis or possible PE, a
chest CTA was obtained which showed evidence of ___
opacifications with concern for an atypical infection, therefore
antibiotic coverage was expanded to ceftriaxone (start ___ end
___. Ms. ___ was also started on a 5 day course of prednisone
40mg daily, fluticasone inhaler, albuterol nebs, and ipratropium
nebs. Given the mucus plugging identified on CT, she received
saline nebs and guaifenasen. Pulmonology was consulted and
recommended continuation of these therapies. Given the rapidity
of the decline in Ms. ___ respiratory status (4 months as
described above), the pulmonary team was concerned for causes
outside of emphysema such as ABPA and ___ they
recommended testing for IgE and ANCA. These results were pending
at the time of discharge. The pulmonary team aslo recommended
pulmonary function tests which were completed on ___ these
showed evidence of COPD with an FEV1 of 1.48 (75% predicted)
which improved to 1.63 (83% predicted) with bronchodilator
therapy. Her FEV1/FVC(%) was 61 (81% prediced) which improved to
63 (83% predicted) with bronchodilator therapy. Ms. ___ noted
improvement in her respiratory symptoms and chest tightness over
the course of her hospitalization and by the time of discharge
was able to walk 30 minutes without shortness of breath. Ms. ___
was advised to follow up with pulmonology in clinic after
obtaining pulmonary function tests and that she would need a
chest CT in 3 months to follow up a concerning pulmonary nodule
identified on her CT-A.
#CHEST PRESSURE/PAIN: Given Ms. ___ history of orthopnea,
dyspnea on exertion, and chest pressure, as well as her
description that the "blood supply through the heart is not
good," the possibility that her symptoms had a cardiogenic
etiology was strongly considered. Lack of elevated JVP and ___
edema are reassuring against congestive heart failure. CXR
showed a normal cardiomediastinal silouhette and no evidence of
pulmonary edema or effusion. EKG was normal; troponin was <0.01;
BNP was within normal limits at 35. Ms. ___ described repeated
episodes of chest pressure/tightness throughout the day ___,
however CXR, EKG, and troponins were normal. Given her cough,
belching, and nausea, it was thought that there was likely a
component of GERD; this was confirmed on barium swallow which
showed gastric reflux. Ms. ___ was started on omeprazole and
simethicone with improvement of her belching, cough, and chest
tightness.
#GERD: As mentioned above, the patient was thought to have
significant contribution of GERD to her cough, nausea, and
sensation of chest tightness. A barium swallow showed evidence
of mild reflux. The patient was started on omeprazole and
simethicone with improvement of her symptoms.
#DYSPHAGIA: Given the appearance of the ___
opacifications on chest CTA, the patient's persistent cough, and
lack of other identifiable COPD trigger, there was concern for
aspiration. Upon further questioning, the patient reported
dysphagia with dry solids, early satiety, belching, and
occsional choking sensation with food ingestion. This history
then promted concern for other esophageal pathology. A barium
swallow esophagram was obtained on ___ which showed mild reflux
with no other abnormality. Speech and swallow was also
consulted; they felt Ms. ___ was having GERD and was not at risk
for upper airway aspiration.
#HEADACHE: The patient reported headache with episodes of wheeze
and cough, likely related to hyperventilation. She was counseled
on breathing techniques and given Tylenol, after which her
symptoms resolved.
#HYPERTENSION: Ms. ___ reported a history of hypertension for
which she takes indapamide (a thizide diuretic prescribed to her
in ___. This was discontinued at the time of admission given
her low-normal pressures. It was not re-started as her pressures
remained well controlled throughout her hospitalization, but
outpatient providers may consider restarting an ati-hypertensive
as needed.
#DIABETES MELLITUS: Ms. ___ has a history of diabetes for which
she takes oral antihyperglycemics at home including gliclazide
and acarbose (from ___. These were held at the time of
admission and the patient was started on an insulin sliding
scale with hypoglycemia protocol. Her sugars were initially
elevated into the ___. She was started on Glargine 6 units
at bedtime with good glucose control. At the time of discharge,
she was transitioned to metformin. This issue should be followed
up with her PCP.
****TRANSITIONAL ISSUES****
- pt noted to have spiculated pulmonary nodule on CT and will
need repeat CT in 3 months for surveillance
- patient with unclear history of ?coronary artery disease.
- f/u glucose control, tolerability of metformin (she was on
ascarbose and gliclizide (meds prescribed in ___ when she came
in and was transitioned to metformin at discharge).
- Pt's thiazide diuretic from ___ was held during her
hospitalization; her blood pressures were well controlled,
therefore it was not continued at the time of discharge, PCP may
want to consider outpatient BP meds as needed
- discharge COPD regimen: spiriva, PRN albuterol inhaler | 419 | 939 |
19223734-DS-15 | 24,715,255 | Dear Mr ___,
Why were you admitted to the hospital?
- You were admitted to the hospital because you were having
worsening shortness of breath and dizziness.
What was done for you in the hospital?
- You had a procedure called a cardiac catheterization to
evaluate the vessels of your heart, and it showed that you had
mild disease in your vessels that did not require intervention.
- You had an ultrasound of your heart which showed moderate
backward flow through your aortic valve.
- The cardiac surgeons were consulted and recommended getting an
image of your heart called a cardiac MRI - this result was
pending at discharge.
- The neurologists were consulted and recommended getting
imaging of your brain to see if there was an abnormality that
was causing your dizziness. The imaging was reassuring and did
not show a cause to your dizziness.
- The ophthalmologists were consulted for a thorough exam of
your eyes and felt this was normal.
What should you do when you go home?
- You should continue taking your mediations as prescribed. Your
new medications are Atorvastatin 40mg daily and aspirin 81mg
daily. You should stop metoprolol and lisinopril for now until
you see your Cardiologist in the outpatient clinic.
- You should follow up with your primary care physician and
cardiologist.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | ___ year old male with PMHx HTN, severe aortic regurgitation
presenting with worsening lightheadedness, SOB, and chest pain
consistent with acute decompensated heart failure. | 222 | 24 |
19318312-DS-13 | 20,013,496 | You were admitted to the hospital after you were involved ___ a
MVA. You sustained a small bleed ___ your head, rib fractures, a
fracture to your neck, and a collapsed lung. You also sustained
a laceration to you scalp. You were monitored ___ the intensive
care unit. Because of your injuries, you had a tracheostomy tube
and a feeding tube placed. You are slowly improving since your
initial injuries. Your trach tube was removed and you are
breathing without any difficulty. You have been evaluated by a
rehabilation facilty and you are now preparing for discharge. | The patient is a ___ year old female who was an unrestrained
passenger ___ a high speed MVC and was ejected from the vehicle.
She was transported to the emergency room on ___. At the
scene, she had a GCS of 3 and was intubated. ___ the trauma bay,
initial workup showed a small subdural hematoma and a small left
pneumothorax. She was found to be desaturating to SpO2 ___ and a
chest tube was subsequently placed with improvement ___ the
saturation. Further workup revealed degloved scalp, C6
transverse process fracture, T1 transverse process fracture and
prevertebral soft tissue swelling ___ the C-spine area. Because
of these injuries, ortho spine was consulted. The patient was
placed ___ a cervical collar for neck stabilization. A small
superficial laceration on the chest was closed by ACS and the
patient was transferred to the ___ intensive care unit after
all injuries were deemed nonoperative. Of note, she was moving
all extremities ___ the emergency room prior to transfer.
The patient's hemodynamic and neurological status were closely
monitored ___ the intensive care unit. A repeat head cat scan
showed no new changes. The Plastic surgery service was
consulted regarding a significant scalp degloving injury from
frontal region to occiput. The lacerations were irrigated and
closed primarily. The sutures were removed ___ ___ days.
The patient's cardiac status was notable for a rapid heart rate
for which the patient received additional intravenous fluids and
albumin. She was evaluated by Neurosurgery and recommendations
were made for placement of a hard collar for ___ weeks for
stabilzation of her neck injuries. As the patient's neurological
status improved, the ___ J collar was replaced by a soft
collar. The patient's neurological status was closely monitored
and the patient displayed no additional deficits. Over the last
few weeks, she gradually became more aware of her surroundings
and communicative.
On ___, it was determined that the left chest tube was no
longer needed and it was placed to water seal. The patient's
respiratory status remained stable and the chest tube was
removed on ___.
During the ICU course, the patient was noted to have a decrease
___ her hematocrit to 19.6 with resultant tachycardia. There
were no obvious signs of bleeding and no evidence of bleeding on
cat scan imaging. The patient received 1 unit of packed red
blood cells and the tachycardia diminished. The patient remained
on serial hematocrit's and they stabilized throughout the
hospitalization.
On ___, the patient was evaluated by physical and occupational
therapy and the patient was cleared by the Spine service to get
out of bed. The patient continued to have temperature spikes and
she was started on ancef. Her wounds were examined and forehead
sutures were removed.
The patient was reported to have an episode of pupillary
asymmetry on ___. A head cat scan was done which was stable.
Blood work showed hyponatremia and the patient was started on a
hypertonic saline infusion. Her electrolytes were closely
monitored. The patient continued to have drops ___ her hematocrit
and there was concern for a paraspinal hematoma. A cat scan of
the thoracic spine was done and no hematoma was seen. Her white
blood cell count continued to spike and the antibiotics were
switched from cefazolin to cefepime for MSSA. The PICC line was
removed and the tip was sent for culture. There was no evidence
of infection on the catheter tip. ID was consulted and
recommended discontinuing the current antibiotic regimen and
starting unasyn.
Because the patient failed to extubate, she underwent a trach at
the bedside on ___ and PEG placement on ___. Tube feedings
were started. She continued to have bouts of tachycardia which
responded well to metoprolol. The screening process for
rehabilation placement was initiated. ___ preparing for rehab,
the patient was started on the trach mask trials. Her
respiratory status remained stable. Chest x-ray on ___
indicated improved lung volumes and no evidence of pneumothorax,
pneumonia, or pleural effusion. The trach was downsized to a
fenestrated Portex #6 on ___. The patient was transferred to
the surgical floor from the trauma intensive care unit on ___.
The patient remained stable during stay on the surgical floor.
She was tolerating the tube feedings via the PEG. Her
neurological status was slowly improving. Her vital signs were
stable and she was afebrile. On ___, the trach tube was
removed and the patient showed no signs of respiratory distress.
The patient passed a bedside swallow and was started on a
mechanical soft diet. Again she was evaluated by physical
therapy and progressed to the point where she could sit on the
side of the bed with assistance. She continued to do well until
placement ___ a rehab facilty. She was cleared for rehab on ___.
At the time of discharge she was doing well with no acute
issues. She will benefit from being ___ a rehabilitation facility
for both cognitive and physical rehabilitation. | 101 | 855 |
15171541-DS-4 | 28,325,813 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
somnolence and confusion. This is most likely due to
intoxication from the medications you received for alcohol
withdrawal as well as toxin build up from poor liver function
(known as hepatic encephalopathy). We held further sedating
medications and treated your confusion with a medication called
lactulose. Your mental status subsequently improved.
When you leave the hospital, you will need to follow up with
your primary care physician and ___ new doctor called ___
hepatologist, or liver doctor. You will need to take lactulose
daily until then, increasing the dose to twice a day or more in
order to have at least two bowel movements a day.
You were seen by physical and occupational therapists who
recommend inpatient physical rehabilitation or 24-hour
supervision with outpatient services. The social worker has
offered you resources for alcohol addiction, which we hope that
you utilize with the help of your partner and family.
As for your home medication, clonazepman, we recommend waiting
until you see your PCP before restarting this. Also, you have
been started on vitamins and minerals to help with your
nutritional deficiencies. You should have your electrolytes
checked next week and followed up by your PCP.
In summary, we made the following changes to your medications:
STOP clonazepam
START lactulose
START multivitamin
START folic acid
START thiamine | ___ yoM with history of alcohol abuse who presents from ___
HRI/alcohol detoxification with altered mental status and
difficulty ambulating.
#Altered mental status: Thought to be multifactorial -
combination of alcohol withdrawal vs benzodiazepine intoxication
from excessive CIWA scoring at detox center vs hepatic
encephalopathy. He was treated with benzodiazepine vacation and
lactulose for encephalopathy. Pt was noted to have significant
asterixis and ataxia on exam which improved dramatically over
the course of his hospitalization. As did his mental clarity. By
time of discharged he continued to have some slower than normal
speech but fluent thought process and no ataxia. He was given a
prescription for lactulose, titrated to ___ BM per day.
#Cirrhosis: Suspected by labs (pancytopenia, low albumin,
elevated coats) and ultrasound showing cirrhosis. Pt was treated
with lactulose as above. Further management was deferred to
outpatient hepatology follow up, as will need the suspected
diagnosis confirmed. Patient and partner aware of the importance
of comfirming this diagnosis, including to determine appropriate
treatment options, if they do exist. Alcohol abstinence was
reinforced, both to the patient and HCP, specifically as this
relates to his suspected liver disease.
#Alcohol abuse: pt did not require diazepam per ___ protocol.
He did not have hallucinations or seizure. He was started on
MVI, folate, and thiamine. SW was consulted, who helped set the
patient and his partner up with outpatient addiction resources.
#RLE ulcer: Per patient and partner, the ulcer is at baseline
and has been a chronic issue for the last ___ years. It causes
him pain and disability. He was seen by wound care recs and
discharged on a home wound care regimen. He requested vascular
surgery referral (scheduled outpatient). No antibiotics were
given.
# COPD/asthma: No wheezing on exam. No dyspnea. Continued home
fluticasone IH, PRN albuterol and combivent.
# Psychosocial issues: pt was continued on his home meds, minus
clonazepam due to sedation. | 222 | 315 |
16717030-DS-17 | 24,926,064 | Dear Mr. ___,
You were hospitalized due to symptoms of left weakness,
numbness, left neglect, left visual field cut, and inability to
swallow safely resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
Diabetes
Cholesterol plaques
Talking extensively with your family, we understand that you
would not want to live long term with these problems and a
feeding tube. Therefore, we will focus on making you comfortable
and making sure the time you have left is as enjoyable and
comfortable as possible.
We are changing your medications by using only the medications
needed to keep you comfortable.
Sincerely,
Your ___ Neurology Team | PATIENT SUMMARY:
================
___ PMH DM, remote smoking, HTN, DM who presented with slurred
speech and left-sided weakness to an OSH, and subsequently
transferred to ___ and is s/p thrombectomy and ICA angioplasty
and stenting whose hospital course has been complicated by
aspiration pneumonia, dysphagia. Family felt he would not want
PEG placement in this situation and he will be discharged with
plan for comfort measures only and hospice care.
# Right ICA Occlusion
# Right MCA infarcts
Patient presented with speech difficulties and left sided
weakness to an OSH, last known normal approximately 13 hours
prior to presentation. Exam notable for NIHSS 13, non-fluent
aphasia, neglect of left with left homonymous hemianopia, left
arm>leg weakness. Pre-procedure imaging notable for near
complete right ICA occlusion and CTP with very large area of
mismatch. Underwent thrombectomy with right ICA angioplasty and
stenting (___) that was complicated by likely clot propagation
into MCA branches with retrieval. MRI revealed extensive right
hemispheric late acute infarcts including all right-sided
cerebral lobes, right basal ganglia, right thalamus, and right
cerebral peduncle. There was also a punctate foci of GRE
susceptibility within the right caudate and right thalamus
suspicious for microhemorrhage, although mineralization can have
a similar appearance. Echo did not show structural source of
embolism and EF was unclear. Etiology of stroke most likely
artery to artery in setting of ICA stenosis. Risk factor labs
show LDL 59, HbA1c 6.6. He was started on plavix 75mg daily and
ASA 325mg daily as well as atorvastatin 20mg qPM secondary to
stent placement.
# Aspiration PNA
Patient spiked temperature of 101.6 on the morning of ___.
In the setting of recurrent emesis following thrombectomy,
highest concern for aspiration event. CXR was obtained and
showed possible RLL consolidation. Blood cultures and urine
culture were both obtained and ultimately negative. He was
briefly on Unasyn before being switched to azithromycin and
ceftriaxone for CAP coverage. Due to continued fevers he was
transitioned to Cefepime and Flagyl for aspiration coverage.
This was stopped after a 5-day course. WBC had normalized and
there were no fevers. CXR also improved and CTA without evidence
of PNA. MRSA swab was negative.
# Hypoxia
# Emphysema
# Bronchiolitis
# Mucous Plugging
The patient had been recovering well on the neuroscience
intermediate care unit until the afternoon of ___ when he
developed acute hypoxic respiratory distress. He was apneic for
several seconds and then subsequently coughed up a large mucous
plug spontaneously with rapid improvement in his hypoxia. He was
transferred back to the neuroscience ICU for further monitoring.
A CTA was performed and was negative for PE but did show severe
centrilobular emphysema. This was felt to be the explanation for
his persistent hypoxia and he was thus started on standing
Duonebs before being transferred back to the step-down unit.
Goal SpO2 was set at 88-92% in setting of emphysema. He
occasionally needed PRV Lasix for volume overload (typically
every ___ days).
# Melanotic stools
Informed by nursing on ___ that pt had a large melanotic stool
raising concern for GI bleed. IV PPI was started and GI was
informed. Serial H/Hs were stable.
# Hypernatremia
Patient became progressively hypernatremic in setting of tube
feeds, insensible losses and diuresis. He was started on FWF;
currently at 200mg q4h.
# Hematuria
Unclear etiology, but evident on UA on admission. Unclear if
foley insertion/removal was traumatic but H/H stable.
# Type II DM
A1c 6.6, but has had uncontrolled BG this admission. Most likely
related to critical illness as A1c does match degree of
hyperglycemia. Required insulin regimen including long acting
and short acting insulin in addition to ISS.
# FEN
TF through NGT, currently at goal of 70cc/hr.
#Goals of Care:
Multiple family discussions were held, including formal family
meetings on ___ and ___, during which expected prognosis,
medical complications, and options of PEG vs CMO/Hopsice care
were discussed in great detail. See separate family meeting
notes from these dates for full details. Decision was made on
___ that Mr. ___ would not want PEG and would want to be
made comfortable. Given goal to get him to a ___ facility
near their home in ___, current level of care was
continued until hospice placement was extablished, then comfort
measures were instituted. | 202 | 694 |
14250520-DS-7 | 20,132,383 | You presented to ___ with abdominal pain and were found to
have severe pancreatitis. It appears that your pancreatitis was
caused by extremely high triglycerides. You were transferred to
the ICU for a procedure called pheresis to try to lower your
triglycerides. You improved with this treatment and were
transferred to the medical floor.
Of note, your labs on admission were also significant for a new
diagnosis of diabetes. You met with our diabetic educators
while you were in the hospital. It will be very important for
you to follow closely with your PCP for further management of
your diabetes.
You decided to leave the hospital against medical advice on
___. Your physician wanted to observe you in the hospital,
as the white blood cell count was increasing. This can be a
marker of infection that we have not had time to diagnose. You
understood that there is a possibility of infection, recurrent
pancreatitis/complications, and even death, although unlikely.
It is very important that you keep your appiontment with your
PCP this ___, see below for details. | ___ admitted for pancreatitis due to hypertriglyceridemia.
# Acute pancreatitis: Likely due to hypertriglyceridemia. No e/o
biliary obsruction, no hx excessive EtOH use. He was initially
admitted to the floor and was treated with agressive fluid
resuscitation, bowel rest. However, he did not improve with this
and was ultimately transferred to the FICU for pheresis.
Underwent pheresis x 1, with clinical improvement, and was then
transferred back to the floor. Lipase and triglycerides trended
down throughout admission. Pt was continued on his home
fenofibrate. On ___, WBC count rose from 8.5 to 11.4.
Patient was counseled that we would like to monitor him until
WBC count improved, but patient declined and decided to leave
against medical advice. He has close follow up with his PCP ___
___, and this writer gave a verbal signout to the PCP,
updating the PCP on hospital course, on day of discharge.
Patient was informed that an appt was being set up for him to
follow up with Dr. ___ in clinic.
# DM: New diagnosis during this admission. A1C on presentation
was 12.4. Pt endorsed several months of polyuria, polydipsia,
and weight loss. He was initially started on SSI and was
transiently on insulin gtt in the ICU. He was then transitioned
to subcu long-acting and sliding scale insulin, and was able to
administer insulin without assistance prior to discharge.
# Hypertension: new diagnosis; started lisinopril, will need
chemistries checked with PCP after discharge.
# Vision Changes: While in the ICU, Ophthalmology was consulted
for visual symptoms and did not find an ophthalmologic cause for
his "seeing things that were not there." On the floor, he
complained more of blurred vision. It was felt that this could
potentially be related to poorly-controlled diabetes.
# Mental Status: Pt's wife raised concerns of increased
irritability, which was felt to likely be related to adjustment
to new diagnoses. Pt's wife also reported that he was more
forgetful. It was felt that this was likely related to
medications. He was alert and oriented x 3 prior to discharge,
without any issues with mental status or decision-making
capacity.
# Back Pain: Treated with flexeril, lidoderm
# CONTACT: Wife, ___ ___ | 182 | 362 |
12153677-DS-13 | 29,246,638 | Ms. ___
It was a pleasure taking care of ___ while ___ were in the
hospital. ___ were brought in because ___ were not acting
yourself and were not responsive. ___ were found to have a
sodium level of 100 (dangerously low) on admission. ___ were
slowly corrected back up to normal range and your mental status
improved. ___ did well and were able to eat and drink more and
did not require any IV fluids to maintain your sodium. ___ also
were rfound to have a urinary tract infection that rose to the
level of the blood. ___ are on the ___ antibiotics at this
time. ___ will need to complete a 14 day course of
ciprofloxacin. Please follow up with the appointments below. ___
will also need to follow up with your primary care doctor when
___ leave the rehab facility.
PLEASE START THE FOLLOWING MEDICATION:
1. Ciprofloxacin 500mg By mouth twice a day for 14 days (start
day ___ | ___ year old female with HTN presents with lethargy and recent
falls, found to have severe hyponatremia Na = 100.
#) SEVERE HYPONATREMIA: Etiology unclear, likely hypovolemic
hyponatremia. While in the MICU she was slowly corrected. Her
sodium began to rise too quickly, and she required D5W to slow
her correction rate. Prior to leaving the MICU she was
tolerating a regular diet with 500cc fluid restriction to be
sure that she was not correcting too rapidly. As her sodium
normalized in the low 130s her diet continued to be liberalized
and she was eventually not on any fluid restriction. He sodium
continued to be monitored and maintained in the low 130s. It
began to drop to 130 and the patient was placed back on a 1L
fluid restriction and her sodium began to increase into the
normal range. She was placed on a 1.5L fluid restriction and did
well. The workup for cause of hyponatremia was unrevealing and
felt to possibly be a combination of hypovolemia and underlying
SIADH of unclear etiology, possibly from recent infection or
medication. With her sodium stable she was felt to be safe for
discharge with outpatient renal follow-up.
#)Septicemia due to UTI: The patients WBC count trended up from
10.8 on ___ to 16 on ___. A U/A was checked that was
positive and she became febrile to 101.1. Blood Cx were drawn
and ceftriaxone was started. Her UTI grew out e.coli with the
resistance pattern on the results section, and her blood also
grew out GNR with the same resistance pattern. She was continued
on the IV ceftriaxone for 72 hours while her fever broke and her
WBC trended down to 9.4. Surveillance cultures had no growth and
she was transitioned over to PO Ciprofloxacin for complete a 14
day course with the start date of ___ once she had been
afebrile for 48 hours. She will complete the antibiotics on
___.
#) ACUTE LIVER INJURY: Noted on admission labs, but workup was
negative for viral hepatitis, or Tylenol. CK was also elevated,
but trended down prior to discharge from the MICU. Her AST and
ALT continued to trend down while on the floor.
#) Rhabdomyolysis: Initially elevated to 8000s on admission and
thought to be possibly secondary to seizure in the setting of
severe hyponatremia and found incontinent to urine. EEG was
negative for seizure. She was treated with IVF and her CK
trended down. It had normalized by the time of discharge.
#) HYPERTENSION:Prior to transfer to the floor she was restarted
on her home dose of amlodipine. Her B was maintained in the
normal range without issues while in the hospital. | 161 | 443 |
13791337-DS-21 | 28,010,719 | Dear Ms. ___,
Thank you for choosing ___ for
your care.
You were admitted to the hospital with confusion and difficulty
with speech. You were found to have a hemorrhage (bleeding) on
the right side of your brain. This was most likely due to being
on blood thinning medications and having high blood pressure. In
the hospital we gave you medications to reverse your blood
thinners and control your blood pressure. You are being
discharged to rehab where you will have speech therapy to help
with stroke recovery.
.
Please attend the follow up appointment listed below.
.
We made the following changes to your medications:
1. STOPPED warfarin
2. STOPPED enoxaparin (lovenox)
3. STARTED Diltiazem 120 mg four times per day.
4. INCREASED metoprolol to 50mg three times daily
5. CHANGED furosemide to as needed from standing | ___ yo LH F with h/o HTN, HLD, mild dementia, cervical
spondylopathy and newly-diagnosed AFib on Coumadin/Lovenox
presents with acute onset of confusion and speech problems,
found to have right temporal lobe IPH with small
intraventricular extension.
# NEURO: In the ED, patient was somnolent with a significant
expressive and receptive aphasia. Her blood pressure on arrival
was 190/70, so she was started on nicardepime drip. She was
given activated factor IX, FFP and vitamin K to reverse her
anticoagulation. She was admitted to the neuro ICU for close
monitoring and BP control with nicardepime drip. On HD #2 her
somnolence was improved but she developed a more marked global
aphasia. Repeat head CT on HD #3 showed some edema around IPH,
but no extension of bleed. Comparison with prior MRI from ___
showed evidence of ?underlying cerebral amyloid angiopathy (vs.
head trauma). She was transferred to the step-down unit for
close BP and neuro monitoring (given ongoing risk for cerebral
edema after her bleed). Her aphasia and confusion improved over
the course of her admission but she had significant residual
deficits on discharge.
# CARDIOVASCULAR
(1) AFib: Patient was in sinus rhythm on admission and while in
ICU. Given h/o symptomatic AFib, her home metoprolol was
restarted at lower dose during hospitalization. She then went
into asymptomatic AFib with RVR, which required IV metoprolol
and diltiazem (including drip) for rate control. At discharge,
her metoprolol had been increased from daily to TID and she was
on PO diltiazem 120mg QID. Her anticoagulation was stopped given
head bleed, as risks clearly outweighed benefits, and ASA 81mg
daily was started for clot prevention.
(2) HTN: On metoprolol only at home, previously on valsartan
before prior hospitalization. BP initially controlled with
nicardipine drip, then metoprolol.
(3) diastolic CHF: Made home Lasix PRN. Remained euvolemic.
Lisinopril discontinued per cardiology, can be restarted at
their follow-up.
# ID: UA on admission showed 20 WBCs so received single dose of
ceftriaxone in ED. This was discontinued in ICU. UCx with no
growth, CXR with small bibasilar pleural effusions (stable from
prior imaging).
# ENDOCRINE: On ISS for tight glycemic control while
hospitalized. Home statin was held in post-hemorrhage period
given risk of increased vessel friability.
# CODE STATUS: Patient is DNR/DNI (confirmed). | 128 | 377 |
13141357-DS-7 | 28,315,501 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital for cough and rib pain. A chest X-ray
showed multifocal pneumonia, and you were treated on IV
antibiotics. A PICC line was placed in order for you to receive
antibiotics at home. While you were in the hospital, an
endoscopy was performed which showed portal hypertensive
gastropathy but no varices.
After discharge, it is important that you complete your
antibiotic regimen. You are receiving two antibiotics through
your IV (vancomycin, cefepime) and one by mouth (azithromycin).
Your last day of antibiotic therapy is ___.
Please see your primary care physician as well as your
hepatology team in outpatient follow-up after your discharge
(details below). | Mr. ___ is a ___ w/ decompensated EtOH cirrhosis admitted
for treatment of multifocal pneumonia. | 122 | 15 |
14366914-DS-20 | 22,398,796 | Dear Ms. ___,
You were admitted to ___ for left leg weakness and a buttock
abscess. The abscess was drained and you were given antibiotics
to treat both the abscess and your bronchitis.
.
For your leg weakness, we got an MRI and talked to neurologists.
The MRI showed no serious findings and your left leg weakness
improved with time suggesting you likely compressed a nerve
temporarily. Please avoid doxepin as this might have contributed
to your presentation.
.
The following medications were changed:
START doxycycline 100mg by mouth twice a day for seven days.
This will help treat both your bronchitis and your abscess.
START albuterol inhaler ___ puffs every six hours as needed for
shortness of breath
.
Your wound dressing will need to be changed tomorrow. Please
apply wet to dry dressings in the wound every other day using
the supplies provided.
.
Take your other medications as previously prescribed. | ___ female with IV heroin/cocaine use presenting with
one day of left leg sensory loss and weakness as well as four
days of low back pain and a right buttock abscess.
.
# Left leg weakness: Pt presented with acute on chronic low back
pain and left leg weakness and numbness. Preliminary MRI results
ruled out epidural abscess, showing only disc bulging at L3-L4
without nerve compression and possibility of focal panniculitis
at L1. Initial exam was significant for mild tenderness to
palpation of lumbar spine/paraspinal muscles, numbness over left
medial leg, and diminished strength and reflexes in LLE.
Symptoms were consistent with L3-L4 radiculopathy. Patient's
symptoms improved over the course of the day and by discharge
patient was back to full strength and sensation. Physical
therapy felt patient was at her baseline. ESR and CRP were
elevated but this was thought to be due to her concurrent
abscess.
.
# Abscess: Pt with abscess on right buttocks that was drained in
the ED. Gram stain of wound has 1+ GPCs in pairs. Patient
remained afebrile and without leukocytosis. Wound is small but
indurated and tender, still packed after the incision and
drainage. Surrounding tissue is soft and does not look
cellulitic in appearance. Patient was discharged on doxycycline
and given instructions on how to do wet-to-dry dressing changes.
.
# Rhonchorous breath sounds: Patient with productive cough,
subjective chills and myalgias, and diffuse coarse breath sounds
on exam. Chest x-ray was unremarkable for focal pneumonia so
felt her symptoms were consistent with bronchitis. Patient has
diagnosis of underlying asthma though denies inhaler use so this
would make her susceptible to lung infections. Patient was
discharged home on doxycycline for bronchitis and an albuterol
inhaler to be used as needed.
.
CHRONIC ISSUES
.
# Polysubstance abuse: Utox was positive for cocaine and
opiates. Pt has history of IV drug use including crack and
heroin with last use of crack yesterday. Patient was re-tested
for HIV and hepatitis B and C during this admission, but those
results were pending at the time of discharge. Patient
experienced no signs of withdrawal during her stay.
.
# Depression: Stable. Continued wellbutrin.
.
TRANSITIONAL ISSUES
- HIV and Hepatitis serologies were pending at the time of
discharge
- Gabapentin dosing would be 600 every 8 hours if renally dosed,
so should re-examine reason for this increased dose
- Patient has a diagnosis of asthma but is not prescribed any
controller medications. She was discharged with a rescue
inhaler.
- Blood, urine, and abscess cultures were pending | 144 | 419 |
13188963-DS-31 | 29,307,879 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital with
pneumonia and were treated with antibiotics. You will be on
antibiotics were for several weeks with follow-up with the
infectious disease physicians.
You also were found to have a fluid collection near your renal
transplant that was evaluated by the transplant surgeons. Your
CT scan was re-assuring.
You will continue to follow-up with the renal transplant team to
further manage your renal transplant.
Wishing you the best,
Your ___ team | Mr ___ is a ___ with a recent DDRT who now presents with a
persistent RUL and right-sided pulmonary effusion despite
antibiotic course, dyspnea on exertion, and afib with rvr.
Diagnosed with nocardia pnuemonia and discharged on minocycline
for an extended course pending repeat imaging and ID follow-up.
ACUTE ISSUES
# Nocardia pneumonia
Mr. ___ presented to the hospital with tachycardia,
tachypnea, fever and leukocytosis. Pulmonary source from a RUL
pneumonia or infected pulmonary effusion are most likely
sources. Infections in a relatively immunosuppressed patient 3
months after a transplant include PJP, opportunistic endemic
fungal infections, TB, and CMV. There is some question of
immunosuppressant non-compliance so more standard bacterial
infections and organizing pneumonia are on the differential as
well. Parapneumonic effusion may also be a source given its
chronicity. HDS, lactate normal. Patient refused CT in the ED.
After admission, in addition to pan-culturing, the patient had a
thoracentesis and pigtail placement performed by the
interventional pulmonology team. Pleural fluid was sent, and was
not indicative of a florid infection but cultures were sent
regardless. In addition, given a history of AFB positivity, the
patient was ruled out for TB pneumonia with multiple AFBs. His
cultures showed THIN BRANCHING GRAM POSITIVE ROD(S). Nocardia
specific cultures pending at time of preparing this summary. ID
reviewed gram stain of sputum and felt very strongly about
nocardia. He was treated initially with Vancomycin and Cefepime
and this was transitioned to PO bactrim and finally discharged
on minocycline because of elevated Cr on Bactrim. The infectious
disease team was consulted as well.
# Afib with RVR: Patient with RVR, likely driven by SNS of
sepsis. Hemodynamically stable. Not on anticoagulation as an
outpatient. Anticoagulation was considered but not started in
the setting of acute illness. This resolved with treatment of
his pneumonia
# ESRD s/p DDRT: Patient with a previously failed SCD in ___.
Most recently underwent a DDRT in ___ in ___. The
patient had daily tacrolimus levels checked, and given that he
has a transplanted kidney, the transplant team requested that
the patient receive pre- and post-hydration for contrast.
Mycophenolate Sodium ___ ___ in setting of PNA as above;
tacrolimus decreased to 6 mg BID. Placed on dapsone for PCP
___.
# Type II Diabetes: Patient not on oral antiglycemics at home.
Blood sugars not elevated, likely in the setting of sepsis. No
DKA. Sliding scale insulin provided prn. | 88 | 397 |
11153842-DS-7 | 22,217,732 | Dear Ms. ___,
You were admitted with a UTI and treated with antibiotics. Your
decubitus ulcer did not appear to be infected. | ___ with history of neurofibromatosis type II and astrocytoma
s/p resection complicated by paraplegia with neurogenic bladder
and frequent UTIs who presents with dysuria, increased urinary
frequency and worsening pain at sacral decubitus.
# Complicated UTI: Patient self caths and has recurrent UTIs
which have been difficult to treat due to multiple antibiotic
allergies. Last culture with pansensitive Klebsiella. ID
consulted. Started on meropenem due to multiple antibiotic
allergies while sensitivities pending. Renal ultrasound negative
for pyelonephritis. Ultimately switched to fosfomycin per ID
recs. Pt declined ___ to help her with self-catheterization and
review sterile technique.
# right gluteal decubitus Ulcer: Wound did not appear infected.
Patient's plastic surgeon Dr. ___ was emailed per patient
request. Wound care consult placed & recs followed.
# Concern for secondary gain with IV narcotics: Patient was told
on admission that she will not be given IV narcotics during this
admission, as there is no indication for this.
# Insomnia: Continue ambien prn
# Anxiety: Continue Ativan
# Code Status: Full | 21 | 169 |
11717514-DS-15 | 24,247,453 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You were admitted because you had a persistent cough and CT
scan showed multifocal pneumonia.
What was done for me while I was here?
- You were given nebulizers, inhalers, and cough suppressants to
improve your shortness of breath and cough.
- You were given additional prednisone because your cough did
not improve initially. Please continue this until ___
- Your pneumonia was treated with Cefpodoxime. Please continue
this until ___ to complete a course.
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should attend all of your follow-up appointments.
- You should be evaluated by Occupational Health at ___ prior
to returning to work.
- Please continue your inhalers until you see your primary care
doctor.
We wish you the best in the future.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female with PMH
hypothyroidism, paroxysmal A. Fib, OSA not on CPAP, uterine
adenosarcoma s/p TAH/BSO ___, R breast atypical ductal
hyperplasia s/p PPX b/l mastectomy, and HTN admitted for
multifocal pneumonia not responsive to PO Abx/prednisone as
outpatient. | 147 | 44 |
19528617-DS-24 | 26,887,265 | Dear Mr. ___,
You were admitted to the hospital after three days of chest pain
that began after using heroin. You had a fever in the emergency
room. We were initially worried that you had a serious infection
so we gave you a few doses of IV antibiotics, but your chest
pain slowly got better and you didn't have any more fever or lab
abnormalities to suggest a serious infection, so antibiotics
were stopped.
In order to determine the cause of your fevers and pain, we did
a number of imaging and lab studies. In the emergency room, we
got a CT scan of your head which showed no abnormalities. We
also got an ultrasound of your heart which did not show any
evidence of infection. We collected blood cultures which did not
grow any bacteria. We think your fever may have been due to a
reaction from your IV drug use or due to a viral infection. We
got concerned for your heart after a few of your EKGs showed
worrisome signs. We did a nuclear stress test which was normal
as well and did not suggest heart disease.
Finally, you met with a social worker to discuss some of the
ways in which we can ensure that you get the best methadone
treatment possible. You stated you would prefer to talk to your
counselor to discuss changing to a more convenient ___
clinic.
It is very important that you go to the new primary care
appointment that we set up for you. You should also continue to
see the providers at ___ and take the medications
you were taking when you came in.
Thank you for letting us be a part of your care!
Warmly,
Your ___ care team | This is a ___ year old male with past medical history of prior
endocarditis, prior pulmonary TB, fungal lumbar osteomyelitis,
opiate dependence on methadone maintenance, admitted with chest
pain following reported IV heroin use, with unremarkable
persantine MIBI, feeling improved and discharged home
# Chest pain: Pt p/w three days of chest pain that was constant,
non-exertional, and not relieved by rest or SL nitro. Pulmonary
embolism felt to be unlikely given absence of tachycardia,
hypoxia, or pleuritic pain on exam. Given concern for cardiac
etiology ___ EKG showing new TWI in V3-V5, patient underwent
p-MIBI that showed no evidence of cardiac ischemia. Patient
rapidly improved without intervention. Symptoms were felt
likely to be due to costochondritis vs pleuritis from recent
viral respiratory infection. Remainder of infection workup
including blood cultures remained negative. Patient counseled on
reasons to return to care, including recurrent fevers, worsening
back pain, or any leg weakness.
# Opiate Abuse, Complicated - per patient, recently relapsed
after missing an appointment at the ___ clinic. Endorses
using own clean needles, cotton filter. Stated that it was often
difficult for him to get to his previous clinic during the
narrow window in which it is open (8am-11am). SW consulted,
recommended that ___ clinic in ___, Community
Substance Abuse Centers (___), was closer to patients
home. Pt reported he preferred to contact them himself after
discharge to discuss transitioning to them. Pt's current
methadone dosing confirmed at 68mg daily. Current clinic is:
___ ___.
# Leukopenia / Neutropenia - on admission, WBC 4.4, ANC 0.98,
with subsequent nadir of 0.37 on hospital day 4. On review of
history, mild leukopenia and neutropenia has been present in the
past, albeit to a lesser extent compared to his nadir. He
subsequently improved to ANC >0.5. It was suspected patient had
a chronic leukopenia that was complicated by acute viral
infection (as above), that subsequently resolved.
# Depression - continued home trazodone 100mg QHS, Seroquel 25mg
BID, Prazosin, Paroxetine
Transitional Issues
- Set up to establish care at ___
- Would consider repeating CBC with diff (follow-up ANC)
# CONTACT: ___ (wife/girlfriend)
# CODE: Full (confirmed) | 286 | 354 |
14688791-DS-7 | 28,955,977 | Dear Mr. ___,
It was a pleasure caring for your during your hospitalization at
the ___. As you know, you were
admitted following an episode of palpitations and sweating. We
did tests which did not show you were having a heart attack. We
repeated an ultrasound of your heart which showed reduced
pumping ability of your heart. We did tests to look at your
heart vessels called coronary arteries which did not show any
major blockages. Tests of your heart rhythm did show very
frequent abnormal heart rhythms called premature ventricular
contractions (PVCs). Your symptoms are likely due to heart
muscle dysfunction called cardiomyopathy from these PVCs. As a
result, we started you on new medications called sotalol and
spironolactone, which you will need to continue to take. You
will have your heart rhythm monitored (called ___ of Hearts)
and a repeat ultrasound of your heart after one month. Please
take your medications as instructed. Please followup with your
primary care physician and cardiologist. If you develop any
chest pain, shortness of breath, palpitations, lightheartedness,
nausea, or vomiting, please seek medical attention urgently.
Sincerely,
Your ___ Care Team | ___ yo M with history of HTN, HLD, DM2 and obesity who presents
with palpitation and diaphoresis, recently abnormal stress test,
with nonischemic cardiomyopathy.
# Nonischemic Cardiomyopathy: TTE ___ LVEF 30%, no
significant valvular disease. EKG notable for frequent PVCs.
Patient presenting with palpitations, diaphoresis,
lightheadedness, and nausea but no chest pain. Presentation is
concerning for tachycardiomyopathy. PVC burdent only 15%
(classically PVC-induced cardiomyopathy PVC burden is greater
than 20%). HIV cardiomyopathy and hemochromatosis were less
likely given negative HIV antibody and normal ferritin levels.
He was started on sotalol with decrease in PVC burden and
resolution of his symptoms. His QTC was 500 at discharge. Beta
blocker was deferred due to long QTc. He was also started on
spironolactone and his chlorthalidone was stopped at discharge.
He was discharged with ___ of Hearts monitor and will follow
up with cardiology in 2 weeks with arrangements for Holter
monitor and repeat ECHO in 1 month. | 185 | 160 |
17018536-DS-4 | 28,207,391 | Dear Mr. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital after you fainted at
home, and you were also found to have swelling around your eye.
We think that you fainted because your heart rate was very slow,
and there was also an irregular rhythm that we found on an
electrocardiogram of your heart. We had the heart specialists
come and see you and they want you to follow up with them as an
outpatient. They also want you to start taking a medication
called Pradaxa for the next month (see below). We also want you
to stop some of your medications (see below) because they can
cause your heart rate to slow down.
We think that the area around your eye started to swell because
some bacteria entered through a break in the skin. We started
you on antibiotics through your vein to treat this infection.
As the swelling improved, we transitioned you to antibiotics by
mouth that you will have to continue at home for another five
days (see below).
.
The heart doctors also recommended starting you on Lasix, a
medication that will help remove excess fluid from your lungs
and allow you to breathe better. You should get your blood work
done on ___ with Dr. ___ below for your
follow-up appointments).
.
It is very important that you follow in clinic with Dr. ___
___ in one month. His office will call you to set up an
appointment. His office number is ___
.
We made the following changes to your medications:
START Pradaxa 150 mg by mouth twice a day
START Bactrim double srength 1 tab daily (LAST day is ___,
___
START Augmentin 875 mg by mouth twice a day (LAST day is ___,
___
START Lasix 20 mg by mouth daily
STOP topiramate 25 mg by mouth daily
STOP pregabalin 50 mg by mouth daily
STOP atenolol 25 mg by mouth daily
START artifical tears as needed for dry eyes | Mr. ___ is a ___ year old male with PMH of pulmonary HTN, HTN,
hypercholesterolemia, obesity, OSA, gout, low back pain, and h/o
leg cellulitis/abscess presenting for further evaluation of left
facial swelling and syncope evaluation.
.
#. Left pre-orbital facial cellulitis: The patient was found to
have swollen L orbital area with erythema, consistent with
cellulitis. CT imaging showed no involement of the orbit
itself, making it preseptal cellulitis; likely that small
laceration under left eye was the portal of bacterial entry.
The patient did not have any visual changes or pain with eye
movement, and was started on IV Vanc and Zosyn. As his
infection improved, he was transitioned to Bactrim and
Augmentin, and continued a total of ten day antibiotic course.
.
#. Syncope: The patient presented from home with ?syncopal event
and on ekg was found to have new atrial flutter with variable
4:1 to 8:1 conduction, with heart rates intermittently dipping
down into the ___. The patient was monitored closely on tele
and remained asymptomatic during his brief bradycardia episodes,
usually lasting anywhere to ___ seconds on tele. His home
atenolol, as well as his pregabalin and topiramate were both
held. No evidence of ischemia was seen on EKG and the patient
was ruled out for MI with troponins. EP was consulted and the
patient decided to have an EP study in one month, and was
started on Pradaxa 150 mg twice daily to ensure adequate
anticoagulation prior to EP study.
.
# hypoxia: The patient had new O2 requirement while he was
hospitalized. Initially, it was thought to be due to volume
overload, as he had evidence of pulmonary congestion on CXR. He
was diuresed, but still continued to require 2L NC. On RA, he
would desat down to mid-80s with ambulation and also with rest,
but would spontaneusly bounce back up to mid90s on his own. As
per prior pulmonary clinic notes, this has been a long standing
issue with the patient, likely related to his baseline obesity
hypoventilation and OSA. The patient was discharged on home O2,
for his comfort. He was also encouraged to use his CPAP at
night for his OSA.
.
# creatinine bump: The patient's creat on discharge was 1.5,
baseline 1.1-1.2. Likely in the setting of aggressive diuresis.
The patient is going to follow up with his PCP ___ ___ will
need to have lytes and creat checked at this point to ensure
that creat stabilizes.
#. HTN. The patient was continued on his home valsartan and
triamterene/HCTZ. His home atenolol was held given his
bradycardia.
.
#. Hyperlipidemia. The patient was continued on his home
ezetimibe, atorvastatin.
.
#. Peripheral Neuropathy. The patient's topiramate and
pregabalin were both held, out of concern for sedation and
worsening hypoxia
.
#. Gout. Continue home allopurinol.
.
#. GERD. Continue home omeprazole.
. | 335 | 493 |
14134486-DS-20 | 26,415,130 | Dear ___ was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you had a severe headache
accompanied by sensory deficits on the right side of your body.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had imaging and a lumbar puncture to rule out a stroke and
CSF infection, respectively, per our neurology and neurosurgery
teams.
- We briefly treated you with a PCA pump to try to treat your
flare per our pain specialists recommendations.
- Your pump was interrogated and found to be working normally.
- You received bilateral supraorbital blocks and bilateral
occipital nerve blocks to try to alleviate your headache.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You already have a neurologist/HA specialist. If you need an
additional appointment at ___ for whatever reason, we recently
hired a headache specialist, and you can schedule an appointment
by calling ___.
We wish you the best!
Sincerely,
Your ___ Team | ___ is a ___ year old woman with a past medical
history significant for chronic low back pain (s/p L4-5 fusion
with laminectomy of L5 and S1, revision L4-5 fusion, multiple
escalating oral opioid doses leading to intrathecal fentanyl
pump placement with resolution of back pain) who presented with
right sided sensory deficit and brief right hand weakness
accompanied by severe positional headache. She was ruled out for
TIA/Stroke by neurology/neurosurgery teams and diagnosed with
complex migraine requiring PCA briefly.
#Complex Migraine
#Pain Management
Patient unfortunately suffers from a chronic, positional
headache since intrathecal pump placement in ___. She
presented with severe headache flare associated with right sided
(including face, right arm, right leg) sensory deficits and a
brief episode of right hand weakness. Non-Contrast Head CT and
CTA head and neck were negative. CT Abdomen & Pelvis with
contrast was negative for leak. Neurosurgery consulted and felt
symptoms unlikely related to pain pump malfunction. Neurology
consulted and felt most likely a complex migraine rather than a
TIA. LP unremarkable (only 2 nucleated cells). Pain service was
consulted who administered bilateral supraorbital blocks and
bilateral occipital nerve blocks. Per patient, relief was
temporary, which she attributed to lidocaine injection. Pain
medication was tapered using pain service recommendations. She
was also on standing Tylenol 1g q6hr
Patient was maintained on home migraine medications including
topirimate 100mg QAM, 200mg QPM; home Amitriptyline 50 mg PO
QHS; and a bowel regimen to combat constipation from high doses
of narcotics.
CHRONIC ISSUES
==============
# Chronic Back Pain ___ Fall - Pain well-controlled by
intrathecal pump.
The patient has chronic low back pain after sustaining a fall
and is now s/p L4-5 fusion with laminectomy of L5 and S1,
revision L4-5 fusion, multiple escalating oral opioid doses
leading to intrethecal pump placement. She was also continued on
home Tizanidine 4 mg PO TID. Intrathecal pain pump working well
per pain service evaluation (576 mcg fentayl daily).
# Depression
Patient continued on home fluoxetine. | 190 | 326 |
13898303-DS-4 | 24,245,530 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were here because of a fever as well as low white blood
cell and platelet counts
WHAT HAPPENED IN THE HOSPITAL?
- You received a platelet transfusion
- You were given antibiotics originally but they were stopped as
your counts had improved significantly and you did not have any
fevers
- you were monitored overnight but did not have any fever or
concerning signs of infections
WHAT SHOULD YOU DO AT HOME?
- Follow up with Dr. ___ on ___ for planning of next
chemotherapy treatment
- Please report to the ER if you have a fever above 100.4
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | Patient summary:
===================
___ year-old gentleman with history of mantle cell lymphoma s/p
3 Cycles Rituximab/Bendamustine and recent HiDAC (___)
who
presented with headache, oral pain and febrile neutropenia and
thrombocytopenia. He had received a dose of Neulasta on ___ as
outpatient. Started on Vanc/cefepime/flagyl with concern for
possible mucositis/sinusitis source of infection overnight.
However, neutropenia resolved following morning without any
evidence of infection. Antibiotics were stopped and patient
remained afebrile with complete resolution of neutropenia for 24
hours prior to discharge. | 131 | 78 |
11717909-DS-31 | 22,599,852 | Dear Ms. ___,
You were hospitalized at ___ for a cough and runny nose, which
are symptoms that we think are consistent with a viral upper
respiratory infection. Given that you did not have a fever and
that your labs and imaging are reassuring against bacterial
infection, we feel that it is best for you to recover at home.
After close monitoring overnight, we did not feel that
antibiotics are necessary at this time.
If you develop a fever (temperature > 100.4 F), worsening cough,
malaise, or symptoms that are concerning to you, it is important
that you return to the ED immediately.
We have made a few medication changes:
MEDICATION DOSING CHANGED: Tacrolimus (take 1 mg in AM and 0.5
mg in ___
Please have labs checked on ___ morning before you
take your morning dose of Tacrolimus.
You should continue taking Posaconazole at this time, at least
until ___ when your ID doctors ___ its necessity.
It is important that you attend your follow-up appointment
listed below.
It was a pleasure taking care of you!
We wish you the best,
Your ___ Team | ___ y/o M with a h/o familial DCM ___ OHT ___
(CMV+/EBV+/Toxo- donor) with course c/b Ab-mediated rejection
___
plasmapheresis x5 and rituximab c/b MSSA CLABSI in ___, severe
TR ___ tricuspid injury from endomyocardial biopsies, adenovirus
sepsis and aspergillus pneumonia (___), Moraxella
pneumonia (___), compression fractures, who presents for
cough, malaise, rhinorrhea x 2 days, and intermittent bilateral
knee pain
# Cough, malaise, rhinorrhea:
His symptoms were consistent with viral URI as multiple family
members have had similar symptoms. Patient has been afebrile
though he has mild leukocytosis with slight bandemia, which was
down-trending on the day of discharge. Flu PCR negative. UA
negative. No focal abdominal complaints or diarrhea. CT chest
without new focal findings c/f infection. Given
immunocompromised state with multiple, severe infections in the
past, he was admitted overnight for observation. On hospital day
2, he continued to feel well overall, complaining only of dry
cough; his knee pain had resolved (knee exam completely normal).
He was not treated with antibiotics. He was instructed to call
or return for urgent medical care if he develops any signs of
worsening infection.
At time of discharge, two blood cultures, urine culture, and
respiratory viral panel results were pending.
# Dilated cardiomyopathy (genetic) ___ heart transplantation
complicated by antibody mediated rejection and severe TR
following endocardial biopsy. Most recent RHC (___) with
normal filling pressures and cardiac output. Plan for tricuspid
repair at ___ in ___. On this admission he was euvolemic
without any cardiac complaints or active issues. On posaconazole
maintenance for hx of aspergillus pneumonia. Tacrolimus level
was elevated at 12 on admission, with dosing of 1mg BID. Morning
dose of tacro was continued at 1mg, but evening dose was reduced
to 0.5mg. He will have tacrolimus trough and posaconazole levels
and electrolytes and renal function checked on ___. He was
continued on mycophenolate 500mg PO BID and prednisone 5mg PO
daily. PCP ppx was ___ 1500mg PO daily.
# Osteoporosis: Hx of lumbar fracture in the setting of seizures
after being weaned off benzodiazepine sedation following
prolonged intubation in early ___. No longer wears back brace.
Followed by Dr. ___ injections
injections
- Continued calcium 250 QID and vitamin D 1200 U daily
# Hypertension:
- Continued on home clonidine 0.1 mg BID
- Continued home amlodipine 5 mg daily
# Hypothyroidism:
- Continued on home levothyroxine 25 mcg
TRANSITIONAL ISSUES
-------------------
[]Tacrolimus trough on admission was 12. Tacrolimus goal is
___. Tacrolimus dosing reduced to 1 mg qAM and 0.5 mg qPM
[]Posaconazole to continue through at least ___ before
re-evaluation (for history of aspergillus pneumonia)
[]Will go for lab draw to measure Tacrolimus trough and
Posaconazole level on ___
[]F/u pending respiratory viral panel, blood and urine cultures
# Code Status: FULL CODE
# CONTACT: ___ ___ | 176 | 446 |
15856008-DS-11 | 22,109,747 | Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted because you were having
trouble breathing and you felt the swelling in your legs had
increased. You were treated with diuretic medications while
your blood pressure was carefully monitored. Unfortunately,
this fluid build up is due to your CHF, as the pumping function
of your heart is not working efficiently.
Please make the following changes to your medications:
-CONTINUE: Torsemide; however, as your disease progresses this
medication will become less effective in removing the excess
fluid.
Please continue with your other medications as previously
directed. | ___ yo M with h/o sCHF (LVEF of ___, RA, and pacemaker
(tachycardia protective features of which were recently turned
off) who was recently discharged home on hospice presenting to
today with a worsening of his shortness of breath and ___ edema
with skin changes concerning for possible cellulitis.
# PUMP: Acute on chronic systolic heart failure (LVEF of
___.
Patient has known severe systolic CHF (___ stage 4) and was
recently discharged from ___ with hospice care. He presented
a worsening in his respiratory status and increased ___ edema.
Upon arrive, he felt SOB with minimal to no exertion and decided
to come to the ED because he would like to "take some fluid off
to give [him] another month". He was started on a lasix gtt
with careful monitoring of his BP. The patient has known
borderline BP at baseline, with his SBP ranging from 90-100. He
gradually diuresis with some improvement of his respiratory
status and ___ edema. As the diuresis continued, his urine
output decreased with increasing levels of lasix. Upon
discussions with the patient and the medical staff, it was
decided that additional diuresis would not be beneficial at this
time. Of note, patient is not an ___ as he is going
home with hospice.
# RHYTHM: Atrial Fibrillation
The patient has known afib and is not on anticoagulation due to
fall risk. The ICD function of his pacemaker was turned off when
the patient had been placed on hospice last month. His home
medications (digoxin) were continued.
# Chest pain
Patient reports some episodes of substernal/epigastric chest
pain prior to admission. He was vague regarding his symptoms
but he reports that he felt his symptoms may be related to
"indigestion". Patient's troponin were slightly elevated (0.06
on admission -> 0.10, up from 0.05 on previous admission). EKG
did not reveal evidence of acute ischemia. There was limited
concern for ACS and he was not started on anticoagulation as any
intervention would be inconsistent with his long term goals.
His home PPI dose was doubled at he felt some of his discomfort
was similar to heart burn. His home aspirin dose was continued.
# RA
The patient has known severe RA and received infliximab
infusions approximately monthly. No acute interventions.
Patient was given pain medications as needed.
# H/o UTI
UA and culture were checked given his history of a recent UTI
and were negative. Specimen may have been sterilized as patient
received vanc/zosyn in the ED, however the patient did not
endorse s/sx of a UTI.
# Possible Cellulitis
The patient has known poor skin and significant edema. It does
not appear acute infected and likely just due to his worsened
edema. He received vanc/zosyn in the ED, but this was not
continued as it was not felt to be infected.
# BPH
Patient was continued on his home medications.
# Goals of Care
The patient has severe end stage CHF and was recently discharged
home on hospice. He reports that he decided to come to the ED
today to "take some of the fluid off, to give [him] another
month". Multiple lengthy conversations regarding his wishes
were had. He has always been clear that he is DNR/DNI and
decided that he would not wish to have an ICU transfer to BP
supporting medications should he decompensate. He expressed
that he would like to remain at home if at all possible. He
also met with palliative care who had multiple discussions with
the patients about his wishes and expectations. It appears that
the patient did not have a clear picture of what he would
experience as his heart failure progressed. He reported feeling
that he would just "fall asleep one day and not wake up" but did
not think that he would be as uncomfortable as he was. He was
encouraged to use pain medications to help ease his discomfort.
Discussions were had with both the patient and his son that his
condition is not reversible, but he may not pass imminently.
When it became apparently that he would not benefit from
additional diuresis, it was decided that the patient would
return home with hospice care. | 104 | 732 |
13244694-DS-10 | 24,234,642 | Dear Mr. ___,
You were admitted to ___ for a clotted fistula. The
radiologists took a look at your fistula and removed the clot.
Before you left, we tested the fistula with a dialysis session
that went smoothly.
We wish you the best of health,
Your ___ Care Team | ___ PMH HTN, HLD, DM2, ESRD on HD MWF, admitted for clotted AV
fistula s/p fistulogram and successful thrombectomy.
# Clotted fistula
# ESRD on HD ___: Presented with clotted fistula to HD on
___. Underwent fistulogram with thrombectomy w/ ___ ___,
repeat thrombectomy done ___ after a difficult HD session.
Underwent successful dialysis session w/ repaired fistula ___
prior to d/c. Otherwise continued home doxercalciferol,
sevelamer, cinecalcet. Gets epo as outpt.
# ? L toe cellulitis: No e/o active infection, in the middle of
long course IV abx. CRP
normal upon arrival. Continued vanc / ceftaz as previously
determined prior to hospitalization.
# HTN: Borderline hypotensive on admission, initially held
amlodipine, restarted at time of d/c.
# DM2: restarted glipizide at time of d/c, continued insulin
regimen.
# HLD/cardioprotection: Continued atorvastatin, ASA
# Glaucoma: Continued Latanoprost, Brimonidine, Acetazolamide,
Dorzolamide / Timolol, Artificial tears.
# GERD: continued tums, ranitidine
TRANSITIONAL ISSUES
===================
[ ] continue dialysis per previous outpatient schedule,
received session ___ prior to d/c
[ ] watch for any further enlargement of pseudoaneurysm | 48 | 164 |
15393401-DS-33 | 23,337,165 | Dear Mr ___,
It was a pleasure taking care of you at the ___
___.
You were admitted because you were having trouble breathing,
particularly when laying down. Your chest X-ray showed showed
that you had some excess fluid in your lungs, which was likely
causing your difficulty breathing. We had excess fluid dialyzed
off, and this helped your breathing. We also gave you inhaler
treatments which seemed to help your breathing as well. We think
part of the reason you had fluid in your lungs may have been
because your heart is not pumping fluid forward into the body as
well it should, and some of the fluid is backing up into your
lungs. We will have you follow up with your heart doctor to
address this issue.
Your chest X-ray also showed a small nodule, and a CT scan of
the chest was obtained, but completely read by the time you were
discharged. We will contact you with the official results.
However, they did see some small lung nodules, and would like
you the schedule a follow up CT in 12 months. They also noticed
a lesion in your liver, which has been noted before and is
stable. They also noted a lesion in your pancreas, which has
been noted before. An MRCP (an MRI for your pancreas) is
recommended to follow this up.
You are discharged with an albuterol inhaler to help with
wheezing and shortness of breath. We are discharging you with a
medicine, benzonatate, for cough. We also gave you a short
supply of trazadone for sleep - you should follow up with your
PCP if you continue to have difficulty sleeping. We do not
recommend continuing the codine cough medicine as it can cause
seizures in patients with renal faliure.
You should follow up with your cardiologist and pulmonologist as
scheduled. Go to dialysis on ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo M with ___ of ESRD on HD (MWF), T2DM and afib/flutter
presenting with shortness of breath, orthopnea and weakness.
.
ACUTE ISSUES:
.
# Orthopnea ___ dCHF: Secondary to volume overload, likely in
setting of dCHF exacerbation. No suggestion of fluid or sodium
indiscretion, never misses HD.
CXR on admission showed fluid overload, patient improved
significantly with HD on ___ and ___, being dialyzed below his
normal dry weight - he tolerated this well with no cramping or
hypotension. Patient has possible diganosis of amyloidosis,
partially worked up on last admission. Follows with Dr ___
___ ___ ___. Spoke with ___ Cardiology
Inpatient Consult, who felt there were no modifications which
might further optimize patient's cardiac status.
.
# Cough/RUL nodule: since ___, productive of white sputum; has
seen outside pulmonologist at ___. Non-smoker, CXR here
shows RUL nodule. Follow up chest CT showed pleural plaques,
multiple pulmonary nodules, most of which were stable, but some
which require follow up, stable ground glass opacities, stable
hepatic lesion, pancreatic head lesion which requires follow up.
.
CHRONIC ISSUES:
.
# ESRD on HD: HD MWF through R arm fistula, gets zemplar 3 mcg
IV and vit D IV on HD days, continue nephroncaps
.
# HYPOTENSION: issue on last admission, started on minodrine,
seems to be improved, SBP 100-110s throughout stay.
.
# ATRIAL FIBRILLATION: continue comuadin, no rate/rhythm
controlling agents.
.
# ANEMIA: chronic, likely anemia of chronic disease and ___ CKD,
Hct stable throughout stay.
.
# T2DM: ISS w/5 units ___ glargine
.
# GOUT: continue allopurinol
.
TRANSITIONAL ISSUES:
.
Follow-up Chest CT in 12 months to f/u pulmonary nodules.
.
Follow-up MRCP to assess pancreatic head mass.
.
Follow-up with cardiology to further w/u amyloidosis, manage
dCHF. | 329 | 272 |
16789279-DS-13 | 29,508,421 | You were admitted with increasing fatigue and shortness of
breath. Your breathing was stable and improving off
antibiotics. You also had anxiety and were started on Ativan
with improvement. You should follow-up closely with your
primary care physician. | ___ y/o M w/ PMHx HIV on HAART, CAD, HTN, recent hospitalization
for pneumonia ___, discharged on levofloxacin, who presented
with malaise and nausea
# Pneumonia: Pt with recent admission for PNA. Presenting with
persistent dypsnea, as well as nausea and poor PO intake at
home. Given broad HCAP coverage in the ED for possible ongoing
infection. Clinically appeared that pneumonia had resolved, his
respiratory status was stable, no fevers or leukocytosis. He was
observed off antibiotics and felt well. He denies shortness of
breath with activity.
#Diarrhea: Likely antibiotic related, c. diff was rechecked and
was negative. His appetite and nausea improved off antibiotics.
#Psych: History of anxiety and recurrent major depression
requiring psych hospitilization. He is reporting significant
anxiety and depression with both medical and financial factors
exacerbating. He reports previously being on effexor with good
effect. He was given ativan here which helped his anxiety. He
will discuss with PCP whether to restart antidepressant
# HIV: continue HAART, bactrim ppx
# HTN: continue lisinopril, metoprolol
# HLD: continue statin
# CODE STATUS: full | 41 | 172 |
11591196-DS-15 | 27,028,014 | Dear Mr. ___,
You came in feeling short of breath, and a CT scan showed that
you have clots in your lungs. In addition, we noted that your
right leg had increased in swelling and a CTA scan showed an
external compression of one your leg veins by a bursa. We took
you to the operating room and placed a stent in your external
iliac/femoral veins. We started you on a blood thinner called
lovenox while you were here. You will need to take warfarin
(another blood thinner) after leaving the hospital, and you will
also need to continue the lovenox injections for at least a few
days until your warfarin levels are high enough. It is important
for you to have close follow up to monitor your warfarin levels.
The ID doctors also ___ to continue the IV antibiotic for
at least four more weeks to treat your hip infection. They will
also schedule you for follow up in the ___ clinic.
You will be seen by Dr. ___ in one month with
a venous duplex of your right groin. | Mr. ___ is an ___ gentleman who has had extrinsic
compression of the right external iliac vein/proximal common
femoral vein by a bursa in his pelvis. This has previously been
treated with an open incision and drainage procedure, but the
bursa continues to reaccumulate, and caused extrinsic
compression, which leads to swelling and heaviness of his right
lower extremity, and difficulty walking. He presented initially
during this admission with a bilateral pulmonary emboli. He was
started on systemic antiacoagulation based weight based heparin
gtt, which was transitioned to lovenox and coumadin as an
outpatient. In addition, he continued IV ceftriaxone for a
total of 6 weeks per ID recommendations. Please refer to ID
consult for futher details. Once patient was clear from his
medical issues he was taken to the OR for iliofemoral vein
stent. Please see operative note for details. Postoperatively,
he remained afebrile, hemodynamically stable and without oxygen
requirements. His right lower extremity edema was noted to be
decreasing. He ambuakted without issues and was deemed safe to
go home by physical therapy. ___ services for IV antibiotics
were arranged as well as ___ clinic with his PCP. | 178 | 192 |
19695954-DS-22 | 21,226,860 | Dear Ms. ___:
It was a pleasure taking care of you during your hospitalization
at ___. You had come in because you felt more tired,
experienced a 5lb weight gain, and had total body discomfort.
You potassium levels were found to be very high and your kidney
function was noted to be very poor, and emergent dialysis was
performed after a line was placed in your neck. Your renal
function and potassium began to improve after dialysis. You
were taken to the ICU, and later noted to have bloody stool and
a drop in you blood count. You were given blood products and
supportive care. An endoscopy was performed and a large ulcer
was noted in your stomach. You were continued on medications to
help prevent bleeding. You also experienced problems with your
breathing that was related to your heart failure and
hypertension. We began taking off significant amounts of fluid,
and your breathing improved. We transitioned you to an oral
water pill that will help keep the fluid off your lungs.
We have made the following changes to your medication list:
Please START taking torsemide 80mg daily to keep fluid off your
lungs.
Please START taking trazadone 25mg as needed at night as needed
for insomnia.
Please START taking tylenol as needed for pain.
Please START takng Bisacodyl 10mg daily and Senna twice daily as
needed for constipation.
Please STOP taking Clopidogrel, furosemide, and benazepril.
Please CONTINUE taking the rest of your medications as
prescribed.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Please follow up with your appointments as outlined below.
Thank you, | Ms ___ is ___ female with history of CHF, severe HTN, renal
artery stenosis recent hospitalization for CHF exacerbation now
admitted in the setting of acute kidney injury and hyperkalemia
requiring emergent hemodialysis .
# Hyperkalemia: Most likely from ACEI restarted and acute kidney
failure, with contribution from slow upper GI bleed. Presented
with myalgias, weakness to PCP, found to have potassium of 6.7,
was called and instructed to present to the ED where repeat K
measurement found to be 7.3. EKG showed peaked T-waves,
prolonged QRS, prolonged PR interval. patient was given insulin
with D50, bicarbonate, NS 500 cc IV bolus, kayxelate and renal
was consulted, patient was admitted to the MICU for further
monitoring. Repeat K was still elevated and patient required
emergent dialysis on the night of admission, with subsequent
potassium levels within normal limits. As ___ resolved and
creatnine returned to baseline, the potassium levels continued
to be normal.
# Acute on chronic kidney injury: Found to have oliguric acute
tubular necrosis on microscopic examination of urine. Likely due
to relative hypotension, as this has happened before when her
blood pressures were well controlled to "normal" range. This is
likely iatrogenic from ACE inhibitor and increase in diuretic
dose as well as possibly blood volume loss from slow GI bleed.
Renal ultrasound showed chronic disease and trace ascites, no
explanation for acute decompensation. Renal was consulted and
patient underwent one session of emergent dialysis for
hyperkalemia on night of admission with subsequent sustained
improvement in creatinine. Investigation for other causes of
renal failure were negative as . SPEP negative. UPEP negative
for monoclonal bands or bence ___. However, creatinine
remained in mid 4's with difficulty maning fluid status
initially, likely secondary to heart failure exacerbation (see
below). Patient was diuresed and creatinine returned to baseline
(1.7) prior to discharge. Sevalmer was discontinued.
# Chronic systolic and diastolic heart failure.(LVEF 45-50%):
Patient was notably volume overloaded, with elevated JVD,
crackles, dyspnea, and ___ edema upon return from endoscopy on
___. She was notably in distress and imaging illustrated
pleural effusion and pulmonary edema on ___. Diuresis with
lasix and metalozone yielded significant improvment in O2
requirement and adequate output. Per last DC summary dry weight
thought to be 69kg. Heart failure service was consulted and felt
diuresis was adequate. ECHO was performed to assess for interval
changes and yielded increased valvular disfunction and relative
hypokinesis of septum/lateral wall as compared to before.
Patient appeared euvolemic ___, and was transitioned to 80mg
of torsemide prior to discharge to maintain euvolemia. Fluid
restriction was maintained at 2L. Patient's admission weight
was 72kg, and discharge weight was noted to be 62.8kg.
# Hyponatremia. Urine sodium and urine osm c/w kidney poor
perfusion. Resolved with diuresis and restoring intravascular
volume. Resolved during hospital course. Patient was maintained
on fluid restriction to 2L.
# Leukocytosis/Fever: Possibly stress response to GI bleed.
Presented with leukocytosis, negative chest xray, blood cultures
and urine cultures. Received one dose of ceftriaxone when
urinalysis showed leukocytes, but this was stopped when cultures
were negative. Gradually resolved without intervention.
# Normocytic anemia: No clear source of bleeding on admission,
hemolysis labs negative. Initial hematocrit drop from 24.5 to
18.7. Did not bump appropriately to 6 units of pRBCs. CT torso
did not show any occult source of bleeding such as
retroperitoneal bleed. She complained of black tarry stools on
the weekend prior to admission and was reportedly guaiac
negative at clinic, did not produced bowel movement until
several days after admission, which was large, dark and tarry
per nursing. Initial rectal exam with brown guaiac positive
stool in rectal vault. Of note patient is on chronic iron
supplementation therapy. Patient was discussed with GI who
decided to perform endoscopy which showed esophagitis, erythema
and friability of fundus, large superficial clean based ulcer in
stomach body, and gastritis. Patient was continued on high dose
IV PPI, and clopidogrel was held in setting of GI bleed.
Patient's hematocrit remained stable for remainder of hospital
course. Patient was continued on PO ferrous sulfate. Repeat EGD
to be porformed on ___ weeks for evaluation of gastric ulcer and
acquisition of biopsies.
# Thrombocytopenia: Down from baseline of 150-200, negative
hemolysis labs, no known heparin exposure at home prior to
presenting with these lab values. Stabilized at 139.
# Hypertension: Adjusted anti-hypertensive regimen for
permissive hypertension to allow for renal perfusion. (SBPs 130s
to 150s).
# Chronic systolic and diastolic heart failure: Presented with
weight gain since recent admission for heart failure. Weight on
arrival here was 72kg, from discharge weight of 68kg. She had
been discharged on PO torsemide, and when she presented to her
PCP with weight gain and increased creatinine, she was changed
back to furosemide. On presentation this admission she had
bibasilar crackles, chest xray showed mild pulmonary edema, so
she received IV furosemide intermittently and discharge weight
was ____.
# CAD s/p CABG, PVD: Continued beta blocker aspirin. Held statin
for myalgias, held ACEI for ___.
# Hypothyroidism: TSH was 8.6 on ___. Free T4 was normal.
Continued levothyroxine.
# Gout: held allopurinol for ___
# Chronic constipation: Coninued senna, miralax. Bisacodyl and
senna were added as iron seems to be contributing to
constipation.
# History of CVA: After discussion with neurologist and
cardiologist, clopidogrel was discontinued and patient was
continued on monotherapy with aspirin.
#Insomnia: Patient was started on trazadone 25mg HS:PRN
#Chronic pain: Patient was treated with oxycodone to 7.5mg q4.
Patient was given diluadid for breakthrough pain. | 263 | 914 |
15823580-DS-6 | 23,393,787 | Dear Ms. ___ ,
It was a pleasure caring for you at ___.
Why did you come to the hospital?
You came to the hospital because your heart was beating slowly
and you passed out.
What happened during your hospitalization?
During your hospitalization, your heart was beating very slowly
and your blood pressure was very low which necessitated for you
to go to the intensive care unit. In the intensive care unit,
you received medications to help your heart regain its regular
rhythm. After less than 24 hours in the intensive care unit,
your heart rate normalized and you were able to be moved to the
general medicine floor. You underwent two imaging studies to
look at your heart which showed that there was backwards flow
through your valve and some thickening of the valve. You should
follow up about this with your cardiologist. Your clonidine was
also stopped because a side effect of this
What should you do when you leave the hospital?
You should follow up with your cardiologist and your primary
care doctor. You should take care to avoid medications that can
slow your heart and please do not continue to take clonidine
until as directed by your primary care physician/psychiatrist.
Sincerely,
Your ___ Team | Ms ___ is a ___ y/o F with PMH significant for endocarditis
s/p
bioprosthetic MVR in ___, Bipolar disorder, who presents with
bradycardia and syncope likely due to intoxication. She was
bradycardic and syncopal and did not respond to fluid or 2mg
atropine, necessitating a transfer to the intensive care unit.
In the ICU, she received dopamine and was then switched to
levophed for less than 24 hours. She briefly went into a
junctional rhythm that did not require pacing. Clonidine or beta
blocker overuse was suspected, although she did not respond to
glucagon in the ICU. Her clonidine was held during her
admission. Her heart rate and hypotension self resolved and she
was moved to the floor. She underwent a transthoracic
echocardiogram that demonstrated worsening mitral regurgitation
with no vegetations, which was confirmed by transesophageal
echocardiogram. Her TEE showed moderate MR with ___ well-seating
bioprosthetic mitral valve. During her hospitalization, she also
complained of abdominal pain. An upright abdominal X-ray and
right upper quadrant ultrasound were both unremarkable. Rib
series x-rays showed no fractures. It was thought that her chest
wall pain was most likely muscoskeletal in nature, likely
costochondritis. She remained hemodynamically stable on the
floor and her pain was well controlled with Tylenol and
Lidocaine 5% patch.
======================
ACUTE ISSUES
======================
#Sinus Bradycardia and Hypotension
Ms. ___ experienced sinus bradycardia (heart rate in the ___
and associated hypotension that was minimally responsive to
fluids (2L in ED and 500cc X3 on floor) and atropine (2mg
received on floor). She had no documented structural abnormality
on previous echos (last ___. Troponins were negative and TSH
within normal limits at 4.1. There was concern for drug overdose
(beta-blocker though no prolonged PR, or sedative type
medications (such as trazadone (3-5% risk of syncope) or
clonidine (<4% risk of bradycardia). However, patient and
healthcare proxy (daughter) adamantly denied medication
mismanagement or substance use. She briefly received dopamine
and then norepinephrine in the ICU. She did not respond to
glucagon treatment for possible beta blocker overdose. Her
bradycardia and hypotension resolved fairly quickly with
supportive treatment. She required less than 24 hours of ICU
stay and serial EKGs did not show any higher degree block. Her
clonidine was held throughout her admission. She was noted to
have PR prolongation on initial admission, however this resolved
along with her hemodynamics.
It was thought possible that patient's presentation could be due
to substance use. She did receive morphine IV 12 mg in the
Emergency Department and urine toxicology was positive for
opiates (although urine tox was measured after first dose of
morphine). Other potential etiologies considered including
worsening valvular disease or endocarditis, although sinus
bradycardia would not be typical for these disorders. TTE
suggested worsening MR and no vegetations visualized. TEE was
eventually obtained that showed moderate MR with one thickened
leaflet, no vegetations or abscesses. Transthoracic and
transesophageal echocardiograms both demonstrated moderate to
severe mitral regurgitation with thickening of one leaflet of
her bioprosthetic mitral valve, but with no demonstration of
vegetations or abscesses. She did not experience any more
episodes of bradycardia and hypotension. She was discharged on
aspirin.
Of note, she is on multiple sedating medications and instead of
continuing her home gabapentin 800mg QHS and 300mg PO BID, she
instead was switched to 200mg BID dosing plus 600mg QHS given
potential concern this may have contributed to sedation and
potential bradycardia.
#Abdominal and Chest Wall Pain - During her admission, Ms.
___ complained of abdominal pain and chest wall pain. In the
ICU, her pain was primarily in the right upper quadrant,
prompting a right upper quadrant ultrasound which did not
demonstrate any evidence of cholecystitis. Furthermore, KUB did
not show any signs of obstruction. She also expressed focal left
chest wall pain which was reproducible with palpation. Rib
series x-ray did not demonstrate any acute or healing rib
fractures. It was thought that this pain was most likely
muscoskeletal in nature and was well controlled with Lidocaine
patches, capsaicin, and Tylenol.
==========================
Chronic/Ongoing Issues
==========================
# Bipolar Disorder
Patient has been seen at many hospitals in the past for drug use
and drug overdoses. Most recently was at ___ in ___,
following overdose on home sleeping pills, requiring ___
and inpatient psych admission. She states she takes clonidine
for anxiety which per above was held given her symptomatic
bradycardia leading to syncope.
# Fibromyalgia - Her home gabapentin dosing regimen was changed.
Instead of 800mg QHS and 300mg PO BID, she instead was switched
to 200mg BID dosing plus 600mg QHS given potential concern this
may have contributed to sedation and potential bradycardia.
# Insomnia - She was continued on her home dose of trazodone and
zolpidem.
# Reported Hx of CVA - Patients has dysarthria at baseline. She
was continued on aspirin 81mg daily
#Anxiety - She was continued on all of her home medications
except clonidine.
=======================
Transitional Issues
=======================
Medication Changes
- Held clonidine in the setting of bradycardia and hypotension
- Started ASA 81mg daily given prior CVA and bioprosthetic valve
- Changed gabapentin 800mg QHS and 300mg PO BID to ___ BID
dosing plus 600mg QHS to potentially reduce sedating side
effects
[ ] Continue to hold clonidine on discharge
[ ] Provided office number for cardiology department. She should
follow-up with them regarding her bradycardia and syncope
[ ] Worsening mitral regurgitation was seen on TTE and TEE due
to thickening of one of the mitral leaflets although still with
well seated mitral valve. Recommend follow up with cardiology
for further management. | 201 | 899 |
19462352-DS-26 | 25,831,098 | Dear Ms ___,
It was a pleasure to take care of you at ___. You were
admitted secondary to wet gangrene of the left second toe. We
worked with your podiatry team who took you to the OR on 4
separate times for the removal of unhealthy tissue. The left
___ toe was amputated and the wound was partially closed.
You received antibiotics treatment for underlying infection and
you will need to continue on IV antibiotics treatment after
discharge. Now you have a VAC dressing on the the bottom of the
left foot. It is very important that you do not place any
weight on the foot! You should follow the instructions below for
a fast and safe recovery:
Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
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
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
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
ACTIVITIES:
You should get up every day and walk without putting weight on
the left foot.
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower but do not get the foot wet.
Your leg incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed | ___ with DMII and PVD s/p bilateral lower extremity bypass
procedures (see Surgical History) most recently s/p re-do LEFT
SFA-to-AT bypass with LEFT cephalic vein ___ presents to
the ED on POD17 with worsening left ___ toe discoloration
associated with fever and malodor.
She was admitted for IV antibiotics and underwent several
debridements of the foot by podiatry including:
1.Excisional debridement down to and including bone, left foot.
Partial ___ ray amputation, left foot. ___
2. Excisional debridement down to and including the level of
bone, left foot, left percutaneous tendo-Achilles lengthening.
___
3. Excisional debridement down to and including flexor tendon,
left foot. ___
4. Partial excision left ___ metatarsal, I&D abscess plantar
space between between ___ and ___ toes, debridement all
non-viable tissues to bone area wound VAC placement ___
Neuro/ Psych : Pain was controlled on Tylenol / Morphine.
Pt was seen by ___ for evaluation of coping and depression. They
recommended outpatient counseling.
CV: Vital signs were routinely monitored during the patient's
length of stay. Hemodynamically stable throughout. Home
medication regimen maintained.
Pulm: Her activity was limited because of her surgical wound.
She was encouraged to cough and deep breath as well as use the
IS. Oxygen saturation levels monitored as indicated. CXRs
consistent with pulmonary edema consistent with diastolic heart
failure. RR and O2 sat was stable. ECHO unchanged.
GI: . The patient was later advanced to and tolerated a regular
diet at time of discharge.
GU: Patient had a Foley catheter that was removed before the
time of discharge. Urine output was monitored as indicated.
At time of discharge, the patient was voiding without
difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever. The patient was started on/continued on
antibiotics as indicated. Her WBC count peaked at 26 and this
was thought to be due to continued wound infection. At
discharge, she was afebrile with normal WBC.
Heme: The patient had blood levels checked post operatively
during the hospital course to monitor for signs of bleeding. The
patient had vital signs, including heart rate and blood
pressure, monitored throughout the hospital stay. Her Hct was
low postoperatively and she required transfusion. She received
a total of 3transfusions during her stay. Please continue
XARELTO- (renally dosed) and PLAVIX for leg bypass graft
patency.
Endocrine: Pt has poorly controlled DM. She was seen and
evaluated by ___ consult service. Her FSBS and insulin
coverage was monitored closely.
TSH was checked and found to be WNL.
Followup has been arranged with ID, podiatry and vascular. | 410 | 443 |
15516042-DS-3 | 26,912,412 | Dear Mr. ___,
You were admitted for a cellulitis (skin infection) of your
face. We initially treated you with IV antibiotics and then
transitioned you to oral antibiotics prior to discharge. Your
skin infection was improving prior to discharge. You should
continue to take your antibiotics as prescribed.
You also had slight inflammation in your liver. We would like
you to follow up with your liver doctor ___ another member of
the liver team) for further evaluation. They are working on an
appointment and will contact you when one is available.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team | ___ male presents with left sided facial swelling,
erythema, and fevers concerning for facial cellulitis
#Facial swelling + erythema:
#Cellulitis / Erysipelas
Likely cellulitis. Well-dermarcated edges along the face/ears is
suggestive of erysipelas. No evidence of abscess on exam.
Apparently when he was first diagnosed with hepatitis C it was
after being seen by dermatology for a rash with blisters, likely
representing porphyria cutaneous tarda, however his exam now is
more consistent with a cellulitis. It is improving with
antibiotics. We transitioned from vanc/ceftriaxone to
Amoxicillin/Doxycycline with continued improvement. Given high
risk for a complicated cellulitis based on rash location, he was
covered for both Strep and MRSA.
-Amoxicillin and Doxycycline: Last day = ___ for 10 day
course.
#Transaminitis
His LFTs were elevated prior to starting antibiotics. They were
stable during this hospitalization. HCV VL was checked but
pending on discharge.
-F/U HCV viral load
#Hyponatremia:
I/s/o hypochloremic, suspect from volume depletion. He received
1L NS in ED with some improvement in his Na.
-Held HCTZ; can restart as needed as outpatient with electrolyte
monitoring.
#HTN:
-Continued valsartan
-Held HCTZ as above
#HLD:
-Continued simvasatin
#HCV: Treated with interferon/ribavirin with sustained virologic
response but now with rising LFTs.
-f/u HCV VL | 99 | 187 |
16934854-DS-2 | 25,685,244 | 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.
Please do not resume your plavix until after you have been
seen in follow up with Dr. ___.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Patient was transferred to ___ from an OSH for evalaution and
magement after it was found that she had a left sided SDH. She
was admitted to the ICU for further management and udnerwent
repeat CT had which was stable. She remained neurologically and
hemodynamically stable overnight into ___ and was deemed fit
for transfer to the floor after a repeat CT scan of the head
showed no change. She was started on Ceftriaxone for a UTI. In
the evening pupils were found to be anisocoric. She was noted to
have decreased vision from left eye. Visual field testing showed
**
On ___ the patient complained of neck pain and left shoulder
pain. CT of c-spine showed no acute fracture or dislocation.
X-ray of left shoulder showed no acute fracture or dislocation.
Speech and swallow were consulted. They recommended po nectar
thick fluids with pureed solids. Medications could be given
whole or crushed with applesauce. She was transferred to the
floor with telemetry.
On ___ She was seen by ___ and who recommended discharge home
with family and home ___.
On ___ the patient appeared more drowsy on exam in the morning.
STAT head CT was stable. Upon re-evaluation in the evening she
was more awake and alert. Ceftriaxone was discontinued, she was
started on Bactrim for UTI due to continued leukocyte esterase
on urinalysis. She was seen by speech and swallow who cleared
her to advance her diet.
___ The patient was alert and oriented to person, place and
time (including the month and year). At the time of discharge on
___, HD #6, the patient was doing well, afebrile with
stable vital signs, voiding without assistance, stable neuro
exam and pain was well controlled. Her nutritional status is
baseline poor, however, the situation was discussed with the
family and an NG tube for supplemental nutrition was not
something they wanted to pursue. The patient was given written
instructions concerning precautionary instructions and the
appropriate follow-up care. All questions were answered prior
to discharge and the patient expressed readiness for discharge. | 156 | 347 |
18573871-DS-7 | 25,025,623 | Dear Ms ___,
It was a pleasure having you here at the ___. You were
admitted here with bleeding from the rectum and diarrhea. A CT
scan was revealing for some inflammation of a segment of your
colon. These were all thought to be related to a
gastro-intestinal infection. You were managed with antibiotics
(ciprofloxacin and flagyl). You should continue these
antibiotics until ___. Please keep your follow up
appointments below. | Ms. ___ is a ___ year old woman with a past medical history
notable for GERD, HLD, internal hemorrhoids, here with BRBPR in
the setting of diarrhea and abdominal pain. Her hospital course
by problem was as follows:
#BRBPR: Remained hemodynamically stable, HCT remained stable,
bleeding was resolved on arrival to hospital and patient had no
BMs between arriving in ED and discharge. Likely secondary to
colitis visualized on CTAP. No diverticuli on CTAP. Patient does
have history of hemorrhoids and PUD in the 1970s. However,
volume per patient history sounds larger than would be expected
from hemorrhoidal bleed. No UGI symptoms but does take NSAID, no
epigastric pain, prior ulcer was non-bleeding and had completely
resolved in EGD done ___ years ago. Normal lactate, history of
diarrhea preceding bleeding and minimal pain argues against
ischemic colitis. Diarrheal symptoms argue for infectious vs.
inflammatory colitis. She was placed on a clear liquid diet and
transferred to a bland regular diet on hospital day 2.
# Diarrhea: Sudden onset with diarrhea, chills and cramping made
infectious colitis seem most likely, perhaps with vibrio
parahaemolyticus or vulnificus given history of recent shellfish
ingestion or shigella/campylobacter/salmonella given recent
kebab ingestion. No family or prior history of autoimmune
disease, pattern not typical for UC and no CRP elevation argues
against autoimmune colitis and C. Diff unlikely given no recent
abx or hospitalizations. No elevation of WBC. Stool studies were
not sent as patient had not had a bowel movement by time of
discharge. She was started on empiric treatment with
cipro/flagyl for a 7 day course to cover for these entities. | 76 | 266 |
17584785-DS-17 | 28,501,256 | Dear Mr. ___,
You were admitted to the hospital for alcohol
intoxication/withdrawal and for abnormal liver function tests
with concern for biliary obstruction. You did not have evidence
of biliary obstruction on MRCP so likely the cause of your
abnormal liver function tests was inflammation of the liver from
alcohol.
As we discussed, the #1 best thing you can do for your health is
to stop drinking alcohol.
You should follow up with your primary care doctor and your
liver doctor. You should also call to make an appointment with
orthopedics due to your probable shoulder dislocation.
Best wishes for your continued healing.
Take care,
Your ___ Care Team | SUMMARY:
Mr. ___ is a ___ male with a history of alcohol
use disorder and HCV cirrhosis who presented with acute alcohol
intoxication with several subacute complaints, including
fatigue, shortness of breath, RUQ pain, poor appetite, and
memory loss -- ultimately found to have obstructive liver
enzymes concerning for biliary obstruction and was admitted for
MRCP. Ultimately there was no evidence of biliary obstruction
and abnormal liver enzymes were most likely due to alcoholic
hepatitis. | 105 | 75 |
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