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19623595-DS-10 | 23,681,241 | Dear Ms. ___,
You were admitted to our hospital for shortness of breath. You
underwent emergent cardiac catheterization, which did not reveal
any coronary artery disease that require immediate intervention.
You were treated with iv and later po medications to remove
excessive fluid in your lung. We also gave you medication to
better control your hypertension. You tolerated these treatment
very well.
Please note the following changes in your medication:
- START carvedilol 3.125 twice a day
- START lisinopril 20 mg daily
- INCREASE furosemide (lasix) to 40 mg daily, and followup with
your primary care physician for titration
- STOP metoprolol
We also arranged the following appointments for you. | ___ yo F with h/o HTN, HLD, DM2, presenting with DOE and new
onset LBBB, concerning for ACS.
ACTIVE ISSUES
# r/o ACS: Pt presented with DOE and new onset LBBB, although
there were no EKG changes that meet the Sgarbossa criteria. The
clinical presentation was deemed concerning for ACS with STEMI
equivalent. Mr. ___ therefore underwent immediate cardiac
catheterization. During the cath, all coronary arteries were
found to be patent. We continued her aspirin 81 mg and
atorvastatin 10 mg daily for primary prevention of coronary
artery disease.
# Acute on Chronic diastolic heart failure: During the cardiac
catheterization, pt was found to have elevated BP to 208/100.
On reviewing of her previous medical records, we felt that pt
had inadequately controlled hypertension. Her ECHO cardiogram
also demonstrated worsening diastolic dysfunction compared to
the study in ___. We felt that her exacerbation was consistent
with acute on chronic diastolic heart failure secondary to
hypertensive cardiomyopathy. Post cath, pt was given 40 mg iv
lasix and started on nitroglycerin gtt. Her antihypertensive
medications were transitioned to carvedilol 3.125 mg twice a day
and lisinopril 20 mg daily. She also received diuresis
initially with iv lasix, and subsequently po 40 mg lasix on the
second hospital day. Pt tolerated the treatment very well.
CHRONIC ISSUES
# COPD: Pt has known history of COPD. We continued her advair
and ipratropium.
# OSA: She was provided with CPAP at night.
# Diabetes: Appears well controlled. Her blood glucose was
controlled with sliding scale insulin.
TRANSITIONAL ISSUES
# CODE STATUS: Full
# MEDICATION CHANGES:
- STARTED carvedilol 3.125 mg bid
- STARTED lisinopril 20 mg qd
- STARTED furosemide ___ mg daily
# PENDING STUDIES
- None
# FOLLOWUP PLAN
- Pt will be seen in Dr. ___ clinic on ___
- Please check electrolytes given recent initiation of
lisinopril and escalation of furosemide, especially Cr, K, Mg
- Please adjust furosemide dose accordingly | 110 | 338 |
16454394-DS-12 | 22,794,744 | Mr. ___,
You presented to the emergency room with back pain which was
worse than your usual chronic back pain. As you had recently
had an endovascular repair of an aortic aneurysm with renal
stents, we did a CT scan. We were reassured that the pain was
not related to the aneurysm or the repair. An endoleak was
noted that will be addressed at a later date.
You were admitted to the hospital secondary to new onset
asymptomatic atrial fib with rapid ventricular response. This
resolved spontaneously without intervention. None of your
medication were changed. You will be discharged with a holter
monitor and are instructed to followup with Dr. ___
outpatient cardiologist. | ___ with AAA who presents ___ s/p FEVAR with bilateral renal
artery covered stent placement with persistent back pain,
palpations, and SOB. Patient had had uncomplicated post-op
course and discharged home POD2. He had been doing well at home
until ___ when his chronic back pain felt more persistent and
didn't improve with the usual maneuvers (stretching, walking)
and kept him from sleeping. He also felt his heart racing and
had SOB prompting presenting to the ED where on arrival, he was
found to be in new onset a-fib with RVR (HR to 130s) treated
with IV metoprolol with moderate effect on rate.
Given his recent FEVAR, CTA was performed which showed bi-iliac
stent graft shows a Type II endoleak with supply from the
inferior mesenteric artery as well as a Type I endoleak (stent
graft folded at proximal end). Overall aneurysm sac size
roughly unchanged. The endoleak will be addressed at a later
date as an outpatient and was not felt to responsible for his
back pain.
On admission, ECG showed atrial fibrillation with ventricular
response of 130 and stable BP. He converted to sinus rhythm
spontaneously shortly after admission. His medication regimen
was unchanged. Cardiology was consulted who did not feel
anticoagulation was indicated. A holter monitor was arranged
for discharge with followup with Dr. ___ outpatient
cardiologist to review the holter results. | 119 | 232 |
15783916-DS-59 | 20,481,910 | You were admitted to the ___ with a slow heart rate and
confusion. You were in the ICU for 2 days where you had
medicine to help your heart rate and blood pressure. You got
better after hemodialysis. You had hemodialysis twice while at
___. You should try to eat a low salt diet to help decrease
the amount of fluid you have on board. You were also
re-enrolled in the PACT program to help prevent you from having
to come back to the hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo F with ESRD on HD, IDDM, HTN and dCHF presenting with
somnolence and chest pain, found to be hypoxic and bradycardic
in junctional rhythm.
BRIEF HOSPITAL COURSE
Ms. ___ was admitted to the MICU with bradycardia and
hypoxia. She required dopamine gtt while in the ICU. This was
easily weaned off after her first HD session. An ECHO was
performed (read on prior section) which was not elucidative as
to cause. She was transferred to the floor after her HR
stabilized, underwent one more dialysis session, and was
discharged on the same home medications after being set up for
PACT follow up.
# Hypoxia, acute diastolic CHF. Based on exam and CXR, most
likely related to pulmonary edema and pleural effusion ___ CHF
and ESRD. No consolidation, fever, or leukocytosis to suggest
infectious etiology at this time. No tachycardia to suggest PE.
Patient underwent dialysis on HD1 with dopamine support (for BP
and HR) and tolerated. She was able to be weaned to 2L of NC
after HD. CXR also showed improved pulmonary edema and pleural
effusion. She was again dialyzed on HD2 with continued
improvement. She was dialyzed again on day of discharge and was
satting 97 on RA. Suspect all related to volume overload.
# Bradycardia. Asymptomatic throughout. She initially
presented with junctional escape rhythm which later switched to
sinus bradycardia. She was started on dopamine gtt with good
response. She was on dopamine gtt for HD to support the
bradycardia and SBP related to the HD. Dopamine was weaned off
after dialysis. Her HR remained in the ___ in sinus bradycardia
post HD, and remained stable until discharge. In terms of
pathophysiology, difficult to explain this phenomenon with
volume overload, however she has demonstrated on multiple
occasions that excess volume seems to trigger bradycardia.
# Hypotension. Initially presented with hypotension, which was
thought to be related to the bradycardia. This improved with
dopamine, especially during HD. Dopamine was weaned off post
HD, and her SBP was noted to be within normal range after
discontinuation of dopamine. Her BP was noted to be
stable/borderline hypertensive (SBP 140s) at time of discharge
when amlodipine was restarted.
# Somnolence/Acute encephalopathy. This was thought to be
related to medications as well as her mood. She did report that
she takes more oxycodone than prescribed to control her pain.
Oxycodone, gabapentin, and lorazepam were initially held. As
her mental status improved with improved hemodynamics, patient's
oxycodone was started back at home dose 10 mg BID. Of note, she
was noted to become somnolent with lorazepam. She refuses to
consider titrating the dose down. ___ prove to be helpful if
lorazepam dosage as outpatient is decreased.
# Chest tightness. This only occurred during HD. She denied
ongoing chest pain while in the MICU and on the floor. Troponin
was mildly elevated but in the setting of ESRD, and CK was flat.
# ESRD on HD, MWF schedule. Difficult HD at MICU, requiring
dopamine support. Calcium acetate, Nephrocaps were continued.
Further HD went without issue.
# acute on chronic dCHF. Volume overloaded on initial exam,
with recurrent right sided pleural effusion. Respiratory status
and pleural effusion improved post dialysis on ___, and HD
x 2 more sessions.
# Narcotic dependence. Oxycodone was initially held when she
came to the MICU. It was restarted on ___ at home dose
after improvement of her somnolence.
# Transitional issues.
- DNR/DNI
- Pt was noted to be upset with her care team when suggestions
for limiting salt were suggested, and when suggestions for
decreasing narcotics or Ativan dosage were suggested. She will
require close f/u as an outpatient with PACT and HCA to help
decrease likelihood of representation to the hospital.
- blood cxs pending at time of discharge (ngtd). | 103 | 654 |
15519663-DS-4 | 25,767,633 | Dear Ms ___,
It was a pleasure having you here at the ___
___. You were admitted here after you experienced
some bleeding through the rectum. This was thought to be likely
from your hemarrhoids. There is a possibility that it was not
caused by bleeding hemarrhoids and that is why we would like you
to get a colonoscopy as an outpatient.
The day before you came in for your bleeding, you experienced
some shaking of your hand and found to have a small head bleed.
You were given dilantin, but because your liver enzymes were
elevated and you were switched over to Keppra. Please continue
to have Keppra (1g twice a day) until ___.
Your platelets were found to be low and your liver enzymes were
abnormally high during this admission. This was thought to be
from drinking too much alcohol. You will need to get these labs
re-checked as an outpatient and we also strongly advise you to
cut back on your alcohol consumption.
Your thyroid levels were also low, so you were started on
thyroid supplement medications.
Please do not take aspirin or NSAIDs (ibuprofen or aleve) for
your headache. Only take tylenol.
We wish you the very best,
Your ___ medical team | This is a ___ F, who had a fall with head injury 3 weeks ago
___, presents with BRBPR.
#BRBPR: Patient has hx of hemarrhoids and could possibly be
bleeding hemarrhoid. Other etiologies of LGIB include
diverticulitis vs angioectasias. Malignancy lower on
differential given no constitutional symptoms. Patient also
also has low platelet counts, in the setting of heavy drinking
which could exacerbate any bleed.
Patient's hemoglobin was monitored in-house and remained at 10.6
on discharge. Her orthostatics were normal on a daily basis
while in-house. She no longer had blood in her stool on day of
discharge. She will be discharged with outpatient GI
colonoscopy follow up. She was advised to come back to the ___
if she experienced any further bleeding or dizziness.
#ALCOHOLISM : Reports drinking ___ beers and unknown amount of
hard liquor every night. No hx of withdrawal seizures. Did not
score on CIWA. She was counseled about cutting down on her
daily amount of alcohol. She was placed on oral folic acid,
thiamine and multivitamin.
#PANCYTOPENIA: Likely secondary to marrow suppression from
excessive alcohol intake. Discussed with ___ re:
transfusing platelets if below 50 (given her head bleed) and
they did not think that she needed a transfusion. Patient's
platelets stabilized in the ___ on day of discharge.
#TRANSAMINITIS : AST: ALT ratio 2:1 which ties in with alcohol
intake. GGT was also raised. Transaminitis also improved when
dilantin was switched over to Keppra. Hepatitis serologies
pending on discharge.
#FALL: Patient experienced a fall on ___ after slipping on
ice. She did not lose consciousness but did hit her head on the
left side. She had been suffering some headaches there after
and on ___ experienced some hand shaking which brought her into
the emergency room on ___. CT head at the OSH showed small
bleed in the frontal lobe. Neurosurgery feel that small frontal
bleed will not need operative intervention and discharged her
with a 7 day course of Dilantin for seizure prophylaxis. This
was switched over to Keppra in-house given her transaminitis.
She will complete her Keppra course on ___.
#HYPOTHYROIDISM: While patient was in-house, her TSH levels were
found to be high with low free T4 levels. She was started on
levothyroxine. | 206 | 389 |
18860726-DS-8 | 25,061,585 | You were admitted to the hospital for weakness and found to have
very low levels of platelets. You were diagnosed with a
condition called idiopathic thrombocytopenic purpura (ITP). You
received medications for this condition and your platelets
remained low, but the Hematologists think this will get better.
Your hospital course was complicated by difficult to control
hypertension and low sodium level. | ___ with HTN presenting with a few days of weakness admitted for
evaluation and workup of thrombocyopenia. | 64 | 17 |
13212171-DS-10 | 26,475,607 | Dear ___,
___ were admitted to the medical service while we are waiting
placement at a psychiatric facility. ___ are given medications
to treat your anxiety per the psychiatry doctors. ___ finished
your course of antibiotics for your lung infection.
Please call your doctor if any of your symptoms are worsening.
It was pleasure taking care of ___,
Your ___ health care team | SUMMARY:
========
___ is a ___ year old woman with
PTSD/bipolar disorder, opioid use disorder and ETOH use
disorder, seizure disorder (vs. ETOH w/d seizure) and recent
MSSA PNA c/b empyema s/p VATS (___), with multiple recent
admissions to both medicine and inpatient psychiatry, who left
AMA on ___ and subsequently returned to the ED later that day
in the setting of an overdosing on heroin, olanzapine and
clonidine, admitted to the medical floor pending psychiatric bed
search. | 62 | 77 |
16422158-DS-23 | 24,070,448 | Dear Mr. ___,
You were admitted to ___ and
underwent an exploratory laparotomy, ___ procedure, PEG
placement and Tracheostomy. 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.
To the Rehab:
Thank you for participating in the care of this patient. This
patient has had multiple teaching sessions with both the
Wound/Ostomy nurses and with the staff nurses and should have a
good idea of how to care for their own ostomy. They have also
been given several items that will assist them in their own
care, such as instruction sheets, ostomy supplies, and ostomy
output measuring tools. However, we would like to stress a few
important points to assist you in the care of this patient.
Bowel Function:
Ø It is important to encourage the patient to monitor their
bowel function closely every day. The patient should continue
to record their ileostomy output (as much as physically
possible) and the amount of fluid they have taken in, just as
they were taught in the hospital. A urinal or hat should be
used to record their ostomy output daily.
o The patient has been taught to use a daily measurement chart
to record their I&Os. This chart should be continued to be
used at least until their follow-up appointment. If their ostomy
output is less than 500 ml or greater than 1200 ml of liquid
stool in a day, it is very important to call the doctors office
with this information.
o Continue to reinforce to the patient that the major risk
with an ileostomy is dehydration related to fluid loses. Daily
fluid intake is ___ glasses of fluids, including electrolyte
enhanced beverages. In the hot weather, encourage them to take
in increased amounts of fluid and closely measure their
ileostomy output.
o Watch for signs and symptoms of dehydration including: dry
mouth or tongue, decrease in urination, urine darker in color,
dizzy when he/she stands, cramps in his/her abdomen or legs,
dizziness, increased thirst, or weakness.
Stoma Care:
Ø It is also important to monitor the appearance of the stoma.
The tissue of the stoma should be moist, pink or red in color.
o If the stoma has color changes from pink / red to dark
purplish /blue in color, becomes swollen, or a large amount of
continuous bleeding into the pouch, and or at the Mucocutaneous
Junction (Stomal Incision). this is not normal. Call the
patients doctors office for assistance.
If you or the patient has any questions regarding the care of
the patients ostomy, please refer to the instructions provided
to the patient by the wound/ostomy nurses.
___ the patient develops the following bowel symptoms please call
the surgeons office or go to the nearest emergency room if
severe: increasing abdominal distension and cramps, nausea,
vomiting, inability to tolerate food or liquids, decrease in
ostomy output, or have no output from ostomy for ___ hours | ___ with history of pAF, hypothyroidism, chronic constipation
managed with self-administered fleet enemas presented with ~one
week of constipation, with admission CT A/P showing no
obstruction. Manual disimpaction was attempted with no stool in
the vault. A goals of care discussion was had with the patient
on admission, at which point he expressed that he would like
aggressive measures to preserve his life. The patient was given
repeated enemas, as well as oral laxatives with no significant
passage of stool. Ultimately, on HD2, he suffered a bowel
perforation. He was started on cipro/flagyl and transferred to
the SICU. | 797 | 99 |
11185336-DS-17 | 20,216,386 | General Instructions/Information
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, and
Ibuprofen etc.
Clearance to drive and return to work will be addressed at
your follow up
Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101° F. | ___ y/o M with 12 day history of headache presents to OSH where
MRI head showed pituitary lesion concerning for hemorrhage. He
was transferred to ___ for further neurosurgical evaluation.
On ___, a CTA head was ordered for evaluation of vessels.
Opthalmology was consulted for visual field testing and
endocrine to help determine if this lesion is hormone secreting.
On exam, patient reports headache, but otherwise intact. CTA
head showed no abnormalities. On ___, opthalmology visual field
testing revealed no compression on optic chiasm. He was stable
on examination. On ___, patient remained stable and was
discharged home in stable condition with adequate follow up with
endocrine. | 156 | 108 |
18224234-DS-16 | 20,247,152 | Wound Care: Please keep your 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*******
non-weight bearing left upper 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 ___. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left elbow fracture/dislocation. The patient was
taken to the OR and underwent an uncomplicated operative
treatment of left elbow radial head dislocation with radial head
replacement and repair of anterior capsule. 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: left upper extremity non-weight bearing.
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. All questions were answered prior to discharge
and the patient expressed readiness for discharge. | 105 | 168 |
14644059-DS-11 | 21,047,727 | ___ arranged to follow you at home
___ infusion company will supply ___ line supplies and IV
antibiotics
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, PTBD/Liver
drain insertion sites have redness, drainage or bleeding,
dizziness or weakness, decreased urine output or dark, cloudy
urine, swelling of abdomen or ankles, weight gain of 3 pounds in
a day or any other concerning symptoms.
Next lab draw ___ then labwork drawn twice weekly
as arranged by the transplant clinic
You must keep the picc line clean and dry/No tub baths or
swimming
Keep PTBD capped and pinned to your shirt to prevent accidently
dislodging.
Change dry gauze dressing daily and as needed.
Notify transplant office if stat lock or suture is
missing/loose. Notify the transplant office if site is red/has
bile drainage or if you have a fever of 101 or higher.
Keep JP drain pinned to your shirt. Empty and record drain
output. Bring record of output to f/u visits
No driving if taking narcotic pain medication
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids to keep your urine light in color
Check your blood pressure at home. Report consistently elevated
values above 160 systolic to the transplant clinic | ___ h/o EtOH cirrhosis s/p DDLT with right iliac arterial
___ PTBD ___ for biliary stricture, p/w
nausea/vomiting and subjective fevers, RUQ/epigastric pain and
uptrending LFTs concerning for cholangitis. New ___ with Cr 3.0,
likely
dehydrated in setting of vomiting. She was admitted to the
transplant surgery service, pan-cultured and started on
Vancomycin and Zosyn. Aggressive IV hydration was given for
tachycardia in the ED with improvement. She was sent to the SICU
for observation overnight. Immunosuppressive medications and
prophylactic meds were continued (renal dosing). Liver duplex
demonstrated patent hepatic vasculature. Arterial flow was seen
in the left hepatic artery with prompt systolic peaks, diastolic
flow was limited and difficult to discern. The main and right
hepatic arteries demonstrated normal waveforms. No intrahepatic
biliary dilatation. Mild heterogeneous appearance of the
anterior right lobe of the liver was noted.
On ___, she was febrile to 102.1. WBC increased to 22 and
blood cultures isolated GNR and GPC. She was started on Levophed
for MAP of less than 60. PTBD output appeared purulent. Bile
culture grew GNR and Enterococcus. Antibiotics were broadened
and Vanco was changed to Linezolid.
On ___, LFTs increased significantly and continued to rise on
___ blood cx showed gram - rods, gram + cocci.
___ Liver CTA revealed hepatic artery thrombus with complete
occlusion of the proximal common hepatic artery and hepatic
artery-iliac conduit. No arterial flow was seen within the
liver and there was extensive necrosis of the entire left
hepatic lobe. CXR showed no evidence of cardiopulmonary disease.
Antibiotic regimen was broadened to ___. Pressors
were increased, pt received 1L albumin and 1 L NS with low urine
output. Interventional radiology lysed the occluded conduit,
lysis catheter was left in place in left groin with heparin drip
started. She received a one time dose of gentamycin that was
then discontinued.
On ___, blood culture was speciated, showing 2 strains of
E.coli- sensitive to ___ and VREnteroccocus- sensitive to
linezolid and Dapto. She continued on ___ 500mg IV q8, switched
linezolid to daptomycin 8mg/kg IV qd. Blood cultures were
negative to date after ___.
___ took patient back again to recanalize the hepatic artery
conduit with placement of a 6 mm x 3 cm stent just proximal to
the bifurcation of the right and left hepatic arteries with
persistent though improved areas of thrombus and some antegrade
flow.
___ saw good flow, pulled sheath with TPA on ___.
HCT drifted down from 25 to 23.1 then 22.3. She was given 1u
pRBC.
She improved clinically following ___ interventions and drainage,
and continued on antibiotics. She was transferred out of the
SICU on ___ to the med-surg unit, where she remained afebrile
(Tmax of 99), though intermittently tachycardic. The PTDB was
capped on ___. She remained afebrile and LFTs decreased to near
normal. Alk phos was down to 191 from admission value of 1800.
Liver duplex on ___ revealed patent hepatic vasculature with
appropriate waveforms, with exception of the
vasculature of the left hepatic lobe which is necrotic as
previously noted.
The left liver lobe drain to JP bulb output averaged 500cc of
dark green fluid.
Dietary intake was excellent. Weight increased to 75kg from
admission weight of 70kg.
Immunosuppression consisted of mycophenolate sodium, prednisone
tapered to 5mg on ___ and tacrolimus dosed per trough levels as
follows:
___ FK 4.5/4.5 (7.7)
___ FK 4.5/4.5 (8.6)
___ FK 4.5/4.5
___ FK 4.5/4.5 (6.4)
___ FK ___ (7.7)
___ FK4/4(6.4)
___ FK ___ (6.9)
___ FK 2.5/2.5 (6.2)
___ FK 1.5/1.5 (7.3)
___ FK ___
___ FK H/2 (16.2)
Pain at drain sites was managed with oxycodone. She was taking
___ tabs (5mg)of oxycodone per day. She was ambulating
independently and was discharged to home.
Of note, on day of discharge, she noted some vaginal pruritus
without discharge while on fluconazole 400mg qd. She was going
to use monistat at home. She denied UTI symptoms. However, UA
and Urine culture were sent just in case pruritus early symptoms
of UTI.
ID recommended continuing Dapto and Ertapenem until ___ with
re-imaging prior to d/c of antibiotics as well as ID f/u prior
to d/c of antibiotics. | 233 | 685 |
17641111-DS-11 | 24,063,499 | Dear Mr. ___,
You were admitted to ___ in order to start treatment for your
B-cell lymphoma. You received a chemotherapy called EPOCH with
rituximab which you tolerated well. Otherwise, you did not have
any other major issues while you were admitted. Please make sure
to follow up at the appointment with Dr. ___ we made for
you. You will also need an appointment with a gastroenterologist
eventually to discuss when to have your biliary stent removed.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your care team at ___ | Brief Hospital course:
====================================
Mr. ___ is a ___ year old male with PMH of asthma, HTN, who
presents due to recent biopsy proven DLBCL/Burkitt's in order to
initiate chemotherapy. | 94 | 29 |
14249673-DS-14 | 20,854,341 | Dear ___,
You were admitted to the hospital with trouble speaking and
moving the right side of your body. You had scans of your body,
as well as a flexible sigmoidoscopy, which showed that you have
colorectal cancer that has spread to your lungs and brain, which
is causing your trouble speaking and moving. We gave you
steroids to help with the masses in your brain and your
neurologic status improved.
We set you up to meet with many teams to coordinate the rest of
your care once you've left the hospital.
It was a pleasure taking care of you, ___. We wish you the
very best.
- Your team at ___ | The patient is a ___ year old man with a history of cerebral
palsy, chronic leg ulcers and recurrent cellulitis, presenting
with progressive decline with difficulty swallowing and aphasia.
CT chest shows metastatic lung nodules concerning for
bronchogenic carcinoma. Exam shows aphasia, abnormal eye
movements, R sided neglect and R arm and leg weakness. NCHCT
with multiple hemorrhagic metastatic lesions in the L cerebrum
and R cerebellum with extensive associated edema, likely from
the same primary as the lung nodules.
ACTIVE ISSUES.
# METASTATIC COLORECTAL CARCINOMA. NCHCT demonstrates multiple
lesions. CT chest obtained prior to admission with multiple
lesions as well. CT abdomen/pelvis obtained at ___
demonstrated a large, solitary lesion in the sigmoid colon. He
underwent flexible sigmoidoscopy with biopsy; biopsy yielded
colorectal adenocarcinoma. Post procedure, given the friability
of the mass, he experienced bleeding with a drop in Hgb from 13
to 11, but remained stable thereafter. CEA was elevated to 427.
Colorectal surgery was consulted as well, given difficulty in
advancing sigmoidoscope past lesion & concern for obstruction,
however the patient isn't clinically obstructed (still passing
gas/stool). At this time, they advised against surgery, but
recommend in the the event of obstruction, to consider surgery
-vs.- interventional GI stenting. Palliative care was consulted
as well to coordinate goals of care.
- Discharge plan for the patient: outpatient meetings with
Palliative Care to coordinate care, as well as with radiation
oncology & medical oncology to learn about options in treatment.
- Plan to continue PO prednisone 60 mg daily and leviteracetam
1000 mg PO bid until seen at neuro-oncology & radiation oncology
# BRAIN MASSES. NCHCT concerning, given multiple lesions, with
associated edema and abnormal neurologic exam. Etiology of
masses uncertain at this time, however multiple lesions present
in the lungs as well. He received dexamethasone 10 mg x 1 IV in
the ED, as well as 1 g leviteracetam IV. Continued dexamethasone
4 mg IV q6h while on the floor. Was weaned to q8h then to PO
prednisone 60 mg in preparation for discharge. Continued seizure
prophylaxis with leviteracetam 1000 mg IV BID - transitioned to
PO leviteracetam for discharge.
# APHASIA, ALTERED MENTAL STATUS. Secondary to brain lesions.
Improved with steroids, as above, however not fully resolved.
A&Ox2-3 (often says year is ___, then when prompted, recognizes
is ___. His aphasia has improved from only yes/no, to short
___ word sentences.
# DECUBITUS ULCERS. Found on exam on arrival here. ___ care
RN team evaluated patient and recommended: discontinue Mepilex
to gluteals while pt is incontinent of stool - once this slows
or stops, can place Mepilex 6 x 6 to both gluteals. For
incontinence care, cleanse with gentle foam cleanser and
disposable wipes, apply thin layer of critic aid clear barrier
ointment to gluteals, and perianal tissue
reapply after every ___ cleansing. For ___: Cleanse wound with
wound cleanser then pat dry apply soothe and cool skin
conditioner to intact dry skin. Cover wounds with xeroform then
ABD pad, wrap with Kerlix or conform to protect from trauma
change daily.
CHRONIC, INACTIVE ISSUES.
# ANXIETY. Continued diazepam.
# DEPRESSION. Continued fluoxetine.
# HYPERTENSION. Continued atenolol and lisinopril.
# ANEMIA. Continued iron supplementation.
# DEGENERATIVE JOINT DISEASE. Continued analgesia.
# CEREBRAL PALSY. Stable.
******* TRANSITIONAL ISSUES *******
- PO Steroids dosing
- Goals of care discussions, code status, treatment goals
- Whole brain radiation therapy? Chemotherapy? | 109 | 560 |
15735574-DS-5 | 22,019,942 | You were admitted for cystogastrostomy tube placement for your
pancreatic pseudocyst. Please take all medications as
prescribed. You will need a repeat CT scan on ___, and
follow up with Dr. ___. Please call his office
with any questions about your CT scan or follow up.
Please avoid alcohol and driving while taking opioid medication | The patient with history of gallstone pancreatitis s/p cyst
gastrostomy ___ was admitted for management of her pancreatic
pseudocyst. She underwent an upsizing of her cystgastrostomy
stent from 12 mm to 18 mm, and placement of 3 pigtails by
Gastroenterology. Post procedure, patient's diet was gradually
advanced to regular and was fairly tolerated. Repeat CT scan
revealed decreased pseudocyst and improvement in duodenal
inflammation. Patient was discharged home in stable condition,
she instructed to repeat Ct scan on ___. During admission
patient was experiencing pain, which required treatment with
narcotics. She, also was having nausea required multiple
antiemetics. Post EGD patient was treated with Ciprofloxacin x 5
days. On discharge patient was provided with prescription for
variety of antinausea medication and Dilaudid for pain control. | 54 | 126 |
14481207-DS-16 | 20,469,343 | You were admitted to the hospital with abdominal pain and an
elevated white blood cell count. You underwent imaging and you
were reported to have acute appendicitis. You were taken to the
operating room to have your appendix removed. Your vital signs
have been stable and you are preparing for discharge with the
following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | ___ year old female who was admitted to the hospital with
abdominal pain and an elevated white blood cell count. Upon
admission, the patient was made NPO, given intravenous fluids,
and underwent imaging. Review of cat scan imaging showed a
dilated and inflamed appendix with a visible fecalith at the
base. There was no evidence of perforation or drainable fluid
collection. Based on these findings, the patient was taken to
the operating room where she underwent a laparoscopic
appendectomy. The operative course was stable with minimal
blood loss. The patient was extubated after the procedure and
monitored in the recovery room.
The post-operative course was stable. The patient resumed a
regular diet and was voiding without difficulty. Her pain was
controlled with oral analgesia. She was discharged home on POD
#1. Discharge instructions were reviewed and questions
answered. The patient was instructed to call the Acute Care
clinic for a post-operative follow-up appointment. She was
also instructed to follow-up with her primary care provider. | 765 | 181 |
18880949-DS-19 | 21,285,080 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
-Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Touchdown weightbearing Left lower extremity
Physical Therapy:
Touchdown weightbearing Left lower extremity
Treatments Frequency:
- Dry sterile dressing changes daily
- Staples will be removed at the patient's first follow-up
appointment in Orthopaedic Surgery clinic ___ days after their
surgery. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left hip closed reduction
percutaneous pinning, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
The patient was transfused 2 units PRBC for acute blood loss
anemia, with appropriate response in Hct.
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 Touchdown weightbearing in the
Left lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 170 | 258 |
17640601-DS-21 | 25,889,142 | Dear Mr. ___,
You were admitted to ___ after
a traumatic accident. While you were here, the plastic surgeons,
orthopedic surgeons and opthalmologists evaluated you and left
their recommendations. Please follow these instructions to
ensure a safe and speedy recovery:
PLASTIC SURGERY
-Sinus precautions
-F/u in clinic in 1 week
ORTHOPEDIC SURGERY
-TLSO brace
-F/u in ortho spine clinic in 1 month
OPHTHALMOLOGY
-Erythromycin eye drops
Best wishes,
Your ___ surgical team | Mr. ___ presented to ___ as a basic trauma activation after
being struck by a vehicle traveling at 30 mph. Upon arrival, he
was imaged with the following injuries discovered: bilateral
temporal subarachnoid hemorrhage, right parietal subarachnoid
hemorrhage versus contusion, T12 body fracture, L1 transverse
process fracture, left lamina papyracea fracture, left orbital
floor through infraorbital canal fracture, retrobulbar air,
nasal bone/septum/nasal spine fracture, bilateral frontal
process of maxilla fracture and right fourth metacarpal
fracture. He was admitted to the trauma SICU for close
neurologic monitoring based on the extent of his facial and
intracranial injuries.
Based on his injuries, the plastic surgery, neurosurgery,
opthalmology and orthopedic surgery services were consulted.
Plastic surgery recommended to keep the splint on at all times
until follow up, NWB in RLE, sinus precautions, IV unasyn
transitioned to oral augmentin for 7 days, follow up with Dr.
___ in clinic in ___ weeks and follow up in plastic
surgery clinic next week. Neurosurgery recommended a repeat head
CT on hospital day 2 to assess for an progression of his
subarachnoid hemorrhage. Opthalmology recommended artificial
tears in the right eye QID and erythromycin ophthalmic ointment
in the left eye QID. Orthopedic surgery took him to the
operating room for an ORIF of his right medial malleolus after a
fracture was discovered when he had difficulty working with
physical therapy. Ortho spine recommended ___ mobilization when
able, repeat T-spine x-ray when able to stand, non-operative
management with TLSO brace and follow up with ortho spine clinic
in 1 month.
He was transferred to the floor on hospital day 2. He was
transfused one unit PRBCs on hospital day 5 for a hematocrit of
22.2 due to his cardiac history. His repeat hematocrit was
appropriate at 26.1, and follow-up the next day was 24.5. He was
provided a regular diet, which was well tolerated. He had a
Foley catheter placed, which was later discontinued and he
voided without any issues. He had two episodes of emesis on
hospital day 7. He was given an aggressive bowel regimen, after
which he had a large bowel movement and his symptoms resolved.
He was evaluated by physical therapy and occupational therapy,
who recommended discharge to rehab. He was discharged to ___
___ in ___ on ___. | 63 | 376 |
18284271-DS-70 | 27,056,025 | Dear Ms. ___,
You were admitted to the hospital for weakness, shortness of
breath, and generally not feeling well. You were lightheaded
when you were walking. Your lab tests, imaging, and ekg were all
reassuring. We held your water pill (torsemide on ___ and you
felt better. We gave you Lasix (a different water pill) ___.
You were evaluated by physical therapy, who determined you were
safe to go home.
It is very important that you take your medications as directed.
You are followed closely by the heart failure team, most
recently ___, and if you do not here from them
tomorrow ___, you should call their office. The
cardiology number is ___. They will likely need to see
you within the week and/or change your water pill dose.
DISHARGE WEIGHT: 250.6 lbs
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you!
Wishing you all the best,
Your ___ medical team | ___ y/o frail community-dwelling F with aortic stenosis s/p
bioprosthetic AVR ___ c/b bradycardic arrest s/p PPM,
HFPEF, HTN, remote epilepsy off AEDs, cervical stenosis c/b
chronic bilateral arm weakness, and gait disorder, who presented
from home to the ED with dyspnea and weakness.
#Weakness: patient presenting with a constellation of somatic
complaints with seemingly no unifying diagnosis, and she had
reassuring ekg, cardiac enzymes, pro-BNP, remainder of labs were
wnl. She attributed her weakness to overdiuresis, particularly
to torsemide and felt subjectively better after holding
torsemide ___.
She had negative orthostatic vital signs and ambulated without
desaturation. Her B12 and TSH were WNL. ___ evaluated and cleared
for home. She would not take torsemide 40mg po on ___, but
would take Lasix po. She was informed she needed close follow up
with Heart Failure service, confirmed she would be in touch
___ for further direction re her diuresis. | 158 | 149 |
14202013-DS-19 | 25,897,743 | Dear Ms. ___,
You came into the hospital with L arm pain, L sided headache and
blurry/double vision. We did a CT/CTA scan to rule out stroke.
You did NOT have a stroke. There is a possibility that you had
a transient ischemic event or "mini stroke," however your
symptoms were not typical. Another possibility, is perhaps your
blood sugar was low when you had these symptoms. Please follow
up with your primary care doctor in the next ___ weeks. Also,
weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to take part in your care.
-___ Neurology Team | ___ is a ___ year old right handed female who
complains of L arm pain, L mild headache and blurry
vision/diplopia admitted for work of up possible TIA.
Prior to the arm pain and headache, she did feel hot and
nauseous. CT/CTA showed scattered atherosclerotic
calcifications but no stenosis of the intracranial or cervical
arterial circulation. Pt was unable to have a MRI due to having
a pacemaker. By ___, symptoms have resolved. Her pacemaker
was interrogated and evaluated by EP. On physical exam on day
of discharge, TIA is possible, but would be atypical given the
distribution of sensory changes to pinprick but not temperature
and vibration and different vascular distribution. Another
etiology may be a hypoglycemic episode. | 112 | 130 |
19681894-DS-15 | 24,287,295 | Dear ___,
___ was a pleasure taking care of you in the hospital. You were
admitted because of an infection of your kidneys. You had two
nephrostomy tubes placed and you had your left ureter stent
removed. Your right ureter stent was attempted to be removed but
because it was a difficult removal, it was changed with a
different stent. The external tube on the right was then
removed.
You were found to have an infection called Staph Aureus in your
urine that spread into the blood. Hence you will need IV
antibiotics for a total of 4 weeks, with the last date
tentatively scheduled on ___.
You also had anemia which was treated with blood transfusion.
You will need to follow up with the urology team within the next
week to have your new right ureteral stent removed.
You will follow up with Dr ___ as well as scheduled.
Regards,
Your ___ Team | ___ w/ metastatic rectal cancer with multiple complications
including b/l malginant hydronephrosis s/p b/l double-J ureteral
stents who p/w septic shock from MSSA pyelonephritis, and renal
failure s/p urgent b/l PCN ___..
#Septic shock: Pt admitted to MICU w/ fevers and hypotension
despite IVF resuscitation, did require pressors transiently.
Transferred to floor ___ and has remained HD stable. Source
control as below
#MSSA pyelonephritis w/ bacteremia - ___ have been related to
stent infection, pus present at time of PCN placement. urine and
blood cx ___ + MSSA
- Continue nafcillin 2g q4h x 4 weeks, D1 ___ (Vanc ___,
end date ___. Patient will f/u in ___ clinic
- pt underwent removal of pre-existing ureteral stents
- all subsequent cultures negative
- TTE did not show vegetations
#Malignant Hydronephrosis - ___ pelvic mass had pre-exising
ureteral stents. in setting of sepsis and renal failure
underwent
urgent bilateral PCN placement ___.
- ureteral stents removed on ___, left ureteral stent removed
on the floor followed by right ureteral stent removal in the OR
as was difficult and required urgent cystoscopy, was replaced
with new 6 x 26 cm JJ ureteral stent
- foley removed ___ and pt w/ some bladder UOP
- Renal US ___ showed possible malposition of the R
nephrostomy
which had not been draining urine, this was removed on ___,
renal function and UOP remained stable
- she will f/u in ___ clinic in ___ weeks for R stent
removal
# ___ on CKD - obstructive as above. recent Cr baseline 1.5 -
2.0, peaked at 5.3 this admission, has now gradually improved to
prior baseline. hydronephrosis improved post PCN placemenet
# Bilat ___ edema - likely due to renal dysfunction in setting of
large volume IVF resuscitation in setting of sepsis. LENIs
negative ___. cont compression stockings.
# Metabolic acidosis - ___ ___ on CKD as above. Increased sodium
bicarb on ___ w/ increasing nausea. switched to Calcium
carbonate, bicarb stable after stopping as Cr improving
# Anemia: ACD in setting of malignancy and chemotherapy.
requiring intermittent transfusions (last 2 unit PRBCs ___
# Coagulopathy: likely nutritional or related to antibiotics.
has
now resolved after total 7.5 mg vit K.
#high ostomy output: per pt this is chronic, she is typically on
loperamide and opium. C diff testing negative
# h/o Afib - s/p ablation, never on anticoag. In sinus on EKG on
admit. Cont ASA daily
# Dermatitis: has hx chronic rash. Dermatology evaluated and
recommended steroid cream and emollients, pt uses triamcinolone
and clobetasol at home
# Colorectal cancer: currently on chemo (most recently ___:
Panitumumab) and being evaluated for phase I anti-PDL1 trial
- she will f/u Dr. ___ on ___ to discuss chemo
>30 min spent coordinating care for discharge inc home care for
IV antibiotics | 149 | 424 |
19057937-DS-3 | 29,050,829 | Dear Mr. ___,
You were admitted to ___ with a possible left sided facial
droop. On exam, there was a slight asymmetry of the left corner
of your mouth but no obvious droop. You had an MRI which did not
show any evidence of stroke. You should continue to take all
medications as prescribed and follow-up with your doctors at the
___ scheduled below.
It was a pleasure taking care of you,
Your ___ Neurologists | Mr. ___ is a ___ yo man with PMH significant for sensorimotor
neuropathy secondary to peripheral nerve vasculitis thought
secondary to polyarteritis nodosa who presented with concern for
left facial asymmetry who did not have a stroke.
# Left facial asymmetry: Patient presented from rehab to his
outpatient rheumatology appointment where there was concern for
possible left nasolabial fold flattening. The patient and his
wife did not appreciate the finding but his niece felt very
strongly about it. The patient does have a resting facial
asymmetry, which manifests as a subtle droop of the mouth
however with symmetric activation, there is no droop present.
There was no other significant weakness on the left side. His
speech was dysarthric but baseline given a long history of
speech imediment as a child. The patient had vascular risk
factors including known vessel atherosclerosis and
vasculitic/inflammatory process and was admitted for work-up of
possible stroke. He underwent CTA head and neck which showed
patent head and neck vasculature. He also had an MRI brain which
showed mild global cerebral atrophy and evidence for chronic
small vessel ischemic disease but no infarction. Given that he
did not have an acute stroke, he was sent back to his rehab
facility for further treatment.
# Progressive sensorimotor neuropathy with acute weakness,
concern for peripheral nerve vasculitis due likely to
polyarteritis nodosa: Patient was continued on prednisone 60mg
daily with Bactrim for PCP ___. He will follow-up with
neurology and rheumatology for further treatment including
Rituximab infusions.
# Interstial lung disease: This was noted on CTA and seen on
prior admission, likely related to vasculitic process. He will
follow-up with pulmonology as an outpatient. | 75 | 277 |
19992875-DS-17 | 27,668,708 | Dear Mr. ___.,
It was a pleasure taking part in your care at ___. You were
admitted because of abdominal pain and a lightheaded feeling.
You underwent studies which showed you did not have any
concerning issues with your heart. We checked blood and urine
and could not find evidence of infection. Your abdominal studies
were not concerning, and we think your abdominal pain was
related to constipation. You were monitored and improved.
.
It is important for you to stay well-hydrated. You should have
at leave 2 liters (64oz) or water or Power Aid per day. You also
should have a low-salt diet. Be careful when you eat out as most
___ put a lot of salt in their food. Change positions (ie
stand up) slowly to prevent feeling lightheaded. | BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ year old gentleman with advanced PBC, listed
for liver transplant, and fairly recent hemorrhagic pericarditis
s/p pericardial window (___) who presented with abdominal
pain, weakness, and lightheadedness. His abdominal pain was
likely from constipation. His lightheadedness was presyncopal in
nature and improved by discharge.
ACTIVE ISSUES
==============
# Abdominal Pain due to constipation: He reported post-prandial
abdominal pain without rebound/guarding. LFTs and Tbili were
largely unchanged from baseline, though INR was elevated in the
setting of stopping PO vitamin K. He actually had a recent
admission with abdominal pain which was attributed to
constipation; he had an abdominal x-ray done which showed feces
throughout the colon.RUQ ultrasound with doppler was not
concerning for thrombotic event. Stool studies, including c.
diff, were not revealing. Bowel regimen was uptitrated with BID
miralax (for stool bulking), senna, lactulose.
# Lightheadedness: He reported presyncopal symptoms on two
occasions while urinating, another time while at ___ eating
a meal, and once while eating during this admission. History was
most consistent with vasovagal symptoms. His orthostatics were
negative twice. EKG without new changes. Cardiac enzymes were
flat. Given history of hemorrhagic pericarditis s/p window, with
coagulopathy, and a great deal of ___ concern regarding
lightheadedness, he underwent TTE to evaluate for pericardial
effusion, which did not show any accumulation of fluid. Of note
he did not have physiology concerning for significant
pericardial effusion. He was encouraged to hydrate daily with
fluids such as gatorade.
CHRONIC ISSUES
===============
# Coagulopathy: INR on previous admission ranged ___ but on
recent discharge had been 1. He was treated until recently with
daily vitamin K (hepatologist discontinued his vitamin K
recently). INR elevation likely from discontinuation of vitamin
K, though worsening liver synthetic function also possible.
# Pancytopenia: CBC, WBC, and platelets were largely within
recent baseline.
# Primary Biliary Cirrhosis: He has advanced PBC and is
currently listed for transplant. His MELD score on admission was
26. Recent EGD on ___ did not show evidence of varices.
Albumin 4.1 and his coagulopathy was previously corrected fully
with Vitamin K, suggesting relatively intact synthetic function.
He was continued on ursodiol 300mg q6h.
# Gastritis / Esophagitis: Continued on home omeprazole,
ranitidine, sucralfate, and clotrimazole troches.
# History of recent hemorrhagic pericarditis: Please see
discussion above. He is s/p pericardial window ___ and
reports has had chronic chest pain ever since. Avoid NSAIDs due
to liver disease. EKG, echo not concerning for repeat
effusion/pericarditis.
# Hyperlipidemia: He has highly elevated cholesterol due to his
PBC, and most recent lipid panel on ___ with TC 724, ___
311, HDL 12, and LDL 141. The benefit of statins in PBC is
unclear, and statins can certainly be associated with liver
injury. He reports that his hepatologist discontinued his home
atorvastatin, and this was held in house as well.
# Vitamin D Deficiency: His last Vitamin D level on ___ was
undetectable. He was continued on cholecalciferol and calcium
carbonate.
# Chronic Pain: There was concern that his narcotics could be
contributing to fecal loading despite bowel regimen. He was
continued on home regimen, but bowel regimen was uptitrated. He
was managed with fentanyl patch, gabapentin, and oxycodone.
# Bipolar Disorder: Continued on home risperidone.
TRANSITIONAL ISSUES
====================
- Code status: Full code, confirmed.
- Emergency contact: Father ___ ___.
- Studies pending on discharge: All finalized.
- Noted to have constipation, so bowel regimen was increased.
- We re-educated on low sodium diet (appears to be not fully
compliant with low sodium diet; ie, eating at ___ and
___). | 128 | 583 |
14710117-DS-2 | 22,796,023 | Discharge Instructions:
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 for 2 weeks.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment except for
hygiene and showering.
ACTIVITY AND WEIGHT BEARING:
- Do not bear weight in left upper extremity, but range of
motion as tolerated | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left forearm fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF left forearm which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB with ROMAT in the right upper
extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 149 | 237 |
17363674-DS-13 | 29,965,129 | You were admitted to the hospital with abdominal pain. Testing,
including a CT scan of the abdomen showed no clear cause for the
pain. It's possible that it was related to your bowels. Your
pain improved and was controlled on pain medication with
oxycodone. You should continue to take this at home for pain.
You should take stool softeners and Miralax as needed for
constipation and make sure you are having a regular formed bowel
movement each day.
Dr. ___ will call you tomorrow. You have an
appointment scheduled for ___ at 9am but this may
be changed depending on Dr. ___. Dr. ___
will discuss with you plans for further management of your
breast cancer and the clinical trial.
Please check your blood sugar regularly after leaving the
hospital.
Please | ASSESSMENT/PLAN: ___ female with breast cancer currently on
trial with herceptin/navelbine admitted with abdominal pain.
1. Abdominal Pain:
Etiology was somewhat unclear. CT showed no pathology.
Navelbine has been reported to cause GI problems such as
ileus/necrosis/perforation but this was not clear on the CT
scan. KUB done 2 days later did show colonic ileus. She was
given an aggressive bowel regimen of colace, senna PRN, miralax
and lactulose. She took the colace and miralax regularly and
was have ___ bowel movements per day. Her abdominal pain
improved somewhat. She felt that it was worse when she was
stressed or anxious and perhaps it was related to anxiety. It
was well-controlled on the day of discharge with oxycodone. She
was discharged on PRN oxycodone. She was not interested in
taking Oxycontin for long-acting releif. She was given
prescriptions for omeprazole, colace, miralax and oxycodone.
She was advised to see a gastroenterologist as an outpatient if
her pain did not improve.
2. Diabetes:
Her metformin had been held prior to admission due to elevated
creatinine. She was continued on glipizide and an insulin
sliding scale. She was discharged on glipizide alone. She
will monitor blood sugars at home.
3. Hypertension:
She had been taken off losartan in the past due to ___. Blood
pressue was controlled around 120 systolic, so her losartan was
not restarted.
4. Hx of DVT:
She was continued on warfarin.
# DVT ppx: on warfarin
# Diet: diabetic
# GI Prophy: omeprazole
# IV access: PIV
# Precautions: None
# Code status: Full
Attending addendum: I was not the attending of record on the day
of discharge, but the details of her hospital course are correct
to the best of my knowledge | 134 | 288 |
16839986-DS-19 | 23,661,824 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with joint pain and dehydration. You were seen by
rheumatologists. You were started on new medications to treat a
flare of your lupus. You improved and are now ready for
discharge home.
For Prednisone- You should continue to take Prednisone 10mg
twice daily x 7 days (until ___ you can then reduce the
dose to Prednisone 15 mg once daily until you see your
rheumatologist. If you have questions regarding your lupus
medications, please discuss with Dr. ___.
We wish you the best,
Your ___ Care team | This is a ___ year old female with history of lupus complicated
by lupus nephritis, on plaquenil, recent discontinuation of
cellcept admitted ___ with several weeks of progressive joint
pain, found to have ___, now started on prednisone with
improving symptoms
# Joint Pain
# SLE Flare
Patient with SLE, previously on MMF that she self-discontinued 1
month prior to presentation who was admitted with joint pain so
severe that she was unable to complete ADLs including
independently feeding herself or going to the bathroom. She was
seen by rheum and started on prednisone and myfortiq (for a
better side effect profile than MMF). Patient pain improved
over subsequent 72 hours. Started calcium, vitamin D, PPI. Per
rheumatology PCP prophylaxis not indicated given plan for
steroid taper. The patient was discharged on Prednisone 10mg BID
x 7 days followed by Prednisone 15mg daily until rheumatology
follow up.
# ___
Patient with a history of lupus nephritis with baseline Cr 0.7,
admitted with ___ Cr 1.3. On admission appeared dry, and she
reported poor PO intake x several days. Thought to be
dehydrated. Received IV fluid resuscitation and Cr improved to
0.8 on discharge.
# Abnormal TTE
Obtained per rheumatology recommendations, and incidentally
showed borderline pulmonary hypertension. Per rheumatology
consult this would be rare complication of SLE. Would consider
whether additional outpatient workup indicated.
#Anemia
Patient with longstanding anemia, on day of discharge hemoglobin
lower than on admission but close to baseline. Would repeat CBC
at follow up.
Transitional issues
- Consider evaluation for pulmonary hypertension given TTE
findings
- Consider repeating CBC at follow up given downtrend in H/H on
discharge
Code: Full
HCP: ___- Mother | 101 | 272 |
12601627-DS-17 | 28,750,353 | Dear ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having increased
thirst and urination. You had also noticed some pain in your
scrotum.
What did you receive in the hospital?
- You were found to have a new diagnosis of diabetes. You were
started on insulin and a medication called metformin to treat
your diabetes.
- You were given antibiotics for an infection on your scrotum.
What should you do once you leave the hospital?
- Please take all of your medications as prescribed and attend
all of your follow up appointments as scheduled.
We wish you all the best!
- Your ___ Care Team | TRANSITIONAL ISSUES
===================
[ ] Assess for resolution of scrotal cellulitis, if not
resolved, may require urology referral.
[ ] Ensure PCP follow up at ___.
BRIEF HOSPITAL COURSE
=====================
___ year old man with asthma and pre-diabetes presenting with
polyuria and polydipsia found to have mild DKA treated in the ED
with AG closure, admitted for treatment of scrotal cellulitis
and titration of insulin regimen.
# DKA
# Hypokalemia
# DMII
Presented with polyuria and polydipsia for at least one month
with A1c 6.1% on last check in ___ climbing to 13.9% on
admission. Found to be hyperglycemic with elevated anion gap and
ketones in urine consistent with DKA. No preceding illness or
other trigger identified. S/p insulin gtt in ED with closure of
anion gap and transition to subcutaneous insulin. ___ was
following during his admission and titrated his insulin to a
regimen of lantus 45mg qAM, Humalog 15U TID with meals, and
sliding scale Humalog (1 unit for every 40 increase in glucose
starting at 140 with meals and 200 at bedtime). He was started
on metformin 500mg BID.
# Scrotal cellulitis:
Patient reported mild discomfort with sitting, relieved by
repositioning scrotum, x ___ days. Received IV Clindamycin x2
days in ED. Denies pain or any other associated symptoms. No
systemic symptoms, no leukocytosis. Scrotal US with scrotal
thickening along inferior left margin, no abscess or gas,
possibly cellulitis with area of edema with overlying pustule
noted on exam. S/p treatment with IV clinda and IV cefazolin. A
5 day course of antibiotics was completed with clindamycin 300mg
q6h.
CHRONIC ISSUES:
===============
#Asthma: mild, intermittent. Does not recall last time he used
inhaler. Continue home albuterol inhaler.
>30 minutes spent on discharge planning and care coordination on
day of discharge. | 116 | 286 |
18675961-DS-24 | 24,800,113 | Dear Mr ___,
You presented to ___ hospital because you were having
trouble walking.
While in the hospital, you were seen by our physical therapy
team, who recommended rehab placement.
After leaving the hospital, make sure you take your medications
as prescribed and follow up with your primary care doctor and
neurologist in clinic.
We wish you the best,
Your ___ team | Mr. ___ is a ___ year-old M w/ hx of Developmental Delay,
Epilepsy, and RLE DVT on Pradaxa who presents with unsteady gait
c/b multiple falls. NCHCT stable from prior studies. Falls are
likely due to a functional decline, with no recent events over
last ___ months coinciding with his increasing gait issues.
Whether also related to his more chronic decline is unclear, as
is the origin of his lean toward the left. He was admitted to
Neurology and evaluated by physical therapy, who recommended
placement at rehab.
He was continued on his home AED regimen: Lamotrigine 250mg BID,
Gabapentin 100mg TID, Zonisamide 300mg qhs. Given his history of
paranoid behavior, he was also continued on home Risperdone 2mg
qhs. He was continued on home furosemide and simvastatin.
He will follow-up with Dr. ___ in epilepsy clinic on ___. | 57 | 140 |
19509694-DS-7 | 20,710,321 | Mr. ___, you were admitted to the hospital for pneumonitis,
which is inflammation of your lung tissue secondary to your use
of crack cocaine. This caused you to be very short of breath and
to require oxygen for a short period of time. It is important
that you stop smoking crack cocaine as this is the cause of your
lung inflammation.
We also treated you for worsening congestive heart failure. You
required IV medications to remove fluid from your lungs. Your
symptoms improved after a few days.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
ADD carvedilol 6.25 mg by mouth twice a day
STOP metoprolol 100mg daily
DECREASE Lisinopril to 5mg | ___ with h/o non-ischemic dilated cardiomyopathy (LVEF 20%),
COPD, presenting with acute respiratory decompensation.
# Hypoxia secondary to crack pneumonitis: Patient presents with
acute respiratory decompensation, over the course of hours,
associated with hypoxemia, with bilateral opacifications in the
bilateral lung fields consistent with likely pulmonary edema and
pneumonitis/pneumonia. In the past, patient has had similar
presentations, usually following crack cocaine use, thought to
be due to acute crack lung inhalation injury. His most recent
reported crack cocaine use was five days prior to admission, and
his symptoms of dyspnea started 3 days prior to admission, which
is consistent with crack cocaine pneumonitis. Patient also had
elevated JVP, rales on lung exam, and imaging suggestive of
fluid overload, making CHF exacerbation a likely diagnosis. The
patient was aggresively diuresis 4.5 litter over the next ___
hours until his creatinine bumped and he was at his dry weight.
His respiratory status did NOT marketly improved with diuresis
(continue to require 50-100% O2 by face mask) and pulmonary was
consulted. Per pulmonary, the patient's clinical presentation
was most consistent with crack cocaine pneumonitis, but an
atypical penumonia could not be ruled out. He was started on
levofloxacin on ___ for a 7 day course. He was also started on
solumedrol 60mg q6 hours and was tappered to oral prednisone and
stopped 2 days prior to discharge. The patient's oxygen
requirement decreased and was weaned off oxygen. A repeat chest
x-ray showed marked improvement in his lung fields. Patient was
discharged with a normal ambulatory oxygen saturation.
# Acute systolic congestive heart failure, non-ischemic dilated
cardiomyopathy: The patient has a history of LVEF 20%. Despite
his clinical presentation (see above), the patient reported
taking his medication faithfully without dietary indiscretions.
Given his clinical presenation, the patient was given lasix 40mg
IV and started on an lasix gtt. The patient was aggresively
diuresis 4.5 litter over the next ___ hours until his creatinine
bumped and he was at his dry weight. His home medications were
intially held. He was initally started on Captopril 6.25 mg
TID. On the floor the patient was euvolemic and additional
doses of IV lasix were held. Patient was transitioned to
carvedilol and discontinued the metoprolol as he is at risk for
continued cocaine abuse. He remained euvolemic during his stay
and was discharged without oxygen requirement.
# Diabetes mellitus: it is unclear whether patient actually has
type 1 or type 2 diabetes but he has been able to go extended
periods of time without medications making it more likely he has
type 2 diabetes. Due to his high steriod dosing patient had
significant increases in his insulin requirements. ___
diabetes consult was placed and assisted in dosing insulin.
There was no evidence of DKA while he was inpatient. Eventually
after he came off of steriods he was able to be transitioned
back to his home insulin regimen.
# Hyperlipidemia: continue home atorvastatin dose
# COPD: patient with history of COPD. He was started on
albuterol and ipratropium nebulizers. His home
fluticasone-salmeterol was held and he was started on
Fluticasone BID.
# Acute on chronic normocytic anemia: patient hematocrit around
baseline.
# Substance abuse: Patient with history or cocaine use and
tobacco use. Patient was counseled on risks of continued cocaine
abuse including readmission and even death. He was also
discharged for prescription for nicotine replacement therapy and
he seemed agreeable to stopping both the tobacco use and cocaine
abuse. | 124 | 590 |
17042066-DS-9 | 20,943,800 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to us after your heart stopped conducting electric
signals properly and as a result was beating very slowly,
causing ___ to have shortness of breath. This is a condition
called complete heart block. For treatment, ___ underwent a
pacemaker placement on ___, and now your heart is beating
correctly.
Please refer to the following instructions for post-pacemaker
recovery:
- Please take your oral antibiotics every 6 hours (2 more doses
today, 4 total on ___, after which your course is complete)
- Leave dressing on for 72 hours
- After removing exterior dressing, leave steri-strips in place.
They will fall off on their own.
- ___ can shower with dressing on, and after ___ remove it. Let
water run over incision, do not scrub or soak. Do not take baths
or go swimming until skin incision has healed completely.
- No driving, racket sports, running, or sleeping without sling
for 6 weeks, until cleared by device clinic.
- Continue to sleep in sling at night for 6 weeks.
- ___ can take walks, but do not run until after ___ have
followed up at the ___ clinic. | ___ man with hyperlipidemia presenting with exertional fatigue
and chest tightness, found to be in complete heart block with
junctional rhythm at 40bpm. TTE mostly unremarkable, EF 65%.
Pacemaker placed on ___ without complication. Pt discharged
with post-procedure instructions after CXR on ___.
TRANSITIONAL ISSUES:
====================
- Medication changes: Clindamycin for prophylaxis, course will
end on ___
- Follow-Up: ___ in 1 week, Dr. ___ in 1
month
- Pacemaker was placed on ___ for complete heart block | 193 | 75 |
16243268-DS-8 | 23,219,846 | You will be transferring to ___ today
Please call Dr. ___ ___ if you have any of
the following: fever of 101 or higher, chills, nausea, vomiting,
increased abdominal pain, JP drain output stops/increases
significantely or changes color/odor, increased diarrhea or G
tube feed clogs
Empty and record JP drain output.
No heavy lifting straining
G tube will be use for tube feedings. | ___ PMH renal transplant in ___, DVT on coumadin, CKD stage 4,
IDDM, HTN, HLD, presented with 4 days of watery nonbloody
diarrhea and pain in LLQ. She was empirically treated for
colitis with cipro/flagyl. Stool studies were negative. CMV
viral load was negative as were blood cultures. An NGT was
placed to suction given nausea, vomiting and concern for an
obstruction. ABD CT demonstrated loops of small bowel in the
left lower quadrant with extensive bowel wall thickening and
adjacent soft tissue abnormality and fat stranding, with
secondary involvement of the adjacent transverse colon.
Findings were concerning for lymphoproliferative disease (PTLD).
Omental nodules and hypodensities in the liver were seen. On
___, she had ___ guided biopsies of the liver with results
showing mucin, but no malignant cells. On ___, she was
transferred to the transplant surgery service for management.
GI performed a colonoscopy with biopsies of colonic mass,
splenic flexure, mucosal biopsy superficial fragments of
adenocarcinoma(low-grad). She continued to have nausea, vomiting
and abdominal pain with repeat CT findings consistent with small
bowel obstruction. On ___, she underwent exploratory
laparotomy with lysis of adhesions, resection of small bowel
with enteroenterostomy, partial resection of transverse colon
with colocolostomy, placement of a gastrostomy tube and biopsy
of in the abscess cavity. JP drain outputs decreased to 10cc/day
(serosanguinous). She was continued on cipro and flagyl which
ultimately continued for 2 weeks ending on ___.
Postop, she was NPO with an NG and G tube to gravity drainage.
TPN was started on ___. Hct decreased to 20 on postop day 2 for
which she was transfused with 2 units of PRBC. The next day, she
desat'd with tachypnea and tachycardia. IV lasix doses were
given for fluid overload. CXR demonstrated pulmonary edema. O2
sat, tachycardia/tachypnea improved. The NGT was removed and she
was started on sips. Over subsequent days, the G tube was capped
and diet advanced and tolerated. However, po intake was
insufficient to support caloric need. Tube feeds were 40cc/hour
continuous). She did have some diarrhea and stool was negative
for C.diff on ___ and ___. Low dose Imodium was started with
frequent stooling.
On ___, WBC had increased to 19. A repeat abdominal CT was done
to assess for abscess/leak. CT demonstrated no evidence of
anastomotic leak or abscess within the abdomen or pelvis. 2
hypodense lesions were seen in the liver, the largest measuring
4.5 x 6.8 x 5.4 cm in hepatic segment VI similar in appearance
to ___. Bilateral pleural effusions with associated
atelectasis.
Pathology of OR biopsies demonstrated segment of small intestine
with organizing serositis; no malignancy identified. One lymph
node, no malignancy identified (___).
Transverse colon, resection: colonic adenocarcinoma;
diverticular disease. Liver, biopsy: metastatic adenocarcinoma,
histologically similar to specimen #1. No liver parenchyma
identified. Oncology was consulted and she was seen by Dr. ___.
She will follow up with him on ___.
Per records, baseline cr is 1.8-2.5. She initially had some ___
on CKD but her Cr improved to baseline with IVF. Tacrolimus and
Prednisone were continued and her tacro level was followed. She
was given daily lasix 80mg which was increased to bid on ___.
On ___, she was restarted on torsemide 40mg (home dose 20mg).
Creatinine started to increase on ___ from 1.6 to 1.9 then 2.0
on ___ and 1.7 on ___. Immunosuppression was continued with
prograf, alternating dose of prednisone (5mg 3x per week and
10mg 4x per week)and Cellcept which was held early in hospital
course for GI symptoms. Cellcept was restarted on ___ at a
lower dose (500mg bid) Home dose is 1gram bid.
Given h/o DVT, she was restarted on on coumadin at 2.5mg daily
on ___ (home dose). INR was 1.3 on ___ then 1.5 on ___ and
___. It is unclear when the patient had a DVT, although patient
notes she has been on long term coumadin. Anticoagulation was
reversed for procedure by ___ early in hospital course, and she
was maintained on SUBQ heparin since.
___ worked with her as she was extremely debilitated and rehab
was recommended. ___ rehab accepted her and a bed was
available on ___. She was transferred in stable condition. | 60 | 710 |
13117361-DS-25 | 25,397,781 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were having chest pain that was concerning for a
recurrence of the inflammation that involved the lining
surrounding your health, called pericarditis.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You underwent an ultrasound of your heart that showed no
evidence of reaccumulation of fluid in the lining surrounding
your heart. There was still a small amount of fluid present, but
was not causing any problems with the pumping of your heart and
it was not possible to drain.
- Given you were already on maximum dose anti-inflammatory
medications, we started you on prednisone to decrease the
inflammation after consultation with your outpatient
cardiologist, Dr. ___ your oncologist, Dr. ___.
- Your chest pain improved somewhat and should continue to
improve over the next couple of weeks.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Monitor yourself carefully for symptoms, including fast heart
rate or shortness of breath and call your cardiologist with any
changes or go to the emergency department.
- Continue taking prednisone 20mg daily until your follow up
appointment with Dr. ___, at which point you will discuss the
taper for this medication.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ___ woman with history of stage IV mantle cell lymphoma
in CR, Sjogren syndrome, OSA, GERD, recent hospitalization for
pericarditis (idiopathic versus rheumatologic) complicated by
pericardial effusion and paroxysmal atrial fibrillation now s/p
pericardiocentesis, and recent ED visit (___) for recurrent
chest pain re-admitted for similar chest pain.
# Recurrent Pericarditis: Patient previously admitted for
pericarditis complicated by effusion requiring
pericardiocentesis. Suspect idiopathic/viral versus
manifestation of Sjogren as noted in prior admission. TTE showed
only small pericardial effusion with no signs of tamponade. CRP
elevated to 173.9. Previously had normal TSH and only weakly
positive ___ (1:40). Given she was already on maximum dose
NSAIDs, we started prednisone 20 mg daily after discussion with
patient's outpatient cardiologist and oncologist. Taper will be
assessed at follow up appointment with her cardiologist on ___.
She was continued on her colchicine and NSAIDs.
# Paraoxysmal atrial fibrillation: Likely provoked by
pericarditis/effusion +/- ibrutinib per previous
hospitalization. Two paroxysms of symptomatic atrial
fibrillation noted during prior hospitalization, which were
fluid responsive. Recent Ziopatch without evidence of atrial
fibrillation. She was continued on metoprolol. Anticoagulation
was deferred recently in setting of provoked atrial
fibrillation, but should be reconsidered as outpatient if
recurs.
# Stage IV mantle cell lymphoma: In complete remission s/p 6 BR
cycles with CR recently s/p C13 of ibrutinib maintenance, though
now off the trial given development of new atrial fibrillation
and pericardial effusion. Hem onc consult deferred after
discussion with outpatient oncologist. Will follow up with Dr.
___. | 240 | 245 |
16621352-DS-22 | 25,028,382 | You have undergone the following operation: Lumbar Kyphoplasty
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
Wound Care: Remove the dressing in 2 days.If
the incision is draining cover it with a new sterile dressing.If
it is dry then you can leave the incision open to the air.Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office ___ and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions.We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Ambulate twice daily if patient able
Thoracic lumbar spine: when OOB
corset for comfort when OOB
Treatments Frequency:
eval wound
remove dressing tomorrow
Restart Coumadin on ___ | Patient was admitted on ___ for severe lower back pain
secondary to L2 fx and ne l4 fx. On ___ he underwent the
above state procedure. He tolerated procedure well. He did
well post op. ___ eval recommend acute rehab. He is stable for
discharge in stable condition | 575 | 52 |
12970765-DS-12 | 22,744,085 | Dear Ms. ___,
It was a pleasure caring for you during your recent admission.
You were admitted because you became very dehydrated after you
recent stomach virus, and we were concerned about your heart and
kidney function.
We gave you some fluids through your IV, and monitored your
heart and kidney function, which improved. You were able to
drink and eat a normal diet without any nausea or vomiting.
You were discharged home with instructions to continue your
usual home medications. Please follow up with Dr. ___,
as detailed below. | Ms. ___ was admitted after she saw her PCP following several
days of vomiting, and an EKG showed changes compared to ___
EKG. She was then sent to the ___, where she was also found to
have a creatinine of 1.7, WBC 16, Troponin of 0.04, and Na 128.
She was given IV fluids, and her creatinine decreased to her
baseline 1.3-1.5, and her hyponatremia resolved. She tolerated
PO and ambulated with no difficulty. Her admission blood
cultures grew gram positive cocci in ___ bottles, for which she
was started on vancomycin pending speciation. The vancomycin was
discontinued when the culture did not show staph aureus or
enterococcus as there was a high suspicion for skin flora
contamination. She was discharged to home in stable condition.
___ This was likely in the setting of hypovolemia. After IV
fluids and good PO intake, her creatinine decreased to her
baseline 1.3-1.5
#Orthostasis: This was likely in the setting of hypovolemia.
After IV fluids and good PO intake, she was asymptomatic and
ambulated with no difficulty and no instability.
#Hyponatremia: Na of 128 on admission, resolved with 1 L IVF to
134. Likely due to hypovolemia.
#Asymmetrical blood pressures: She has had this for many years.
No evidence of dissection: no pain, HD stable, no evidence of
widened mediastinum on admission chest x-ray. This is most
likely the result of aortic surgery many years ago. Could also
be subclavian stenosis from long hx of tabacco use.
# Transitional issues:
1. Lisinopril was held on admission due to her elevated
creatinine, but was restarted on discharge. Please recheck her
creatinine and blood pressure at follow up
2. WBC count was slightly elevated (12.5) at discharge. This may
be due to resolving GI viral infection. Please repeat at follow
up to make sure it has returned to normal.
3. She was started on maintenance Advair for her COPD as she
reported frequent use of her albuterol inhaler. | 89 | 319 |
10006029-DS-16 | 27,104,518 | Dear Mr. ___,
You were admitted to the hospital after you were found to have a
blockage of your bile ducts causing a serious infection called
cholangitis. You were also found to have bacteria in your blood
stream. You underwent an ERCP with a plastic stent placed.
After the procedure your bilirubin continued to rise and you
underwent a second ERCP to place a metal stent.
For your serious infection you were started on IV antibiotics
and will need to continue this for two weeks.
This blockage in the bile duct was caused by a stricture.
Samples of the stricture were taken and found to be cancer
(adenocarcinoma). You were seen by the oncology team and have
follow up with them in a few days to talk about treatment
options.
It was a pleasure caring for you,
Your ___ Team | SUMMARY/ASSESSMENT:
Mr. ___ is a ___ male with IDDM, HTN, BPH, and
metastatic clear cell RCC s/p radical L nephrectomy (___) on
chemotherapy (sunitinib), with recent admission (___) for
biliary stricture s/p ERCP with plastic stent placement (CBD
brushing cytology non-diagnostic) and non-occlusive portal vein
thrombus started on enoxaparin who presented to the ED with
fever, jaundice, and confusion, found to have persistent
intrahepatic biliary dilation and gallbladder sludge on ___ US
s/p ERCP x2 with placement of plastic, then metal biliary stent
and EUS with pathology from FNB of CBD mass consistent with new
pancreatobiliary adenocardinoma. | 139 | 100 |
15677158-DS-11 | 29,928,776 | You were admitted to ___ Neurosurgery service after you were
found to have a left opthalmic artery aneurysm. You were seen
by Dr. ___ based on his evaluation, would like to perform
a cerebral angiogram on ___.
In the meantime, please take the following medications daily
unless otherwise indicated by Dr. ___ his office:
Plavix 75mg daily
Aspirin 325mg daily (___ over the counter). | Mrs. ___ was admitted to the Neurosurgery service after she
was found to have a left ophthalmic artery aneurysm on an
outpatient MRI. The patient has had frequent headaches and was
recently diagnosed with multiple sclerosis. Upon further
clinical workup, she was found to have this aneurysm. Mrs.
___ headache was on the right side and vertex area and
based on her history and physical, appeared to be chronic in
nature. She had no sudden-onset headache(s).
Upon presentation to ___, the patient underwent a CTA which
acknowledged the ophthalmic aneurysm but found no other vascular
malformations or aneurysms of the head or neck. After further
discussion with the patient and her family, it was decided that
she return on ___, for a cerebral angiogram and
stent-assisted coiling of the aneurysm.
In preparation for the angiogram, Mrs. ___ was started on
aspirin 325mg daily as well as Plavix 75mg daily. She was
discharged home in the care of her family. The patient was
asked to contact Dr. ___ office if she didn't hear from them
by ___ afternoon. | 64 | 184 |
19454978-DS-25 | 26,880,522 | Dear Ms. ___,
It has been a pleasure taking part in your care during your
hospitalization at ___. You
were admitted to the hospital for fevers and abdominal pain. You
were found to have an infection of the bile ducts of your liver
and found to have an infection in your blood stream. You
underwent a procedure, ERCP, to remove blocking stones in your
bile ducts, and a small pipe, called a stent, was placed to keep
it open. Your symptoms improved, but you were noted to have
abdominal bloating after the procedure. This improved, and you
were feeling better and able to go home.
Please take the new antibiotics, ciprofloxacin as prescribed
(last day: ___. You will need another procedure to remove the
stent in ___ weeks. Please see below for your appointment.
Should you note any new or concerning symptoms, please seek
medical care immediately.
Given how sick you were, we held your blood pressure
medications, amlodipine and losartan. You should continue
holding these medications until directed by your doctor.
We would strongly recommend a follow up with a liver doctor,
called a "hepatologist." Your liver is likely not functioning
well. The number to our ___ is: ___. Please
call to make an appointment.
Please call your primary care doctor to be seen within the next
week. It is very important he sees you to ensure that you are
still doing well.
Again, it has been a pleasure taking part in your care, and we
wish you the best!
Your ___ care team | Impression: Ms. ___ is an ___ yo woman with history of ___'s
disease, with h/o pyogenic cholangitis and h/o hepatic abscesses
and multiple past ERCPs who p/w fevers and abdominal pain, found
to have choledocholithiasis, cholangitis, and E.coli bacteremia.
# Sepsis ___ Cholangitis
# E.coli bacteremia
Patient p/w abdominal pain and fevers and found to have
cholangitis with elevated T.bili and stones present on CT
abd/pelvis. She underwent ERCP with stone extraction and
placement of biliary stent. Blood cultures grew GNRs and
eventually speciated pan-sensitive E.coli. She was initially
treated with broad spectrum antibiotics and narrowed to
ciprofloxacin to complete a 14 day course (day 1: ___, day 14:
___. ERCP was c/b post-procedure abdominal distension and
abdominal pain. Repeat CT day after procedure showed mild
ascites and right colonic wall thickening, likely reactive in
nature. Ascites was not amenable to drainage and raised concern
for decompensated cirrhosis (see below). No evidence of
pancreatitis. Her abdominal pain improved with bowel rest and
her diet was advanced as tolerated. At discharge, abdominal pain
and distention had improved.
# Possible cirrhosis, decompensated with ascites, jaundice
# ___'s Disease
Patient noted to have history of thrombocytopenia with evidence
of portal hypertension with intra-abdominal varices seen on CT
scan. Albumin was decreased and INR elevated, additional markers
of synthetic dysfunction. This raised concern for underlying
cirrhosis, likely due to ___'s Disease and recurrent
infections/stones. Patient's tbili remained elevated post-ERCP
and she developed ascites, both of which were concerning for
decompensated cirrhosis. Decompensation likely due to active
infection and tbili improved with treatment. Patient was
referred to outpatient hepatology. Unclear if she has had workup
with EGD. Patient should have LFTs monitored as outpatient.
# dyspnea
# pleural effusions
Patient complaining of dyspnea intermittently during
hospitalization. Her home Lasix was initially held given sepsis
physiology on admission, but resumed given dyspnea complaints
and evidence of volume overload on CXR. Symptoms improved at
discharge.
# HTN
Given sepsis physiology on arrival, patient's home
antihypertensives including amlodipine and losartan were held.
These were also held on discharge as she was normotensive.
Please restart as outpatient as needed.
# T2DM: Patient managed with ISS while hospitalized and noted to
have labile BG levels. | 250 | 358 |
10793093-DS-8 | 22,053,003 | You were admitted to the hospital after a fall at home and also
with recent outpatient imaging showing ___ and lung masses
concerning for advanced cancer. You underwent bronchoscopy with
biopsy which confirmed lung cancer. You were started on
steroids and radiation therapy for the cancer in your ___.
You will complete a course of radiation therapy. You will see
Dr. ___ in ___ ___ for follow-up to discuss
chemotherapy.
.
Please follow-up with your physicians as listed.
.
Please take your medications as listed.
. | ___ yo F with HTN, HLD, RA, PAD, significant tobacco history, p/w
new lung mass and ___ masses discovered on w/u of her ataxia,
now confirmed to have metastatic small cell lung cancer.
.
# Bowel incontinence: This is a new symptom, although patient
reportedly was brought in from home covered in feces. Currently
without any other focal neuro findings on exam, and has intact
rectal tone, but given this new symptom, and risk for spinal
mets, did obtain MRI of the entire spine to evaluate for spinal
lesions. She is already on systemic steroids for her ___
lesions. MRI spine without spine mets and no cord compression.
Suspect that her incontinence may be due to weakness limiting
her ability to get to the commode / BR in a timely fashion.
.
# Small cell lung cancer with ___ mets, with ataxia
Patient was started on systemic steroids for her ataxia, likely
from her ___ metastases. She had an MRI ___ (see above)
that did not show any clear spinal lesions concerning for spinal
mets. Her neurologic symptoms remained stable, although without
significant improvement. She underwent bronchoscopy with
biopsy, with pathology concerning small cell lung cancer. She
was seen by Radiation-Oncology and started on whole ___ XRT,
with 2 sessions received as an inpatient, and will continue 3
more sessions (___) to complete a total of 5 sessions.
Following completion of her XRT sessions, her decadron can be
tapered, reducing the dose by half every 3 days. She will
follow-up with Dr. ___ of ___ Oncology for
discussion and likely initiation of chemotherapy on ___.
.
# Hyperglycemia: no history of DM. Currently elevated BS likely
steroid-induced. Her blood sugars have been mainly in the
200's. Given that she has no history of DM2, is insulin naive
and will be weaned off her steroids soon, will use just gentle
PRN units of short-acting insulin for BS >300.
.
.
# HTN: BP suboptimal, but likely due to high dose steroids, will
continue home dose lisinopril for now. Can uptitrate lisinopril
as needed.
# HLD: continue home statin
# RA: She is on weekly methotrexate (25mg IM qweek) and
leucovoroin at baseline. Per d/w her ___, since she
is currently on dexamethasone, which will control her RA
symptoms, can hold off on continuing methotrexate at this time.
Furthermore, if she is to initiate chemotherapy for her lung
cancer, MTX can also continue to be held. .
# PAD, s/p bypass: continue full dose ASA
.
# FEN: Regular diet
# DVT PPx: HSQ
# Code: Full Code (confirmed)
# Contact: ___, HCP / nephew, ___ (cell),
___
. | 85 | 443 |
19438264-DS-43 | 25,687,640 | You came to ___ with complaints of right knee pain. Your knee
pain was evalauted by the Rheumatologist. They removed fluid
from your knee which did not look infected and gout crystals
were not seen. Your pain improved after injection of a steroid
in your knee. You will be discharged home with close follow up
with your PCP and ___. Please be aware that your
blood sugars may be elevated for a few days due to the steroids
injected into your knee.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
.
Medication changes:
1) start calcium and vitamin D for thinning bones
2) tylenol ___ mg Q6H prn mild pain
3) tramadol 50 Q12H prn moderate pain
4) oxycodone 5 mg Q8H prn severe pain
5) continued an aggresive bowel regimen if on narcotics | ___ yo w/MMP, of note CAD, CHF, CKD, gout, OA, spinal stenosis
presents with r knee/thigh pain found to have a small right knee
effusion and XR's that show degenerative changes and osteopenia.
.
# R Knee Monoarthritis:
The patients knee pain was thought to be due to OA but given the
patient history of multiple medical problems (including DM) we
also considered acute gout and septic arthritis. The
Rheumatology service was consulted and the patient underwent an
arthrocentesis of the knee. The synovial fluid gram stain was
negative and did not show any crystals. Septic arthritis and
gout unlikely given these findings. The patients knee was also
injected with steroids which improved the patients symptoms
markedly. The next morning, the patients range of motion was
improved and his mobility was back to baseline. The patient was
sent home with pain medications, calcium and vitamin D for his
osteopenia and a bowel regimen. The patient was discharged to
home with close follow up with his PCP and ___.
.
# DM
The patient was warned that he may require extra insulin as a
result of the steroid injection. The patient understood.
.
# Transitional Issues:
-Follow up with PCP ___ ___ weeks and follow up with Rheumatology
in ___ weeks | 137 | 210 |
14057922-DS-5 | 24,872,373 | Keep your staples or sutures should stay clean and dry until
they are removed.
Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting >10lbs,
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.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
Do not drive until your follow up appointment.
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. | Mr. ___ was evaluated in the ED and admitted to the
Neurosurgery service. He was taken to the operating room on the
day of admission for a right sided craniotomy for subdural
hematoma evacuation. Post operatively he was extubated and
transferred to the ICU. On ___ the paitent was doing well, he
remained on bedrest with a subdural drain; his diet was
advanced. On ___ his drain was d/c'd, post-pull CT showed
pneumocephalus, transferred to the floor and remained stable for
the rest of his admission. On ___ ___ recommended rehab versus
home ___ -- since the patient has good family support he elected
to ___ home with home ___. At the time of discharge he was
tolerating a regular diet, voiding, stooling, ambulating with
assistance, and expressed readiness to return home. All
questions were answered prior to discharge. | 179 | 140 |
14607991-DS-27 | 23,830,065 | Dear Ms. ___,
You were hospitalized for right-sided facial droop, also known
as a Bell's palsy. This is most likely the result of a viral
infection. Upon admission it was also noted that your kidney
function had slowed down compared to the last time you were
seen, and your blood sugar was running high.
For your Bell's Palsy (facial droop), it is recommended that you
complete a 7-day course of Prednisone and Valacyclovir. These
medicines may benefit you in helping to recover faster, but this
is not certain. Make sure you use the eye lubricant drops and
ointment at least every night until your eye is able to fully
stay closed.
Continue taking your Tacrolimus 2mg BID and Azathioprine 100mg
day.
Do NOT take your lisinopril until your are directed to by your
kidney doctor.
It was a pleasure taking care of you,
Your ___ Team | ___ female with ESRD s/p kidney tx ___, uncontrolled
T2DM, HTN, HLD, AFib on Eliquis, mild-moderate aortic stenosis
here with 2 days of right facial droop c/w bells palsy also with
allograft dysfunction consistent with transplant glomerulopathy.
#Bells Palsy
Ms. ___ was diagnosed with a right-sided Bell's palsy
(lower face paralysis) likely secondary to viral infection.
Lyme titers were pending at the time of discharge. She is to
complete a 6 day Prednisone taper (40mg for 2 days, 20mg for 2
days, 10mg for 2 days) and Valacyclovir 1g q12h for 7 days. The
Valacyclovir was adjusted to account for her acute on chronic
kidney injury. She was also provided with mineral oil-based
ophthalmic lubrication ointment at least nightly until right eye
is able to close.
#Allograft dysfunction
She also had an acute allograft dysfunction during
hospitalization. She has had proteinuria consistent with
transplant glomerulopathy seen on biopsy in ___. On
review of OTTR her Cr has recently been 1.28 (___), 1.69
(___), and 1.53 (___). At the time of discharge her Cr was
stable at 1.9, which may be her new baseline due to persistent
glomerulopathy. She was maintained on Tacrolimus 2mg BID and
Azathioprine 100mg day.
# Atrial Fibrillation:
She has a history of atrial fibrillation on anticoagulation. She
was previously on warfarin, but was recently switched to
Apixaban. During hospitalization her Apixaban dose was increased
to 5mg BID. She was continued on home sotalol 40mg PO BID,
metoprolol Tartrate 50 mg PO BID, digoxin to 0.125 mg PO/NG
DAILY (dose adjustmented based on Cr).
# Punctate L basal ganglia restricted diffusion on MRI:
Unknown if this is acute or subacute. Brain imaging
demonstrated old punctate infarcts in the basal ganglia. This is
incidental and unrelated to presentation. Neurology feels this
is most likely old embolic disease in the setting of A-fib.
Unlikely to represent an apixaban failure, as dose was only
recently increased. Carotid US unremarkable.
#DM:
She has refractory type II diabetes mellitus and was evaluated
by ___ during hospitalization and received
U-500 150U/200U/200U and sliding scale with Humalog. Note that
this in-hospital regimen was less aggressive than her home
regimen and was complicated by hyperglycemia, worsened by
steroid administration. Discharged on usual home regimen of U500
Insulin 200 units at breakfast, lunch, and dinner with Humalog
insulin sliding scale at breakfast, lunch, and dinner
(FSG=150-200->30U; 201-250->40U; 251-300->50U; >300->60U).
#HTN:
Continued home amlodipine 5mg. Home Lasix was restarted day of
discharge. Lisinopril held until follow up appointment.
# BMD
Continued calcitirol and Vitamin D.
# Recurrent UTIs
Continued Cephalexin 250 mg PO/NG Q24H.
====================
TRANSITIONAL ISSUES
====================
Discharge Creatinine=1.9
BELL'S PALSY
[ ] Complete 6-day taper of Prednisone: 40mg daily x2 days, then
20mg daily x2 days, then 10mg daily x2 days (last day: ___
___
[ ] Complete a 7-day course of Valacyclovir 1g q12h (last day:
___
[ ] F/u lyme and CMV titers
[ ] Should use mineral oil-based ophthalmic lubrication ointment
at least nightly until right eye is able to close
ALLOGRAFT DYSFUNCTION
[ ] Monitor creatinine
[ ] F/u BKV urine PCR
[ ] Held Lisinopril at discharge; consider restarting when
kidney function improves. | 141 | 513 |
13073377-DS-25 | 21,986,879 | You were admitted to ___ because you had a seizure. This
happened because the level of sodium in your blood became too
low due to you drinking too much water. Please do not drink
more than 2 liters of water a day. We also decreased your dose
of lamotrigine, in the event that this is also a factor in your
sodium level dropping too low and we also holding your lasix for
now. | Ms. ___ is a ___ with a PMHx of HTN, HLD, T2DM, AFib not
on coumadin, CKD Stage IV, Bipolar disorder with multiple prior
suicide attempts, hx brachial plexus injury residual R-sided
hemiparesis, hx seizures in the setting of hyponatremia c/b
episodes of aspiration who presented following a witnessed
seizure and found to be hyponatremic to Na 117.
# Hyponatremia:
Pt was found to have Na 117 on admission on ___ but Na was 140
on ___ at ___. Na trended to 114 after 1L NS in ED.
Pt was admitted to ICU for management. Hyponatremia was thought
to be ___ psychogenic polydipsia, low osmostat in setting of
psychiatric illness, med effect from Lamictal (dose of which had
recently been increased). In ICU, sodium was slowly corrected
using hypertonic saline. On the day of discharge, sodium level
was 142. She was maintained on a two liter fluid restriction.
She continued to ask for more water and to complain of thirst,
but she was euvolemic. We counselled her at great length not to
drink more than 2 liters a day. Also, we held her lasix.
# Seizures:
The patient developed seizures in the setting of hyponatremia.
EEG did not show new epileptiform discharges. Given concern of
medication effect of lamictal in contributing to her
hyponatremia, we reduced her dose from 50 mg po bid to 50 mg in
the morning and 25 mg in the evening.
# ? diastolic heart failure:
Patient on lasix - ? for impaired fluid handling in context of
CKD in context of some diastolic dysfunction seen on ECHO.
Patient appears euvolemic at time of discharge; given this, and
that lasix may contribute to her hyponatremia, it was held at
time of discharge. Outpatient providers can consider restart.
# Depression/Bipolar Disorder:
Pt did not endorse suicidal ideation.
Risperidone was continued. Abilify was initially held but
resumed during the hospitalization. QTc was 414 msec.
# AFib:
CHADS-2=4 (HTN, DM, prior CVA), on ASA 325 daily but not on
coumadin. Rate was well-controlled in 60-70s. ASA, metoprolol
and diltiazem were continued in fractionated doses but resumed
at full doses on discharge. Was in sinus rhythm during this
hospitalization.
# CKD Stage 4:
Cr was 2.5 but trended up to 4.3 and was 3.7 on the day of
discharge. She was seen by the nephrology service and will have
close outpatient followup with Dr ___. She has an right
upper extremity AV fistula recently placed. She does not have
current acute need for hemodialysis, but she requires close
followup with ___, her nephrologist to determine when
HD will start.
# Hypothyroidism:
TSH wnl. Levothyroxine was continued at home dose.
# Diabetes Mellitus: Contnued on home lantus dose. | 76 | 468 |
13849850-DS-14 | 23,580,323 | Dear Mr ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital after you had
a cardiac arrest and a fall. You were resuscitated and intubated
and admitted to the ICU. You were also found to have an
intracranial bleed and a concussion as a result of your fall. We
initially had difficutly taking the breath tube out becuase you
had a pneumonia, but we treated this with antibiotics and your
breathing got better. We are not entierly sure why you had the
arrest. You underwent cardiac catheterization which showed a
near complete occlusion of one of the vessles of your heart.
This was stented open. It is also possible your heart is
predisposed to arrythmias. For this reason you will eventually
get a "Life Vest", which will help shock you out of any abnormal
rythyms again. You will follow up as an outpatient with
Electrophysiology to evaluate whether you will need a permanent
defibrillator. You had both traumatic (from the fall) and
hypoxic (from the arrest) brain injury. It will take time for
you to recover. For this reason we are sending you to a special
rehabilitation center. You will have follow up with neurology
was well.
You have several new medications you will have to take to
protect both your heart and your brain; these are reviewed in
your discharge paperwork. | ___ unknown PMHx, with presumed VT/VF arrest requiring CPR and
cardioversion in the field, with SAH/SDH/intraparenchymal
hemorrhages seen on CT here.
# Intracranial Hemorrhages: Multiple intracranial bleeds with
subdural, subarachnoid, intraparenchymal and extra-axial
hemorrhages, with bilateral temporal bone fractures as well.
Fluid within the sphenoid sinuses and ethmoid air cells thought
d/t intbuation. Seen by Neurosurgery here, who deferred ICP
monitor placement and (presumably) did not want to evacuate
various hematomas. Pt was placed on Keppra 1000mg bid until
further follow up with neurology and neurosurgery. Serial NCHCT
showed that contusions, fractures, and bleeds are stable. Pt was
placed on C-collar for concern for cervical ligamentous injury
based on cervical MRI for 10 days.
# VF/VT Arrest: Presumed d/t shock given in the field. Unclear
etiology. Pt has had 4 syncopal episodes in the past that were
thought to be most likely vasovagal. Seen by Cardiology consult
in the ED who did not believe he had signs of heart failure or
___ clots. Their differential included underlying structural
abnormality (i.e., HCM, ARVC, scar), channelopathy, or PEA
arrest from spontaneous ICH or PE/hypoxia (although this last
was thought unlikely). No AS murmur. Per Cardiology recs, aim
for normothermia and defer anticoagulation (due to ICH). Pt was
in Afib s/p arrest but went into sinus rhythm shortly after
arrival to CCU and esmolol was discontinued. TTE on admission
showed EF 40-45% with mild global biventricular hypokinesis, no
structural abnormalities. Cardiac catheterization was performed
and showed 80-90% stenosis of LAD s/p BMS x2 to LAD. Pt was
started on plavix and aspirin. Plavix should be continued x1
month. Cardiac MR was recommended to assess for scar as the
cause of arrhythmias but it was deferred due to pt's MS and
agitation. Pt was bradycardic to low 40's at times, particularly
during sleep. However, pt was started on low-dose beta blocker
(metoprolol succinate 12.5mg daily) and should be continued as
an anti-arrhythmic agent despite low HR. Pt will follow up with
EP for further management.
# CAD s/p PCI: Pt underwent cardiac catheterization to assess
for ischemia that showed 80-90% stenosis of mid LAD s/p BMS x2.
- cont. atorvastatin 40mg daily
- cont. ASA 81mg
- cont. plavix 75mg daily x1 month
- cont. metoprolol succinate 12.5mg daily
# sCHF: EF on TTE on presentation 40-45%. Pt was started on
metoprolol succinate 12.5mg daily and lisinopril 5mg daily.
- repeat TTE in 40 days
# Aspiration pneumonia: Pt was treated with vancomycin and zosyn
for 7 days. Pt had low grade fevers and purulent sputum.
# Lipase/transaminitis/hypertriglyceridemia: Urine was noted to
be green in color. Triglycerides 400's and lispase 125. This was
thought to be most likely due to propofol, which was
discontinued. LFT's trended down.
- check LFT's | 231 | 456 |
11173335-DS-24 | 24,932,132 | Ms. ___,
You were admitted to ___
because you had been feeling short of breath and you were found
to have fluid on your lungs. This was felt to be due to a
condition called ___ failure, where your ___ does not pump
hard enough and fluid backs up into your lungs. You were given a
diuretic medication through the IV to help get the fluid out.
You improved considerably and were ready to leave the hospital.
Additionally, you underwent an imaging procedure to study
the pressures in your ___ and study the health of the arteries
that supply blood to your ___. This test revealed increased
pressure in artery from the ___ to your lungs (called
pulmonary hypertension). This may be caused by several medical
issues but a very likely disease is obstructive sleep apnea.
This disease is caused by obstruction of you upper airway while
sleeping that causes you to stop breathing temporarily. This can
cause pressure in the blood vessels in your lungs to increase
and require your ___ to work harder. You will need further
work up after your discharge to confirm this diagnosis and
initiate treatment.
After your discharge, you will need to weigh yourself every
day in the morning. Call your doctor if your weight goes up by
more than 3 lbs. Your dry weight is 258 lbs. Take all
medications as prescribed. Follow up with all healthcare
providers listed below.
Thank you for allowing us to be a part of your care.
Sincerely,
Your ___ Cardiology Care Team | Ms. ___ is a ___ year old female with a history of metastatic
breast cancer(on letrozole), HTN, DMII, HFpEF, AFib/flutter on
warfarin who was admitted for worsening DOE and desaturation
with ambulation and was found to have an elevated BNP concerning
for an acute on chronic ___ failure exacerbation.
# PUMP: EF 58%; ___ Cath ___ - severe pulmonary HTN
# RHYTHM: paroxysmal atrial fibrillation, but sinus rhythm on
this admission
# Coronaries: normal myocardial perfusion on nuclear stress
___ Left ___ Cath ___ - normal coronary vessels
ACTIVE ISSUES:
==============
# DOE
# Acute on Chronic ___ Failure Exacerbation:
Given her symptoms of DOE and hypoxia with ambulation in
addition to her elevated BNP and hypervolemia on clinical exam
an acute exacerbation of her underlying ___ failure was the
most likely cause. It was unclear which triggers could be
involved in this exacerbation. Unlikely ischemia given negative
troponin and clean coronary arteries on coronary angiogram.
Additionally, occult infection is also unlikely as she remained
afebrile without leukocytosis or clinical symptoms of infection
and negative urine and blood cultures. It is more likely that
further titration of her diuretics was required. She had her
diuretics increased in the recent month, possible that she may
need a higher dose still. TTE showed hyperdynamic LV w/EF
75-100%, LVH, RH not well visualized, suboptimal study. CXR
PA/Lat reveals worsening engorgement of pulmonary vasculature
concerning for increased pulmonary HTN. She was actively
diuresed with Lasix 80mg IV BID and Lasix gtt 10mg/hr with ___
net negative. Her admission weight was 119.7kg. By 117kg she
appeared euvolemic on exam, however, a ___
catheterization on ___ had a PCWP of 18 suggesting she was
still volume up. She was discharged with a weight of 116.3kg on
100mg of Torsemide daily for maintenance. Her course was
complicated by ___ and hyperglycemia iso of steroid
premedication prior to cath due to self reported IV contrast
allergy. Her DOE improved but seemed to be persistent.
Therefore, a ___ and left ___ catheterization was performed
on ___ to investigate other causes for dyspnea. As
previously mentioned, her PCWP was 18 suggesting some continued
volume overload. Additionally, the cath revealed a mPAP fo 37
consistent with severe pulmonary hypertension; the etiology of
which may include OSA or CTEPH. By discharge, she was feeling
better with improved functional status and ready for discharge.
- Preload: 100mg oral Torsemide
- NKBB: Metoprolol Succinate 25mg QD
- Afterload: Spironolactone 12.5mg daily (reduced from 25mg
daily due to hyperK)
# ___:
Patient with increased Cr from baseline 0.7 upon admission to
1.1. However, diuresis further complicated ___ to a peak Cr of
2.0. This likely represent a pre-renal process following active
diuresis. By discharge, her Cr was downturning; her discharge Cr
was 1.6.
#Atrial Fibrillation/Flutter:
She has a CHADS2 score of 3. Patient has a history of paroxysmal
atrial fibrillation on Flecainide. She was initially treated to
150mg BID. Ambulation trails did not revealed any lightheadness
or telemetry changes. However, has had multiple pauses and
bradycardia on telemetry, therefore, Flecainide was reduced to
100mg BID (her home dose). No AFib on tele, with resolution of
pauses and bradycardia. Warfarin was continued during this
admission and held temporarily during catheterization but
restart before discharge. Her discharge INR was 1.6. Given that
the patient remained in sinus while in house, it was decided to
discharge the patient without a bridge. In addition, she has a
follow up appointment two days post discharge with her PCP ___
___.
# Leg Pain:
Patient with chronic ongoing bilateral leg achiness. ___ be more
neuropathic in nature given her uncontrolled DMII or more likely
related to significant peripheral edema as the leg pain improved
with diuresis even during ambulation which is a great
improvement.
# Microcytic Anemia:
Hgb on this admission was at baseline of ___. This is coupled
with a severely depressed MCV of 65 concerning for a iron
deficiency anemia vs. an underlying thalassemia trait. Iron low
normal with elevated TIBC and Tranferrin and Fe/TIBC 0.06 more
consistent with ___. Her Hgb remained stable and she required no
transfusions during this admission.
CHRONIC ISSUES:
==============
# DMII:
Her blood glucose was poorly controlled and worsened by steroid
premedication for IV contrast allergy. Her BG ranged 100-200's
before steroids and 200-500's after treatment. ___ was
consulted and followed closely with significant adjustments in
Lantus (used in place of her home Tresiba for which was not
available during her admission) and standing Humalog doses. She
has close follow up with an Endocrinologist on discharge. Her
final discharge insulin plan was:
- ___ 84U Breakfast, 40U Bedtime
- Humalog 35U Breakfast, 35U Lunch, 35U Dinner
- Humalog SSI => Start 160 mg/dL q40mg/dL, Start 4U + 2U
increase per range
# HTN
Her home Spironolactone was continued during this admission but
decreased to 12.5mg given hyperK. Her SBP's ranged 110-150's.
# GERD:
Her home Omeprazole BID was continued during this admission.
# Breast Cancer:
Her home Letrazole was continued during this admission.
#CODE STATUS: FULL CODE
#CONTACT: ___ ___ | 268 | 817 |
19999068-DS-14 | 21,606,769 | You were admitted with a fall while intoxicated. You were sent
here as there was concern that you had bleeding in your brain.
Your follow-up head imaging showed resolution of bleeding in
your brain. You were briefly on precautionary (prophylactic)
anti-seizure medication. You were seen by the S/W regarding
your alcohol abuse history, and you were provided with
information regarding resources for alcohol abuse treatment.
You Should not be driving.
Medication changes:
STARTED Thiamine and Folate
Started Erythromycin eye ointment | HOSPITAL COURSE:
Patient is a ___ yo male with history of alcohol abuse who was
brought to OSH after fall and found to be in ETOH withdrawal at
OSH with question of intraventricular hemorrhage and transferred
to ___ for further eval who required 36 mg iv lorazepam in the
ED for signs of ETOH withdrawal, intubated for CTA given concern
for question of aortic dissection and for increasing agitation.
Patient was kept on propofol and IV ativan prn while intubated.
He was started on standing ativan for agitation and extubated
successfully on ___.
.
# Alcohol withdrawal/Delirium Tremens: Patient had evidence of
delirium tremens and severe alcohol withdrawal in the ED with
tachycardia to 150s, BP to 153/93, agitation and question of
hallucinations. He received 36 mg iv lorazepam in ED. Patient
was first maintained on IV ativan prn on CIWA, however, he
required increasing doses of IV ativan, up to 16 mg at a time.
He was intubated and placed on propofol gtt with prn ativan for
increasing agitation, and for the need for CTA of chest (as
below) given question of aortic dissection. His agitation and
ativan requirement decreased over time and he was started on
standing PO ativan and extubated successfully. He was started
and continued on thiamine, folate and MVI daily. His Mg and K
were repleted aggressively throughout the hospital stay. He
required intermittent doses of IV haldol for acute agitation. Pt
remained stable and was transferred to the floor ___.
.
# Intraventricular hemorrhage vs contusion s/p fall: Patient
presenting to outside ED with evidence of trauma given his large
R forehead hematoma and lacerations on extremities. CT head was
done at OSH and showed possibility of intraventricular
hemorrhage and transferred to ___ for neurosurgery eval.
Patient seen in ED by neurosurgery who reviewed the imaging,
which showed a hypodensity in R temporal horn. C-spine was
cleared by CT and by exam. It was thought to be due to artifact
and no hemorrhage seen. He had no edema on head CT from OSH.
Neurosurgery recommended Dilantin 100 mg q8hrs x7 days for
prophylaxis. Patient had an episode of oversedation and
unresponsive, and given change on neuro exam on ___, repeat
head CT was obtained without acute abnormality. Had f/u head CT
on ___, which continues to show no evidence of acute
abnormaility or bleed.
.
# Question of aortic dissection: Patient has a new finding on
CXR of potential aortic dissection. Given discordant blood
pressure of 150/90 right arm and 130/85 left arm, and as patient
was unable to relate clear history given his agitation, he was
intubated and CTA of chest was obtained. The imaging did not
show aortic dissection.
.
# History of GERD: Pt has hx of GERD per OSH, on pantoprazole
daily per OSH record. He was continued on pantoprazole in house.
.
# Social: patient reports living in a house with a girlfriend,
and also reports a daughter. Unable to contact any of these
people, social work was consulted to assist with locating family
members and to assist with his alcohol dependence. Daughter was
able to be located, is amenable to becoming health care proxy.
#Conjunctivitis: erythema, injection, and exudate on R eye
present on ___. Rx for erythromycin drops started | 80 | 540 |
12665592-DS-8 | 26,243,607 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for difficulty breathing due to fluid in your lungs. You were
given medications (water pills) to get rid of the fluid and your
breathing improved on this. You were also given medications to
lower your blood pressure since a high blood pressure can strain
the heart and cause back up of fluid into the lungs.
Please weigh yourself every morning, and call your PCP if your
weight goes up more than 3 lbs. Please see below for your
medications and appointments. Thank you for allowing us to
participate in your care. | ___ PMHx CAD, HFpEF with CHF exacerbation.
# Acute on Chronic Congestive Heart Failure with Preserved
Ejection Fraction: CXR suggestive of pulmonary edema, with
elevated BNP and recent cardiac cath showing LVEDP 31mmHg.
Etiology of exacerbation is unclear, but likely secondary
hypertensive urgency, exacerbated by decreased responsiveness to
lasix in setting of worsened kidney function. Differential also
includes infection (though no signs or symptoms), or
hyperthyroidism (TSH low but within normal limits). Patient was
initially on NIPPV, but this was weaned off as patient was
diuresed. Case was discussed with ___, who recommended
continuing with diuresis rather than starting hemodialysis.
Because the patient was not diuresing well to furosemide, she
was transitioned to torsemide with better effect. She was
discharged on this medication.
# Troponinemia: Elevated at baseline, likely chronically
elevated in setting of CKD. No EKG changes concerning for
ischemic changes. Low level of suspicion for demand ischemia in
setting of CHF exacerbation. CK-MB was flat.
# Asthma: PaCO2 on admission was 34 (after having been on
non-invasive ventilation), raising concern for asthma
exacerbation; she also has a 40-pack year smoking history, so
COPD was considered (though she is not on home COPD
medications). Her hypoxia and work of breathing responded to
diuresis alone, so no futher medications were added.
# CKD Stage 5: Has LUE AV fistula with thrill. Not yet initiated
on HD. Being screened for kidney transplantation.
# CAD: Single vessel CAD with AV groove CTO, which is a small
vessel and receives good quality collaterals from the RCA. EKG
on admission shows no specific ischemic changes. Continued on
home aspirin and rosuvastatin.
# Type 2 Diabetes: A1c 7.5% in ___. Covered with glargine and
insulin sliding scale while here. Transition back to home
insulin regimen and glipizide on discharge.
# HLD: Continued home rosuvastatin.
# Sarcoidosis: Stable per report, not on sarcoid medications.
Was noted to have normal intervals while tachycardic on
admission EKG, however (these intervals should be short in
setting of fast heart rate), raising concern for possible
cardiac sarcoid causing conduction delay. | 104 | 342 |
11586389-DS-9 | 22,931,597 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
the ___. You were admitted for cellulitis that was not
adequately treated with oral Bactrim. We put you on IV
antibiotics and you had a significant improvement in your
symptoms, as the swelling and pain in your left leg decreased.
We did a biopsy of your leg which showed that you had
inflammation in your blood vessels called vasculitis.
Because you continued to improve clinically on the antibiotics,
we transitioned you to an oral form.
You should take these medications for a total of 7 additional
days.
Please note that while taking these medications, you should (1)
take them with a large glass of water and food, as they can
cause GI upset, and (2) avoid direct sunlight - if you are going
to be outside, please wear long sleeved clothing and a hat to
avoid any direct sunlight, as it can cause a rash on your skin.
CONTINUE Doxycycline 1000mg, take by mouth every 12 hours, LAST
DAY ___
CONTINUE Keflex ___, take by mouth every 6 hours, LAST DAY
___
Please make sure you are seen in ___ on ___ so they
can reevaulate your rash.
Please call the ___ at ___ to set up
an appt with Dr. ___ to follow up all of your blood work results
that were sent while you were in the hospital. | Mr. ___ is a ___ w/ hx of chronic kidney stones who was sent in
by dermatology for a cellulitis unresponsive to bactrim, started
on IV vanc and showing clinical improvement; biopsy c/w
cutaneous vasculitis, thought to be from infection, transitioned
to PO doxycycline and keflex, continuing to clinically improve.
# LLE skin changes: Initially thought to be cellulitis s/p 9
days of outpatient treatment with Bactrim with no improvement.
Was seen by Derm and referred to ER. Ruled out for necrotizing
fascititis and started on IV Vanc. Clinically improved with IV
Vanc and biopsy results came back as vasculitis. Rheum was
consulted and the multiple studies were sent, including
hepatitis serologies, HIV, C3, C4, ___, anti-dsDNA, anti-Ro,
anti-La, anti- RNP, ___, anti-dsDNA, RF, serum
cryoglobulins, ANCA, SPEP, UPEP.
Because the patient was clinically improving on IV antibiotics,
he was transitioned to PO Keflex and Doxycycline, and he was
instructed to complete a 10 day total course of antibiotcs. He
has outpatient follow up on ___ in HCA, at which point
his LLE can be reevaluated.
# vascultitis: LLE biopsy showed e/o localized vascilitis.
Rheum was consulted and it was felt that there was no systemic
involvement. Labs sent and will need to be followed up in
outpatient Rheum (hepatitis serologies, HIV, C3, C4, ___,
anti-dsDNA, anti-Ro, anti-La, anti- RNP, ___, anti-dsDNA,
RF, serum cryoglobulins, ANCA, SPEP, UPEP, CXR). The patient
was instructed to call ___ clinic to schedule an appointment
as an outpatient.
# ACUTE KIDNEY INJURY: Pt presented with Cr spike to 2.0 from
baseline 1.4-1.5. He was given 2.0L NS and Cr improved to 1.8
then with good PO improved to 1.6. FeNa was 0.8 suggesting
prerenal pathology, and the patient's creat trended back down to
baseline after fluid challenge.
TRANSITIONAL ISSUES
- The patient has many labs pending as part of his vasculitis
w/u including, hepatitis serologies, HIV, C3, C4, ___,
anti-dsDNA, anti-Ro, anti-La, anti- RNP, ___, anti-dsDNA,
RF, serum cryoglobulins, ANCA, SPEP, UPEP, CXR.
- The patient was instructed to call the ___ at
___ to set up an appt with Dr. ___.
- Of note, the patient is due for colonoscopy. Had one in ___
and was instructed to have a repeat in ___. This should be
followed up by PCP. | 227 | 391 |
14657386-DS-15 | 20,072,758 | Dear Mr. ___,
WHY WERE YOU ADMITTED?
- You were admitted to the hospital because you had chest pain
and felt short of breath
- Your blood pressure was high causing you chest pain and making
it harder to breathe
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
- You were given medications to manage your blood pressure
- We performed an ultrasound of your heart and obtained several
EKG studies to evaluate your heart function, which is still
pumping normally
- You received hemodialysis as per your usual schedule.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Please follow-up with your psychiatrist and your primary care
provider
___ was ___ pleasure taking care of you,
Your ___ Care Team | BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ year old gentleman with a history of HTN, COPD,
HFpEF, CAD, ESRD on HD, T2DM and recent admission for
hypertensive emergency who presented with 1 day of dyspnea and
chest pain and was diagnosed with Type II NSTEMI, hypertensive
emergency, and volume overload being ___ above his dry
weight. | 114 | 56 |
16603070-DS-20 | 27,768,445 | Dear ___,
___ were admitted to the ___
with shortness of breath and weakness. ___ had the past
diagnosis of pneumonia and were found to have signs of pneumonia
on a chest xray in our ED. We treated ___ with supplemental
oxygen, nebulized breathing treatments, IV fluids, and
antibiotics. Upon going home, we would like ___ to continue
taking the antibiotics that we started in the hospital for 5
more days.
We have made the following changes to your medications:
# START levofloxacin 750mg by mouth for 5 more days
# START albuterol inhaler ___ puffs every ___ hours for
shortness of breath or wheezing
Please continue all of your other medications as previously
prescribed | Mrs. ___ is a ___ year old female with a history of
depression recently diagnosed with PNA s/p 5 days of
azithromycin who presents with SOB, cough, myalgias and
arthralgias.
1. Pneumonia: CXR showed a Left lower lobe consolidation. She
was treated with levofloxacin and supplemental oxygen given
hypoxia. After observation she improved and was discharged to
complete a 5 day course of levofloxacin. She was also prescribed
an albuterol inhaler since her breathing was somewhat wheezy on
day of discharge.
2. Insomina: Trazadone used with good effect.
3. Myalgias: Resolved with acetaminophen. | 113 | 91 |
16949991-DS-23 | 20,909,192 | Dear Mr. ___,
It was a pleasure caring for you here at ___
___.
Why you were here:
- You had pain and swelling in your L leg.
What we did while you were here:
- We did a CT scan and an ultrasound which showed a fluid
collection in your leg.
- Your vascular surgeons think that this is most likely a blood
collection, called a Hematoma.
- The Infectious disease doctors wanted to make sure there was
no infection in the leg.
- We arranged for you to have a drainage of the fluid on ___.
You will come back in to have this done and the infectious
disease team will follow up the results.
- We started a new medicine for pain, called Lyrica.
What to do when you go home:
- Use the lidocaine, capsaicin and Tylenol ___ up to every 6
hours to control the pain.
- You can use dilaudid ___ every 6 hours for breakthrough
pain.
- You make take 400mg of ibuprofen if you still have pain after
all the above. Do not take ibuprofen for more than 3 days as it
can damage your kidneys.
- Take the lyrica 25mg twice daily. Your primary care doctor
should work with you to increase this dose slowly with time.
- Follow up with you primary care doctor, your diabetes doctor,
and your infectious disease doctors as below.
- Please hold your warfarin until ___ and resume your usual
dose (7.5mg daily) on ___ after the biopsy. Please have your
INR checked on ___.
Sincerely,
Your Care Team | ___ hx T1DM multiple complications, HTN, seizure, depression,
GERD, hx polysubstance use disorder who presents with severe LLE
pain, swelling, warmth and fluid collection c/f infection vs.
hematoma.
#LLE pain, swelling and fluid collection
Seen on ultrasound of the leg. Vascular surgery evaluated him
and felt this was most likely a hematoma. Infectious disease was
consulted given his complex infectious history in that leg, and
recommended rechecking of CRP. This was elevated to 18, so the
decision was made to pursue an ___ guided drainage. The patient
had received empiric antibiotics on arrival so there was concern
that the collection may have been sterilized. Given his
hemodynamic stability and low concern for infection, antibiotics
were held and the drainage was scheduled for outpatient setting,
on ___.
- recommend that he stop warfarin until after his biopsy on
___. Repeat INR on ___ at his usual ___ clinic. We decided
against bridging him given high suspicion for hematoma and long
lapse since last acute clot.
#Stump pain
Acute on chronic, worsened I/s/o fluid collection. He was
treated with Tylenol, lidocaine and capsaicin, and dilaudid as
needed. Chronic pain was consulted and recommended addition of
lyrica. Of note, the patient declined gabapentin and
amitryptiline due to bad prior experiences years prior (hand
pain from gabapentin and mood changes from amitryptiline).
#T1DM:
Poorly controlled with labile blood sugars. Per ___, prior
d/c regimen was 5 mg lantus bid, 2U Humalog TIDAC. He has a plan
to get insulin pump with his outpatient endocrinologist.
#Recurrent DVTs and PEs:
Chronic femoral DVT seen on prior admission. Not appreciated on
U/S
___. He has a history of recurrent VTE and has been on
warfarin for many years. Anticoagulation as above.
Transitional Issues:
- Pain regimen: lidocaine 4% patch, capsaicin cream, dilaudid
___ q6h PRN breakthrough pain, Tylenol ___ q6h PRN
- Addede lyrica after consultation with chronic pain team. 25mg
BID. Please uptitrate in outpatient setting. Consider outpatient
pain consult if continues to have poorly controlled pain.
- Has ___ appointment ___ for ultrasound guided drainage of
fluid collection at 7:30 am. patient aware. Please follow up
cultures and start antibiotics if concern for infected fluid
collection.
- Blood sugar was labile, per records appears he has plan to
start insulin pump as outpatient, recommend close follow up with
endocrinology.
- Consider switching him from warfarin to NOAC for ease of use.
- Patient should stay off his prosthetics until after acute pain
resolves. He should be refitted for prosthetics.
- recommend that he stop warfarin until after his biopsy on
___. Repeat INR on ___ at his usual ___ clinic. We decided
against bridging him given high suspicion for hematoma and long
lapse since last acute clot. | 264 | 447 |
12559662-DS-12 | 29,631,812 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted after an episode of chest
pain and slurred speech. After neurological evaluation, we
found that you did not have a stroke, but may have suffered from
an episode of Parkinsonian autonomic failure. You improved with
supportive care and your regulraly scheduled medications.
Regarding you chest pain, we obtained a stress test and an
expert evaluation with our cardiology team. Your stress test
was positive, but after discussion with you and your family, it
was decided that no invasive intervention (cardiac cath) be
undertaken currently since your chest pain appears to be a rare
event. You should follow-up with your cardiologist as an
outpatient.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Mr. ___ slurred speech and chest pain were evaluated by
the neurology and cardiology teams. Regarding his slurred
speech, his neuro exam was unchanged from apparent baseline and
his CT head was normal, so a cerebrovascular accident was felt
to be unlikely. A Parkinsonian autonimic failure was discussed
as a possible etiology, but no changes in his medications were
necessary.
Regarding his chest pain, he underwent a stress test with
myocardial perfusion imaging. He had no chest pain or ischemic
ECG changes, but several reversible perfusion defects were
discovered. The cardiology team discussed the possible
management options, including cardiac catheterization, but since
the patient was asymptomatic and his chest pain events were felt
to be infrequent, an elective cardiac catheterization was
deferred. This was communicated to his outpatient general
cardiologist, Dr. ___ and a follow-up
appointment was scheduled. He was also scheduled to see his
electrophysiologist, Dr. ___ at ___.
Regarding his atrial fibrillation, there was some confusion
regarding his dofetilide therapy, since there was incongruous
information in his medication reconciliation. It appears that
he was on dofetilide in the past, but not currently. Per his
family, the only medications he has been taking are dispensed at
the ALF, and the documentation from there does not list
dofetilide. He was given one dose of dofetilide before this
information was uncovered. His QTc was monitored and found to
be WNL at 425 on 12-lead ECG prior to discharge. | 138 | 245 |
15845632-DS-12 | 25,921,017 | Dear Mr. ___,
You were admitted to ___ because you were having fevers, pain
with urination, and pain in your right flank and scrotum. These
symptoms were concerning for a urinary tract infection.
We sent a sample of your urine for culture and started you on
broad antibiotics to treat the infection, while we awaited the
results of the culture.
Your symptoms improved with reduction in your pain and no
further fevers. The urine culture came back showing klebsiella,
which was sensitive to ciprofloxacin. You should continue to
take this antibiotics for a total course of 2 weeks to end on
___.
You were also noted to have high volumes of urine in your
bladder. You should increase the number of times you straight
catheterize yourself from ___ to ___ times per day. Please keep
track of the post-void residual volume and let your kidney
doctor know the value. If you have more than 150cc, you will
need to increase the frequency of your straight cath.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old gentleman with congenital bladder
outlet obstruction s/p neobladder, ESRD due to obstructive
uropathy s/p DDRT (___) on tacro/MMF, with recurrent
complicated urinary infections who presents with fever, dysuria,
and right testicular pain. Scrotal ultrasound showed known right
hydrocele, but no other source of infection. Transplant
ultrasound was negative for abscess or ultrasound from LURT
kidney. Patient was started on broad spectrum coverage with
vanc/zosyn for coverage of UTI. UCx grew klebsiella pneumonia
sensitive to cipro. Patient was started on cipro 500mg BID for
total treatment course of 2 weeks to end on ___. Given high
post-void residuals, he should increase frequently of straight
cathing from ___ times per day to ___ times per day.
# UTI ___ chronic reflux and urinary retention:
Patient with history of fluoroquinolone sensitive E. Coli and
vanc sensitive enterococcus. He initially presented with fever
and right flank/testicular pain. Scrotal u/s was negative for
source of infection and transplant ultrasound was negative for
abscess. He was started on vanc/zosyn on ___, which was
narrowed to ciprofloxacin 500mg BID on ___ after culture showed
klebsiella sensitive to cipro and Bactrim. Blood cultures were
negative at time of discharge. He should continue cipro 500mg
BID for a total treatment course of 2 weeks to end on ___.
He had post-void residuals of 100-200 cc and consequently should
increase frequency of straight cath from ___ times daily to ___
times daily. He was continued on home tamsulosin.
# R testicular pain
# B/L hydroceles:
Complained of right scrotal pain at admission. Testicular
ultrasound demonstrated no acute abnormality and right hydrocele
that was not significantly changed in size. Likely referred pain
in setting of UTI. Pain improved with abx and pain control with
acetaminophen 500mg PO q6H.
# Headache: Patient had headaches with that were relieved by
acetaminophen.
# s/p LURT: Cr at 1.2 at admission, which is patient's baseline.
Tacro level was 4.7. He as continued on tacrolimus 4mg PO q12H
and mycophenolate mofetil 500mg PO BID
# Diabetes: Sitagliptin and tresiba were held as non-formulary.
He was switched to lantus 20mg QPM and ISS. He should resume
tresiba and sitagliptin after discharge.
# HLD: Continued on home atorvastatin.
# Gout: Continued home febuxustat.
Transitional Issues
====================
[] Urine culture grew klebsiella pneumonia that was sensitive to
cipro and Bactrim. Continue ciprofloxacin 500mg BID for total
treatment course of 2 weeks to end on ___ - ___
[] Increase frequency of straight catheterization from ___ times
per day to ___ times per day given high post-void residual.
[] Patient will follow up with transplant nephrology, they will
call him to schedule appointment. Please ensure that follow up
after discharge.
[] Can discuss with urology if additional benefit from
finasteride
-Code Status: Full
-Emergency Contact/HCP: ___ - ___ | 183 | 455 |
16993106-DS-6 | 20,624,904 | Ms. ___,
You were admitted to ___ after a fall you sustained at home.
You were evaluated and treated by the medicine service. You were
found to have a left 7th rib fracture. You were able to walk
without assistance and your pain was controlled with pain
medicaion. Please use 2L of oxygen when walking and while
sleeping. You should follow-up with you primary care doctor in
about 2 weeks. Please take your medications as prescribe and
keep your outpatient appointments. | ___ F with PMHx tobacco dependence, COPD on home O2,
hypothyroidism, and osteoporosis presents s/p mechanical fall
and hit to ribs, splinting, and inability to take nebs for 1d
with TTP over the left anterior aspect of the ___ ribs with
prelim CT reading showing 7th rib fracture that did not impact
breathing.
# Non-displaced 7th rib fracture after mechanical fall: Chest CT
showed non-displaced 7th rib fracture. Patient had TTP over the
mid-axillary line over the ___ ribs. Her pain was controlled
with APAP and oxycodone and she felt comfortable performing ADLs
# COPD: Continued tiotropium, Symbicort, Nebs and home
supplemental oxygen stable at 2L with activity.
# Hypothryoidism: Continued levothyroxine.
# Depression: Continued home Imipramine, Bupropion and
Divalproex | 82 | 118 |
13148985-DS-41 | 25,041,947 | Dear Mr. ___,
It was a pleasure taking care of you! You were admitted to ___
for evaluation and treatment of chest pain. You were evaluated
for severe and serious causes of chest pain inculding your
heart, lungs, aorta, and chest wall by a CT angiogram of you
chest, serial EKG's, cardiac enzyme monitoring, review of your
prior catheterization reports/images, and lack of significant
response to nitroglycerin. The results of these tests show that
you did not have a heart attack, that your pain is likely not
coming from your heart, you don't have a clot in your lungs, you
don't have damage or disruption to your aorta or your lung
tissue, and you have no broken bones in your chest.
The following changes have been made to your medication:
-START Lidocaine Patch 5% to your chest wall
-Continue taking your other home medications as previously
instructed
Please follow-up with the appointments as below. | ___ with hx of HTN, HLD, DM2, chronic body pain, CAD s/p PCI to
___ and recent DES to PDA here with ongoing chest pain. | 149 | 28 |
15132645-DS-8 | 24,019,130 | You were admitted to ___ for
___ of blood in your stool. You had a colonoscopy/EGD on
___, which showed irritation in your stomach and duodenum.
You should stop taking your Aspirin for 5 days. You should
follow up with your PCP and GI doctor.
.
Medications changes:
1) hold your aspirin for 5 days
2) decrease your dose of atenolol to 50 QD
3) increased omeprazole to 40 mg po BID | Mr. ___ is a ___ man w/ PAD, CAD, DM, HTN, HL and colonic
adenomas previously found on colonscopy who p/w BRBPR in the
setting of having been on plavix and asa for a popliteal stent
that was recently placed with Hgb 11.3 and stable hemodynamics
on presentation
.
## Bright red blood per rectum due to duodenal erosions
The etiology of the patient bleed was thought to be due to
recurrent bleeding polyp vs. colon CA, hemorrhoids vs. UGIB.
The patient was monitored with serial hemoglobins, lowest of
which was 10.5. He did not require PRBC's during his course.
GI was consulted and the patient underwent a colonoscopy and
EGD. The colonoscopy showed polyps in the sigmoid colon and the
EGD showed erythema and erosions in the duodenal bulb consistent
with duodenitis and gastritis. Biopsies were taken to rule out
h. pylori. The patient returned to the floor and showed no
clinical signs of bleeding. His Hgb was stable at 10.5, he was
able to tolerate a diet and he was eager to go home. He was
sent home on omeprazole 40 BID and was instructed to hold his
ASA for 5 days. He should have a follow up CBC in 1 week and
have it faxed to his PCP. The bleeding was thought to be due to
him being on multiple anti-platelet medications in the
background of possible NSAID use.
.
## chest pain with thoracic and lumbar back pain
Etiology of this was thought to be chronic due to MSK related
back pain and pleurisy. The patient had serial EKG's and TnI's
checked to rule out ACS. CXR was wnl. It was noted that the
patient had a h/o an aortic aneurysm but the pain was largely
unchanged from his prior pain after interviewing the patient and
his partner. The patient should follow up with his
Cardiologist.
.
## PAD s/p stent to left popliteal artery
The patient ASA was held while in house. His Hgb was stable and
he did not show any clinical signs of bleeding the day of
discharge. His ASA should be held 5 days prior to re-starting
it. Plavix was discontinued as an outpatient.
.
## HTN
The patient atenolol was held while in house due to relative
bradycardia in the ___. He reports a history of this in the
past. He was temporarily placed on metoprolol 25 BID. Upon
discharge he was placed on half his normal dose of atenolol, 50
QD. This should be titrated further as an outpatient.
.
##Transitional Issues:
-patient needs to follow up biopsies from EGD and colonoscopy
-patients needs to follow up with PCP ___ 1 week (after getting
CBC checked) for further anti-HTN medication titration and
assuring that the patient re-started his ASA
. | 68 | 467 |
17947312-DS-18 | 25,228,559 | Dear Mr. ___,
It was a pleasure taking care of you while you were here at
___. You were admitted to the hospital for abdominal pain.
Your workup was reassuring and negative. This may have been due
to constipation and we recommend you continue with a bowel
regimen to ensure you have regular bowel movements. You should
also follwoup with your PCP and ensure you undergo your
previously scheduled screening colonoscopy. | In the ED, initial vital signs were: T 98.6 P 60 BP 206/58 R 16
O2 sat 98% RA
Exam notable for abdomen mildly distended, distant/scant bowel
sounds, soft, mild diffuse tenderness in RLQ, no guarding or
rebound, palpable masses or organomegaly
Rectal vault w/dark-green FOBT negative stool, normal tone, no
hemorrhoids
Labs were notable for: Trop < 0.01, Lactate 2.4, pH 7.52 on
blood gas with normal bicarb on chem 7, Ca ___, FreeCa 1.17, Mg
1.4, Phos 1.4, T Bili 1.3 (last 0.7 in ___), lipase 29, WBC 11.
Patient was given 1L NS, zofran 2 mg, 8 mg total morphine IV, 1
mg dilaudid IV, 1 dose cipro/flagyl, 2g MgSO4, 15 mmol KPhos,
omeprazole 20 mg, hydralazine 20 mg, atenolol 25 mg,
levothyroxine 125 mcg. He also received an enema which produced
a small, hard BM.
On Transfer Vitals were: 98.4 145/62 49 16 100/RA
Pt came to floor, vital signs stable throughout admission.
Started on colace/senna scheduled. Was able to have a small BM
with enema (hard, formed stool). Next day had another BM. Day of
discharge had 2 bigger BM. Exam remained unchanged, non-specific
without focal findings except for localized tenderness to
muscles below right scapula as noted above. The pain was not
post-prandial in nature, and had no specific triggers, apart
from rolling from side to side in bed. | 71 | 219 |
14121516-DS-20 | 25,799,537 | Dear Mr. ___,
You were admitted to the hospital for a leg ulcer infection. You
were started on antibiotics and you improved. You were seen by
ID who recommended a 14 day course of Vancomycin. We used wound
dressing change recommendations as per the wound consult team.
Pain medication regimen was adjusted by our pain specialists.
___ terms of the HES and possible RA, we consulted both
Hematology and Rheumatology. Rheumatology did not think you had
RA currently, but may ___ the future. You may want to consider a
Rheumatology appointment once the infection heals. Hematology
did not think you had active HES given the low level of
eosinophils ___ your blood. Hematology will do a bone marrow
biopsy as an outpatient.
Please keep the follow-up appointments made for you. | ___ male w/ obesity, DVT on Coumadin, hypereosinophilic
syndrome, b/l idiopathic AVN, and chronic venous stasis ulcers
with h/o multiple infection who p/w reinfection of chronic
venous ulcer.
# Chronic Venous Stasis Ulcer: On admission with increased
malordorous drainage from ulcer and leukopenia, likely due to
re-infection of ulcer. Has h/o infections with a variety of
resistant bugs, see PMH. Followed by ID as outpt, specifically
Dr. ___. No fevers or increased pain compared to baseline at
wound site on admission. Finished a recent course of
Vanco/Cefepime on ___ for a similar ulcer infection. Failed
Augmentin PO prior to admission which was prescibed by outpt ID
attending. Started on Vanco and Cefepime on arrival to ED,
continued on the floor (___). Pt underwent bedside
debridement by Vascular surgery ___ ED but no micro sample was
sent. On arrival to the floor, a swab (which was positive for
MRSA) was taken superficially, not an ideal sample. ID followed
the pt while admitted. Cefepime was d/c on ___. PICC was
placed and final recommendation was a total 14 day course of
Vancomycin to ___. Pain Medicine addedd recomendations on
pain control and they were used during admission. The wound was
changed daily and it improved during the admission, 3mg IV
Dilaudid prn dressing changes.
# HES: S/p steroids and Campath, last treatment ___ ___. As
discussed ___ HPI, there is a possibility that patient may have
HES with a concomittant RA variant given his worsneing pain and
possible weakness despite normal AEC. AES on admission was only
210. Has not had absolute eosinophilia since ___, resolved
with tx, and has only been on Prednisone 5mg PO QD. Prednisone
was d/c during the admission on ___, as per discussion
between outpt providers. Pt stated that he feels like he is
developing the sxs when he was thought to have HES ___ ___ but
denies association with recent taper. Pt voiced concerns about
worsening weakness and lack of improvement during the admission.
We consulted both Hematology and Rheumatology ___ order to assess
if it was related to worsening HES or possible RA, respectively.
Rheumatology thought that the pt may have underlying RA given
family history of RA and high CCP, however, they did not think
there was evidence of active RA on exam, and thus no role of
Prednisone at this point. As such, ___ the setting of a chronic
infection, DMARD therapy can be considered as an outpt once the
infection resolves and he is found to need tx for RA. They also
did not find evidence of a vasculitis, and recent Xrays did not
support erosive disease. He has diffuse OA. Hematology wanted to
perform a bone marrow biopsy on ___ ___ order to send a
sample to ___ given his complicated pmh, however, it was not
done prior to discharge and will be done at his next outpt
Hematology visit. During this admission, Hematology did not feel
like he had active HES disease at this time given the lack of an
elevated AEC. Discharged without Prednisone, which can be
reconsidered as outpt. Has appropriate follow-up arranged,
including with Hematology for bone marrow biopsy.
# Rash: Appeared to be psoriasis and pt with a family history of
psoriasis, seen by Derm who did not initially do biopsy because
they thought it was clearly Psoriasis. ID wanted biopsy done
given his immunosuppression and possible underlying
rheumatological process with the hopes that it would help
elucidate a clearer diagnosis. S/p biopsy on ___. Results
were pending at time of discharge. Plan is to send biopsy to ___
for further evaluation. Pt does not complain about the rash at
this time and is asymptomatic. If he were to become symptomatic,
can consider clobetasol 0.05% ointment.
# Leukopenia: History of leukopenia ___ the past, could be
related to chronic ulcer infection, could also be due to bone
marrow suppression due to his chronic diseases. Platelets normal
but had anemia. No recent tx with Campath but could be due to
the tx done ___ ___ as well. Hematology also recommended CMV
given his immunosuppression, results pending at time of
discharge. After reviewing lab results, leukopenia is a chronic
finding present ___ past labs.
# Sepsis/SIRS: Initial presentation ED was tachycardia, and
leukopenia, fullfilling SIRS. Source of infection likely his
chronic venous stasis ulcer given change ___ drainage. Lactate
elevated to 4.8 which responded to 3L of NS. Decreased to 2.5.
Tachycardia also resolved prior to transfer. On arrival to the
floor, no longer tachycardic which does not fit SIRS criteria.
Lactate 1.5 on recheck after an additional L of NS.
# B/l idiopathic AVN: Seen recently by Orthopedics who
recommended weight loss before any type of surgery and overall
improvement ___ health due to ___ complications that would
arise with hip replacement surgery. Films confirm findings from
recent MRI of AVN.
# HTN: Controlled on admission. Held home Lisinopril/Lasix
initially due to elevated lactate. Bolused and lactate
normalized. Restarted home Lasix on ___. Was planning on
restarting home Lisinopril, however, pt later informed the
medical team that he is not taking the medication anymore. Prior
to discharge, VSS not on Lisinopril.
# Microcytic Anemia: Iron studies showed normal ferritin stores
which does not suggest iron deficiency, most likely anemia of
chronic dz. Retic of 1.6. Started on ferrous sulfate.
# OSA: Refused CPAP.
# H/o DVT: Supratherapeutic INR on admission of 4. Likely
related to infection. INR normalized to 2.0 on ___. Last
dose 7.5 mg before admission. Restarted at 5mg PO QD. Titrated
the dose to 7.5mg PO QD prior to discharge.
# GERD: Stable. Continued home omeprazole given h/o GIB ___
stomach ulcers.
# Depression: Continued Citalopram. Increased to 40mg due to pt
voicing concerns of depression. EKG on ___ with a QTC wnl.
# Constipation: Continued bowel regimen. | 127 | 958 |
10549546-DS-25 | 26,068,185 | Dear Mr. ___
You were admitted to ___ on ___ after experiencing
worsening shortness of breath along with lower leg and abdominal
swelling. You were treated for heart failure with a medication
called Lasix, which helps take fluid off your body. Please go to
___ to get labs checked on ___, they already have the
prescription for this. Please follow up with Dr. ___ on
___ at the appointment scheduled for you.
We also believe your COPD contributed to your trouble breathing.
You were given nebulizer treatments while in the hospital, and
ordered for CPAP which is a machine that can help you breathe
better at night. You will have repeat pulmonary function testing
on ___ at ___. You should NOT use inhaler on the
morning of this appointment.
You should continue taking all of your prescribed medications
(except Spiriva the morning of lung testing) and attend
appointments with both Cardiology and Pulmonology (see
appointments below).
We wish you the ___,
Your ___ Care Team | Patient is a ___ with IDDM who presents with worsening SOB
concerning for new onset congestive heart failure.
#Acute Diastolic Heart Failure: Patient presented with Given ___
edema and abdominal swelling, BNP may be falsely normal given
obesity and with diastolic failure which would likely have lower
wall stress. Other possibility that was considered was isolated
R sided failure from pulmonary HTN from poorly controlled
respiratory disease. His last TTE was in ___ with normal EF at
that time, confirmed with current TTE. He also had mild-moderate
emphysema seen on CTA of the chest, with significant smoking hx,
concerning for an COPD exacerbation. He was treated with IV
Lasix drip with symptomatic improvement, along with nebulizer
treatments and tiotropium inhaler. Patient was initially
breathing in low 90% on ___, weaned down to 2L NC, then
subsequently off oxygen and on room air. He also received CPAP
treatments at night. He may warrant outpatient evaluation of
ischemia as a precipitant; cardiology follow up is scheduled
with Dr. ___. His daily weights were monitored and
discharge weight was 130.4kg. Patient requested discharge prior
to being diuresed to euvolemia. He was discharged on Torsemide
40mg PO daily and Metoprolol XL 100mg daily with close
cardiology follow up.
#COPD: Pulmonary workup in ___ showed obstructive and
restrictive disease. Patient is not on any COPD medications at
home, or on home oxygen.
During admission, patient treated with Albuterol nebulizer
treatments as needed, along with Spiriva inhaler daily. He was
able to be weaned off O2 prior to discharge. Discharged home on
Spiriva daily with appointments for repeat PFT's and pulmonology
follow up. Patient was also counseled on smoking cessation and
was discharged with nicotine patches.
#SVT: Patient had symptomatic SVT runs up to HR 150s, each time
breaking with vagal maneuvers. Patient experienced palpitations
during these episodes. Patient had no episodes of SVT in 48 hour
prior to discharge and no further intervention was needed. The
patient will be followed closely by cardiology as outpatient and
knows to call Dr. ___ he develops palpitations at home.
#Insulin Dependent Diabetes Mellitus: Patient on 70/30 50U QAM
and QPM at home with metformin 500 BID. Metformin was held, and
patient was continued to home 70/30 with HISS.
#History of opioid abuse: Patient continued on home
Buprenorphine-Naloxone | 165 | 379 |
11958032-DS-12 | 23,283,331 | Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with neck pain. MRI Imaging showed that you still have a fluid
collection in your neck next to your spine. We spoke with
radiologists, your general surgeon, your primary care doctor,
and infection doctors.
We believe that these fluid collections are the same as they
were before and they are not infected. We believe that
attempting to drain these fluid collections may cause more
bleeding, which will delay your body's natural reabsorption of
these collections.
We recommend giving the body time to heal and allow these
collections to resolve on their own. We believe this may take
up to 2 months. In the meantime, we recommend controlling your
symptoms with Tylenol, gabapentin (a new medication) and a soft
neck collar.
If your symptoms do not get better within 2 months, or if they
begin to get worse, we recommend discussing with your doctors
regarding repeat ___ of your neck and spine.
For the treatment of your COPD, you have 4 more days in your
steroid taper (2 days of taking 10mg per day [1 pill], followed
by 2 days of taking 5mg per day [0.5 pill]) | This is a ___ year old male with past medical history of
diastolic CHF, CAD s/p CABG, hypertension, COPD, DM type 2, with
recent history of neck pain and subsequent identification of a
cervical fluid collection, recurrent despite drainage attempts,
admitted with neck pain thought to be secondary to fluid
collection, recommended against additional interventions which
were thought to be worsening localized bleeding, started on
regimen oriented towards symptomatic control
# Cervical Neck Pain secondary to C7 and T1 perivertebral fluid
collection
Patient with history of perivertebral fluid collection that has
been drained by ___ service 3 times prior, with workup for
etiology negative including negative infection workup. On this
admission, given recurrence of symptoms and persistence of
fluid, his prior images were reviewed with radiology and
determination was made that given the solid components of these
collections, they likely were never completely drained, nor
could they be completely drained. It was felt that prior
attempts at drainage likely resulted in additional slow bleeding
into that space (replacing the blood that was drained) and
causing reccurence of his symptoms. Over several days, via
discussion with PCP and his outpatient general surgeon, as well
as ID consult, it was felt that additional drainage attempts
would likely result in further bleeding, and put him at risk for
seeding an infection in those spaces. Decision was made to
focus on symptom management and allow his body to re-absorb
those collections over several months. Started tylenol,
gabapentin (given neuropathic component to his pain), and a soft
collar, with good effect. Patient pain much improved, he
reported being able to move around with minimal symptoms and
sleep without being awoken by pain. Of note, bleeding diathesis
was considered as possible cause of his hematomas, but labs
including coags, factor VIII and vWF-related workup was all
unremarkable, and patient did not have any history of
post-operative or post-traumatic issues with hemostasis.
# L arm ecchymosis
Course was notable for ecchymosis at L arm at site of blood
draw. No hematoma formed and it remained stable.
# Acute COPD Exacerbation
Patient had recently been started on prednisone taper by PCP as
outpatient. Continued taper this admission. Discharged with 4
days remaining. Continued home inhaler regimen
# Allergies
Continued Loratadine
# CAD s/p CABG
# Chronic diastolic CHF
# Hypertension
Weight stable, and he remained euvolemic this admission.
Continued ASA, Metoprolol, statin, Lasix, Isosorbide,
amLODIPine, Lisinopril
# GERD
COntinued PPI
# BPH
Continued Finasteride , Tamsulosin
# Diabetes type 2
Held home metformin during admission and restarted at discharge
Transitional issues
- Discharged on new trial of gabapentin and soft collar
- Remaining days of his steroid pulse (started as an outpatient
prior to this admission = 10mg daily x 2 days, 5mg daily x 2
days)
- Discharge weight 68.95 kg
>30 minutes spent on this discharge | 209 | 469 |
10026479-DS-13 | 21,649,207 | You were admitted to the hosptial with abdominal pain. You had
a cat scan of your abdomen done which showed a twising of the
colon. This can lead to a bowel obstruction. You were taken to
the operating room where you had a segment of your colon
removed. You have made a nice recovery and you are ready for
discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
You will need to follow-up in the acute care clinic for removal
of your staples. | ___ year old female admitted to the acute care service with
abdominal pain and nausea. Upon admission, she was made NPO,
given intravenous fluids, and underwent a cat scan of the
abdomen which showed a cecal volvulus. She was placed on
intravenous antibiotics. On HD #1, she was taken to the
operating room where she underwent a
right colectomy with primary anastomosis. Her operative course
was stable with minimal blood loss. She was extubated after the
procedure and monitored in the recovery room.
Her post-operative course has been stable. Her surgical pain was
controlled with intravenous analgesia. She was started on sips
on POD # 1 and her pain regimen was converted to oral analgesia.
Her bowel function was slow to return and she underwent an x-ray
of the abdomen which showed a ileus vs obstruction. She was
given a dose of methynaltrexone. On POD #5, she began passing
flatus and her diet was advanced. She resumed her home meds.
Her vital signs are stable and she is afebile. She is
tolerating a regular diet. Her white blood cell count is 7.0
with a hematocrit of 35. She has been ambulating. She is
preparing for discharge home with follow-up in the acute care
clinic for staple removal. She has also been advised to follow
up with her primary care physician to further evaluate the
finding of left bundle ___ block on recent EKG. | 268 | 244 |
12805506-DS-13 | 28,223,567 | Ms. ___,
You were admitted with abdominal pain that was possibly related
to the UAE that you had in ___. For this, you were
empirically treated with antibiotics. The pain could also be
from degenerating fibroids.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ is a ___ year old s/p UAE in ___ for fibroid
uterus presents with abdominal pain concerning for degenerating
fibroids versus PID. Imaging revealed no adnexal masses or
torsion, many fibroids, and a hemorrhagic cyst in the right
ovary.
She was admitted and given antibiotics, levofloxacin and flagyl,
empirically for treatment of possible PID given +CMT on exam.
She was never febrile with a normal WBC and no vaginal bleeding.
Her pain improved with toradol. | 57 | 80 |
13132730-DS-16 | 20,578,252 | You had an pacemaker because your heart rate was too slow
Continue all your current medications without change.
Activity restrictions and care of the pacer maker site are
included in your discharge instructions.
If you have any urgent questions that are related to your
recovery from your medical issues or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the Atrius Heartline at
___ to speak to a cardiologist or cardiac nurse
practitioner.
If your followed at ___, then please call
___ or your Doctors ___. | Assessment: Ms. ___ is a ___ history of advanced Alzheimers
long-term care resident ___, T2DM, HTN,
hypthyroidism, bipolar disorder, vascular dementia, anxiety,
chronic peripheral venous insufficiency, parkinsonism, basal
cell
Ca of face s/p MOHs, non-ambulatory at baseline uses wheelchair
who is referred from her facility for bradycardia, found to be
in
CHB and is now s/p PPM ___.
Plan:
===============
ACTIVE ISSUES:
===============
#Complete heart block - Per review of atrius records, patient
previously noted to be bradycardic in ___ at that time per
cardiology evaluation thought to have sinus bradycardia with 2:1
AV block Mobitz type II. Referred to the ED for persistent
bradycardia now found to be in complete heart block. Now s/p PPM
___.
TSH 2.1, Lyme pending.
- Post device implant access site care and activity restrictions
per protocol.
- No abx per EP.
- f/u Dr. ___ in ___ days from device placement
___ aware and will reach out to ___
directly.
#QTC prolongation - Previously has had prolonged QTc >500, here
491. Is on multiple QTc prolonging meds including risperdal and
paxil. Does have chart history of schizoaffective and bipolar.
Will need to closely monitor and if further evidence of QTc
prolongation may need consideration of switching to alternative
agents, though now has device. No acute events on telemetry.
-Follow up with Dr. ___ as above
#Cough - complains of several week history of cough and sore
throat. CXR no evidence of PNA otherwise unremarkable. Afebrile
without leukocytosis. ___ be viral upper respiratory process.
Symptomatically treated with Tessalon pearls. throat lozenges,
guaifenesin PRN.
-Continue symptomatic treatment as necessary
#Peripheral venous insufficiency - Per chart review has
documented peripheral venous insufficiency is on lasix 40mg
daily. Will continue for now. Unclear though if she has ever had
CHF, no documentation of this and last TTE was in ___. TEE was
repeated here showing EF 83% and no valvular disease.
- Continue home lasix
#Constipation - Initially constipated upon arrival, now resolved
per nursing. -Continue home bowel regimen
================
CHRONIC ISSUES:
================
#Hypothyroidism - Continue home Synthroid. TSH 2.1 here.
#Schizoaffective disorder
#Bipolar Disorder - Continue home divalproex, paxil, risperdal
per above
#T2DM
- Continue home metformin
#GERD - Cont home omeprazole
Dispo: Back to ___
#Transitional: Unclear what ASA 81mg is for, she does not appear
to have a stroke or CAD history. Could dc if for primary
prevention in light of new evidence that risk for bleeding
outweighs benefit. | 98 | 375 |
11431685-DS-15 | 22,775,116 | You were admitted after an accidental fall. You were found to be
more anemic than you usually are. You received two blood
transfusions. You were still weak, and the physical therapy
department recommended that you go to a rehabilitation facility
to gain strength. During this admission the level of you blood
thinning agent (Coumadin) was low, so you were restarted on
Coumadin and another medication (Lovenox) to help thin the
blood.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo F with multiple medical problems, h/o lymphoplasmacytic
lymphoma, recurrent DVT/PE on anti-coagulation, chronic anemia
who presented to the ED with generalized weakness, s/p fall.
# s/p fall: history is suggestive of a mechanical fall, as
described by patient and family members. She has had many
similar falls, per family. She has no prodrome and no LOC. Most
likely related to spinal disease, peripheral neuropathy, and
generalized weakness. Given history of seizure disorder, EEG was
done and did not show evidence of seizure activity. She was
evaluated by Physical Therapy, who recommended disposition to
___ rehab.
# Generalized weakness: as above, though anemia probably
contributed as well.
# h/o recurrent DVT/PE: She claims to be taking warfarin on a
regular basis but her INR on admission was 1.0. Her PCP and
___ were contacted regarding pros/cons of
anticoagulation treatment given her frequent falls. They
recommended continuing anticoagulation, with fall precuations.
As her INR was subtherapeutic, she was bridged with therapeutic
dosing of enoxaparin while awaiting INR to rise. On discharge
INR was still 1.5, so enoxaparin should be continued until
INR>2.
# Anemia (and h/o lymphoplasmacytic lymphoma/Waldenstrom's):
acute on chronic likely due to her lymphoma. She also has cold
agglutinins and evidence of chronic hemolysis. She was
transfused with 2 units of PRBC, and Hct rose from 20 to 23.5,
which is her baseline range. Folic acid was continued.
# Hypothyroidism: continued levothyroxine. TSH was 1.5 in ___.
# Bipolar d/o: stable. continued quetiapine, lithium
# Spinal degenerative disease. Cervical rethrolithesis on
initial CT, but it was thought more likely to be reflective of
degenerative. The patient had no pain or numbness/tingling with
full range of motion of her neck. Per discussion with
Neurosurgery/Spine, C-collar was not needed.
Code status: Do not resuscitate (DNR/DNI) Discussed with patient
and her husband.
___: The patient was discharged to ___
___. Rehab stay was expected to be less than 30 days. | 85 | 313 |
12907727-DS-18 | 28,649,994 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Ms. ___ was admitted to ___ on ___ due to ___
chest CT notable for right lower lobe branch pulmonary embolism,
multiple pulmonary nodules concerning for septic emboli.
Hospital course notable for TTE/TEEs with multiple large
tricuspid valve vegetations with evidence of ongoing septic
emboli to the lungs, as well as right middle lobe pneumonia. She
was started on Methadone on ___ and treated with adjunctive
medications for her withdrawal. She has been closely followed by
social work and addiction psychiatry. She was started on
escitalopram on ___ for anxiety and depression.
She had recurrence of fevers (___) throughout her
hospitalization despite negative blood cultures since ___. For
her bacteremia, initially she was treated with Nafcillin
transitioned to Cefazolin due to patient request. With the
recurrence of fevers but negative blood cultures, repeat imaging
revealed new RML pneumonia for which she was treated initially
with vancomycin (d/c-ed after negative MRSA swab) and cefepime
for ___efore being transitioned back to Cefazolin.
There was also likely some contribution from ongoing septic
emboli burden as seen on CT imaging. She remained afebrile from
___ before developing recurrent fevers, transitioned back
to cefazolin with repeat infectious workup notable for worsening
of the RML pneumonia. Per ID recommendations, she was placed on
vancomycin and zosyn to be treated for an extended course ___
days pending clinical improvement). She has remained afebrile
since ___. Following completion of HAP treatment on ___ she
was transitioned back to cefazolin.
ID, cardiology, and cardiac surgery followed Ms. ___ during
her hospitalization. Her last positive culture occurred on
___, with most recent imaging showing stability and
improvement in notable septic emboli throughout the lungs.
Initial TEE with evidence of TV vegetation and other
pre-existing vegetations but reassuringly without paravalvular
abscess. Despite improvement in emboli burden on CT, TTE on
___ showed that the TV vegetation had grown, that the
tricuspid leaflets do not coapt, worsened TR compared to prior
echos, and evidence of RV volume overload. Clinically, she
remained euvolemic on exam with reassuring LFTs and thus, the
recommendation was to continue serial TTEs and antibiotics as
discussed above. She was noted to have microcytic anemia of
chronic disease vs iron deficiency vs vitamin deficiency. She
did not demonstrate evidence of bleeding or hemolysis despite
initial presentation with scant hemoptysis. She was transfused 2
units of PRBCs to correct anemia. A TTE ___ with concerning
increase size in tricuspid vegetation to 2.3cm prompting plan
for cardiac surgery.
She was taken to the operating room on ___ and underwent
tricuspid valve replacement and patent foramen ovale closure.
She tolerated the procedure well and was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
She weaned from sedation, awoke neurologically intact and was
extubated at midnight. She was weaned from inotropic and
vasopressor support. Pain was an issue post op and she was given
Dilaudid for pain control. Addiction service and social work was
following. She remained hemodynamically stable and was
transferred to the telemetry floor for further recovery.
Dilaudid was slowly weaned off throughout hospital course and
she was started on Methadone with plans for ___ clinic to
follow as outpatient. Beta blocker was not started due to
absence of coronary artery disease. She was diuresed toward her
preoperative weight with Lasix but this was stopped on POD 13
with patient euvolemic. She completed her 6 week course of
antibiotics with Ancef for MSSA endocarditis on ___ and PICC
was removed after completion of antibiotics. OR tissue cultures
were negative. No anticoagulation was necessary for PEs (not
acute) per Dr ___. She was kept additional days in the
hospital awaiting a NH Medicaid card in order to enroll in the
___ clinic. She was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 18 she was ambulating freely, the wound was
healing well, and pain was controlled with Methadone. She was
discharged home in good condition with appropriate follow up
instructions. | 104 | 664 |
17331361-DS-14 | 20,126,984 | It was a pleasure taking care of you at ___
___. You were admitted to the hospital after two
procedures: a right femoral endarterectomy and a peripheral
angiogram with stenting.
Femoral endarterectomy
This surgery was done to improve blood flow to your leg. You
tolerated the procedure well and are now ready to be discharged
from the hospital. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
Vascular Leg Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes within
a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will likely receive a visit from a Visiting
Nurse ___. Members of your health care team will discuss
this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain. You
will also receive a prescription for stronger pain medicine, if
the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your leg
up on a pillows. If your swelling continues, please call your
surgeon. You may be instructed to use special elastic bandages
or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches or
staples. This is normal.
It is normal to have a small amount of clear or light red fluid
coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This will
go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician.
Peripheral Angiogram with stenting
To do the procedure, a small puncture was made in one of your
arteries. The puncture site heals on its own: there are no
stitches to remove. You tolerated the procedure well and are
now ready to be discharged from the hospital. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
Peripheral Angiography
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may remove the bandage and shower the day after the
procedure. You may leave the bandage off.
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the first 48 hours:
Do not drive for 48 hours after the procedure
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may
then gradually work back to your full routine.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
For Problems or Questions:
Call ___ in an emergency such as:
Sudden, brisk bleeding or swelling at the groin puncture site
that does not stop after applying pressure for ___ minutes
Bleeding that is associated with nausea, weakness, or
fainting.
Call the vascular surgery office (___) right away if
you have any of the following. (Please note that someone is
available 24 hours a day, 7 days a week)
Swelling, bleeding, drainage, or discomfort at the puncture
site that is new or increasing since discharge from the hospital
Any change in sensation or temperature in your legs
Fever of 101 or greater
Any questions or concerns about recovery from your angiogram | Patient was admitted on ___ for right foot pain and
swelling. At the time of admission, right foot x-ray
demonstrated no evidence of gas or osteomyelitis. Patient was
confused, tachycardic to the 130s - however, this presentation
eventually resolved. Patient was also started on IV antibiotics
vanc/cipro/flagyl for his right lower extremity ulcer. On ___,
patient had vein mapping performed, which demonstrated no
suitable lower extremity bypass conduits in the upper or lower
extremities. In addition, a biopsy of his right calf ulcer was
obtained, which demonstrated no evidence of calciphylaxis. On
___, patient went to OR for R femoral endarterectomy with
patchy angioplasty; he was subsequently started on heparin gtt
and placed on lisinopril. He was eventually transitioned to PO
augmentin/clindamycin to complete a 2 week abx regimen (last day
___. On ___, patient underwent right lower extremity
angiography with PTA and stenting of the right SFA and popliteal
arteries. Following this procedure, he was started on aspirin,
Plavix, cilostazol, and apixiban. Physical therapy saw the
patient, and recommended ___ rehabilitation given the
limited mobility of his right leg.
At the time of discharge, patient was HDS and doing well
overall. He was voiding and eating without assistance, and could
perform activities as tolerated independently. Antibiotics were
discontinued at the end of his hospital stay. He will follow up
in Vascular Surgery clinic with Dr. ___. | 1,314 | 227 |
16241244-DS-12 | 22,314,445 | Dear Ms. ___,
As you know, you were admitted with right shoulder and arm
pain, swelling. You were treated with intravenous morphine for
the pain and obtained multiple tests to assess for the cause of
the pain. A MRI of the spine, shoulder and arm showed partial
tear of one of the rotator cuff muscle, but otherwise no
significant swelling/inflammation in the muscles or joints. A
rheumatology team was also consulted and recommended multiple
blood tests - all of which did not reveal any signs of active
autoimmune disease (like lupus). An ultrasound of the blood
vessels in the right arm also was done - and it did not show any
signs of a clot.
For the gout in both your foot (and also for any possible
inflammation in the right shoulder/neck region), steroids were
started. This should help reduce the inflammation and
subsequently the pain. PLease continue with the taper of the
steroids as detailed in the prescription below.
The physical therapist and occupational therapist
recommended rehab (due to limitations from pain), but due to the
likely lack of availability of Demerol at rehabs, it might be
best (as we had discussed) if you were at home so that you can
obtain the medications that historically worked best to rid of
the pain.
Please continue with your home medications as previously
prescribed. The only addition is the steroid medications. Also
the only change is the reduction in the digoxin dose (as your
levels here were high).
We wish you a quick recovery and wish you good health!
Your ___ Team | ASSESSMENT & PLAN: ___ h/o DM2, dilated CM EF ___, CKD III,
lupus panniculitis, gout, chronic pain on chronic meperidine,
extensive medication allergies/intolerance admitted with ___ wks
worsening R
back, shoulder, and arm pain and swelling, fever (reported
103-104).
# Thoracic and cervical spinous process tenderness
# R scapular tenderness
# R arm tenderness and reduced sensation to light touch
# Reported recent fever
Ms. ___ was admitted with the above complaints - with
limited movement ___ to pain in the R shoulder/neck/arm/scapular
region. Due to concern of a lupus-related flare, rheumatology
was consulted and multiple tests were performed. She was noted
to have mildly elevated CPK, CRP 64 (but elevated CRP possible
in setting of acute gout see below). Extensive rheum tests
(C3/C4, ___, anti dsDNA, Ro/La, RNP) were sent but all returned
negative. MRI of the C-spine, shoulder, arm were obtained and
showed no signs of myositis. The only positive finding was
evidence of partial infraspinatus tendon tear on MRI, but no
clear pathology to account for pain.
To address the pain, Ms. ___ was given IV morphine Q3h
with mild-mod relief. She was also eventually placed on
prednisone (largely for gout below), in case there was an
inflammatory component. ___ and OT was consulted and recommended
rehab. This recommendation was not for weakness per se, but for
limited movement ___ pain. She was encouraged to apply cold
packs and to continue with ___ to address a likely
musculoskeletal cause of pain (? Trigger points/myofascial
syndrome).
The morphine provided little relief and she felt strongly
that morphine had historically did little for her pain. She
preferred to go home so that she would be able to utilize the
Demerol she has at home. She was recommended to follow up with
musculoskeletal rheumatology as an outpt.
#Gout with recent flare of L ___ MTP: Ms. ___ was admitted
with L foot pain c/w acute gout(Podagra). This was initially
treated with febuxostat 80 mg daily (for prophylaxis) but did
not have the abortive therapeutic effect. The gout then
involved her R ___ MTP (reportedly, the pattern for her). She
was initiated on prednisone taper for treatment of the acute
gout. We held off on NSAID (CKD) or Colchicine (myositis) due
to their specific adverse effects.
# Dilated chest wall veins:
# RUE swelling (mild)
To further eval, Ms. ___ had RUENI which was neg for DVT
with normal flow patterns. Clinical picture overall not
suggestive of SVC syndrome or other vascular obstruction. This
can be considered for outpt workup if still concern.
# Dilated cardiomyopathy (EF ___. Followed at ___,
reportedly on transplant list. She had no evidence of
decompensation. She was continued on home Lasix 80, coreg 25
BID (patient reports allergy to generic, so allowing her to take
her home brand), enalapril 20 mg daily. Her digoxin level was
mildly elevated at 2.2, and thus held during this
hospitalization. She was discharged on a lower dose of 0.125 mg
daily at home.
#CKD: baseline cre reportedly in ___ range. She continued to
be in this range in the hospital.
#Microcytic Anemia: likely multifactorial with thalassemia,
CKD, chronic inflammation. Stable.
#DM: Ms. ___ takes her own special ___ insulin. She was
allowed to take her own home medications and maintain her
sliding scale - as it was done at home. The sliding scale is
checked 6 times daily (typically ___ units), reports excellent
control; very resistant to changing to hospital sliding scale.
Cont on diabetic diet. | 288 | 607 |
19782315-DS-12 | 24,544,327 | It was a pleasure taking care of you at ___!
You were admitted to the hospital due to a fracture in your
pelvis. In the hospital we treated you with pain medications and
had you seen by physical therapy. You were also treated for a
urinary tract infection. You did well and will continue your
physical therapy at a rehabilitation center.
See below for instructions regarding follow-up care: | Ms. ___ is an ___ year-old woman with advanced dementia and a
history of CAD who presented ___ after an unwitnessed fall
at her nursing facility. Found to have superior and inferior
pelvic rami fractures.
ACTIVE ISSUES
-------------
#. Pelvic Fracture - The patient was brought to ___ after an
unwitnessed fall at her nursing facility. In the emergency room,
spine, head, knee, hip and chest radiographs were unremarkable.
A CT scan of the patient's plevis reveal inferior/superior
fractures. An ECG was not concerning for ischemia and laboratory
testing showed no evidence of infection.S he was seen by
physical therapy in the ED who found the patient unable to
ambulate due to pain. She was admitted for pain control and
early phyiscal therapy. On the floor the patient's pain ws
controlled. Seen by ___ who recommended rehab stay.
#. Urinary Tract Infection - The patient was noted to have
urinary frequency. A UA was consistent with a UTI but the urine
culture showed mixed flora. The patient was treated with a 3-day
course of cefpodoxime and her symptoms improved.
#. Delerium - The patient initially suffered delerium in the
setting of new environment and pelvic pain. Her delerium
improved over the course of her hospital stay and with treatment
of her UTI.
# Irregular heart rhyhtm - intermittently irregular, with one
EKG caputuring premature atrial contractions. Felt to be a
benign rhythm. Electrolytes normal. Beta blocker continued.
CHRONIC ISSUES
--------------
#. Coronary artery disease - The patient had a myocardial
infarction with ___ ___ years ago. Unkwnown type of
stent. She has been on clopidogrel since. This was continued in
house along with her statin and bblocker. Continued use of
clopidogrel in the setting of frequent falls should be discussed
with her outpatient provider.
#. Depression - Continued Escitalopram and held ativan in
setting of fall. Ativan was not restarted on discharge.
#. Dementia - Continued exelon.
TRANSITIONAL ISSUES
-------------------
#. Consider stopping clopidogrel as risks may outweigh benefits
#. Consider echocardiogram for ? syncope workup as part of eval
of falls | 67 | 336 |
15544188-DS-4 | 24,380,410 | Dear Dr ___,
___ was a pleasure taking care of you at ___
___.
You were in the hospital after you fell and fractured your
femur. This fracture does not require surgery.
In the hospital, we gave you medicine to control your pain.
When you leave the hospital, you will go to rehab to continue
getting stronger and hopefully prevent falls.
We would recommend you follow up with a movement disorders
specialist for evaluation of possible ___ Disease.
Best wishes,
Your ___ team | ___ year old man presenting from rehab with a likely mechanical
fall and subsequent right femur fracture which is being managed
non-operatively. He has been falling more frequently as of late
though his fairly extensive evaluations have been unremarkable.
There is some concern for Parkinsonism, according to his
outpatient providers.
#Right trochanteric femur fracture. He was evaluated by
orthopedics, who recommended: "this is a closed injury and the
patient is neurovascularly intact. This injury will not require
surgical fixation." Pain was controlled with Oxycodone, Lidocain
patch, Tramadol, Ibuprofen, and Acetaminophen. He was
anticoagulated with Lovenox 40mg SC QPM. His activity status
remains weight bearing as tolerated in the RLE, with assistance.
#Recurrent falls
#Chronic dizziness. MRI/MRA unremarkable as outpatient except
for some dilated ventricles, likely central volume loss as
opposed to NPH. Seen by Dr. ___ as outpatient, felt
likely multi-factorial, but would consider some autonomic
dysfunction given that his symptoms seem to be worse in AM and
improve with coffee, before any meds are given. His afternoon
dizziness was thought secondary to tramadol, and he was
instructed to increase Tylenol and wean tramadol. Also
instructed to wean compression stocking to treat edema instead
of using a diuretic. During admission, he was monitored on
telemetry but no events were captured. Orthostatic vital signs
on ___ showed drop in systolic BP of 30 upon standing, for
which he received IV fluid resuscitation.
#Anemia: Hgb ~12 on admission, only recent check in our system
shows Hgb 14. Likely some amount of bleeding into fracture site.
However, his hemoglobin remained stable and he did not require
transfusion. | 77 | 269 |
13626185-DS-17 | 26,983,655 | Dear ___ was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after being admitted for abdominal pain and being found to have
acute cholecysitis. Becuase of this diagnosis, you underwent a
laparoscopic cholecystectomy. You have recovered from surgery
and are now ready to be discharged to home. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directed.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
- Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | ___ w gastric bypass, DM, panniculectomy, asthma p/w presumed
choledocholithiasis and presumed cholangitis, though appears
actually to have cholelithiasis and cholecystitis only.
____________ | 818 | 24 |
11912803-DS-4 | 21,968,306 | Dear Ms. ___,
You were admitted to the Acute Care Trauma surgery Service on
___ after a fall sustaining and injury to your right eye.
You were evaluated by the ophthalmologist who took you to the
operating room for repair of a globe injury to your eye. You had
a laceration over your eye near the eyebrow sutured. You were
evaluated by physical and occupational therapy to assess your
function and mobility given decreased vision in your right eye.
It is recommended that you continue to have ongoing physical and
occupational therapy at your nursing home.
You are now doing better, pain is controlled, and your are ready
to be discharged to home with the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
No NSAIDs or anti-platelets medications. You can take Tylenol as
needed for pain. (AVOID: aspirin, ibuprofen, Advil, Naproxen,
ect.)
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.
Keep head of bed elevated at least 30 degrees at all times. You
can do this by either placing a wedge pillow under your mattress
or sleeping on several pillows. Some patient prefer to sleep in
a recliner chair.
Keep eye covered with fox shield at all times. You may remove
shield to place eye drops.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Ms. ___ is an ___ yo F transferred from outside hospital after
sustaining a witnessed mechanical fall from standing with
hyphema of the right eye and vision loss. CT head and C-spine
were negative for acute injury. Chest xray and right knee films
were obtained and negative for acute fractures. Opthalmology was
consulted given suspicion for open globe injury in the right
eye. She was taken to the operating room with opthalomogoy for
exploration and found to have a limbal laceration with ___
prolapse superiorly and hyphema. The injury was repaired and she
was given IV antibiotics x 48 hours, eye drops, and a fox shield
was placed over the affected eye. She was admitted to the Acute
Care Trauma surgery service for ongoing management.
She remained alert, oriented, and pain was controlled with oral
acetaminophen. She remained stable from a cardiopulmonary
standpoint and vital signs were routinely monitored. Post
operatively, she was given a regular diet which she tolerated
without difficulty. She voided adequate urine and intake and
output closely monitored and remained adequate. The patient was
evaluated by physical and occupational therapy who recommended
discharged to her current assisted living facility with ___.
Anticoagulation/antiplatelet medications were held given
hyphema. After 48 hours of IV antibiotics, the patient was
discharged with 5 days of moxifloxacin.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 485 | 262 |
16320616-DS-27 | 20,659,878 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital because you
were having trouble brething. We gave you medicine to help take
fluid off your lungs. You were also found to have bacteria in
your urine and a pneumonia, which we treated with antibiotics. A
few nights ago your suction got clogged, and some of your
secretions may have gone into your lungs, causing inflammation.
You will need oxygen for a few days until the inflammation calms
down.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Patient is a ___ F with history of atrial fibrillation,
recently admitted for flash pulmonary edema in setting of RVR
(discharged ___ also with history of CVA, residual R facial
droop/dysphagia s/p G-tube, and CAD s/p PCI of RCA in ___ who
presented to the ED with respiratory distress and altered mental
status.
# hypoxia: On arrival to the MICU, pt was treated for acute on
chronic sCHF given pulmonary edema and bibasilar crackles on
exam. She was also covered for HCAP with vancomycin/ceftazidime.
Her O2 requirement quickly declined after diuresis, and se was
called out to the floor on HD 2. Pt continued to do well until
the night of ___ when she became acutely hypoxic, requiring
50% facemask. Pt has been suctioning her own secretions here,
and her suction had become clogged. Her sats improved with
aggressive suctioning, and CXR and history was felt to be c/w
aspiration pneumonitis. She was able to be weaned back to nasal
canula for >48 hours prior to d/c, over the next several dasy
should be able to be weaned back to RA. Would recommend setting
up a suction for the pt to help her manage her secretions as she
recovers from PNA.
# Fever, tachypnea: Fever defervesced quickly. ___ have been ___
PNA. UA was negative; urine culture grew 100,000 aerococcus.
This organism may not have been pathogenic, but it would have
been adequately covered by the course of vancomycin she received
for PNA.
# Encephalopathy: On admission to the MICU, pt had acute
lethargy and minimal responsiveness potentially c/w hypoactive
delirium, probably from sepsis. CT head was negative for
aneurysmal rupture. Pt appeared back to baseline by HD 2.
# Atrial Fibrillation: Recently diagnosed, on admission was rate
controlled with Metoprolol and Digoxin but not anticoagulated.
Metoprolol was uptitrated to 100mg q6 hours and diltiazem 30mg
was added for rate control. She did not require any IV nodal
agents this admission. Diltiazem can be uptitrated as needed.
She was continued on full-dose ASA, and her ECF providers can
discuss whether or not the risks of coumadin would outweigh the
benefit in this patient.
# Hyperthyroidism: Diagnosed during previous admissions and has
been treated with Methimazole. Hyperthyroidism is most likely
cause of atrial fibrillation, especially with RVR. TSH 0.088 on
admission, FT4 1.5. Home methimazole was continued.
# Coronary Artery Disease, chronic sCHF: EKG which some lateral
STT felt to represent demand ischemia from RVR. troponins were
negative x 3. Continued aspirin and increased metoprolol as
above. Lisinopril 5mg was added. Pt's long term providers can
weigh the risks vs benefits of resuming a stain in the setting
of prior transaminitis. 20mg po Lasix was tried, but lead to a
contraction alkalosis, but could be considered in the future to
help maintain euvolemia. | 103 | 475 |
18896643-DS-8 | 22,625,390 | You were admitted with fatigue, cough, and sore throat. You
have been diagnosed with the Flu. Please take Tamiflu to
complete your course and monitor your symptoms. IF you need to
return to the hospital or clinic, please inform staff and wear a
mask. Please stay home until you are feeling better | ASSESSMENT AND PLAN: ___ w/HIV presents with AMS, spontaneously
resolved, and URI found to have influenza A
Influenza A: cause of his lethargy and URI symptoms. no other
focal signs to suspect infectious cause. LP neg. CT neg. CXR
neg. Labs otherwise normal. Given recent onset and history of
HIV, patient was started on Tamiflu 75mg BID for 5 day course.
He was encouraged to stay at home and rest, only return to MD if
___ worsening, and should wear a mask.
Acute encephalopathy: Related to above. LP excluded CNS
infection. HSV PCR and cx pending on discharge
HIV: Continued home regimen. Per patient, CD4 count
high/normal.
FULL CODE | 56 | 115 |
17427032-DS-17 | 26,142,756 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with worsening abdominal pain
and nausea secondary to a blockage in your biliary tract. You
underwent a procedure called ERCP and had a stent placed to
relieve this obstruction. We took biopsies of the polyp-like
mass that caused the blockage and results are still pending at
this time. Your PCP and ___ doctor, ___ will inform
you of these results. Additionally, you will need to have a
repeat ERCP in approximately 4 weeks to have the stent removed.
You are being prescribed and short course of pain medications to
take as needed. Please take all medications exactly as
prescribed and follow up with all appointments as detailed
below.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with history of primary
biliary cirrhosis, choledocholithiasis, GERD, hiatal hernia, IBS
presenting with abdominal pain and nausea in the setting of
acute cholestatic liver injury.
# Abdominal pain:
# Primary biliary cirrhosis:
# Extrahepatic biliary obstruction secondary to ampulla lesion:
Patient presenting with subacute on chronic abdominal pain,
found to have elevated transaminases and hyperbilirubinemia.
Imaging demonstrates CBD of 1.2 cm with abrupt transition at the
ampulla suggestive of obstruction and MRCP demonstrated a lesion
at the ampulla of Vater with differential including malignancy
versus benign polyp. She underwent ERCP on ___ with EUS/biopsy
and placement of stent. Noted improvement of symptoms following
the procedure. Tbili still elevated at 3.2 but possibly related
to underlying PBC. KUB was obtained that demonstrated proper
location of stent. She was discharged with prn oxycodone and
Zofran for nausea. Pathology pending at the time of discharge
with plan to discuss at PCP follow up if results available at
that time. Alternatively, her outpatient hepatologist is closely
involved and is scheduled to see the patient as well. She will
need repeat ERCP in 4 weeks for stent removal.
# Diarrhea:
Patient with report of loosely-formed stools for the last week.
___ be secondary to IBS, but of note CT A/P did demonstrate
focal wall thickening along the sigmoid colon that could
represent possible infectious colitis. Diarrhea had resolved
upon admission and thus no further work up pursued. | 132 | 239 |
16976073-DS-12 | 24,933,528 | You were admitted after being found down and with low
oxygenation. You were admitted to the ICU and treated with
antibiotics for pneumonia. Please continue the antibiotics for
an additional 3 days. A swallow evaluation was done and showed
no evidence of aspiration.
Due to initial confusion, an EEG was done and found no
evidence of seizure. | ___ with PMH CVA in ___, HTN, HLD, DM2 (diet controlled),
depression admitted to ___ with altered mental status,
hypotension requiring pressor support, and b/l PNA. Transferred
to floor on ___ for further management.
#) Pulm - bil LL PNA - admitted to the unit not for respiratory
failure but largely for airway protection. Evidence of b/l
infiltrates on ct chest to suggest an aspiration event while ?
episode of syncope on toilet. No healthcare exposure. Placed on
vanco/cefipime/levo ___ day 1) and treated with vanco/cefepime
while on the floor. Given h/o CVAs, swallow eval done which
revealed no evidence of aspiration - diet advanced to regular.
Vancomycin and cefepime were discontinued and she will cont on
levoflox - total 7 day course (complete ___. She did not
require any O2 on the day of discharge.
#) AMS - She came confused and may have ingested a number of
oxycodone pills at home. Urine tox were negative but oxycodone
levels have been sent and are pending. She improved
significantly while on the floor and returned close to baseline
per family. There has been significant titration of her meds
recently over the past few weeks per step daughter. To rule out
any seizure as an etiology of confusion (with CVA areas as
nidus), 24 EEG was done and negative for seizure. Sedating meds
were held and she was discharged in good mental state.
#) Anemia - stable based on most recent lab work from ___
although had Hct 30's prior to that. Ferritin, Folate, B12, TSH
wnl. Guaiac stools negative.
#) Hypotension - likely dehydration with possible overlying
sepsis. Lactate was evelated c/w tissue hypoperfusion. Had
leukocytosis, hypoxia, and evident b/l LL infiltrated on chest
CT, possibly attributed to aspiration. Also, likely dehydrated
with e/o ARF on admission. UA was clean, blood cx negative,
urine legionella neg, and bedside echo revealed no significant
cardiac dysfunction or pericardial effusion. TSH, cortisol wnl.
Hct stable. Ingestion was considered a possibility but negative
tox screen at our ED. Oxycodone levels pending (sending). Off
pressors now.
#) ___ - likely prerenal given hypotension. Initial Cr 2.5, and
0.9 upon discharge, improved after hydration. There was no e/o
postATN diuresis. She was eating well without difficulty.
#) hx of CVA - stable right sided deficits
- continue asa
- continue baclofen
#) DM - not on meds at home, diet controlled
- ISS
#) HTN: Ms. ___ became hypertensive while on the floor. THe
lisinopril was continued but her SBP remained elevated at
150-160. Beta blockers were added for better mgmt of the HTN.
#) Weakness: She was evaluated by ___ and felt initially to be
too weak to go home given the recent illness. Various acute
rehabs were screened for, but the following day, Ms. ___ had
no interest in going to rehab and revealed some significant
improvements. She will be followed by outpt ___ and with the
home care assistant services.
#) Depression
- hold mirtazapine
- continue citalopram
#) Loose stools - check stool c.diff. D/C colace
#) FEN: IVF, replete electrolytes, regular diet
#) PROPHYLAXIS: Subcutaneous heparin
#) ACCESS: peripherals
#) COMMUNCATION: Patient ___ (step-daughter)
___
#) CODE STATUS: Full (x) | 62 | 561 |
12416363-DS-14 | 22,295,596 | Dear Ms. ___,
You were admitted to the ___
after presenting with a headache.
You had a lumbar puncture (spinal tap), which did not show any
sign of an infection. You also had a brain MRI that showed the
swelling in your brain related to your neurocysticercosis is now
gone. Therefore, we do not think your headache is related to
your neurocysticercosis or any new infection.
We started you on a new medication, nortriptyline, that can help
with your headaches, as well as your back pain. You can also
take Tylenol and ibuprofen as needed for pain. We also gave you
a physical therapy referral to help with your back and neck
pain.
Please follow up with your primary care doctor and your
neurologist after discharge.
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ R handed woman, with a history
of prior seizures at age ___, and a diagnosis of
neurocystercicosis diagnosed (___). Recently admitted for spell
capture with no seizures captured; imaging notable for right
frontal lesion with some surrounding edema, for which she was
given a course of albendazole and prednisone (now complete). She
was admitted to ___ neurology service after presenting for the
third time with on-going headaches.
Patient was given migraine cocktail (IVF, Compazine, Toradol)
followed by a dose of Depakote, with improvement in her
headache. Because of concerns about neck stiffness, she had an
LP in the ED which was bland. Repeat MRI showed resolution of
the edema surrounding her right frontal neurocysticercosis
lesion, with no new lesions or acute intracranial processes.
Therefore, we do not believe that the headaches are related to
her neurocysticercosis. She was started on nortriptyline for
headache prophylaxis, and she was continued on her home Keppra
dose.
Transitional Issues:
# Started on nortriptyline for headache prophylaxis
# Outpatient physical therapy script for myofascial release
# Follow up as scheduled with PCP and neurology | 128 | 180 |
15914630-DS-13 | 25,484,832 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Patient was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis. She was taken
to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic in 2 weeks. | 729 | 173 |
15785689-DS-23 | 22,332,792 | You were admitted to the hospital with abdominal pain. You were
treated for a urinary tract infection. You underwent a CT scan
that showed mild inflammation of a small part of the large
intestine.
You attempted to prep for a colonoscopy, but unfortunately the
prep was not tolerated, and the colonoscopy was unable to be
completed. As we discussed, this is ok, you just need to make
sure you have a repeat colonoscopy closer to home- I will talk
to your doctor about this.
Because the bowel prep took so long, I think you should stay on
a liquid diet for 2 days prior to your next colonoscopy- please
discuss this with Dr. ___.
You have done well without antibiotics, and your HIV is well
controlled (viral load is negative). Thus, it is safe for your
to return home and repeat a colonoscopy arranged with Dr. ___.
Please contact Dr. ___ office to arrange renewal of your pain
medications tomorrow.
It is important that you continue to wear oxygen while you sleep
to help treat your sleep apnea. You should also have another
sleep study to see if the newer CPAP masks work for you.
Please see below for your follow up appointments and
medications. | Impression/Plan:
The patient is a ___ year old woman with known HIV, hepatitis B
and C with suspected cirrhosis with splenomegaly, Type II
Diabetes with neuropathy, sleep apnea not currently on CPAP or
BiPAP, and chronic pain and prior IVDU on a complex regimen of
opiates, who presents with several weeks of increased abdominal
pain.
# Encephalopathy: Hypoactive symptoms, in the setting of a
complex medication regimen. Given that the patient has just
re-established care at ___ with Dr ___ need to confirm
her medications prior to prescribing full doses, particularly in
the setting of observed somnolence when the patient has not been
able to demonstrate her list of medications. She does appear to
have had difficulties with medication interactions, per OMR
notes, prior to her departure from ___ several years ago.
Several medications held or reduced in dose initially, but did
med rec the day following admission and resume her home meds.
Ultrasound did not show evidence of cirrhosis, and she does not
appear to be in decompensated liver failure, has normal ammonia
level. In reviewing with Dr. ___ saw her on day of
admission and also knows her from previous care (approximately ___
years ago), she is at her mental baseline. She remained at her
baseline, A and O x 3, independent, on her home regimen
throughout the remainder of her hospital course.
# Diabetes mellitus 2, well controlled (last A1C in ___), with
neuropathy, presenting with hypoglycemia. She notes that she
follows actively with ___, and takes both metformin and
insulin therapy. Patient provided food on arrival to floor,
given BG 66, and was not noted to have associated nausea or
vomiting. Initially held metformin given liver disease,
restarted home regimen at discharge, she remained euglycemic for
days prior to discharge.
# Positive UA, urine culture grew polymicrobial, received
ceftriaxone for 3 days for possible UTI, although diagnosis was
uncertain.
# Abdominal pain: Abdominal US and Renal U/S unremarkable, CT
showed very mild colitis in the cecum and ascending colon. Exam
reassuring. Underwent bowel prep for 48 hours (slow, patient
had difficulty staying on schedule). Colonoscopy unfortunately
aborted given significant amount of stool at transverse colon.
Given suppressed HIV viral load and negative CMV, low suspicion
for CMV colitis. Patient will need to have repeat colonoscopy
as outpatient for complete evaluation of colon. She was
counseled on need to start a liquid diet for ___ hours prior
to starting outpatient prep.
# HIV- negative viral load, continued ___ follow up with
Dr. ___.
# Hepatitis B and C, question of cirrhosis: ultrasound as
above, normal synthetic function, no encephalopathy during
hospital course. Will re-establish care with Dr. ___ in the
coming weeks, continued lamivudine.
# OSA, not on therapy: Patient with sats in the 75-low ___ on
sleeping on arrival to the floor. Continuous O2 monitoring was
initiated. Attempted to continue tele monitoring, but patient
initially refused, then agreed later in her course. Aware of
risks and accepts these risks. Given persistently lower
saturations, will use supplemental oxygen with 2Liters
overnight, prior to gaining further collateraly on her prior
treatments and potential options. She continued to have O2 sat
< 85% during day on room air, and was provided with home oxygen
therapy. She was counseled on the importance of wearing oxygen
when sleeping, and to discuss re-evaluation in sleep clinic to
attempt to try newer CPAP masks with her outpatient providers.
She was provided with home oxygen to be delivered to her home,
and was evaluated by a home oxygen delivery company prior to
discharge.
# Chronic pain on multiple medications:
- Giving lower dose methadone and holding other medications
overnight until mental status clarified.
- Giving reduced dose of oxycodone for breakthrough also given
concern for somnolence and reduced respiratory status requiring
supplemental oxygen.
- Confirmed with ___ that these medications are prescribed by
PCP and are prepared for patient in bubble packs
- Patient will contact PCP on day after discharge for medication
renewal.
# Disposition: Pending tolerating a diet, clarification of urine
culture data, and medication reconciliation including hepatic
adjustments.
# Full code | 204 | 688 |
15657734-DS-18 | 23,259,325 | Microdiscectomy
You have undergone the following operation: Minimally Invasive
Microdiscectomy
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit or
stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk for
___ minutes as part of your recovery. You can walk as much as
you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some
constipation after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
Follow up:
___ Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the day
of the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/Pneumoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was not required. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. | 464 | 138 |
16804791-DS-8 | 22,691,326 | Dear ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a chest pain.
What happened while I was in the hospital?
- We did blood tests and an EKG which showed that you had a
heart attack. You likely had a heart attack because you had
blockage in one of the arteries that supplies the heart. We did
a cardiac catheterization procedure to get a better look at your
heart. You wer were found to have 2 blocked arteries. We opened
those arteries with stents.
- We also treated you with blood thinning medications to prevent
any further heart attack, especially with your new stents. You
will need to continue taking 3 blood thinning medications at
home: aspirin, Plavix, and Lovenox injections.
- You were also found to have a small 1.3 cm spot on your liver
on ultrasound, which will need to be followed up after you leave
the hospital.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- please establish care with a heart doctor (___) in
___ to follow up your coronary artery disease
- please establish care with a liver doctor (___) in
___ to evaluate the 1.3cm liver spot that was found on
ultrasound.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ___ woman from ___ with a history of hypertension,
visiting family in ___, who presented as a transfer from
___ for anterolateral STEMI complicated by apical wall
akinesis, now s/p coronary angiograhy and PCI to LAD (x1) and
distal RCA (x2). | 263 | 41 |
12162956-DS-18 | 28,782,055 | Dear Ms ___,
You were admitted to ___ on ___ after having some
confusion and increased pain at home. We found that you had a
urinary tract infection and had also been taking more pain
medicine than usual. We treated your urinary tract infection and
changed your pain medication schedule and your symptoms
improved, however it was felt that you still may not be safe at
home so we recommended that you go to a rehab. You were
concerned that your bowel/bladder incontinence may be due to a
fistula or prolapse but you were examined thoroughly without
evidence of these problems. It is felt that your bowel and
bladder incontinence are likely due to the cancer on your spinal
cord however your oncologists felt that there was not a good way
to shrink that lesion at this time with either radiation or
chemotherapy. You did not have a significantly enlarged bladder
on ultrasounds to suggest that you need a catheter to drain your
bladder. They also felt that neurologically, you had not had a
decline in your strength or sensation that was significant
compared to prior exams. Please take all of your medication as
prescribed and attend all of your follow up appointments. It was
a pleasure taking part in your care.
Sincerely,
Your ___ Healthcare Team | BRIEF HOSPITAL COURSE:
=======================
Ms ___ is a ___ year old female with a history of metastatic
renal cell carcinoma to L1 conus of spinal cord off pazopanib
due to side effects currently on avastin who was admitted with
worsening back pain after fall 2 weeks ago at which time
suffered L4 fracture.
#Back pain: Patient has chronic pain related to spinal disease
as above, acutely worsened after fall due to L4 lateral
fracture. MRI also showed increase of distal cord lesion.
Unclear which area is causing pain, likely multifactorial. It is
unclear how much of her pain medications she was taking at home,
per self report she was taking significantly more than
prescribed and than previously likely in setting of recent fall.
This likely contributed to her altered mental status at
admission. Her prn dilaudid was continued at actual prescribed
dose which patient asked for even less frequently. She started
using a lidocaine for her feet and her gabapentin was increased
from 600 BID to ___ TID. Her dexamethasone was increased to 4mg
on admission and then decreased to 2mg, with the plan that she
will follow up with Dr. ___ in clinic in 1 week to continue
taper. She was started on Celebrex which was titrated up to
400mg BID.
#Urinary retention and incontinence: Patient reports increasing
difficulty urinating, she has prior history incontinence. This
has been noted previously in ___. Straight cath in ED yielded
400cc. Patient has been incontinent throughout her admission
with post-void residual bladder scans were mildly abnormal
around ~200 mLs. Her retention is likely a combination of
myelopathy from her L1 tumor, medication effect from opiates,
and possible pelvic floor dysynergia (noted ___ with
anorectal manometry, balloon expulsion, and pudendal nerve
latency). We recommend that this issue continued to be followed
with bladder scans at rehab and straight cath for >500cc of
urine. If she routinely is unable to void or has bladder scans
with >500mL of urine, she may require Foley catheter and ___
clinic follow up.
#Complicated cystitis: + Nit and leuks. Culture grew ESCHERICHIA
COLI. Started on ceftriaxone on ___ then started cipro ___. It
was found that she was resistant, so we started Macrobid (day 1
= ___ last day ___ for 10 days). She may be at risk for
recurrent UTIs due to mild urinary retention.
#Myelopathy and peripheral neuropathy: Weakness, spasticity, and
bladder dysfunction likely due to intramedullary lesion at L1.
However, patient on admission complaining of worsening distal
extremity pain in her LEs which improved with increase in
gabapentin to TID. Her gabapentin dose was increased three times
daily.
#Emotional liability and out bursts: Likely multifactorial with
UTI and pain medication use contributing. Patients outpatient
psychiatric provider ___ recently made
medications changes. Also patients family is concerned with her
mental status at home saying she appears to be confused and may
be self titrating her pain medications. She improved
significantly quickly after admission with treatment of her UTI
and changes as above to pain medications. She continued her home
medications. Psychiatry evaluated her and did not believe recent
psychiatric medications played a part in her presentation.
#Renal cell carcinoma with oligometastatic disease within the
conus of the spinal cord at L1: She is s/p IL2, XRT in ___,
axitinib, bevacizumab (15 cycles) and is now recently restarted
on bevacizumab for progression of her spinal cord metastasis.
Continues to have gradual progression of mass and conus edema
noted on MRI done in ED also noted progression on MRI in ___ and
was restarted on
avastin at that time. Last ___, dosed D1 and D15. ___ strength
remains preserved, has chronic saddle anesthesia and urinary
incontinence as well as bowel dysfunction.
After discussing with patients primary oncologists and radiation
oncology it was felt that further systemic treatment or
radiation treatment were not appropriate at this time.
Dexamethasone was given as above. | 216 | 640 |
17567410-DS-16 | 26,301,888 | ___ ___,
___ vino ___ por ___ de
___ dolor de pecho y dolor/picazon genital. ___ recibio
tratamiento antifúngico por ___ comezon de vagina y expectamos
___ sus sintomas se resvuelven en menos de una semana. ___ no, es
necesario ir ___ doctor para ___ una ___ dosis ___
___.
Nuestras pruebas no mostraron ningun problema con ___
cardiaca. ___ de estres con ejercicio salio normal. ___
ultrasonido tampoco mostro ningun ___ dolor. Pensamos
___ dolor no ___ en este momento. Por eso, no
hemos cambiado sus medicinas. Por favor continue ___
___ contra ___. Por favor regrese ___ doctor ___
___ dolor de pecho empeora.
Queremos ___ una ___ con un doctor ___ en
___ ___ hospital. Por favor llame
a ___, ___ 8am-5pm y pida alguien ___
___ para ___. Tambien, describe ___
___ doctor para ___ quitarla. | The patient is a ___ YO ___ F with PMH HTN who
presented with vaginal pain/itch and a two-week history of
exertional chest pain. Her vaginal pain/itch was diagnosed as
vaginitis and she was treated with PO fluconazole 150mg x1 in
the ED. Her chest pain was initially suspicious of coronary
artery disease, but troponins were negative x2 and a exercise
stress test showed no ischemic changes. A cardiac echo showed an
LVEV = 70% and mild diastolic dysfunction. At discharge, she was
chest-pain-free x 4 days and her vaginal symptoms had improved.
**Transitional Issues**
-Vaginitis s/p Fluconazole 150 PO x 1 on ___ need repeat
dose/further evaluation if sx do not resolve
-F/u A1C and lipids
-Medication changes: None. Please evaluate need for Statin.
-patient has skin tag on medial thigh that causes some
discomfort. Please evaluate for removal. | 139 | 139 |
15114531-DS-49 | 20,968,968 | Dear Ms. ___,
It was a pleasure caring for you. You were admitted because you
had worsening abdominal pain and fevers with pain on urination.
We found you had a likely urinary tract infection. We did CT
scans to make sure there was no other problem in your colon,
kidney or neck, all of which were reassuring. You also had an
endoscopy which did not show any bleeding or ulcer. It is likely
that opiates caused slowed gastrointestinal motility and opiates
are likely harmful for you and best avoided if at all possible.
You will follow up with your GI doctor to continue your
management.
You should also see an allergist given your history of recurrent
infections and low antibody levels.
You will need a CT scan of the chest to continue to monitor a
nodule in ___ year, and an MRI of the pancreas by ___ to follow
the cysts in your pancreas.
Please take lorazepam only as needed for abdominal discomfort,
metoclopramide only as needed for nausea.
Please continue taking vancomycin four times daily for the next
two weeks. If you have diarrhea in that time, please call your
primary care doctor.
We wish you the best in your recovery. | ___ w/ recurrent nephrolithiasis, recurrent UTI/pyelonephritis,
history of remote R nephrectomy and partial L nephrectomy, CKD
II, diverticulitis s/p ___ hemicolectomy, chronic abdominal
pain, uncomplicated Crohn's disease, recurrent
C diff (recurrence earlier last month, currently being treated
with PO vanco) admitted for cystitis. Resolving abdominal pain,
some of which is distractible and some of which may be due to
cystitis.
#CYSTITIS:
Unlikely pyelonephritis given lack of imaging findings on CT and
renal ultrasound despite flank pain. Inflammatory UA, bladder
inflamed on imaging, Cx negative but s/p extra dose of
fosfomycin as o/p may limit yield. Renal US and CT shows no new
or obstructing calculi. The most recent non-remote prior urine
cultures have been positive for enterococcus and pan-sensitive E
coli. She was started on CTX in the ED, but inpatient team
covered for enterococcus given prior cultures so switched to
levofloxacin (d1 levofloxacin ___, plan to end ___. A course
of 7 days was chosen for complicated UTI, balancing the risk of
abx in a patient with C diff with the need for treatment of
complicated UTI. She has numerous antibiotic allergies and so a
narrower agent was not possible.
#SEVERE ABDOMINAL PAIN, R/O ACUTE ABDOMEN:
# CONSTIPATION
Has had intermittently very severe sxs/exam early in exam with
pain in L flank, suprapubic and intermittently epigastric,
developed rebound/firm abdomen/severe pain, but it is often
distractible and her labs/imaging are extensive and reassuring.
Given initial non-improvement over serial exams, surgery was
consulted and they found her exam to be distractible and
reassuring. GI, to whom she is very well known, was also
consulted. They reported that she frequently worsens with the
high dose opiates (here she had been receiving ___ IV q3h), in
large part due to constipation. She was therefore treated with a
very aggressive bowel regimen per GI recommendations (Miralax
34g TID) and uptitration of her PPI to max dose (recognizing the
risk with C diff) and downtitration of her high dose opiates,
with significant stool output and much improvement in her
abdominal pain. EGD performed given report of melena (though see
below) and her epigastric pain component and history of iron
deficiency (given recent colonoscopies without findings) without
bleeding/inflammation, but notable for possible delayed motility
(likely ___ opiates). Opiates were further quickly weaned down
and ondansetron switched to metoclopramide with good effect.
Patient was well aware that opiates were harmful for her abdomen
and was in agreement about weaning down. Though coopertive
throughout, it was thought there may have been a large anxiety
and hyperalgesia component to her exam and symptoms. Social work
met with the patient.
# MELENA:
Reports melena, has a history of transfusion dependent iron
deficiency anemia with a presumed cryptogenic GI source despite
aggressive w/u. Reassuring is her vitals, hct still at baseline.
Guaiac positive x1, but thereafter although she reported melena
to MD stools were guaiac negative and non-melanotic by nursing,
making true melena less likely. EGD negative ___. Her PPI
was increased to 40BID (recognizing C diff risk).
# NEPHROLITHIASIS:
Known nephrolithiasis in solitary kidney, but non-obstructive by
multiple modalities, and reassured by continued urination and
creatinine at baseline. Discussed with urology who agree that no
intervention necessary at this time, but that should follow up
with them as outpatient. No pyelo. She was continued on her
Bicitra, and started on tamsulosin. She should follow up with
urology in ___ weeks.
#RECURRENT C DIFF
Diagnosed with C diff ___ and had recurrence ___. We
continued and extended her PO vancomycin course which was
supposed to end on ___ but will now extend two weeks beyond
completion of levofloxacin. Continue PO vancomycin (two-week
course started at OSH initially supposed to end on ___, but
since she is on antibiotics now, this will be extended until 2
weeks after completion of abx, to ___.
#? R PAROTID MASS
Noted on exam to have swelling and tenderness/firmness over R
parotid gland. Resolved without specific intervention. CT
performed several days into abx (delayed given significant
contrast load previously) was negative beyond mildly asymmetric
size of parotid without abscess/infection.
#HYPOGAMMAGLOBULINEMIA
Carries a diagnosis of CVID, but labs tested on this admission
are not consistent with this. Noted to have low IgG. Discussed
with immunology and no need for IVIG at this point. It is noted
that some data indicate hypogammaglobulinemia increases C diff
risk (though not, per allergy, UTIs). In order to faciliate
workup of her deficiency, IgG subclasses, diphtheria toxoid ab,
strep pneumo ab were sent as inpatient and should be followed up
by allergy and/or PCP as an outpatient.
# HYPOKALEMIA: with repletion
#CROHNS: continue PO budesonide 3 mg daily. Not thought to be
flaring.
#GERD: increased PPI as above.
#HTN: initially held home lisinopril but resumed and tolerated
well.
# TRANSITIONAL ISSUES:
- will need repeat CT chest ___ year) for known pulmonary nodule
and repeat MR pancreas ___ ___ for known pancreatic cysts
as outpatient
- outpatient follow up with urology ___ weeks
- given recurrence of C diff, can consider FMT as outpatient
- not able to send tetanus toxoid ab as part of
hypogammaglobulin w/u as ___ have to be sent as
outpatient
- f/u as immunology labs on discharge with allergy to pursue
more specialized testing | 198 | 854 |
12482447-DS-15 | 20,762,566 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· 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
· You have been discharged on blood thinning medication
(Aspirin and Coumadin) which has been cleared by the
neurosurgeon. Your goal INR is 2.5-3.5 for the maintenance of
your mechanical valve.
PLEASE HAVE YOUR INR CHECK tomorrow ___ and reviewed by your
Cardiologist
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating,
and remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may also experience some post-operative swelling
around your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | This is a ___ year old M on coumadin for mitral valve replacement
with headache for 5 days. He also admitted to taking aspirin and
ibuprofen. Head CT revealed a Right SDH with significant midline
shift. INR was elevated, he received vitamin K and KCENTRA at
the OSH and was medflighted to ___. He was taken to the OR
emergently to the OR for evacuation of SDH. He was transferred
to the ICU for monitoring. Post operative head CT showed
reaccumulation of SDH, he received platlets and was taken back
to the OR for repeat R craniotomy for evacuation of SDH. A
subdural drain was left in place at this time. He was extubated
in the SICU and repeat head CT showed good evacuation of
hematoma. On post op exam, he was neurologically intact.
On ___, The patient remained stable. A repeat head CT was
obtained and showed a stable MLS and SDH. The SD drain remained
in place. He was started on ___.
On ___, the patient become somulent and a head CT was obtained
and showed increased thickness of SDH and increased shift. The
drain was kept in place.
On ___, the patient remained stable on exam and orders were
written for transfer to floor. His SD drain was removed without
any difficulty. A CT was obtained and was stable compared to
yesterday's head CT.
On ___, the patient remained stable. A ___ consult was
obtained and recommended rehab. Case Management initiated
discharge discussion and planning with Mr. ___ to begin
screening for rehabilitation.
Prior to intiating Mr. ___ home anticoagulation regimen for
his mitral valve, a repeat non-contact head CT was performed on
___ which showed acute blood in the resection bed and a
mid-line shift of 1.2cm. The decision to resume the patient's
anticoagulation was held until coagulation labs were obtained
and time to further monitor the patient's neurologic status.
On ___, the patient was stable neurologically. He continued
his aspirin. Given the acute blood seen on his CT, it was
decided that coumadin would be held and the patient would stay
for observation over the weekend. A repeat head CT was planned
for ___ to assess the stability of the SDH. His INR was 1.1.
On ___, the patient remained neurologically stable but
complained of a persistent headache. A NCHCT was obtained and
found to be stable.
On ___, the patient remained neurologically stable. Cardiology
was consulted regarding timing of starting a Heparin gtt. Per
Cardiology, recommend starting a Heparin gtt on ___,
___. The patient complained of left-handed clumsiness in
the late afternoon. A NCHCT was ordered and found to be stable.
On ___, the patient continued with complaints of left hand
clumsiness which persisted. He underwent a MRI with DWI protocol
which was ordered to rule out a stroke. Preliminary read was
negative.
On ___, the patient remained neurologically stable. He continued
with complaints of left hand clumsiness. An OT consult was
placed. His incision was clean, dry and intact without edema,
erythema or discharge. The MRI performed ___ was finalized and
was negative for stroke. Pt remained stable on ___.
On ___ A NCHCT was repeated which revealed slight interval
decrease in right subdural hematoma. He was started on a heparin
gtt for bridge to coumadin with a goal PTT of 50-70.
On ___, patient had a stable repeat head CT with a theraputic
PTT. He was started on 6mg of coumadin. Dilantin was
discontinued and keppra was continued.
On ___, PTT was 76.2 and exam remained stable.
On ___, his PTT remained theraputic and coumadin was increased
to 7.5mg. He was intact on exam. ___ recommended home with ___.
On ___, the patient remained neurologically and hemodynamically
stable. His PTT was 76 and his heparin drip was decreased to
1400 units/hr. His INR was 1.3 and he received another dose of
6mg of coumadin po.
On ___, the patient remained stable. His PTT was WNL x3, with
heparin drip at 1400nits/hr. His INR was 1.3 this morning and
his coumadin dose was increased to 7.5.
___ INR was 1.4. PTT remained a goal. A routine CT head was
performed and revealed decreased size of R SDH, and no midline
shift, improved from previous scan.
On ___ INR was 1.4. He continued on 7.5mg of coumadin daily.
On ___, he remained stable, INR 1.6. On ___, INR 1.9, his
heparin gtt was increased to 1500u/hr for a drop in PTT.
On ___, INR 2.2 and PTT slightly elevated. Heparin gtt was
decreased to 1400u/hr.
On ___, The patient was neurologically stable. On exam
the patient was ambulating independently and was full strength.
On ___ patient's morning PTT was 73. The heparin gtt was
decreased to 1250units/hr. The INR was 2.3. The patient's
current INR was discussed with inpatient cardiology and it was
determined that the patient must stay until INR 2.5. This was
discussed with the patient.
On ___, The patients INR was 2.5. The heparin intravenous
infusion was discontinued. The patient was sent for a ___
which was consistent with Interval decrease in size of
right-sided subdural hematoma without evidence of new
hemorrhage. The patient was neurologically intact and was
discharged home with a plan to follow up with his cardiologist
this week. He will have his INR checked at his cardiologist
office tomorrow. | 737 | 892 |
19226487-DS-5 | 24,260,985 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the Acute Care Surgery Service on
___ after being struck by a car on your motorized scooter.
You sustained several injuries including: a head
bleed/concussion, scalp laceration, and neck pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by the neurosurgery team. Your head bleed did
not need surgery, and got better by itself.
- You had a CT scan that showed one of the vertebrae in your
neck slipped backwards ("C3-C4 retrolithesis"), so you were
given a neck brace to wear for six weeks.
- You developed an infection in your lung that made it difficult
for you to breath. You were treated with antibiotics and this
improved.
- You had difficulty swallowing, so a tube was placed through
your nose into your stomach so that you could get nutrition and
medications. To figure out why you were having trouble
swallowing, the neurology team evaluated you, and you had
imaging done of your brain. This showed no stroke and no
worsening of your multiple sclerosis. It is likely that your
trouble swallowing was because of your concussion from being hit
by the car, and that this will slowly improve. We discussed
placement of a PEG tube (a tube that goes through your skin into
your stomach) but then your swallowing started to improve and
you did not need this. You decided to accept the risks of
swallowing soft foods.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Surgery Team Hospital Course:
================================
Mr. ___ is a ___ year old male with a history of multiple
sclerosis who presented to ___
on ___ as a trauma activation after being struck by a
car. Trauma workup was significant for left frontal SAH and
posterior scalp contusion with laceration. Numerous services
were consulted from the trauma bay. Neurosurgery recommended no
additional imaging and to hold Aspirin for 3 days. Spine surgery
was consulted for findings of degenerative changes on his CT
neck and recommended continued use of C collar. Hand surgery was
consulted, per policy, after the patient's IV infiltrated with
contrast in the CT machine. They recommended serial exams. The
patient was admitted to the trauma service for further
observation and management.
On the floor, the patient was found to have difficulty with
swallowing. ___ was evaluated by speech and swallow, which ___
failed, and an NGT was placed for feeds. ENT was consulted to
evaluate for structural etiology of his dysphagia, of which
there were none. Neurology was also consulted to evaluate his
dysphagia, and they recommended a stroke workup (detailed below,
but negative for acute stroke).
On ___, the patient had acute hypoxic respiratory failure
requiring a non-rebreather mask for support. This was presumed
to be due to an aspiration event. ___ was transferred to the SICU
in this setting. CTA was performed which was negative for
pulmonary embolism. His mental status was also found to be
altered at this time. Repeat head CT was performed which showed
an enlarging L SAH and a new R SAH. Neurology was consulted due
to concern for acute stroke. A CTA head and neck was performed
which showed a linear filling defect in the left carotid
bifurcation concerning for a web. ___ subsequently had an MRA
which similarly showed a web but no carotid dissection.
On ___, ___ spiked a temperature and was pan cultured. Chest
xray was performed which was suggestive of pneumonia, so ___ was
started on broad spectrum antibiotics for treatment of presumed
aspiration pneumonia. ___ did not require intubation. His
respiratory status gradually improved and ___ was transitioned to
room air. His secretions also improved with antibiotic therapy.
On ___ overnight, the patient had significant epistaxis. ENT
was contact and they recommended afrin, packing and bacitracin,
and the bleeding stopped.
When his respiratory status was appropriate, medicine was
consulted for consideration of transfer to their service. ___ was
called out to the medicine floor on ___.
MEDICINE TEAM HOSPITAL COURSE
PATIENT SUMMARY
===================
___ man with multiple sclerosis admitted to trauma service after
being hit by car while on scooter with mild TBI, nonsurgical SAH
and cervical spine injury, course complicated by aspiration
pneumonia, epistaxis, and worsening dysphagia.
ACUTE ISSUES
===============
# Mild retrolisthesis of C3 on C4
Spine surgery was consulted for cervical collar clearance and
further imaging recommendations. The patient has no neck pain at
rest but does endorse some with neck range of motion, which ___
attributes to the collar. ___ should be maintained in the
C-collar for 6 weeks from the accident, may remove for feeding
and cleaning. Follow up with ___ to be cleared for
discontinuation after 6 weeks (___).
# ___
Patient presented with left frontal subarachnoid hemorrhage and
large left parietal subaleal hematoma and laceration without
fractures after being hit by a car while on his scooter.
Neurosurgery was consulted, and there was no surgical
intervention required. His SAH remained stable on repeat
imaging. CTA showed no aneurysm or vasospasm, and ___ completed a
7 day course of keppra seizure prophylaxis. ___ was cleared for
DVT PPx and ASA, and his blood pressure was maintained <150.
# L Carotid Web vs dissection
MRA of the neck was limited by motion artifact, however it was
read as either a left carotid web or dissection. There was no
clear dissection or intramural hematoma. A repeat MRA with fat
sats should be obtained when the patient is more able to lay
supine for a prolonged period. ___ was continued on ASA 81 mg for
prophylaxis in case of dissection/web.
# HCAP
# Aspiration Pneumonitis
Cough, hypoxic event while on floor ___ while working with ___
requiring suctioning and transfer to SICU for monitoring. Did
not require intubation, and was improving with seven days
cefepime/Vancomycin, however ___ had increased secretions and
leukocytosis on his seventh day of antibiotics requiring
suctioning on ___. At that time his antibiotics were continued
for 48 more hours and flagyl was added. During that time his
secretions improved and it is thought that the second event was
aspiration pneumonitis, not a new pneumonia. Antibiotics were
then discontinued ___ and ___ continued to improve.
# Dysphagia
# AMS - Resolved (___)
No acute stroke or MS flare on MRI, and his dysphagia was likely
worsening of underlying MS dysphagia in the setting of TBI/acute
illness per neurology. Mr ___ received nutrition through his
NGT, however this unfortunately was inadvertantly removed during
suctioning after his aspiration event on ___. NGT placement
previously very difficult with trauma causing significant
epistaxis, so replacement was deferred over the weekend until
speech and swallow could re-evaluate the patient. At that time
___ was deemed able to swallow nectar thick liquids and pureed
solids, so the NGT was not replaced. A video swallow study was
performed that deemed him high risk for aspiration, so a goals
of care meeting was held with the patient, his son, speech and
swallow, the primary team, and palliative care team with a
___ interpreter. The patient decided that ___ wanted to
accept the risks of swallowing with a soft dysphagia diet and
thin liquids. His diet was adjusted accordingly, and ___
continued speech and swallow rehabilitation while in house with
gradual improvement.
# Epistaxis
On ___ Mr. ___ developed significant epistaxis, likely
secondary to trauma when NGT placed ___. ENT was consulted and
nasal packing was not required. His epistaxis continued slowly,
and there was concern of aspiration of blood from his
nasopharynx. ___ was put on a QID oxymetazoline regimen
interespersed with TID nasal saline and humidified mask oxygen
with improvement of his epistaxis.
# Scalp laceration
Patient with laceration of posterior scalp on admission from
MVA, closed with sutures on ___. Throughout admission
intermittent bleeding from scalp wound which resolved with
pressure. New closure was not required during this admission.
Please continue to evaluate, if bleeding has stopped sutures can
be removed on ___.
# Goals of care
During this hospitalization, patient became DNR OK to intubate
for reversible situations. ___ expressed that ___ thought ___ was
dying, and that ___ would not want life sustaining treatment.
Since the patient will likely have future complications
requiring hospitalization given his MS, palliative care was
consulted the help elucidate his wishes and guide development of
advanced directives. | 296 | 1,110 |
10538657-DS-22 | 21,754,601 | Dear ___,
___ were admitted to the hospital with decompensated congestive
heart failure. ___ were suffering from worsening
shortness-of-breath at home.
Your symptoms improved quickly with a modified set of
medications to control heart failure. We felt your heart failure
progressed due to worsening valve regurgitation, which we saw on
Echocardiogram.
___ should continue limit your fluid intake to 1.5 liters per
day and limit your salt intake to no more than 2 grams total per
day. Please remember to read labels carefully and look out for
hidden sources of salt like prepared & canned foods, crackers,
spice mixes & soy sauce.
We made the following changes to your medications:
HOLD your warfarin dose today
STARTED IMDUR, TAKE 30 MG DAILY
STARTED DIGOXIN, TAKE 125 MCG EVERY OTHER DAY
*INCREASED* TORSEMIDE DOSE, TAKE 60 MG TWICE DAILY
STOPPED HYDRALAZINE
STOPPED METOLAZONE
.
Please review the attached medication list with your doctors at
your ___ appointments (see below for scheduling details).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ w/chronic sCHF EF20-25%, chronic afib and recent ICD
placements p/w persistent tachycardia and dyspnea w/minimal
exertion despite ICD adjustment 2d prior to admission, now
admitted for CHF management, with marked clinical improvement
after diuresis and initiation of long-acting nitrate & digoxin.
.
# sCHF w/ EF ___
Volume overloaded on admission exam; concern that her current
flare may represent an exacerbation of an already-declining
baseline cardiac pump function, likely ___ uncontrolled atrial
fibrillation, and possibly also worsening valvular disease.
Noted to be s/p very recent ICD placement for primary
prevention. TTE repeated here shows worsening MR, worsening LV
dilation, and TR 2+ -> 4+. Heart failure medication regimen
modified to be: Metoprolol Succinate XL 100 mg PO DAILY,
Torsemide 60 PO QD, Imdur 30 QD, digoxin 125 mcg QOD (NB: s/p
dig loading 0.25 mcg q12h x 2 doses on ___. Not on an ACEi bc
of chronic renal insuffiency. She was feeling well, euvolemic on
exam, walking around carrying on comfortable conversation with
staff for two days prior to dischargem and for >24h on oral
regimen. Discharge weight 69 kg. Needs f/u TTE while euvolemic
to re-assess TR.
.
# AFIB W/RVR
Chronic issue; here on admission and 2d ago in the ED, EKGs &
telemetry demonstrate poor rate control, HR 100-120 w/frequent
self-limited RVR to 140s. Tachycardia thought to worsen CHF, so
rate control was a major goal at this time. Significant
improvement after dig loading, 0.25 x 2 doses q12 on ___,
with resultant HR baseline ___ on telemetry. She was seen by the
EP consult team who recommended AVJ ablation in ___ weeks.
Coumadin dosing unchanged.
.
# HTN
BP baseline 90-100s, not altered by diuresis or initiation of
nitrate. Hydralazine discontinued, started on imdur + ongoing
diuresis w/torsemide as above.
.
# NAUSEA/VOMITING
Vomited once on ___. Pt has hx of nausea due to abdominal
congestion when volume overloaded. Symptoms resolved w/diuresis.
.
# HX CAD s/p CABG
No anginal chest pain during this admit. Cardiac enzymes at
baseline (MB fraction negative) on admission. Review last cath
report from ___ demonstrating widely patent grafts. Continued
ASA, statin, Coenzyme Q.
.
# HEADACHE
Congestion and headache ongoing x weeks. Pt awaiting outpatient
ENT evaluation. Not responsive to tylenol at home, good response
to fioricet here.
.
# DM2
Onset ___ years ago. BS well-controlled on ISS and a diabetic
diet.
.
# CHRONIC RENAL INSUFFICIENCY
Baseline Cr 2.2-2.5 over the past year. Within baseline at 2.4
on admission, now downtrending. Underlying issue is lack of ___
kidney - s/p nephrectomy for complications of nephrolithiasis.
Cr was monitored closely while diuresing. Discharge Cr 2.4.
.
# Hypothyroidism
Continued synthroid ___ mcg qday.
.
TRANSITIONAL ISSUES
1. CHF - trend weights, adjust torsemide dosing PRN
2. CRD - recheck Cr
3. Hypokalemia - required aggressive repletion while on IV lasix
in-house, discharged on oral potassium but may need dose
adjustment/monitoring
4. Needs follow-up echo when euvolemic to re-assess TR | 162 | 476 |
17860497-DS-21 | 28,700,238 | Ms. ___,
It was a pleasure taking care of you while at ___. You were
admitted for dizzines/vertigo causing a fall. The cause of your
symptoms wasn't quite clear, but it may be due to Gaucher's
disease and history of meniere's disease. You did have a
urinary tract infection which was treated with antibiotics. We
had the neurologists see you who recommended an MRI to rule out
a posterior stroke which was unremarkable.
Please start taking clonazepam 0.5 mg twice daily for the
vertigo. Only take the ativan should you become anxious, as
clonzepam is a similar medication | Impression: ___ y/o F with PMHx signicant for Meniere's disease
and HTN who presented with a fall in the setting of vertigo.
#Vertigo with fall- Patient's symptoms do sounded vertiginous in
nature although history was difficult to obtain. We suspect, in
speaking with her outpatient neurologist, that these symptoms
were related to her known Gaucher's disease. Other potential
etiologies were difficult to ascertatin as there was lack of
evidence of meniere's disease given absent tinnitus and changes
in hearing. Given history of Gaucher's, we suspect there may be
subtle changes playing a role as has known ataxia and disordered
movements. Her underlying disease may be exacerbated in the
setting of UTI. There was no evidence to suggest cardiac nature.
Posterior circulation stroke was considered given high pressures
recently, although nothing focal to suggest that. However,
given the confusing presentation, a neurology consult was placed
to help guide clinical decision making. They recommended an MRI
which was negative for an acute stroke. Her primary neurologist
recommended clonazepam for her vertigo which was started here.
#UTI- patient with +UA treated with Macrobid in the ED. Given
history of fall and dysuria, deserves treatment. She received a
5 day course of macrobid given pen, bactrim, and cipro allergy
#HTN- Amlodipine 2.5 mg daily was increased to 5 mg daily.
Bystolic was held during this admission. She was discharged on
her home dose of amlodipine 2.5 mg and bystolic was restarted
#Asthma- albuterol prn was continued
#GERD -omeprazole (Nexium non-formulary) was given.
#Transitional Issues
-Patient will be getting standing clonazepam. She should only
receive ativan should she have breakthrough anxiety.
-Pt needs to follow up with her neurologist, Dr ___ was
aware of plans for discharge to rehabilitation. | 101 | 285 |
12145903-DS-14 | 25,473,728 | Dear Mr. ___,
You were admitted to the hospital after a motorcycle collision.
You suffered from facial fractures, a severe traumatic brain
injury, and spine injury. You had a prolonged hospital course
and required a breathing tube (tracheostomy) and feeding tube
(PEG) be placed while you were in the intensive care unit. Your
tracheostomy has now been removed. You are tolerating your
pureed food and the PEG tube will be removed at your follow-up
appointment in the Acute Care Surgery clinic. You were also
noted to have a left back rash in the hospital and were started
on an antiviral medication by Dermatology. You will be seen in
the Plastic Surgery clinic for follow-up of your facial
fractures and you will be seen in ___ clinic for your
spine injuries.
You are now medically stable enough to leave the hospital and go
to ___ in ___ for ongoing care for your traumatic
brain injury. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Mr. ___ presented to the ___ trauma bay on ___ after
a motorcycle crash. His GCS was 3 at the scene and he was
intubated prior to arrival. Exam and imaging were notable for a
blown left pupil, left orbital fracture, left zygomatic
fracture, left maxillary fracture and a left periorbital
hematoma.
CT C-spine was initially read as a C7 facet fracture and spine
surgery was consulted. They recommended MRI C-spine which showed
no fracture and what was previously visualized was thought to be
a vascular channel. MRI C-spine did note cord edema at the level
of T3 and an MRI T-spine was ordered. MRI T-spine showed a
spinal cord contusion for which neurosurgery recommended nothing
to do. No Keppra was felt to be necessary.
Ophthalmology was consulted for evaulation of the left
periorbital hematoma and blown left pupil. Intraocular pressures
were normal and the blown left pupil was felt to be chronic in
nature.
Neurology was consulted given patient's inability to move his
left side and recommended MRI head with orbit protocol which
showed small bilateral foci of microhemorrhage and slow
diffusion, more numerous suggestive of hemorrhagic contusions
and shear injury likely consistent with grade II diffuse axonal
injuries. There was a question of seizure activity for which EEG
was placed, but after being witness by neurology, was felt not
to be a seizure and EEG was discontinued.
Plastic surgery was consulted for multiple facial fractures and
recommended non-operative management with sinus precautions in
place.
He was extubated on ___ and had increased work of breathing
and subsequently reintubated the same night. On ___ he had
fevers and was started on vancomycin/cefepime/flagyl for
presumed pneumonia. Mini BAL was sent which was negative for
MRSA so vancomycin was discontinued. On ___, the patient
went to the OR for tracheostomy/PEG placement. Antibiotics were
ultimately discontinued as they were no longer needed. The
patient tolerated tube feeds and was transferred to the floor.
Speech and Swallow followed the patient. On POD #7, the patient
self d/c'd his tracheostomy tube and breathing remained stable
in the mid-high ___ on 2L NC. ___ and OT followed the patient.
On ___, the patient had a fall from bed and was uninjured.
Psychiatry followed the patient and adjusted his medications.
The patient had several episodes of urinary retention for which
he was straight catheterized and ultimately had a foley catheter
replaced. The catheter which is currently in place, was placed
on ___.
The patient was noted to have a left hip/back rash and
Dermatology evaluated it and felt it may be shingles. A wound
swab was obtained (preliminary reads shows no evidence of HSV or
VZV). Dermatology recommended that he complete a one week
course of Valacyclovir.
Guardianship paperwork was filed and ___ was approved. At
the time of discharge, the patient was doing well, afebrile and
hemodynamically stable. The patient was tolerating a pureed
diet, ambulating with assist, foley catheter in place, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was cleared to
be discharged to ___ rehab. | 355 | 532 |
12626283-DS-4 | 22,767,037 | Hi Ms. ___,
You were admitted to ___ after you fell. You had a CT scan of
your head, neck, and chest that did not show any injuries. You
had an xray of your right hand and were found to have a fracture
in your pinky finger. The orthopedic surgery team placed a
splint on the finger to re-align the bones. You will need to
wear the splint for several weeks while your bones continue to
heal. You were seen by the physical and occupational therapists
who recommend discharge to rehab to improve your strength and
mobility. You are now doing better, tolerating a regular diet,
and ready to be discharged home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. | Ms. ___ is a ___ yo F who presented to the emergency department
on ___ after a fall from standing and found to have an
isolated right ___ finger fracture. Hand surgery was consulted
and reduced and splinted the fracture at bedside. Post reduction
xrays showed adequate bone alignment. The patient was admitted
to the trauma service for pain control, hemodynamic monitoring,
and physical therapy assessment.
Neuro: The patient was alert and oriented at baseline throughout
hospitalization; pain was initially managed with oral
acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a regular diet without
difficulty. Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance, voiding adequate urine, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 315 | 244 |
15120673-DS-18 | 24,665,544 | Dear Ms. ___,
You were admitted to our hospital because of convulsions. We
determined that these were not due to epileptic seizures. You
have psychogenic nonepileptic convulsions (seizure-like fits due
to stress). We will not add any seizure medications. We suggest
that you stop your topiramate (Topamax), which is a medication
that is used for both migraines and seizures, because it has
been ineffective for you. We also suggest that your
oxcarbazepine (Trileptal) should be gradually decreased in the
outpatient setting, because it is not helping your convulsions.
You were seen by our psychiatry service here. They were
concerned that you were too sedated, and suggested decreasing
your quetiapine (Seroquel) from 200 to 100 mg in the evening.
Please follow up with your primary care physician and your
psychiatrist at the next opportunity | ___ year old woman who has a history of epileptic seizures and
non-epileptic seizures who presents from OSH after several
convulsive events, and subsequent sedation requiring intubation.
She was transferred to ___ ICU where she was quickly and
uneventfully extubated and transferred to the neurological floor
team.
It was the team's assessment after observation of several
events, Ms. ___ symptoms were not due to epileptic
seizures. The diagnosis of psychogenic nonepileptic convulsions
(seizure-like fits due to stress) was made. Ms. ___ was
discharged home with recommendation not to add any seizure
medications, and to stop her topiramate (Topamax). It was also
suggested that she gradually taper the dose of her oxcarbazepine
(Trileptal) in the outpatient setting, because it is not an
appropriate treatment for non-epileptic convulsions.
Ms. ___ was also seen by our psychiatry service here. They
were concerned for sedation, and suggested decreasing Ms.
___ quetiapine (Seroquel) from 200 to 100 mg in the
evening.
We recommend that she maintain close follow up with her PCP and
psychiatrist after discharge to home. | 132 | 172 |
12882754-DS-7 | 22,325,047 | Ms. ___,
You were admitted for a pneumonia and a bronchiectasis and COPD
exacerbation. You were treated with antibiotics and steroids and
you got better. Please continue taking your medications as
directed (see below). Please follow-up with your primary care
physician and Dr. ___ repeat CAT scan and any
further changes ___ your medications.
It was a pleasure caring for you,
-___ medical care team | Ms. ___ is a ___ year old female with PMHx stage IIIB
adenocarcinoma and Asthma/COPD overlap with bronchiectasis
presents from ___ with 3 days shortness of breath and
susupicious lesions on CXR along with hyponatremia.
She was originally transferred for a CT scan due to concern for
malignancy recurrence. Her CT showed evidence of pneumonia, but
no evidence of malignancy and they recommended a repeat CT after
her pneumonia clears. Her sodium was 129 on admission, but
returned at 135 the next morning after receiving IVF. She was
wheezing on exam and was given duonebs and started on prednisone
as well as CTX/azithromycin. Her sputum gram stain showed
GNRs/GPCs so she was switched to levofloxacin given possibility
of pseudomonas.
#Chronic obstructive pulmonary disease/bronchiectasis
exacerbation:
#Community acquired pneumonia:
Based on CT chest findings (bronchial wall thickening, mucous
impaction, and ___ opacities predominantly ___ the mid
and lower left lung and lower right lung) and clinical picture
of subacute dyspnea, productive cough, wheezing, and mild
leukocytosis, Ms. ___ was diagnosed with
community-acquired bilateral pneumonia c/b COPD exacerbation.
She was started on IV ceftriaxone and azithromycin, prednisone
40 x5 days, duonebs q6h, and albuterol nebs PRN (approx. q3h
while awake). She did well overnight on this regimen, with no
fevers, vital sign abnormalities, or O2 requirements. At the
time of discharge, her blood and urine cultures had no growth,
her urine Legionella antigen was negative, and her strep pneumo
antigen and sputum culture were pending. Her sputum gram stain
showed >25 PMNs and <10 epithelial cells/100X field, 2+ GRAM
POSITIVE COCCI ___ PAIRS, 2+ GRAM NEGATIVE ROD(S), 1+ GRAM
POSITIVE ROD(S). She was switched to levofloxacin after speaking
with her outpatient pulmonologist given concern for possible
pseudomonas so she was started on a 14d course. At discharge,
she still required PRN duonebs, and was sent home with a
nebulizer to continue these treatments at home (will be
delivered). She requires a follow-up CT chest once pneumonia
has fully resolved to assess whether any malignant process is
present and whether this was a post-obstructive pneumonia.
#Hyponatremia:
On admission, Ms. ___ serum Na was 129. Her urine lytes
(urine Na of 50; urine osms of 309; difficult to interpret as
she receive IVF prior) suggested SIADH or HCTZ was the most
likely cause; Legionella test was negative. We held her HCTZ
and her serum Na increased to 135.
#Hypertension:
Home metoprolol continued during admission. HCTZ held due to
hyponatremia. Her blood pressures remained well-controlled
(110s-120s/60s-70s) throughout her admission.
#Gastroesophageal reflux disease:
Held home pantoprazole and ranitidine for cefpodoxime.
#Hyperlipidemia:
Continued home pravastatin and ASA for cardiac primary
prevention
#History of atrial fibrillation: Remained ___ sinus rhythm during
this admission. | 63 | 445 |
17784248-DS-16 | 29,601,478 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because blood work showed your kidney
function was not normal.
What happened while I was in the hospital?
-You received fluid because your water pills had removed too
much fluid from your body
-You had a "heart catheterization" that showed you did not have
too much fluid for your heart to pump
-You were seen by kidney doctors to ___ for any other kidney
problems
What should I do after leaving the hospital?
**Medication changes**
-Stop taking metolazone once a week
-Your torsemide dose is being decreased to 10mg daily. Please
start this ___. Every other day take 1 additional pill for
total of 20mg.
-Your weight on discharge is 136 lbs.
-Please weigh yourself every morning, call your doctor if your
weight goes up more than 3 lbs.
-Please follow-up with your cardiologist and primary doctor as
listed below.
-Please call the kidney doctors ___ ___ to schedule an
appointment
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ___ year old female, patient of Dr. ___, with history
of breast cancer status post left mastectomy, chemotherapy and
XRT, COPD, history of left upper extremity DVT in ___, coronary
artery disease status post RCA PCI in ___, reduced LVEF
of 35-40%, who was admitted for ___ with creatinine 2
#ACUTE KIDNEY INJURY: Likely ___ overdiuresis. Presented with
acute increase in creatinine from baseline 1.2 to 2, in the
setting of recently being started on torsemide 20mg (from being
on Lasix 20mg qd) as well as metolazone weekly (also took
additional dose of metolazone last week). She reports decrease
in urine output over the last 2 days with orthostatic positive
vital signs and elevated BUN/Cr ratio. All suggestive of
pre-renal injury in the setting of increased renal losses from
overdiuresis (likely due to large increase from Lasix 20mg qd to
torsemide 20mg qd + metolazone). No hydro noted on formal US.
Urinating well after removal of foley. Seen by nephrology who
recommended outpatient follow-up. R heart cath showed normal
filling pressures and creatinine improved with 500c NS and
holding diuresis. Creatinine 1.2 on discharge. Discontinued
metolazone and changed torsemide regimen to alternating 10mg and
20mg daily.
#CHRONIC SYSTOLIC HEART FAILURE: TTE week prior to admission
showed newly depressed EF from 50% to 35%. RHC ___ revealed
normal filling pressures. BNP in clinic prior to admission 460,
diuresis was held she was discharged with plan to start
torsemide 10mg on ___ and alternate daily 10mg and 20mg.
Already on metoprolol succinate, will need outpatient titration
of optimal medical therapy. | 184 | 258 |
17961065-DS-8 | 25,765,880 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital for management of your
headache. You had a CT scan and xrays to assess your
ventriculoperitoneal (VP) shunt; these were normal. You were
evaluated by neurosurgery who determined that your shunt is
functioning properly. Your headache is likely related to a viral
upper respiratory infection, which is also likely causing your
blocked ears and runny nose. You were started on standing
Tylenol (acetaminophen), in addition to increasing the dose and
frequency of your tramadol. Your headache improved by the time
of discharge. | ___ with PMHx of a pituitary mass and pseudotumor cerebri, now
status post VP shunt placement ___, who presents with
gradual onset severe headache over the past ___ days.
# Headache, likely related to viral syndrome, and tension
headaches: Patient reported that over the past ___ days prior to
admission, she had worsening headache and head pressure
associated with intermittent myoclonic jerks. Also reports
symptoms of a viral URI coincident with her worsening headache
(nasal congestion, rhinorrhea, green nasal discharge). There was
no evidence of shunt malfunction or increased intracranial
pressure on imaging; ventricles appeared unchanged in size.
Patient appears to have a head cold with associated headache;
she was managed supportively with fluids, standing
acetaminophen, and tramadol prn, and symptoms improved.
# Fever: Patient had a temperature 100.7 in the ED, but was
afebrile throughout her admission. Likely related to upper
respiratory virus. There was no evidence of pneumonia on chest
xray, and urinalysis was negative. Blood cultures were pending
at the time of discharge, but no growth to date.
# Pseudotumor cerebri s/p VP shunt: Followed by neurosurgery
and neurology as an outpatient. Patient was evaluated by
neurosurgery in-house, and they determined that her VP shunt is
functioning properly.
# Anxiety: Patient is very anxious and has poor coping skills
with her pain. She continued her citalopram & clonazepam prn and
was followed by social work while in-house.
# DVT Prophylaxis: Patient received heparin products during this
admission.
# Code status: Patient was confirmed full code during this
admission.
TRANSITIONAL ISSUE
- Blood cultures pending at the time of discharge. | 103 | 255 |
18463116-DS-6 | 20,439,405 | you have gallstones in the gallbladder and inflammation --
called cholelithiasis and cholecystitis.
you can continue your regular home activities as you feel up to
it, but avoid high fat foods at this time | ___ female with epigastric pain, nausea, vomiting, now
resolved but concern for cholecystitis and mild pancreatitis.
Cholecystitis, cholelithiasis, pancreatitis
The patient was placed on unasyn for empiric coverage. General
surgery and the ERCP team were consulted. She was made NPO and
given IVF. She had no further abdominal pain, nausea, or
vomiting. She underwent MRCP that showed no sign of biliary
dilation or stones. Therefore, an ERCP was not needed. Surgery
recommended for the patient to have an outpatient
cholecystectomy. her diet was advanced without problems and she
was discharged to home. | 34 | 99 |
13242444-DS-9 | 28,689,760 | Dear ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- You were having leg pain
- You were found to have damage to your artery where your last
procedure had been done.
- You were found to be bleeding in your leg
What happened while I was in the hospital?
- You had pictures taken of your leg to look at damage to the
blood vessel
- You had blood tests to monitor your blood levels
- You had pictures taken of your heart which showed that part of
your heart is not working
- You had surgery to repair the blood vessel in your leg and you
received pain medication
- Your heart was treated with medication
- You were started on a blood thinner
What should I do when I go home?
- You will need to have your blood thinner levels monitored
closely. Please go to the coagulation clinic regular to monitor
the levels of your blood thinner with blood tests
- You will have follow up appointments with the surgeon who did
your procedure, the surgeon will remove the staples in your leg
- You will have follow up appointments with a primary care
doctor and ___ heart doctor
- When you return to the ___ you will need to
meet with your cardiologist to monitor your blood thinner and
heart function | ___ is a ___ year old woman with H/O
hypertension, bronchiectasis s/p L pneumonectomy, coronary
artery disease with recent STEMI s/p LAD DES and balloon
angioplasty of D1, newly reduced EF 45% in ___, who
presented with left leg pain found to have left femoral artery
pseudoaneurysm and hematoma.
# Post Catheterization Left Femoral Artery Pseudoaneurysm, acute
blood loss anemia: Patient presented to the ED ___ for left
leg pain and on U/S was found to have a 1.1 x 0.7 cm left
femoral artery pseudoaneurysm with a 0.4 cm neck with
surrounding hematoma measuring 7.4 x 2.9 cm. Her hemoglobin was
8.5 on presentation and patient was hemodynamically stable.
Warfarin was held but patient was maintained on DAPT given
recent ___ to LAD. Left femoral pseudoaneurysm was in
the setting of recent repeat coronary angiogram via left femoral
access on ___ as right femorla artery had aortic balloon
pump in place on presentation. She underwent surgical repair of
left groin pseudoaneurysm on ___ with vascular surgery. A
___ drain was placed at time of surgery and then removed on
___. Patient was resumed on therapeutic anticoagulation
with heparin bridge to warfarin on ___. She continued to be
hemodynamically stable and have stable Hgb. Her pain was
controlled with oxycodone as needed and acetaminophen in post
operative period. Patient was able to ambulate. Patient will
follow up with Vascular Surgery on ___ at which time her
groin staples will be removed. Patient is being anticoagulated
with warfarin with goal INR ___ in setting of bleeding risk on
triple therapy. Hemoglobin at discharge 7.8.
# Apical Akinesis, Heart Failure with Reduced Ejection Fraction
on oral anticoagulation: Patient had repeat echocardiogram on
___ which demonstrated reduced LVEF 40% and continued
presence of apical akinesis but no mural thrombus. Patient was
resumed on therapeutic anticoagulation with heparin bridge to
warfarin on ___. She continued to be hemodynamically stable
and have stable Hgb. She has a goal INR of ___ given bleeding
risk in setting of recent surgery and ongoing DAPT. Patient
continued to appear euvolemic and was not diuresed. Patient
maintained on lisinopril 5 mg daily for afterload reduction and
metoprolol succinate 50 mg daily as neurohormonal blockade.
Patient will need to be anticoagulated for at least 3 months but
has additional indication for lifelong given possibility of
paroxysmal atrial fibrillation (see below). Goal INR for patient
is ___. Patient was connected to ___ clinic.
She will have her INR checked at ___ and
have labs faxed to ___. Patient will need to establish
care with cardiologist when she returns to ___ in
___ to monitor warfarin/INR. Patient will need repeat
echocardiogram to evaluate for akinesis in ___.
Contact information for patient's cardiologist in ___ | 221 | 450 |
10263098-DS-10 | 20,854,118 | You were admitted to the hospital for postoperative constipation
after your recent abdominal surgery. You were also found to have
a pneumonia which we began treating with antbiotics. You were
given bowel rest and intravenous fluids and a nasogastric tube
was placed in your stomach to decompress your bowels. Your bowel
have now started moving again after conservative management. You
have tolerated a regular diet, are passing gas and your pain is
controlled. You may return home to finish your recovery.
Please monitor your bowel function closely. It is important that
you have a bowel movement in the next ___ days. If you notice
that you are passing bright red blood with bowel movements or
having loose stool without improvement please call the office or
go to the emergency room if the symptoms are severe. If you are
taking narcotic pain medications there is a risk that you will
have some constipation. Please take an over the counter stool
softener such as Colace and Miralax to keep your bowel movements
regular. We have also prescribed you a suppository that you can
take as needed. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You also sustained a wound to your left elbow after a fall prior
to arrival in the hospital. You were seen by the wound nurses
who recommend changing your dressing daily. You should apply
melgisorb Ag to the wound and a moisture barrier ointment around
the wound, cover the wound with gauze, and wrap with Kerlix. We
will have a visiting nurse assist you with these dressing
changes and recommend that you follow up with your primary care
physician in the next ___ weeks.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. | Mr. ___ presented to the ED on ___ with a
postoperative ileus and constipation. He was admitted for
conservative management and improved greatly, tolerating a
regular diet and having multiple bowel movements prior to
discharge.
Neuro: The patient was stable from a neurologic perspective. He
received his home dose of oxycodone for his chronic back pain.
CV: The patient was stable from a cardiovascular perspective.
Pulm: The patient was stable from a respiratory perspective.
GI: The patient received a nasogastric tube which was removed
when the output had decreased and the patient was adequately
decompressed and passing flatus. His diet was advanced as
tolerated. He was given a bowel regimen and suppositories and
had multiple bowel movements prior to discharge without issue.
GU: The patient was followed by the renal service for his
hemodialysis, which he continued on his normal regimen without
issue.
ID: The patient was monitored for signs and symptoms of
infection. He was found to have a pneumonia and started on
levofloxacin which was renally dosed.
MSK: The patient sustained a wound to his left elbow in the fall
he had prior to his arrival at ___. Wound nurse was
consulted and provided recommendations for wound care which were
provided to the patient. A ___ was set up to assist with wound
care at home and he will follow up with his primary care
physician.
Heme: The patient was stable from a hematologic perspective.
On ___, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply: | 335 | 289 |
16293344-DS-31 | 22,489,839 | Dear Ms. ___,
It was a privilege to care for you at ___.
You came in after a fall on your knees and xrays and CT scan
showed a fracture. The fracture was to your right knee cap and
you ___ not need a surgery. However, you need rehab and a brace
for 6 weeks. You will follow up with the bone doctors
(___) in two weeks.
Your platelets were decreasing as well, and we taked to Dr.
___. Your labs will be checked at rehab and faxed to him.
Because of the low platelet count we ask that you do not take
your aspirin for the time being. | ___ with ITP (s/p recent IVIG therapy), CAD (DES to ___ and
DES to distal-LAD in ___, dCHF, recent admission for syncope
___ AVNRT, presents with epistaxis and R patellar fracture and
quad tendon rupture after mechanical fall.
#Right Quadriceps tendon rupture and patellar fracture: ___
traumatic fall. Seen by ortho trauma who recommended
non-operative management. She underwent aspiration of fluid in
the right knee with 110cc of blood aspirated. Has been placed in
___ brace x 6 weeks with follow up with Ortho in two weeks.
Pain control with tylenol and prn oxycodone. Physical therapy
was consulted and rehab recommended rehab. WBAT till f/u with
ortho. R leg in full extension with brace x 6 weeks.
#Epistaxis: one episode prior to admission. Resolved with
rhinorocket tampon application. Tampon taken out prior to
discharge without rebleed.
# ITP: platelets on admission in the 100s, up from prior
admission when it was 10. On prior admission she was given IVIG
as treatment (she refused steroids). Platelets downtrended to
67,000 by discharge. No obvious active bleed; epistaxis
resolved. Spoke with her hematologist, Dr. ___ states
patients baseline is in the 50's to 60's. Reccommended
continuing to hold aspirin but ok heparin for DVT prophylaxis
with heparin SC as long as ___. Labs will be faxed to Dr.
___ rehab and she will have outpatient follow up.
# Chronic dCHF: Most recent ECHO was ___, showing normal
biventricular cavity sizes with preserved global biventricular
systolic function (LVEF 60%). Euvolemic and stable during
admission. Continued metoprolol,spironolactone and torsemide
60mg
#h/o AVNRT: prior admission for syncope felt to be from AVNRT.
EP study was not done because of low platelets and the decision
was for her to f/u with outpatient cardiology. She was supposed
to wear ___ of hearts but didnt know how to use it. Continued
metoprolol.
# CAD s/p PCI: ___ and mid-LAD lesions in ___. Continued
atorvastatin and metoprolol. Held aspirin ___ platelets | 106 | 322 |
19064155-DS-4 | 23,844,917 | Dear Ms. ___,
You were hospitalized due to symptoms of left side weakness and
slurred speech 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:
Atrial Fibrillation
High cholesterol
Diabetes Mellitus
You also have difficulty swallowing because of the stroke. You
were seen by swallow specialist who recommended a Pureed diet
and thin liquids, slow pace and strict supervision and
assistance. You will continue swallow therapy after discharge.
We are changing your medications as follows:
Adding Aspirin, Atorvastatin and metoprolol as prescribed
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ woman with history notable for
Atrial fibrillation on warfarin, hypothyroidism, DMII, and PMR
(on prednisone) transferred from ___ after
presenting with left hemiparesis, with imaging notable for
distal M1 occlusion s/p tPA prior to arrival. She underwent
emergent thrombectomy with subsequent TICI 2c perfusion. She was
subsequently admitted for further management .
#Acute right MCA stroke
- s/p tPA at 12:48 on ___. Followed by thrombectomy the same
day. Post procedure her left lower extremity weakness and gaze
deviation resolved but had persistent left UE weakness, L facial
droop and dysarthria. Etiology of infarct likely cardioembolic
in the setting of subtherapeutic INR. Follow up CT head 24 hrs
post TPA showed no hemorrhage, but revealed the right MCA
infarct. She was subsequently started on aspirin and statin.
Stroke risk factors are A1c-7.3% , LDL- 111, TTE showed normal
left ventricular cavity size with mild regional systolic
dysfunction most consistent with single vessel coronary artery
disease (PDA distribution) with normal overall biventricular
systolic function. She was subtherapeutic on Coumadin on arrival
which likely contributed to her current stroke. Her
anticoagulation was switched to apixaban after follow up head CT
with no new change. She was seen by ___ who recommended
continuing care in acute rehab post discharge.
# Oropharyngial dysphagia: gradually improved during her stay
and diet was advanced to Moist Ground, thin liquids, Meds whole,
assistance with meal tray setup and to check for oral pocketing
#PMR
-Continue prednisone taper, currently on 3 mg daily. follow up
out patient
# A.fib - Rate controlled at rest but transiently goes up to
120's- 130's.She remains asymptomatic. Added metoprolol 6.25 mg
Po BID which she tolerated well. On apixaban | 279 | 280 |
15086322-DS-14 | 29,587,906 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital from the
Dialysis center to be worked up for chills you experienced
during dialysis. We have found no evidence of infection during
our workup here at the hospital. We would like you to continue
your normal hemodialysis schedule once discharged from the
hosptial.
No changes have been made to your medications.
Please see below for a follow up appointment that has been made
on your behalf. | Mrs. ___ is an ___ with ESRD on HD ___ @___
___, HTN, DM2, HLD, and previous catheter-induced BSI's
refferred to the ED from dialysis for shaking chills during her
session.
.
# CHILLS:Per pt she feels well and at her baseline. She claims
that she was cold at hemodialysis center and that was what was
causing her to shake. She denies fevers, rigors, nausea,
vomiting, diarrhea, dysuria. Her urinalysis was indeterminant as
well. She was started on Vancomyin and Gentamycin at the
hemodialysis center and initially these medications were
continued on admission. These antibiotics were discontinued the
next day as her infectious workup was unremarkable.
.
# FATIGUE: unclear etiology- she relates it to insomnia. Her TSH
was normal. Most likely this is an age related compliant.
.
# ESRD ON HD: on a ___ schedule for hemodialysis. Her
catheter site showed no evidence of infection. Her tunneled line
was re-sutured prior to her being discharged.
.
# HYPERTENSION: continued amlodipine
.
# HYPERLIPIDEMIA: continued simvastatin
.
# DIABETES MELLITUS TYPE TWO: she was placed on a Diabetic diet.
She is not on medications for diabetes as an out patient.
.
#TRANSITIONAL: 3 blood cultures are still pending at the time of
discharge. She has a follow up appointment with her primary care
physician ___ discharge. | 82 | 229 |
10168247-DS-9 | 29,293,693 | ###Discharge paperwork TBI information###
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. Don't try to
do too much all at once.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings
are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or
visit ___
When to Call Your Doctor at ___ for:
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 | ___ year old female who presented to ___ emergency room as
transfer from ___ after she suffered a fall with
unknown loss of consciousness. Patient had imaging completed at
___ and was found to have found to have a ___,
right ___ rib fractures, small apical pneumothorax and right
clavicle fracture. Patient was awake and alert on arrival here
and mental status at baseline as per husband. Patient was
evaluated by orthopedics, neurosurgery, and acute care surgery
and found to be non operative.
Physical therapy and occupational therapy were consulted and the
patient was determined to need rehabilitation as part of
discharge planning. Throughout admission, the patient
experienced intermittent periods of confusion which she
experienced prior to her admission. She also reported right
shoulder pain for which shoulder x-ray was completed and
consistent with right subclavian fracture. Case management able
to facilitate transfer to ___ for ongoing care and
rehabilitation. Outpatient follow up with neurology, concussion
clinic, and acute care surgery planned.
At time of discharge, the patient's vital signs were stable and
her pain was well managed with oral analgesics. She tolerated
sitting in the chair. She was tolerating a regular diet and had
return of bowel function. She did sustain a fall while
attempting to get out of bed with reported head strike on the
day of discharge. Cat scan imaging of the head was done which
showed no changes to prior studies, therefore she was cleared
for discharge. Follow-up appointments were made with the
Orthopedic and acute care surgery clinic. | 390 | 258 |
12685748-DS-4 | 29,364,654 | Dear Ms ___,
It was a plesure caring for you at the ___
___. You were admitted for cellulitis. We performed a
CT scan of your leg and confirmed that your cellulitis is
confined to the superficial layers of your skin. We started on
you on antibiotics and your cellulitis improved. You are now
safe to leave the hospital. You will need to follow up with the
infectious disease doctors. Thank you for allowing us to
participate in your care.
Please see the attached sheet for an updated medication list. | Primary Reason for Admission: Ms. ___ is a ___ y/o woman with a
history of obesity and DM who presents with several weeks of
severe cellulitis of the BLE which has been difficult to treat
___ allergic reactions to antibiotics.
. | 90 | 40 |
12067437-DS-24 | 25,529,088 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted for lethargy and inability to
tolerate time off the ventilator.
You were found to have both a lung infection and a urinary tract
infection. You will take two different antibiotics. One through
an IV (last day ___ and one through the PEG tube (last day
___. This will be managed by the nurses at the facility
where you live. Prior to discharge you were tolerating
significant time off the ventilator.
Please take your medications as prescribed. If you have any
questions about your hospitalization feel free to contact the
ICU at ___. | Ms. ___ is an ___ year old female with PMH significant for
cerebral palsy, diastolic HF, mild to moderate AS, tracheostomy
on chronic vent, and atrial fibrillation s/p ablation who
presented with increased lethargy and reported poor PO intake.
#LETHARGY: The patient's caretakers reported lethargy over the
several days prior to her admission. Her presenation was most
consistent with a toxic/metabolic insult, potentially from a low
grade infection, hypovolemia, or medications. The patient was
started no fluconazole on ___ for funguria which can increase
diazpem levels, potentially leading to increase lethargy. Her
mental status was noted to improve after fluid boluses in the
ED, as did her renal function based on BUN/Cr. The patient was
also found to have a retrocardiac PNA and UTI. She was started
on broad spectrum antibiotics and improved. She started to
tolerate longer periods on the vent prior to discharge. The
patient was discarhged alert and oriented to person, place.
#HCAP: Left lower lobe pneumonia with retrocardiac opacity on
chest xray. Family reports recurrent PNA in that area. Sputum
culture growing multiple GNR species for which speciation was
not performed as growth was considered non-pathogenic. On
cefepime IV for HCAP to complete 8-day course to end ___.
Vancomycin initially started but discontinued after no GPCs in
sputum. Clinically improving.
#UTI: Urine grossly dirty in ED upon admission. Urine culture
positive for Proteus and E. coli species. E. Coli is Carbapenem
resistent, but senstive to nitrofurantoin. Blood cultures have
remained negative. Will complete a 7-day course of
nitrofurantoin for uncomplicated UTI (last day ___.
#CHRONIC RESPIRATORY FAILURE: The patient has been trached for
approximately ___ year after a severe episode of pneumonia. Has
continued on her chronic ventilator settings while hospitalized,
with increased time on trach T-piece. Mild desaturations during
the days with periods of anxiety, but easily re-directed with
improvement in saturation without any medical intervention
required.
#AS/DIASTOLIC HF: The patient presented to the hospital
hypovolemic. CXR was w/o signs of pulmonary edema. Her last echo
showed an aortic valve area of 1.2-1.9cm2 and an EF of 55-60%.
Repeat echo revealed preserved EF with only mild AS, unlikely to
be contributing to her respiratory or mental status issues.
Continued on PO metoprolol, though bradycardic to ___ while
asleep. If persistent or symptomatic, may consider discontinuing
at rehab facility.
#1ST DEGREE AVB: Not resulting in hemodynamic compromise. The
patient is on a beta blocker at home.
#HYPOTHYROIDISM: Stable. Continued on home levothyroxine. TSH
normal.
TRANSITIONAL ISSUES
==================
1) Consider d/c metoprolol for bradycardia symptomatic
2) Complete 8 day course of cefepime for HCAP (last day ___
3) Complete 7 day course of nitrofurantoin (last day ___
4) Monitor volume status with exam and chem 10 weekly to
maintain hydration | 106 | 443 |
10999782-DS-10 | 22,527,963 | Dear Mr. ___,
You were admitted to ___ with a cellulitis in the left thigh.
You were given IV antibiotics to treat the infection. An MRI was
done that showed no deep infection. You were then given oral
antibiotics. You will need to continue the Augmentin until ___.
Please take all of your medications and follow up with all of
your appointments as detailed in this discharge summary. If you
experience any of the danger signs listed below, please call
your primary care physician or come to the emergency department
immediately.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team | ___ with hx of MDS, HTN, hypothyroidism, R thigh MSSA abscess
___ treated with abx x6 weeks presenting with L thigh pain,
erythema, edema, and low grade fever x2 days found to have L
thigh cellulitis.
# Cellulitis:
The patient presented with left thigh pain, erythema,
induration, low grade fever consistent with cellulitis. In the
ED an ultrasound was without abscess. ACS was consulted but
there was no surgical indication. He was initially placed on
vancomycin, ceftazidime, flagyl that was deescalated to unasyn.
MRI was performed on ___ that showed diffuse subcutaneous edema
throughout the left thigh with some possibility of early
phlegmonous changes without any drainable fluid collection. He
was transitioned to PO augmentin on ___ of ___. His induration
of the left thigh has markedly improved through his course. He
had one temp to 100.3 on HD1 but since has been afebrile. Of
note, he had a small collection noted on the initial ultrasound
that appears to be a LN by MRI.
# Lesion on left calf:
Derm was consulted for lesion on the left calf (image in OMR)
that was concerning for possible sweet syndrome. They felt that
it was consistent with carbuncle in resolving stages. They
recommended upon discharge, would have patient use benzoyl
peroxide wash or cleanser 10% on a daily basis to aid against
bacterial super infections; alternatively can use chlorhexidine
washes in shower.
#MDS
___ stable during this hospital course. No leukopenia. No
transfusions.
# Hypertension: Held chlorthalidone in setting of cellulitis.
# Hypokalemia: ___ chlorthalidone. | 107 | 249 |
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