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17933993-DS-4 | 26,232,754 | INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weightbearing, right upper extremity in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
Cover your splint with a plastic bag and DO NOT get splint wet.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
Please call ___ to confirm this appointment. | The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a severe R hand injury and was admitted to the hand surgery
service. The patient was taken to the operating room on ___
for R hand table saw injury s/p CRPP ___ digital n
conduit/flexor repair, ___ extensor tendon repair, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was given an upper extremity nerve block
pre-operative. He progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, splint was clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right upper extremity. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 557 | 238 |
18885079-DS-17 | 27,314,996 | You were admitted to the hospital with an infection of your left
arm and bloodstream. Your infection was most likely caused by
using intravenous drugs. We treated your infection by draining
the fluid collection and with intravenous antibiotics. Your
fevers resolved and your signs of infection improved. You will
need 9 more days of antibiotics.
You will need to follow-up with a primary care doctor after you
are discharged from the rehab facility. You need treatment of
your diabetes and your hepatitis C. | Patient is a ___ y/o M with h/o IVDU with recent debridement of
bilateral forarms for compartment syndrome and fascitis who
presented with increased swelling and erythema at wound site as
well as leukocytosis and fever consistent with new abscess and
wound infection now s/p I&D of bilateral forearms as well as
bacteremia.
#. Bacteremia/ abscess: Polymicrobial wound infection. The
patient presented with an abscess complicated by profound edema
of the left forearm and pain. He had multiple I and D's by
plastics with significant purulent drainage. This along with
antibiotics led to considerable improvement in swelling and
pain. His initial leukocytosis resolved and fevers resolved as
well. Cultures from ___ grew MRSA and GNRs and BCx from ___
grew GPRs. BCx from ___ grew GPCs. BCx from ___ and ___ have
had no growth to date. Wound culture also grew ___. No
endocarditis was seen on echo. On discharge, he was afebrile,
WBC 11.7. He received TID dressing changes. His bacteremia was
treated with Vanc/ unasyn. ___ in wound infection was
treated with Fluconazole 400 mg PO/NG Q24H. Infectious disease
was consulted and is in agreement with the following plan. He
will need a 2 week total course of all antibiotics from ___
(last day ___. He will follow-up with plastic surgery
___. His pain was treated with morphine 45 mg po q3h, tylenol
and advil. PICC line was placed ___ and was initially in the
azygos vein, pulled back 2 cm, now in SVC.
#. Diabetes: Blood sugars labile on admission, now better
controlled on insulin sliding scale and NPH BID. Patient has not
been on insulin previously and will need close follow up to
reestablish care with PCP and continue insulin therapy.
#Hepatitis C: Antibody positive. LFTs abnormal. RUQ with fatty
deposition. HCV viral load pending on discharge.
#Hx of IVDU and skin popping: cause of infection. HCV+,
serologies c/w HepB immunization. HIV negative. No longer
scoring on ___ upon discharge with still with significant
anxiety. He was given lorazepam 1 mg po q6h prn anxiety and
clonidine 0.2 mg po daily. He is interested in quitting IVDU.
#Limb Pain: He was treated with morphine for extensive soft
tissue edema and infectious presumably causing severe pain.
Given drainage of infection, and improved pain and edema opiates
should be gradually tapered and should be stopped prior to
discharge | 83 | 398 |
11397675-DS-22 | 26,420,373 | Dear Ms. ___,
It was a pleasure taking care of you here at ___
___.
Why you were here:
- You had cellulitis, which is an infection of the skin, over
your left chest.
What we did:
- We did a procedure to drain out pus.
- We gave you antibiotics as well as an antifungal cream.
What to do when you go home:
- Take your antibiotic as prescribed.
- If you notice fevers, chills, worsening redness or more
drainage or a firm area that has reaccumulated ___ the skin
please notify your doctor right away.
Sincerely,
Your Care Team | ___ w/ recurrent triple negative breast ca, s/p mastectomy, s/p
XRT to R chest wall on ___, and h/o infected R chest wall
port s/p removal (now w/ L chest port) who p/w worsening R chest
rash w/ serous fluid draining, found to have purulent
cellulitis. She underwent ___ aspiration on ___ and improved on
Vancomycin. Cultures grew MSSA and she was discharged on a
regimen of Keflex ___ q6h for planned 10-day course
(___).
# Chest Wall Infection: She was noted to have an erythematous
skin reaction after radiation ___ the R chest area, at her visit
on ___, but when she represented on ___ to clinic there
was erythema and macerated skin with drainage ___ an area
extending beyond the radiation area. Ultrasound showed 5.8 x 2.3
x 0.5 cm fluid collection and she underwent ___ guided aspiration
on ___ with fluid cultures growing MSSA. She had
improvement of the erythema on vancomycin and was switched to
Keflex on discharge to complete a 10-day course. Given the
presence of additional red lesions possibly representing ___
rash, she was also started on topical terbinafine and discharged
with this to complete a 10-day course (___)
# Breast Ca: recurrent triple negative breast ca, s/p
mastectomy, s/p XRT to R chest wall on ___ with plan for
adjuvant therapy.
# Depression/Anxiety: continued home bupropion, venlafaxine and
clonazepam PRN
# HTN: lisinopril held on admission, restarted on discharge.
# GERD: Continued omeprazole | 101 | 235 |
11273513-DS-13 | 20,230,499 | Dear ___,
___ was a pleasure taking care of you during your stay at ___.
You were admitted for repair of fractures of your jaw and
tolerated surgery well. You had very low electrolytes,
especially calcium. We gave you electrolytes through your IV to
improve this until you were able to take oral electrolytes and
your levels be stable. You will take oral supplementation for
calcium, magnesium, and potassium. Our nutritionists suggested
that you add Glucerna shakes for your diet. Our physical
therapists suggested that you would be an excellent candidate
for rehabilitation. | Ms. ___ was transferred from ___ s/p mechanical
fall with bilateral mandibular fractures for further management.
She underwent open reduction and internal fixation of bilateral
edentulous mandbile fractures on ___ and tolerated the procedure
well. Her potassium, phosphate, and magnesium were repleted with
normalization. Her total and ionized calcium were low, likely a
combination of bisphosphonate use and lenalinomide side effect,
and were repleted with IV calcium until on a stable PO regimen.
# Mandibular fractures
Sustained after a mechanical fall. Underwent operative repair on
___. She must remain with her dentures out and on a full liquid
diet only until follow up with oral surgery.
# Hypocalcemia
Likely multifactorial secondary to lenalinomide side effect and
recent bisphosponate use. She received IV calcium gluconate
until serum calcuim levels increased and she was stabilized on
oral calcium and vitamin D. Her PTH was elevated but felt to be
insufficiently so given her calcium level, probably a result of
post-thyroidectomy. Hypomagnesemia contributed and was corrected
as well.
# Hypomagnesemia/hypophosphatemia/hypokalemia
All of these electrolyte abnormalities can be best explained by
her chemotherapy regimen. Both Revlimid and Zometa have
significant documented side effects of hypomagnesemia,
hypophosphatemia, and hypokalemia. She has also had loose stools
intermittently for the past few months, which could contribute
to her abnormal labs. She is likely with some component of
malnutrition given her age and low albumin. She was corrected
with IV and then PO electrolytes with normalization. She
required daily K+ and Mg+ supplementation.
# Leukopenia
Unclear etiology. ___ be dilutional or baseline for her. Stable
throughout.
# Paroxysmal Atrial Fibrillation
Rate controlled on metoprolol and on digoxin. Warfarin held for
surgery, INR remained elevated likely secondary to antibiotics.
INR held throughout admission, goal INR ___.
# Acute on Chronic Kidney Disease (Stage III)
___ with elevated Cr on admission (1.6), improved with IVF.
CHRONIC ISSUES:
# Multiple myeloma
Held home treatment of Revlimid and Decadron. Will follow-up
with oncologist after discharge.
# CAD s/p CABG ___
No symptoms of chest pain or shortness of breath. Continued on
home metoprolol and atovastatin.
# Diabetes mellitus type 2, controlled.
Held metformin in house and used humalog sliding scale with good
control. Will restart metformin upon discharge.
# Depression
Stable, continued home paxil and wellbutrin
# Hypothyroid
Stable, continued home levothyroxine
# Gout
Stable, continued home allopurinol | 92 | 372 |
11594102-DS-10 | 28,605,076 | Dear Ms. ___,
You were seen in the hospital for shortness of breath and
worsening cough and sputum production. Your symptoms were
consistent with a COPD exacerbation, and you were treated for an
exacerbation with anitbiotics (azithromycin), nebulizers
(albuterol and ipratropium), and steroids (prednisone). Your
breathing improved greatly after these treatments.
In the emergency department you also had a chest x-ray, which
did not show a pneumonia, and a CT scan of your lungs, which did
not show a pulmonary embolism (blood clot in the lungs).
We made the following changes to your medications:
1. azithromycin - this is a new medication
2. prednisone - this is a new medication
3. fluticasone - do not restart this medication until you have
finished the prednisone. (Restart on ___.
We have also made three follow-up appointments for you. Please
note the date and times below. If you cannot make your
appointments, please call the respective office to reschedule. | # COPD exacerbation: SOB and CP likely due to COPD exacerbation
given negative CXR, CTA, cardiac enzymes as well as response to
albuterol/Atrovent treatment. Respiratory status improved
greatly with nebs and pt was saturating well on baseline O2 (2L)
via NC. Pt reported decreased SOB. Cough, CP, and sputum
production also decreased. Pt was started on course of 60mg PO
prednisone daily x 5d. She she also given 500mg loading dose of
azithromycin and d/c'ed home w/ 250mg x 5d. Pt instructed to
restart fluticasone after prednisone course completed.
# Chest pain: Not likely to be due to MI or PE. CTA chest
negative for embolus. EKG without ischemic changes on EKG;
cardiac enzymes were negative x 2. Pain improved during
admission and only occurred with deep breathing. Likely
musculoskeletal in origin.
# Crohn's disease: Inactive. Not on therapy at this time.
# Bipolar disorder: Stable. Not on medications at this time
# Hypertension: Pt was hypertensive at times during admission,
but was not on antihypertensives. We did not initiated any new
antihypertensive medications.
# Osteoporosis: Stable. Continue home calcium/vitamin D | 150 | 177 |
18342622-DS-16 | 29,344,524 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
1 week of shortness of breath and chest pain. Your symptoms were
concerning for cardiac disease, so you had a cardiac echo and a
catheterization. Your cath was clean and showed no coronary
artery disease. You should follow up with your primary care
doctor to determine further investigation and treatment of your
SOB, including evaluation of your lungs.
Continue to take your home medications as prescribed and keep
all your follow up appointments. | ___ yo male with a history of atheromatous aortic disease,
cardiac risk factors and family h/o presents with a story
concerning for unstable angina with stuttering chest pain
progressively worsening to chest pain and SOB at rest.
# SOB on exertion w/ associated chest pain: Negative troponins,
EKG initially showed ventricular bigeminy, which resolved
without treatment. As there was concern for unstable angina
given typical angina story and strong risk factors and famiyl
history, the patient was initially started on heparin ggt, and
recieved a dose of plavix. Cardiac cath showed no CAD, so the
patient was ruled out for unstable angina. Echo showed normal
EF. Since SOB is now known to be non-cardiac in etiology, and
the patient does not have HF, the patient should be evaluated
for other etiologies of his progressive SOB. He has a long past
smoking history, he warrents pulmonology work up as outpatient
for evaluation of possible COPD. There were no medication
changes at discharge. The patient was continued on home ASA,
lipitor, lisinopril, metoprolol.
# HTN: Continued lisinopril and metoprolol
# HL: Continued atorvastatin
Transitional issues
- f/u with PCP outpatient for further eval and treatment of SOB
on exertion, cardaic etiology is now ruled out | 87 | 203 |
16980011-DS-5 | 22,040,300 | You were admitted to the Neurology service for a flurry of
seizures. You were placed on lorazepam with a plan for taper. We
did not witness a cluster of seizures here while on the EEG
machine. We will prescibe for you lorazepam taper. | ___ yo woman with CP, cognitive impairment, and seizure disorder
who presented with great increase in her partial complex events.
Neurological exam on admission showed pt to be at her baseline.
However, during the initial exam ___ had 3 seizures, returning
to baseline within seconds afterwards.
The cause of her increase in frequency of the seizures remained
unclear. No acute changes on NCHCT. Serologies, U/A and CXR do
not show any obvious infectious or metabolic derrangements. PHB
and OXC level therapeutic on admission, and there is no report
of missed doses.
On admission, pt was started on lorazepam 1mg po q8hr for
stabilization, and monitored on cvEEG. The seizure cluster
resolved.
On discharge, we continued pt's home AED regimen: ___
___ oxcarb 600mg TID + 150mg qday at 2 pm, acetazolamide 150
mg BID, with the addition of a LZP taper (0.25 bid on ___ - day
of discharge, then 0.25 qhs on ___, then off).
Family was eager to take pt home. Pt was cleared by ___, with
recommendation of home ___. Family counseled regarding need to
call if she develops
additional seizures, as she may need changes made to her seizure
medications
Pt has f/u arranged with her epileptologist, Dr. ___. | 43 | 198 |
17951619-DS-19 | 25,785,267 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You came to use because you had a fever and chills, and were
worried about infection. Although you were recently admitted for
the same issue and were found to have an infection of your bile
duct, this time there was no evidence of blockage or infection
in this area, and no source of infection or cause of your fever
could be found. Since you were afebrile and feeling better the
entire time you were on the floor, and since we are now
reassured that there are no issues with your biliary drain, we
feel you are safe to be discharged home.
Also, due to your low white blood cell count, we think you
should hold off on your chemotherapy for now, even though it was
scheduled to occur on ___. You should follow-up with
Dr. ___ plans for future chemotherapy and the
Romiplostin.
Please note the medication changes and follow-up appointments
scheduled for you, as detailed below. | HOSPITAL COURSE: Mr. ___ is a ___ year old man with PTSD,
metastatic ampullary cancer s/p Whipple ___, on
Capecitabine/Oxaloplatin, with recent admission for sepsis from
a biliary source. Now presenting with fevers and chills. Had
recent admission for same presentation and was found to have
sepsis secondary to bile duct obstruction and cholangitis.
However, on this admission no source of the fever could be
found, and pt remained afebrile after admission. Started on
cefepime/vancomycin/flagyll, changed to vanc/zosyn, then
narrowed to zosyn, and sent home without antibiotics. Blood
cultures show no growth to date, but are still pending. Alkaline
phosphatase was elevated, but Total bilirubing was normal and
liver/gallbladder ultrasound showed no ductal dilation, making
obstruction unlikely. Urinalysis and chest x-ray were
unremarkable. Bag was placed on drain on ___ to check
function/output, and it drained adequate amount of bilious,
non-purulent fluid, so drain was re-capped. Sent home after 3
days stable on floor. Of note, pt had low white cell counts,
likely due to IVIG, so chemotherapy scheduled for ___
was held. He was discharged with plans to follow-up with
oncologist Dr. ___ future ___ plans.
# FEVER: Unclear source of infection. One possible source is
from his biliary drain. He had some erythema at the site of his
drain on admission, although it was nontender and not fluctuant.
His Alkaline phosphatase was elevated, however ultrasound did
not show dilation of the ducts, his bilirubin is normal, and
after bag was placed at 6AM on ___ it drained bilious
non-purulent fluid, all suggesting there is no obstruction.
Urine clean. Chest x-ray did not show pneumonia. No rash or
other localizing sign. Patient had diarrhea but this iss chronic
from starting chemo. Started on cefepime/vancomycin/flagyll,
changed to vanc/zosyn, then narrowed to zosyn, and sent home
without antibiotics, as pt continued to be stable and afebrile,
and cultures continued to show no growth.
# METASTATIC AMPULLARY CANCER: S/p Whipple procedure in ___.
Chronic diarrhea/malabsorption, unchanged from baseline. Belly
otherwise soft nontender. Was due for chemo ___, but it was
held due to low white count. Was also due for Romiplostim shot
for idiopathic thrombocytopenia. We continued his home Creon for
enzyme replacement and his home diphenoxylate-atropine for
chronic diarrhea. Will follow-up with Dr. ___ as an
outpatient.
# DEPRESSION: Stable. We continued his home citalopram and
ativan.
# CHRONIC ITP: Stable. Gets Romiplostim 793 mcg SC 1X/WEEK (___),
which was held while patient was admitted for insurance
purposes. Due for next shot on ___. | 168 | 411 |
19177257-DS-19 | 23,081,517 | Ms. ___,
You were admitted to ___ with a condition known as vasculitis.
This is where your small blood vessels are "attacked" by your
own immune system. Two causes seem most likely at this point:
"hypersensitivity vasculitis" and "IgA vasculitis". Both of
these are self limited conditions with good overall outcomes.
Steroids can help them resolve.
Instructions:
- Take naproxen 500 mg with breakfast and dinner for 3 days
- Take prednisone 60 mg daily for 1 week, then 40 mg daily for 1
week, then 20 mg daily for 1 week, then 10 mg daily for 1 week,
then stop
- Establishing care with a PCP ___ be very helpful
- If you have any change in symptoms which concerns you, don't
hesitate to return | ___ woman with history of hypothyroidism presenting with
purpural rash, abdominal pain, and arthralgias thought to be IgA
vasculitis or hypersensitivity vasculitis
# Purpura
# Arthralgias:
# Suspected IgA Vasculitis (Henoch-Schönlein Purpura): Patient
presenting with palpable purpura without thrombocytopenia or
coagulopathy, along with arthralgias and abdominal pain,
fulfilling diagnostic criteria for HSP. Seen by dermatology who
also considered hypersensitivity (post-infectious or
drug-induced). No evidence of renal failure. Started on steroids
and NSAIDs with improvement in symptoms and CRP. Differential
diagnosis includes other small vessel vasculidities. Given her
age and lack of other symptoms, vasculitis associated with SLE
would be more likely than granulomatosis with polyangiitis
[Wegener's], microscopic polyangiitis, eosinophilic
granulomatosis with polyangiitis, or vascultitis associated with
hepatitis B or C
- Prednisone 60 mg daily for 1 week, then 40 mg daily for 1
week, then 20 mg daily for 1 week, then 10 mg daily for 1 week
as faster tapers can cause relapse of IgA vasculitis
- Naproxen 500 mg BID for 3 days
- ASO Ab pending at time of discharge
# Nausea
# Abdominal pain
# Diarrhea: Patient with several days of nausea, abdominal pain,
and loose stools. Given palpable purpura as above and
arthralgias, suspect that this is a gastrointestinal
manifestation of Henoch-Schonlein purpura, and the rash
typically precedes GI symptoms. Intussusception is rare in
adults, and the patient's abdominal exam is reassuring. LFTs
within normal limits. It is possible that her gastrointestinal
symptoms could be unrelated to her rash, such as viral
gastroenteritis. However, suspicion for infectious, particularly
bacterial, cause is lower. She was able to eat breakfast and
lunch without difficulty. | 120 | 260 |
18918035-DS-17 | 21,129,220 | Dear Dr. ___,
___ was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for low sodium levels and a headache.
What was done for me while I was in the hospital?
- You were given medications to reduce your blood pressure and
to alleviate your headache.
- You were encouraged to eat and given supplemental IV fluids.
- You were started on a new medication for your depression.
What should I do when I leave the hospital?
- Please continue to follow up with your doctor's appointments
as noted in your discharge paperwork.
- Please continue to take your medications as prescribed.
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES:
=================================
[] Patient started on mirtazapine 7.5mg qHS for depression to be
increased to 15mg qHS on ___. Fluoxetine held I/s/o
hyponatremia.
[] ___: Make sure she is not taking HCTZ at home
MEDICATIONS:
- New Meds: mirtazipine
# CODE: DNR/DNI
# CONTACT: Son ___ ___
BRIEF HOSPITAL COURSE
=================================
Ms. ___ is an ___ yo ___ female w/ PMH
significant for HTN, remote h/o migraine headache, anxiety, and
recent episodes of hyponatremia who p/w left occipital throbbing
HA, w/ unremarkable CT head and neuro exam, most likely
secondary to hypertension, subsequently found to be hyponatremic
to 125. Patient's sodium improved with increased PO intake and
was believed to be related to poor solute and fluid intake at
home where she has difficulties with cooking. Case management
worked to establish increased services at home from 8h/wk to
16h/wk. Outpatient psychiatrist contacted who recommended
patient's depression should be treated with mirtazapine 7.5mg
x3d, followed by 15mg qHS. She was discharged with home ___ and
___ services. | 122 | 165 |
11062873-DS-23 | 24,693,141 | Dear Mr. ___,
You were admitted to ___ for abdominal distention. You were
found to have a fungal infection in the blood stream and a
pneumonia that will require antibiotic treatment. You returned
to your facility for continued care.
Sincerely,
Your ___ team | SUMMARY
=======
___ with PMHx of dementia (non verbal at baseline), L MCA CVA,
CAD, CKD, COPD, AVR on Coumadin, with PEG and chronic
trach-vented living at ___ who presented as a transfer
for abdominal distention, found to have candidemia.
ACTIVE ISSUES
=============
#Candidemia. Patient grew ___ parapsilosis in 2 sets of
blood cultures from PICC line (PICC Line was removed with
negative tip culture however). ID was consulted. Besides the
PICC additional possible sources included urinary (also grew in
urine), seeded renal stone, itnraabdominal (NG on ascetic
fluid), and endocarditis. Patient was started on micafungin. TTE
showed no vegetations. TEE was deferred in the setting of high
risk procedure and multiple medical comorbidities. Ophthalmology
was consulted and exam showed no signs of endogenous
endophthalmitis in the Right eye but the left eye could not be
evaluated due to dense cataract. He was transitioned from
Micafungin to Fluconazole as felt to have better penetration for
urinary infection. He had a new PICC line placed on ___. On
___ he had a new blood culture showing growth of likely the
same ___. After discussion with ID, the decision
was made to keep the PICC in place (until completion of IV abx
course as below on ___, then remove) and continue treatment
with Fluconazole 200mg indefinitely given this is second
systemic fungal infection and that it was not possible to r/o an
ongoing seeded sight of infection (such as endocarditis or renal
stone)
# Ethics/___. Ethics team was consulted for concern that the
healthcare proxy was refusing to respond to phone calls and
asked to be contacted as little as possible. Ethics team
recommended continuing treatment as long as not inhumane or
causing suffering per the ___ "Policy on Interventions that
are Ineffective or
Harmful." The recommendation was "If at any time the responsible
___ attending
determines that a potential intervention -- such as attempting
CPR in the event of cardiac arrest -- would "cause likely
suffering or other risk of harm that grossly outweighs any
realistic medical benefit to the patient", then the attending
should enter a DNAR order in the medical record AND inform that
daughter/HCP of that, and the reasons for it. If the daughter
objects, then she has a right to a second opinion [from a
physician not actively engaged in the patient's care.]"
Furthermore, "If specific decisions need to be made for which it
is not
entirely clear from previous discussions with a health care
proxy what the patient himself would want, then for the health
care proxy to be involved s/he must be both able and willing to
participate in discussions at least to the extent that would be
expected of the patient if he were able to make his own
decisions. If the health care proxy is unable or unwilling to do
that, then she should be informed that in the absence of an
appropriately-engaged proxy the clinical team will be required
to
consult the Ethics Support Service and possibly seek a
court-appointed guardian."
Decision was made to make patient DNAR based on clinical
decision making based on medical futility. Attempts were made to
update the daughter about this decision but she would not return
calls and her voicemail box was full.
# Chronic respiratory failure s/p trach, ventilation.
# VAP, presumed MDR Pseudomonas
Patient presented with chronic trach/vent, without s/s
respiratory distress. Initial sputum cultures grew MDR
pseudomonas, thought to represent colonization. 1 week into
admission patient developed fever with CXR concerning for
consolidation. Repeat sputum demonstrated MDR Pseudomonas. In
the setting of fever, he was initiated on treatment for presumed
Pseudomonas VAP with Tobramycin and Ceftolozane/Tazobactan at
the direction of the ID consulting service. This will be
continued for 8 day course to end on ___, after which PICC
line should be discontinued.
# Abdominal distention. He was sent in for evaluation of
increased abdominal distention over past several days while at
___. CT A/P in ED notable for non obstructive bowel pattern,
e/o likely urinary infection and ?acute bladder injury. Etiology
of distention difficult to discern. Ascites fluid was sampled
multiple times during admission with PMN <250 but with increased
TNC count concerning for possible SBP. He was treated with broad
spectrum GN coverage as above for presumed VAP. His PEG tube was
replaced on ___ by ___.
# Cirrhosis, etiology cryptogenic. Dx during ___ by
US/CT imaging, new ascites and s/s portal HTN. Unclear variceal
status. No h/o HE or SBP. Etiology of cirrhosis unclear;
negative hepatitis w/u, no reported ETOH abuse, AMA, ___
negative. Anti-Smooth muscle positive raising concern for
autoimmune etiology but low titer 1:40 less clinically
significant. Paracentesis with > ___ nucleated cells but did
not meet criteria for SBP.
# Hypercalcemia. Ca ___, corrected to 11 based on albumin 3.2.
W/u for hypercalcemia during ___ notable for low PTH and
elevated PTH-rp (28, ULN 27 on in house assay). PTH was
appropriately low.
# CKD. Admission Cr 2.9, decreased from discharge Cr 3.4 on
___. Medications were renally dosed. Creatinine on discharge
was 2.6.
# Anemia, macrocytic. Admission Hgb 8.8, stable from discharge
value from ___. No acute s/s bleeding.
CHRONIC ISSUES
=================
# Hypothyroidism: Continued levothyroxine 200mcg daily
# HFpEF: Continued PO Lasix 40mg
# IDDM: Continued glargine/regular SS with TFs
# GERD: Continued omeprazole
# Glaucoma: Continued home eyedrops
# History of CVA: Not on ASA or statin
# A-fib: No longer on anticoag per past d/c summary records
TRANSITIONAL ISSUES
====================
- Fluconazole 200mg daily via PEG tube to be continued
indefinitely in the setting of recurrent candidemia.
- Continue IV antibiotics (Ceftolozane/Tazobactan and
Tobramycin) to complete total ___nding on ___.
-- Ceftolozane/Tazobactan 375mg q8
-- Tobramycin. To be dosed based on level. Please draw
tobramycin level at 9pm on ___. If level is <1 then given 1x
dose of 160mg IV. If >1, please re-draw a level at 9pm on
___ and again dose only if level <1.
- Please remove PICC line on ___ after completion of IV
antibiotics
- Please continue weekly LFTs and EKG for QTC for monitoring
while on lifelong fluconazole.
- Ethics consultation as detailed above. Patient was made DNAR
(CPR not indicated) based on detailed discussion as above. | 43 | 1,019 |
16878480-DS-9 | 21,543,989 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever >101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated right upper extremity
No range of motion restrictions, no braces or splints needed
Treatments Frequency:
Dry sterile dressing as needed for right surgical incision
Sutures or staples to be removed at 2-week postoperative visit | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have concern for right shoulder septic arthritis after
outside hospital aspiration showed GPC's and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right shoulder irrigation and
debridement, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
Patient was also followed by the infectious disease service
during her hospitalization who recommended daptomycin omycin
after outside hospital cultures demonstrated MRSA.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the right upper extremity, and
will be discharged on aspirin 325 mg daily for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 563 | 288 |
15444107-DS-3 | 24,793,043 | Dear Mr. ___,
It was a pleasure caring for you here at ___.
WHY WAS I IN THE HOSPITAL?
============================
- You came in to the hospital because you fell down the stairs
and had a spinal cord injury
WHAT HAPPENED IN THE HOSPITAL?
============================
- You were given steroids to protect your spinal cord
- The ___ surgeons operated on you and fused together 6
vertebrae in your neck and decompressed another 2 vertebrae
- You heart was overwhelmed by the fluids you got during
surgery, so you had to stay in the ICU after surgery with a
breathing tube for one night
- You were having trouble urinating, so you got a foley
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
============================
- You will be going to a rehab facility to work on your strength
- Follow up with your ___ surgeon in two weeks
- Follow up with your outpatient PCP and cardiologist
- If you have any worsening of your symptoms, or your symptoms
are not improving, reach out to your primary healthcare provider
or your ___ surgeon.
We wish you all the best.
Sincerely,
Your ___ Care Team | SUMMARY:
===================
Mr. ___ is a ___ y/o male with developmental delay, severe
cardiomyopathy, 3+ aortic regurg, & severe cervical stenosis who
presented w/ a fall c/b central cord syndrome, ultimately
requiring occiput to C6 instrumented fusion. Was demonstrating
neurologic recovery prior to discharge.
#Transitional Issues | 187 | 45 |
12267619-DS-11 | 20,825,668 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated bilateral lower extremity in
bilateral ___
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add tramadol as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take ___ BID for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weightbearing as tolerated bilateral lower extremity and
bilateral hinged long knee braces unlocked, may remove when in
bed
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have bilateral distal femur periprosthetic fractures and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for bilateral retrograde
femoral nails which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable. She was given 2 units of
blood on postop day 1 hematocrit 21.6, which responded
appropriately. By the time of discharge, her hematocrit had
stabilized.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the bilateral lower extremity in
unlocked ___ while ambulating, and will be discharged on
subcu heparin for DVT prophylaxis. The patient will follow up
with Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 630 | 289 |
13251065-DS-63 | 22,328,309 | Dear Mr. ___,
You were admitted to ___ with an infection in your liver and
kidney failure. Unfortunately, we were unable to control the
infection and you developed an abscess in your liver. Because we
are unable to stop these infections from recurring, you have
elected to go home with hospice.
Please keep the drain area clean and dry and take your
medications as needed.
It has been a pleasure taking care of you,
Your ___ Care Team | Mr. ___ is a ___ with a PMHx of ETOH cirrhosis complicated
by ___ s/p liver transplant ___, with subsequent ischemic
biliary strictures with recurrent cholangitis who presented with
septic shock due to repeat episode of cholangitis and E.
coli/Enterococcus bactermemia.
# Recurrent cholangitis with E. coli/GPC bacteremia and
periontonis:
Presented with fever, leukocytosis and RUQ pain in the setting
of transaminitis, elevated Tbili (mostly direct) and known
biliary strictures. Had ERCP on ___ with placement of biliary
stent in the left hepatic duct. Has known history of MDR
organisms, specifically VRE/ESBL. Now s/p ___ biliary
drainage. Completed 14 days of ___ on ___. Enterococcus
in pairs grew in broth from peritoneal analysis showing new
peritonitis. S/p 2L para ___, spiked fever than night to 103
found to have new peribilliary abscess. Bile and BCx grew GNRs
and GPCs. Spiked again overnight ___ and was given gentamycin
x1. ___ recommended exchange of PTBC, however this would not
change his overall trajectory and per patient this was not in
line with his goals of care. He received Amikacin 600IV x1 on
___. He was also sarted on linezolid on ___. His daptomycin
was discontinued given rising MIC. He was also started on
ertapenem ___ from meropenem due to ___ resistance, but this
was deemed unlikely to be active either and was discontinued. He
was continued on home suppressive rifaximin and doxycycline.
Sirolimus was discontinued. Received final dose of meropenem and
amikacin on day of discharge.
# Chest pain/trponinemia: Resolved. Trop to 0.2. EKG stable.
Likely demand ischemia in setting of acute infection and renal
injury. Repeat troponin negative.
# Moderate Malnutrition: Patient initially experienced decreased
appetite in setting of uremia as well as difficulty tolerating
tube feeds with nausea/vomiting. Patient was tolerating tube
feeds and appetite increasing with increased PO intake. Tube
feeds were discontinued as he had adequate PO intake. He was
switched to regular diet for comfort
#R. effusion: Has had thoracentesis in the past with fluid
analysis consistent with transudative process. Noted to be large
but stable with repeat CXR on ___ showing improvement in right
pleural effusion, improving with diuresis. Diuretics were
discontinued from sepsis.
# ATN: Baseline Cr is 1.0-1.2, initially downtrended from peak
of 6.1. Etiology was likely ATN ___ to hypotension and shock.
Patient appears volume overloaded with distended abdomen and
persistent bilateral lower extremity edema. He tolerated
additional torsemide (has received additional 40 mg torsemide on
___ however then became septic. He was managed with
albumin.
# Atrial fibrillation: CHADS2-VASC 3, Rate control = metoprolol,
A/C = warfarin at home. Held warfarin on ___ due to rapid
increase in INR. Restarted at 4mg/2mg alternating,
subtherapeutic today ___. Warfarin was discontinued as he
transitioned to hospice. His metoprolol was fractionated to help
prevent Afib with RVR.
# Alcoholic cirrhosis c/b HCC and s/p OLT (___) and
peritonitis: post-transplant course complicated by delayed graft
thrombosis, ischemic hepatopathy and ischemic biliary strictures
with recurrent cholangitis and liver abscesses. His sirolimus
dose was decreased and then discontinued as infections
developed. He was continued on ursodiol.
# Low mood: Improved lately but patient had reported that his
mood is low, he has been feeling discouraged. Was statrted on
sertraline which was discontinued given risk of serotonin
syndrome on linezolid.
# HFpEF: TTE ___ EF 65%, Dry weight 86.3kg ___, previous
to that pt was ~77.2kg for most of ___. Weight on admission
82.6kg. Current weight is 84.1 kg. Patient experiencing edema in
setting of ___.
# Goals of care: Patient with multiple episodes of recurrent
cholangitis. Expressing hospital fatigue and wish to go home.
Declined drainage of new liver abscess. He was switched to
dilaudid from oxycodone and his medications were optimized for
comfort. He was discharged home with hospice.
CHRONIC ISSUES
# HLD: stable, re-started simvastatin per Cardiology recs.
Discontinued with change in goals of care.
# Thrombocytopenia: Resolved. Developed likely in setting of
cirrhosis and sepsis. 4T score of 3, making HIT unlikely
#Right Lower Extremity Muscle Pain: Resolved. Initially tender
to palpation, however, improved after improvement of kidney
function. Motor/sensation intact. ___: negative for DVT. CK
wnl. Likely secondary to uremia given patient's improvement in
muscle discomfort with improved kidney function.
# Communication: Wife, ___, ___
# Code: DNR/DNI, no ICU transfer | 77 | 705 |
11597311-DS-22 | 27,487,454 | Dear Mr. ___
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you were having
chest pain and there was concern that you were having heart
attack.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were admitted to the hospital because you had chest
pain. You had a stress test done of your heart, that showed no
new problems with the way your heart squeezes, and no new
problems with the way blood gets to your heart. It is possible
that your chest pain came from another source, such as GERD
(heartburn), gas pain, or vasospasm of the arteries that feed
your heart.
- Dr. ___ a message to your nephrologist Dr. ___
your cardiologist Dr. ___ to let them know about the
results of this test, and that you were discharged on the same
medications as when you came in.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You were restarted on all of your medications as they were
when you came into the hospital. You should take them as
directed.
- You should call Dr. ___ ___ to make an appointment
with in the next week
- You should call Dr. ___ to make an appointment within the
next few weeks.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team | PATIENT SUMMARY
==================
Mr. ___ is a ___ man with CAD s/p NSTEMI, HTN, HLD, T2DM, ESRD
on HD TThS, R ICH from aneurysm (___), SDH from head trauma in
(___), GERD, hemorrhoids, diverticulosis, recent GI Bleed
(___), and gout who presented with epigastric pain, admitted
for further management of Type II NSTEMI. pMIBI without evidence
of new ischemia, patient discharged with PCP and nephrology
follow up.
CORONARIES: DES x2 to proximal and distal LAD ___ known
mid-RCA CTO
PUMP: LVEF 60-65% (___)
RHYTHM: pAF
===============
ACTIVE ISSUES:
===============
# Epigastric pain
# NSTEMI Type II
Patient presenting after having a 15-minute episode of
epigastric pain which converted to substernal chest pain with
associated diaphoresis and SOB. This pas particularly concerning
for ACS given his robust cardiac history including recent PCI.
TTE now with regional systolic dysfunction in inferior
distribution. His pain resolved during his hospitalization. He
was noted to have thrombocytopenia on admission, and his
symptoms were resolving, so cardiac catheterization was deferred
and pMIBI was performed. This showed reversible inferior wall
perfusion defect, which is expected with his known total
occlusion of the RCA. Since there were no perfusion defects in
the areas stented previously (distal and proximal LAD),
thrombosis of the stents is very unlikely, and his pain is
thought to be due to possible vasospasms, GERD, or other
abdominal causes. His troponin peaked at 0.41. His elevated
troponin was likely due to demand ischemia in setting of poor
clearance due to CKD. He was discharged on his home medications.
# Acute on Chronic Anemia
# BRBPR
# History of GI Bleed
Patient presented for epigastric pain, as per above. Of note,
patient was noted to have mild BRBPR and guaiac positive stool
in the ED. Baseline Hgb ~11. On admission, with Hgb 12.3 ->
11.1. However, no further episodes of BRBPR. Repeat Hgb once he
reached the floor was 12.1, so may have represented hemodilution
in the
setting of missing HD. Had no further episodes of GI bleed and
hemoglobin remained stable.
# Thrombocytopenia
Thrombocytopenia to 107 on admission, nadir of 59, improved to
94 on discharge. Hepatitis panel negative for active infection,
RUQUS with possible cirrhosis. Initial concern for HIT, with
low-intermediate 4-T score, but platelets started to rise and
patient continued receiving subQ heparin throughout his stay.
================
CHRONIC ISSUES:
================
# ESRD on HD (on ___. Received hemodylaiss as inpatient, and
was followed by nephrology during his hospitalization. He was
continued on home Calcium carbonate and Nephrocaps.
# History of Subdural hematoma
# History of aneurysm in ___
History of SDH in ___ ___s aneurysm in ___. During
his prior admission for NSTEMI in ___, Neurosurg consulted
and recommend pursuing cath and DAPT as needed. He was continued
on home keppra 500mg BID.
# HTN
During hospitalization, received Labetalol 100 mg BID. Per son,
takes only on HD days due to hypotension. Has been normotensive
to hypertensive during this hospitalization, so has been dosing
BID every day. Discharged with instructions to take labetolol as
he was as an outpatient, and to follow up with his nephrologist.
He was started on amlopdipine 5 mg for added hypertensive
coverage, and to help decrease possible vasospasms. However per
the patient's son, he had previously been on amlodipine and it
had been discontinued, so he was not discharged on this
medication.
# T2DM
Well controlled. Last HbA1c was ___ 6.0%. Insulin sliding
scale as inpatient.
# Transaminitis
Discovered on his last admission, likely NASH in setting of
long-standing diabetes and metabolic syndrome. Also with RUQUS
with evidence of possible cirrhosis.
# BPH
Per son, no longer on Doxazosin 4mg daily, so was not started on
this medication
# HLD
Continued home atorvastatin 80mg daily and Fenofibrate 48mg
daily
# Hx of pAF
Per prior records, patient had episode of atrial fibrillation
during admission at ___ many years ago. The
patient was not treated with warfarin at this time due to
bleeding risk. He remained in normal sinus rhythm throughout his
hospitalization.
TRANSITIONAL ISSUES
=========================
# Hypertension
[ ] Patient had been instructed to take labetolol only on days
of hemodialysis, however patient consistently hypertensive
during this admission. Discharged with instructions to take his
medications as he had been before this hospitalization (on HD
days only) and to follow up with his nephrologist for further
titration of BP meds.
#Transaminitis
#Suspected cirrhosis
[ ] RUQUS showed mildly coarsened hepatic echotexture with a
smooth contour. Presence of cirrhosis may be confirmed by a
biopsy, as clinically relevant.
Thrombocytopeniaplatelet count decreased at 92-100 (was 150 in
___. ? If related to underlying mild cirrhosis seen on
Duplex. Follow-up with PCP on this. Patient did receive
subcutaneous heparin throughout without any significant change
sodium did not pursue HIT as it did not clinically appear to fit
the picture.
---- Discharge weight: 68.4Kg (150.79 lbs)
# CODE STATUS: Full code
# CONTACT/HCP: ___ Phone: ___ | 263 | 785 |
13748151-DS-16 | 21,496,364 | Dear Ms. ___,
It was a pleasure taking care of ___ during your stay at ___
___. ___ were admitted for difficulty speaking and
weakness. In the emergency department, the brain doctors were
called to evaluate ___ for a possible stroke. A CT scan of your
head did not show any bleeding in your brain and the brain
doctors did not think ___ had a stroke. Because of your previous
injuries to your brain from last year, which we believe were
micro-hemorrhages, ___ are more sensitive to alcohol. We would
recommend avoidance.
Thank ___ for allowing us to be a part of your care. | Impression: ___ female w/Hep C, CKD, on coumadin for mechanical
valve and h/o CVA ___, p/w sudden onset difficulty speaking,
disorientation to place, and difficulty standing/walking down
stairs.
**ACUTE ISSUES**
# Weakness and speaking difficulties: Given patient's history of
CVA and the sudden onset of her symptoms, a code stroke was
called in the ___. CT head and CTA of the head and neck did not
show any hemorrhagic changes or vascular deformities. Neurology
evaluation of the patient did not reveal any deficits consistent
with a stroke. Serum tox screen revealed ethanol level of 46.
Patient given 2L IVF in the ___ and transferred to the floor for
further care. Her speech did appear impaired and halting in the
setting of extreme anxiety and tearfulness on exam. Her speech
impairment and emotional lability resolved by the morning.
Patient did endorse drinking a small wine cooler the day of
presentation. Given she had no other focal deficits and her
positive urine tox screen for alcohol, it was thought she was
likely intoxicated at the time of her speech impairment.
Additionally, neurology consult evaluated her "CVA" event ___
and theorized that she actually had multiple micro-hemorrhages
in the setting of coumadin. She could certainly be more
sensitive to drugs affecting cerebral perfusion and toxins such
as alcohol. Physical therapy evaluated patient and recommended
out-patient ___.
**CHRONIC ISSUES**
# HTN: Continued home metoprolol. Given her history of
micro-hemorrhages, would consider tighter blood pressure
control.
# CKD: Presented with a creatinine of 3.6, likely not far the
patient's baseline of ~3. She was given 2L NS in the ___ and her
creatinine was 2.4 at discharge.
# Mechanical valve on warfarin: Patient found to be therapeutic
on admission, thus coumadin was continued.
# Depression: Continued home bupropion and mirtazapine, had
current suicidal or homicidal thoughts.
# Insomnia: Continued home trazodone
# Nutrition: Continued home MVI, Ensure supplemental with every
meal. TSH and free T4 did not reveal any hyperthyroidism that
could be contributing to her weight loss.
**TRANSITIONAL**
- Encourage alcohol abstinence
- ___ CVA likely micro-hemorrhages in the setting of
hypertension and coumadin. Would consider tighter BP control.
- repeat UA to assess for microscopic hematuria
- repeat transaminases to assess for resolution of elevation | 102 | 362 |
18308489-DS-15 | 26,658,702 | Dear Ms. ___,
It was a privilege to care for you at the ___. You were
admitted with abdominal pain and unfortunately had imaging that
was concerning for an underlying cancer. You had biopsied taken
for pathology and will have close follow up to discuss these
results.
You are being prescribed some medications to help with any
symptoms you are experiencing. Please note that both of these
medications can cause constipation so be sure to make sure you
are on a stool softener.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with history of papillary
thyroid carcinoma, anemia, anxiety/depression who presents with
abdominal pain, found to have pelvic mass and elevated CA125
concerning for gynecologic malignancy.
# Abdominal pain:
Patient presenting with abdominal pain, bloating and distention,
found on outside imaging to have pelvic mass and CA 125 elevated
concerning for gynecologic malignancy. Given very high CA 125:
CEA ratio, suspect primary ovarian malignancy. Pain likely
secondary to malignancy, ascites, and constipation. Patient
aware of suspected diagnosis. CT chest without obvious
intrathoracic metastasis. Patient underwent paracentesis with
cytology, which is pending on discharge. Results to be discussed
at ___ follow up. Patient also with liver lesion on CT, not
appreciated on ultrasound. She will need this lesion to be
biopsied as an outpatient as this was unable to be performed
over long holiday weekend. Discharged with prn oxycodone,
antiemetics, and bowel regimen.
CHRONIC/STABLE PROBLEMS:
======================
# ADHD: - Continued Adderral
# Depression/Anxiety: - Continued lamotrigine, gabapentin
# Papillary thyroid cancer s/p resection: - Continued
levothyroxine
# Insomnia: - Continued zolpidem as needed (dose reduced to max
recommended dose for women)
# HSV: - Continued suppressive valacyclovir
TRANSITIONAL ISSUES:
==================
[] peritoneal fluid cytology pending at discharge
[] will need outpatient liver biopsy for suspicious lesion
> 30 mins spent coordinating discharge | 91 | 207 |
13203295-DS-16 | 27,371,786 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were more confused
than usual and you weren't able to talk, and the sodium level in
your blood was found to be very low.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You had imaging of your head and neck which did not show
anything abnormal.
-Your blood pressure medication (hydrochlorothiazide) was held
because it can also cause low sodium levels.
-You got fluids through your IV that were high in sodium to help
raise your sodium slowly back to normal.
-Once your sodium was improved, you were feeling a lot better
and were able to converse again.
-You were having symptoms of a urinary tract infection, so you
were started on an antibiotic (Macrobid/Nitrofurantoin).
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take your medications as prescribed. You will NOT
continue your hydrochlorothiazide.
-Please start taking your Fosamax (alendronate) every ___
instead of every ___.
-Please continue taking the antibiotic (Macrobid/Nitrofurantoin)
for your urinary tract infection through ___.
-Please attend all ___ clinic appointments.
-In the future, drink to thirst! Don't simply drink for the sake
of drinking.
-Please see below for future colonoscopy prep. This will also be
sent to your primary care doctor, who will be ordering the
colonoscopy.
We wish you all the best,
Your ___ Care Team
Colonoscopy prep recommendations: Nulytely
1) Three days prior to your procedure
-FILL YOUR PRESCRIPTION FOR NULYTELY.
-BEGIN A LOW RESIDUE DIET. Avoid fruits, salads, cereals, brain,
Metamucil, seeds, and nuts. For example, if your procedure is
booked on a ___ morning begin on ___ morning to eat as
though you were getting over an upset stomach.
2)ONE (1) DAY BEFORE THE PROCEDURE:
One full day before the procedure begin a clear liquid diet, no
milk or dairy products. Use Jell-O, broth, Gatorade, Sprite,
coffee, tea, and clear juices - please make sure you are not
drinking only water, but a mixture of clear liquids that have
electrolytes in them. For example, if your procedure is booked
for ___ morning begin the clear liquid diet on ___.
At 3 to 4 pm, add water to the contents of the Nulytely
container
and mix well. Chilling the solution often helps with the taste.
Begin drinking one glass every 15 minutes until all is consumed.
You can continue to have clear liquids until bedtime. Try not to
have any additional water other than what you need to finish the
prep.
3) On the day of the procedure:
Take your usual medications so long as you take them six (6)
hours before the procedure.
Bring your insurance cards.
Leave your valuables at home.
Your driver may want to wait for you at the hospital or may
decide to return to pick you | PATIENT SUMMARY:
================
___ with PMH of HTN on HCTZ presenting with AMS and aphasia,
found to have severe hyponatremia in the setting of polydipsia
and bowel prep for colonoscopy, likely induced by excess free
water intake and use of HCTZ, symptoms and Na improved after
correction with hypertonic saline. Patient also developed UTI,
initiated treatment with Macrobid. | 446 | 56 |
13956943-DS-26 | 22,262,521 | Dear Mr. ___,
It was a pleasure to care for you here at ___
___. You were admitted for cough and chest
congestion. You were observed overnight and initially started on
antibiotics for a potential pneumonia.
You had a CAT scan of your chest which did not show a pneumonia.
You were negative for influenza (the "flu"). You likely have a
viral infection or bronchitis. At this point in time, we feel
you do not need antibiotics.
If you have fevers or worsening symptoms, please call your
doctor or return to the emergency room.
We wish you all the best.
- Your ___ Team | Summary
___ hx LRRT, DM2, HTN, HLD, AFib, PPM for long QT syndrome, p/w
CP and productive cough. Of note, he was admitted
___ for a pneumonia that was initially treated with
Levaquin, switched to Augmentin/Doxycycline for prolonged QT
interval.
Acute issues
# Cough, chest pain
He presented on ___ with 1 day of chest congestion and dry
cough. He did not have fevers and labs were within normal
limits. A CT chest was performed, which showed resolution of
prior PNA, and a left lung base 1.3 x 1.0 cm ground-glass
nodule, which is unchanged from prior. He was put on
vancomycin/cefepime and observed overnight. Flu swab was
negative; troponin negative x2 and unchanged EKG. Ambulatory
oxygen saturation was 94-97% on room air. Given his history and
well-appearance, he was discharged off antibiotics; it was
thought that he likely had a viral bronchitis.
Chronic issues
# AFib: CHADS2 score of 1. Unable to tolerate warfarin, apixaban
and dabigatran in the past per OMR. Not on rate control agents.
Continued ASA 325mg.
# s/p LRRT: Continued home immunosuppressants
# DM: Continued home lantus with ISS, glimepride.
# HTN: Continued amlodipine & lisinopril.
# BPH: Continued on home tamsulosin. | 99 | 190 |
12545500-DS-9 | 22,200,501 | You were admitted to the inpatient colorectal surgery service
for rectal bleeding. You will not continue the Lovenox therapy
and the bleeding has resolved. Your blood counts have been
stable. There was a small fluid collection near the JPouch that
was drained in radiology and was found to not be infected. You
also were having right sided buttock and upper leg pain and oral
thrush. We started gabapentin for the right sided buttock/leg
pain. We also continued the Fluconazole and Nystatin for the
oral thrush. You will continue The Fluconazolefor 13 more days
and the nystatin swish you should continue for 2 days after
symptoms resolve. If you have any worsening of the thrush
symptoms please call, these are expected to improve with
treatment.
Please call if you have any of the following symtpoms:
If you have any of the following symptoms please call the office
for advice ___:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
You also have a small anal fissure that may also be causing the
pain. Please go to a compounding pharmacy to pick up ___
cream. Please apply this as directed. This ointment has to be
made at a special pharmacy ___. This has been faxed and you can pick up or
they will mail to you. | Mrs. ___ was admitted to the ___ ED with bleeding and
transfused with for 3units of packed red blood cells. Her
hematocrit stabilized. ___ she ws sent to radiology to
aspirate a fluid collection in the abdomen which Dr. ___
___ maybe was causing her pain and the aspirated pus. A drain
was not left in place. She then tolerated a regular diet. She
had transient nausea. She complained of symtoms of rectal pain
and she was found to have a fissure. She seemed to have pain
similar to sciatica and we started gabapentin. Her treatment of
oral thrush was changed. Her symptoms were improved and she was
discharged home not on Lovenox. | 224 | 114 |
18977059-DS-18 | 24,275,145 | Daily weight, call MD if weight goes up more than 3 lbs.
Only needs oxygen if O2 saturation is < 88-90%
Aspiration precautions, sitting fully upright with meals, small
bites, chin tuck with swallowing, thicken liquids, make sure
patient is fully awake and alert with meals.
DNR/DNI | This is a ___ speaking only ___ with dementia, HTN, HL, DM2
(diet controlled), CKD, AF on Coumadin, diastolic CHF with
severe
MR, and recent admission to Geriatrics ___ here for
respiratory failure due to pneumonia and CHF who presents with
worsening cough, dyspnea, and hypoxemia likely ___ recurrent
aspiration.
# Acute recurrent hypoxic respiratory failure, multifactorial
etiologies including
# Pneumonia, likely aspiration, but also possible HAP
# Likely component of acute diastolic CHF on HFpEF
# Severe MR/TR
# Underlying chronic lung disease, possibly with exacerbation
Pt with recent admission to ___ with similar
presentation. She was seen by Speech and Swallow as she was
found to have likely ongoing aspiration. Bedside swallow eval
at
that time showed aspiration but given her limited ___ further
w/u with video swallow not pursued. Plan was for pt to keep
receiving PO intake with modified diet but per pt's
granddaughter
and HCP, does not seem like this diet was followed as pt's
daughters bring her food from home with variable consistencies.
CXR on admission showed bilateral pleural effusions and
consolidation c/w possible volume overload. In this setting,
underlying consolidation could not be excluded. Possible that
volume overload could also be playing role in hypoxia and
respiratory distress as Lasix was held on pt's discharge (though
she was diuresed during the admission) and she was started on
prednisone.
- Sputum culture noncontributory & MRSA screen negative,
afebrile
and WBC has been normal throughout during hospitalization, will
d/c Vanc (started ___. Patient has been documented to be
on
Cefepime, however, had received only 1 doses each of Cefepime
and
Levaquin on ___.
- con't Lasix 20mg IV BID with close monitoring, will d/c foley
catheter
- taper Prednisone quickly to 20mg PO daily (started ___
- Duonebs q6h standing, albuterol nebs PRN
- Continue home Advair
- Continue home PPI (AC, Coumadin, aspiration)
- Supplemental oxygen and titrate as tolerated.
# Recent issues with overt aspiration: Previously discussed
continuation of modified diet and not pursuing other more
aggressive workups/treatments as means of nutrition. Given
above, would suspect that she did not tolerate this diet. Spoke
with pt's HCP and she does not think another Speech eval would
be
helpful as family wants to continue to feed her.
- Monitor for aspiration, aspiration precautions. Daughter was
instructed to make sure patient is sitting up fully upright with
feedings.
- Ongoing ___ discussion with pt's niece/HCP ___
# Toxic encephalopathy, superimposed on
# Dementia
- Treatment of issues as above
- Delirium precautions
- Continue home Aricept
# AF on Coumadin
# intermittent brief bradycardia that spontaneously recovers
# HFpEF, +55%
- Holding Coumadin till INR < 3.0
- Continue diltiazem 15 q6h with holding parameters, if more
frequent, may consider d/c altogether.
- Patient has been spitting up all Imdur pills provided as they
cannot be crushed and she's having difficulty swallowing. Will
con't nitrates for CHF by switching from Imdur to Isordil
# Pyuria with culture only positive for yeast. Doubt true UTI
- On IV vanco for respiratory symptoms, not urine
# Antibiotics associated diarrhea. Cdiff negative. Off all
antibiotics at this point.
# CKD: Cr within baseline 1.2-1.8
- Dose meds for low GFR
- Monitor
# Anemia: Chronic and stable.
- Monitor
# HTN: Stable.
- Continue Imdur with hold parameters | 44 | 501 |
13247654-DS-8 | 28,691,383 | You were admitted to the hospital after you tripped and fell
onto your left shoulder. Prior to this admission, you reported
that you had also fallen and hit your head. On cat scan you
were found to have a small bleed in your head. Neurology was
consulted and determined that you did not need any surgery for
this. You were placed on medication to prevent any seizure.
Because you hurt your left shoulder in the fall, you were seeen
by Orthopedics, who recommended a sling to your arm for comfort.
You were seen by physical therapy who recommended discharge home
with the following instructions:
Please report the following:
*headache/ nausea and vomitting
*visual changes
*facial droop
*weakness on one side of your body
*difficulty speaking
*seizure
Please wear your sling for support of left arm: report the
following:
*increased pain left arm or shoulder
*numbness fingers left arm
*fever
Please report any new symmptom which concerns you | ___ year old female admitted to the Acute care service after a
fall in which she landed on her left side. Upon admission, she
was made NPO, given intravenous fluids, and underwent
radiographic imaging. Imaging showed a left proximal humerus
comminuted fracture and an inferior subluxation of the humeral
head. No surgical intervention was warrented and her arm was
placed in a sling. Head cat scan showed a small 3mm subdural
hematoma. Neurology was consulted and recommended a week course
of dilantin and reversal of her INR to 1.4. Since her
admission, her coumadin was held and she was given 10 mg of
vitamin K. Her neurological status has been closely monitored
along with her INR.
She has resumed her home medications except for aspirin and
coumadin. Her vital signs are stable and she is afebrile. Her
neurological status is stable and unchanged from admission. She
has been ambulating without difficulty with a sling for support
of her left arm.
She is preparing for discharge home with ___ services. She has
follow-up appointments with Neurology and Orthopedics. Her INR
will be monitored by her ___ clinic. She will remain of
the aspirin and coumadin for 1 week.
Of note: as per cat scan of cervical spine, multiple thyroid
nodules noted and follow-up studies recommended. | 153 | 230 |
16754217-DS-20 | 20,804,421 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for lightheadedness, low blood counts and a
bleed from your gastrointestinal tract
What was done for me while I was in the hospital?
- You were given blood to help with your blood counts
- You underwent an imaging study of your abdomen
- You underwent two endoscopies which demonstrated the source of
the bleeding and there was an attempt to stop the bleeding
- You were given a medication to help prevent bleeding in the
future
What should I do when I leave the hospital?
- Please keep all of your appointments
- Please take your medications as prescribed
Sincerely,
Your ___ Care Team | n brief, this is a ___ gentleman with a history of peptic ulcer
disease ___ H.Pylori (treated w/ antibiotics ___ with repeat
endoscopy in setting of ongoing symptoms demonstrating cure by
biopsy in ___ per pt) who presented with lightheadedness
and BRBPR/melena concerning for a UGIB, found to be d/t a
bleeding duodenal ulcer. He was transfused 2u pRBC with
stabilization of his hemodynamics and lactate. Initial EGD
demonstrated duodenal ulcer, which was treated with thermal
cauterization. He required a stay in the ICU because he was
deemed to have a high risk of rebleeding, but was subsequently
transferred to the floors after he remained stable. Repeat EGD
demonstrated clean based 12mm ulcer in the duodenal bulb, and
the plan is to continue him on high dose PPI for 8 weeks after
discharge with potential to expand dosing to 12 wks if symptoms
persist. Of note, he had leukocytosis and a fever shortly after
initial presentation that was felt to be ___ stress response
that resolved without antibiotics.
TRANSITIONAL ISSUES
==========================
[ ] New Medications: 40mg pantoprazole BID for 8 weeks
[ ] PCP: ___ on discharge - Biopsies were taken and are
pending on discharge. Gastrin level also pending (secondary
causes of GI ulcers). Please follow-up these results
[ ] PCP: 40mg pantoprazole BID for planned 8 weeks, but please
reassess symptoms at this time and consider expanding treatment
course to ___ode: Presumed Full
#Contact: Sister
#UGIB | 135 | 227 |
15295532-DS-5 | 28,629,729 | Dear Mr. ___,
It was a pleasure taking care of your at the ___
___. You were admitted for sore throat,
congestion and flank pain. There was initial concern for a urine
infection and you were treated with IV antibiotics. A renal
ultrasound was done that showed no explination for your pain.
Your nasal congestion and cough were concerning for sinusitis
for which you were also given antibiotics. You were also started
on a steroid nasal spray to treat the nasal congestion. You
responded well to antibiotics and your symptoms improved.
Please START taking:
- fluticasone
- levofloxacin
Please take the rest of your medcations as prescribed and follow
up with your doctors as ___. | ___ yo M with hx of orthopedic surgeries, chronic pain, and
anxiety who presents with nasal congestion, sore throat and
cough, dysuria and R. CVA tenderness.
.
# Pyelonephritis - Patient presented with new onset of flank
pain, subjective fevers and UA + for WBCs, few bacteria. Given
these findings, the patient was initially started on ceftriaxone
1g daily for presumed pyelonephritis. His urine culture
subsequently grew <10,000 colonies. Alternative etiologies of
sterile pyuria and hyaline casts were less likely. He did not
have an elevated creatinine to suggest intrinsic kidney damage.
His genital exam and DRE was not concerning for epididymitis or
prostatitis. Urine chlamydia was negative. His clinical picture
was not consistent with nephrolithiasis. Given his persistent
flank pain, he underwent a renal ultrasound which found no
evidence of hydronephrosis or abscess. Etiology of flank pain
and pyuria remained unclear however patient felt clinically
improved at time of discharge.
.
# Sinusitis - Patient presented with nasal congestion for a few
weeks since a recent dental procedure. He reported thick
secretions, subjective fevers, and was noted to have maxillary
tenderness on exam. Given these findings, his ceftriaxone was
changed to levofloxacin to treat both bacterial sinusitis and a
possible urinary source. He was also given fluticasone nasal
spray. His symptoms improved and he was discharged with plans to
complete a course of levofloxacin.
.
# Cough - Patient had nonproductive cough, however he was noted
to have clear lungs and no evidence of consolidation, pulmonary
edema, or effusion on CXR. Cough most likely due to post nasal
drip from sinusitis. Symptoms improved with guaifenesin,
tessilon pearls and cephacol lozenges in addition to treatment
of his sinusitis as above.
.
# Back pain - Chronic. Substituted equivalent dose of oxycontin
instead of Opana (not on formulary) while in house. Continued
other home medications. Pain well controlled throughout
hospitalization.
.
# Dysphagia - Patient has had dysphagia since cervical spine
surgery. He is followed closely by speech and swallow as
outpatient. He was continued on thin liquids, regular solids,
Ensure supplements
.
TRANSITIONAL ISSUES
- blood cultures pending at time of discharge
- code: full
- communication: wife ___ | 111 | 356 |
14260294-DS-14 | 20,634,861 | Mr ___,
It was a pleasure taking care of you at ___
___. You were admitted following a fall and was found
to have a small bleed in your head. You were monitored by
neurosurgery and found to be stable. You were evaluated by
Physical Therapy and Occupational Therapy, and we recommend that
you receive these services at home.
Please follow up with your appointments as scheduled.
Thank you for allowing us to participate in your care.
Take care,
- ___ medicine team
Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
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. | ___ yo M with history of HTN, atrial fibrillation (not
anticoagulated), basal cell carcinoma s/p excision ___, CLL,
and vertigo who presented after an episode of vertigo induced
syncope with head strike and stable subdural hematoma.
ACTIVE ISSUES:
# Subdural hematoma: S/p fall with head strike and LOC 2 days
prior to presentation and presented to ___ after
___ noted slurred speech. There he was found to have SDH with
midline shift, and was transferred to ___ for neurosurgical
care. He was observed in the TSICU by the neurosurgical service,
and remained with stable non-focal exam and stable repeat
imaging. He was placed on prophylactic phenytoin, which he
should continue for a total of 7 days.
- Continue Phenytoin through ___
- Restarted ASA on ___ once cleared by Neurosurg
- Follow up with Dr ___ in Traumatic ___ Injury clinic
- Follow up with Dr ___ in ___ weeks with repeat head CT
prior to visit
# Syncope: Appears to be vertiginous etiology, and this has been
chronic with previous vestibular ___ treatment for symptoms
consistent with BPPV. ___ have been arrhythmogenic as he does
have A fib, noted to have episodes of RVR on telemetry but
usually asymptomatic. Echo normal without evidence of valvular
disease. His orthostatic VS were stable. He was evaluated by ___
and OT inhouse, who recommend further treatments at home.
- Dicharged with home ___ and OT
- Recommend restarting vestibular ___
- Discontinued terazosin to prevent nighttime orthostasis and
risk for fall
# A fib: Paroxysmal, with episodes of RVR on telemetry. CHADS 2
and was previously on anticoagulation, stopped for recent BCC
resection. He was previously on metoprolol, but appears to have
self discontinued this medication. He was maintained on
Diltiazem 180 daily here.
- Continue Diltiazem and aspirin
- Follow up with PCP to discuss rate control and anticoagulation
medications.
CHRONIC ISSUES:
# BCC: Resection from left cheek on ___ and prescribed a 10
day course of cephalexin, which he completed during this
admission.
- follow up with dermatology
# CLL: Leukocytosis with lymphocyte predominance. No treatment.
- Follow up with PCP for monitoring
# GERD
- continued omeprazole
# BPH:
- continued finasteride 5mg
- discontinued terazosin as above | 246 | 370 |
13891645-DS-8 | 28,950,741 | You were admitted to the hospital after a sigmoid colectomy for
surgical management of your sigmoid mass. You have recovered
from this procedure well and you are now ready to continue your
recovery at rehab. Samples from your colon were taken and this
tissue has been sent to the pathology department for analysis.
You will receive these pathology results at your follow-up
appointment. If there is an urgent need for the surgeon to
contact you regarding these results they will contact you before
this time. You have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth.
Please monitor your bowel function closely. You may or may not
have had a bowel
Movement prior to your discharge which is acceptable, however it
is important that you have a bowel movement in the next ___
days. After anesthesia it is not uncommon for patients to have
some decrease in bowel function but your should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are explected however, if
you notice that you are passing bright red blood with bowel
movments 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 if the symptoms
do not improve call the office. 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, prolonges loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
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. Good luck! | The patient was admitted for sigmoid colectomy. She was seen
prior to her procedure by the Medicine service who assessed her
cardiac status and cleared her for surgery. Her potassium was
low at 2.8 which was repleted. She underwent sigmoid colectomy
which she tolerated well.
On POD #0 she has low urine output requiring multiple boluses of
crystalloid fluids and albumin. Her UOP responded appropriately.
Her pain was initially controlled with IV pain medications which
were transitioned to oral medications once she was eating.
On POD #1 her NGT that was placed in the OR had minimal output
and was removed without complication. She again had decreased
UOP and was given boluses and responded appropriately.
On POD #2 her diet was advanced to sips which she tolerated. Her
abdominal JP drain had minimal output and was removed. She was
evaluated by physical therapy who recommended discharge to rehab
for further recovery.
On the remaining post-operative days her diet was slowly
advanced to regular, which she tolerated. She was passing
flatus, although had not yet had a bowel movement. She was
started on colace. She was restarted on her home
hydrochlorothiazide. She was voiding, passing flatus, and
working with ___. She was stable for discharge to rehab and will
follow-up in ___ clinic. | 537 | 210 |
15567127-DS-38 | 20,928,977 | Dear Mr. ___,
You came to the hospital because you passed out. You were found
to have an abnormal heart rhythm called "polymorphic ventricular
tachycardia," which was the result of the effect of high dose of
methadone on the electrical system of the heart. We stopped your
methadone and monitored your heart rhythm closely until it came
back to normal. In order to prevent similar episodes in the
future, you should not take methadone anymore. The chronic pain
service saw you and changed your pain medication regimen. We
talked to your hospice doctor regarding this plan, and he will
further adjust your pain medications as necessary.
Please take all your medications as prescribed.
It was a pleasure taking care of you!
-Your ___ team | Mr. ___ is a ___ with complex medical history including
history of alcohol abuse with cirrhosis by biopsy ___
complicated by esophageal varices, portal hypertensionm, portal
vein thrombosis not on anticoagulation, chronic alcoholic
pancreatitis s/p pancreatic debridement, external drainage of
pseudocyst and distal pancreatectomy with gastrojejunostomy
___, s/p splenectomy ___, recurrent cholangitis and
intrahepatic abscess, recurrent cellulitis and hx C. diff
infection, diabetes, depression with hx suicide attempts who
presents with syncope found to have polymorphic VT consistent
with torsade de pointes in the setting of prolonged QTc and high
doses of methadone.
# Polymorphic Ventricular Tachycardia:
Patient found to have polymorphic VT consistent with torsade de
pointes secondary to acquired prolonged QT in the setting of
high doses of methadone. QTc on admission ~ 560. In ED patient
was given: Mg 4g IV and dopamine IV, and then switched dopamine
to isoproterenol. Isoprotenerol was subsequenty discontinued due
to its limited effect on the heart rate and ventricular ectopy.
Patient was monitored and had adequate repletion of potassium
(>4.5) and magnesium (>2.5). QTc decreased gradually from ~560
on admission to 465 on discharge.
# Syncope:
Possibly secondary to VT as above. Other considerations include
orthostasis given recent h/o nausea and diarrhea, particularly
in the setting of ___. We held home diuretics and gave him IVF
on admission due to soft blood pressure.
# Chronic Pain:
He has been on very high doses of methadone chronically,
previously failing other narcotics. He is followed by palliative
care, and has been seen many times by the chronic and acute pain
services. Earlier this year a ketamine drip was trialed for
opioid resensitization without effect. Give acquired prolonged
QT secondary to methadone, methadone at this time. The chronic
pain service was consulted and the pain regimen was changed to
oxycontin 60mg PO BID and hydromorphone ___ PO q3hrs PRN,
titrated to 80mg oxycontin BIB and ___ PO hydromorphone q3 hrs
PRN.
# Diarrhea:
Pt with history of recurrent C diff infection, presents with
diarrhea after discontinuation of PO vancomycin. Per mother,
diarrhea is unchanged from baseline. Pt also with risk factors
for diarrhea at baseline given multiple ongoing GI issues
including pancreatic insufficiency. Most recent C diff antigen
testing in ___ system negative in ___.
# Acute Kidney Injury:
Cr was elevated to 1.8 on admission from baseline of 0.9-1.1.
Given report of diarrhea and low PO intake, and chronic diuretic
use, patient appeared to be volume depleted. He was given 1 L
IVF on admission and home diuretics were held during
hospitalization. Discharge Cr 1.2.
# Portal Hypertension:
Esophageal varices but no cirrhosis on liver biopsy from ___.
We held spironolactone 50mg and Lasix 20mg PO daily given ___,
then restarted them before discharge. We initially held Nadolol
for EV prophylaxis while on isoproterenol, then restarted it.
CHRONIC ISSUES:
================
# Portal Vein thrombosis not on anticoagulation
# Chronic Pancreatitis: We continued Creon
(lipase-protease-amylase) 24,000-76,000 -120,000 unit,
LOPERamide 2 mg PO QID:PRN diarrhea, and Rifaximin 550 mg PO
BID.
# Insulin Dependent Diabetes Mellitus: We continued Glargine 10
Units Bedtime, Insulin SC Sliding Scale using Novolog Insulin.
# Psych: We continued MethylPHENIDATE (Ritalin) 5 mg PO BID and
ClonazePAM 2 mg PO TID:PRN for anxiety.
# Reactive Airway Disease: We continued Albuterol Inhaler 2 PUFF
IH Q4H:PRN and Fluticasone Propionate 110mcg 2 PUFF IH BID.
TRANSITIONAL ISSUES
===================== | 121 | 545 |
19374927-DS-3 | 28,292,107 | You were admitted for chest pain, felt to be most likely
musculoskeletal. You did not have any evidence of a heart
attack on your labwork or EKG.
An outpatient stress test is being scheduled for you. You
should call your cardiologist's office tomorrow to see if they
have scheduled this for you yet, and if not you should ask them
to schedule you for an outpatient stress test later this week. | ___ with history of hypertension and previous MI in ___ who
presented today with suspected UA.
# Chest Pain: Suspicious for unstable angina although has some
atypical features like reproducible tenderness and worsening
with deep breathing. However the squezzing like pain and very
rapid and distinct relief with NG are concerning especially
given his history of similar anginal symptoms with his previous
MI. ECG is unchanged from baseline and trops negative x2. He has
no risk factors for PE and d-dimer was negative. Nothing to
suggest pericarditis on his ECG or history. Pain felt secondary
to non-cardiac etiology, likely musculoskeletal tx with APAP.
Will ___ with ___ NP tomorrow for further eval of symptoms and
EKG, will have ___ nuclear stress imaging in 6 days and then
___ with his ___ cardiologist. | 74 | 135 |
18449391-DS-11 | 24,320,416 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
abdominal pain and a near fall with weakness at home. You were
also found to have low blood pressure at this time.
You had a CT scan which did not show any particular cause of
your abdominal pain.
Your Imdur was stopped and your carvedilol dose was cut in half.
You blood pressure remained in good control. Please monitor your
blood pressure at home. You should take your carvedilol and
Lasix a few hours apart. Also when going from laying to sitting
to standing please remain at each position for a couple minutes
before moving.
While in the hospital you were found to have a high calcium
level and received a type of medication called a bisphosphonate
(pamidronate) to help lower the calcium and protect your bones.
You were discharged with low dose oxycodone to help with your
nephrostomy-site pain especially at night.
You also had some acid reflux symptoms and were restarted on
your Protonix.
You have appointments with the Genetics team and lung doctor
tomorrow.
You will follow-up with Dr. ___ in clinic on ___
___ at 9:30 AM.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
All the best,
Your ___ Team | Mr. ___ is a ___ man with metastatic high grade
neuroendocrine carcinoma (possible lung primary) diagnosed in
___ with diffuse metastases to liver, bone, peritoneum, and
lymph nodes receiving palliative atezolizumab maintenance (C5D1
___, CAD s/p CABG ___, complete heart block s/p PPM, HFpEF
(EF 50-55%), DVT on eliquis, and prostate cancer s/p TURP/XRT
___ c/b radiation cystitis s/p bilateral PCN who is transferred
from OSH after presenting with abdominal pain and near
fall/weakness.
# Abdominal Pain:
# Near Fall/Weakness:
# Hypotension: His abdominal pain has now resolved after Tylenol
and BM. BP was ___ by EMS. CT A/P at ___ without
any acute pathology. Unclear if this was constipation (wife
states his BMs have been regular). He has a complicated history
of urosepsis, but labs without leukocytosis or systemic symptoms
and nephrostomy sites look good. Most likely his near
fall/presyncope and hypotension was in setting of
deconditioning, medications, and metastatic malignancy. No
events
on telemetry and EKG unchanged. Cultures with no growth. He was
seen by ___ and did well. He was found to have likely disease
progression (see below) which is contributing to symptoms. His
anti-hypertensives were downtitrated.
# High-Grade Neuroendocrine Carcinoma:
# Secondary Neoplasm of Liver:
# Secondary Neoplasm of Bone:
# Secondary Neoplasm of Peritoneum:
# Secondary Neoplasm of Lymph Node: Possible lung primary.
Currently receiving palliative atezolizumab maintenance. Concern
for disease progression with uptrending CEA (rechecked during
admission on ___ and was 3720 up from 3166 on ___ and
hypercalcemia. He will follow-up with Dr. ___ in clinic to
discuss further treatment options.
# Hypercalcemia in Malignancy: Mildly elevated to 10.8 on
admission. Patient with bone mets, notably at L3 vertebral body
without associated pain. He was given pamidronate 60mg IV on
___.
# Fatigue: Likely deconditioning especially in light of his
recent hospitalization for urosepsis on top of his age,
malignancy, and medical comorbidities. Recent TSH and AM
cortisol was normal.
# Obstructive Uropathy s/p Bilateral PCNs:
# Mild Left Hydronephrosis:
# ___ on CKD: Had Cr up to 1.5 at ___, baseline Cr
about 1.2. Most likely prerenal from poor intake. Has received
1L NS. Cr at baseline on discharge. He will continue home Lasix.
# Hematuria: Notable for hematuria from right nephrostomy likely
in setting of anticoagulation. Less likely infection. H/H was
stable.
# Chronic Cough: Not helpful PPI, albuterol, allergy meds, cough
suppressants (benzonatate and codeine-guaifenesin). Continued
recently started gabapentin trial. Continued CPAP and nasal
spray. Has outpatient Pulmonary follow-up with PFTs tomorrow.
# CAD s/p CABG:
# HFpEF (50-55%):
# CHB s/p PPM: Given hypotension reported during fall event at
home his Imdur was held and his carvedilol dose was halved. His
blood pressures were monitored and were well-controlled on
reduced medications. His Lasix was continued.
# Hypomagnesemia: Monitored and repleted PRN.
# LLE DVT: Diagnosed on ___ with ___ showing LLE DVT.
Initially on lovenox and transitioned to apixaban. Continued
home apixaban.
# Anemia: Likely secondary to malignancy and chronic disease. At
baseline. Continue to monitor.
# Hyperlipidemia: Continued home fenofibrate and niacin.
# Anxiety/Insomnia: Continued home oxazepam and fluoxetine.
# RLS: Continued home ropinirole.
# Cognitive Impairment: Continued home memantine.
# IBS: Continued home dicyclomine.
# BILLING: 50 minutes were spent in preparation of discharge
summary, counseling provided to patient and family, and
coordination of care with outpatient team.
==================== | 213 | 525 |
16197567-DS-4 | 21,074,150 | You were admitted to the hospital with abdominal pain. You
underwent imaging and you were reported to have appendicitis.
You were taken to the operating room to have your appendix
removed. Your vital signs have been stable. You are preparing
for discharge home with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary ___ provider after having surgery. We have scheduled an
appointment for you listed below.
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 male admitted to the hospital with right lower
quadrant pain and leukocytosis. Upon admission, the patient was
made NPO, given intravenous fluids, and underwent imaging. Cat
scan imaging showed acute uncomplicated appendicitis without
evidence of organized fluid collection or perforation. Based on
these findings, the patient was taken to the operating room
where he 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 clear
liquids and advanced to a regular diet. His incisional pain was
controlled with oral analgesia. He was ambulatory and voiding
without difficulty. The patient was discharged home on POD #1
in stable condition. The patient was given a prescription to
complete a final day of ciprofloxacin and flagyl. Discharge
instructions were reviewed and questions answered. An
appointment for follow-up was made in the ___ ___ clinic.
The patient was encouraged to call the Acute ___ clinic with
any questions or concerns. | 829 | 190 |
17564186-DS-11 | 22,865,465 | Dear Ms ___,
It was a pleasure caring for you at the ___
___.
You were admitted for chest pain and shortness of breath. You
were evaluated with a stress test which was reassuring, as well
as lab tests for blood clots which was also reassuring. While we
did not identify a specific cause for your chest pain, we are
glad there was no evidence of heart disease on your stress test.
The results of your barium swallow are pending and you can
follow up with your primary care doctor for these results.
Please keep all of your follow-up appointments and take your
medications as prescribed.
Best wishes,
Your ___ Cardiology Team | ___ with PMH DM, HTN, HLD, and chronic pain who presented with
atypical chest pain.
.
# Chest pain: troponins negative X 2. EKG with T wave
inversions, seen on prior EKGs. new rate-dependent RBBB. Pt
spoke in gibberish and stopped moving at times when pain was
worse. Normal neuro exam and patient would return to normal
function when she needed to explain things to the medical team.
-unlikely MI, no dissection on CXR, negative d-dimer and
resolution of sinus tachycardia make PE less likely, consider
psychiatric since she hasn't had her home meds, esophageal
spasm. Prior normal stress MIBI in Atrius records. Repeat showed
normal cardiac perfusion. Prior EGD/colonoscopy in ___
except for a mild, incomplete Schatzki ring; repeat esophagram
showed moderate esophageal dysmotility and mild spontaneous
gastroesophageal reflux into the mid thoracic esophagus.
Increased home omeprazole to 40mg BID
# Diabetes:
- held metformin while inpatient
- ISS while hospitalized
# Chronic pain disorder:
- continued venlafaxine baclofen, gabapentin,
acetaminophen/codeine as needed
# Asthma:
- continued singulair, fluticasone, and levalbuterol PRN
# HTN:
- continued home Triamterene-HCTZ.
# Depression:
- continued home venlafaxine | 107 | 176 |
14337110-DS-34 | 23,357,990 | Dear Ms. ___,
It was a pleasure meeting you and taking care of you.
Why you were here:
- You came in because you were having abdominal pain and feeling
unwell.
What we did in the hospital:
- We treated you for a viral infection (CMV) that we found in
your blood stream. We also saw evidence of infection in your
lungs which made us concerned that this was a very serious
infection. We gave you an IV antiviral medication called
ganciclovir. We monitored your viral level and saw that your
viral load did not improve on the IV Ganciclovir. We recommended
that you stay for additional IV ganciclovir therapy, but you
decided to leave against medical advice. As such we would
recommend that you at the very least take the oral
Valgancyclovir though we feel this may not be adequate for
proper treatment.
- We also discovered that you are actively using heroin and
fentanyl. We started you on a medication called methadone to try
and help you stop using opiates. We strongly encourage you to
continue getting help to stop using opiates and seek out
treatment for your opiate use disorder. Options include
methadone clinics and suboxone providers. Additionally
naltrexone is a common treatment.
What you should do now:
- YOU HAVE DECIDED TO LEAVE THE HOSPITAL AGAINST MEDICAL ADVICE.
WE RECOMMEND THAT YOU SEEK MEDICAL CARE AND RETURN TO THE ED FOR
MEDICAL CARE AS SOON AS POSSIBLE. YOU HAVE BEEN COUNSELLED ON
RISKS OF LEAVING WHICH INCLUDE DEATH, WORSENING INFECTION,
PERMANENT DISABILITY, LOSS OF YOUR TRANSPLANTED KIDNEY.
- WE RECOMMEND THAT YOU TAKE YOUR VALGANCYCLOVIR EVERY DAY AS
INDICATED BELOW AND STRONGLY RECOMMEND THAT YOU GO TO YOUR
APPOINTMENTS, PARTICULARLY YOUR RENAL TRANSPLANT APPOINTMENT.
- IT IS INCREDIBLY IMPORTANT TO GET WEEKLY LABS (EVERY ___
WITH YOUR RENAL ___ SO THEY CAN MONITOR YOUR CMV
VIRAL LOAD TO MAKE SURE THAT YOU DO NOT GET SICKER
We wish you the best,
Your ___ team | ___ with a history of MPGN s/p preemptive renal transplant in
___ s/p transplant nephrectomy requiring PD and then HD and
DDRT in ___ on tacro/MMF presenting with back pain, epigastric
pain, N/V, and fevers, found to have CMV Viremia consistent with
CMV enteritis and pulmonary nodules c/w CMV pneumonitis.
Patient's MMF was held and she was started on IV Ganciclovir for
high CMV VL (5.2). During admission, patient had very little
improvement in CMV viral level after two week of IV ganciclovir.
Per ID, and Renal transplant the patient was recommended to stay
and get additional IV ganciclovir however she decided to leave
against medical advice. Per psychiatry the patient was
determined to be competent to leave against medical advice. As
such she was given PO valganciclovir with course to be
determined at outpatient transplant nephrology appointment.
Of note, patient also left the hospital floor several times, and
had a bed search were she was found to have fentanyl and heroin
w/ rolled bills (no syringes). She was started on methadone,
which was tapered during admission. She reported that she was
not interested at this time in treatment for her opiate use
disorder. Psych was consulted who felt that patient had limited
insight into severity of her disease, and recommended continued
discussion with patient regarding the importance of medicine
adherence but felt that she had competence to leave against
medical advice. | 324 | 233 |
16165869-DS-14 | 26,179,066 | Thank you for allowing me to assist in your care. It is a
privilege to be able to take care of you. Should you have any
questions about your post-operative care feel free to call my
office at ___ during business hours and either myself
or ___, PA-C will address any questions or
concerns you may have. If this is an urgent matter at night or
on weekends please call ___ and ask the page operator
to page the covering ___ call orthopaedic physician.
Prescription refills or changes cannot be addressed after normal
business hours or on weekends.
PAIN CONTROL:
-You may or may not have had a nerve block depending on the
type of surgery. This will likely wear off later in the evening
and it is normal to have increased pain when the nerve block
wears off. Please take your prescribed pain medications as
directed with food prior to the nerve block wearing off.
-Stay ahead of the pain!
-Narcotic pain medications can cause constipation. Please take
a stool softener while taking these and drink plenty of water.
-Please plan ahead! If you are running out of your medication
prior to your follow-up appointment please call during business
hours with a ___ day notice. Prescription refills or changes
cannot be addressed after normal business hours or on weekends.
NON-NARCOTIC PAIN CONTROL
-Multi-modal pain control is critical. If you are able to take
Tylenol (acetaminophen) I would strongly encourage you to do so
according to the instructions on the bottle. Do not take more
than 4,000 mg of Tylenol in 24 hours.
-NSAIDs (Advil, Motrin, Aleve, etc) are also excellent for pain
control post-operatively. Do not take if you have had a bone
fusion surgery, but for soft tissue procedures or most fracture
surgeries these medications are acceptable unless you are unable
to take for other medical reasons or unless we have specifically
instructed you against it.
-Elevation with the operative site above the level of the heart
will decrease swelling and improve pain control
-Ice or cold therapy may also be helpful. Do not keep ice or
cold directly on the skin and do not use for more than ___
minutes to decrease risk of skin injury from the cold. Do NOT
use ice when the block is still in effect as you will not know
if you are injuring yourself. You may place the ice pack behind
your knee if you have a bulky dressing on your foot.
-Every little bit helps. The faster you can come off the
narcotic medication the better. Most of my patients do not need
narcotics after the first post-operative visit!
ACTIVITY:
-You will likely have swelling after surgery. Please keep the
foot elevated on ___ pillows at all times possible. You can
apply a dry, covered, ice-bag on top of your dressing or behind
your knee for 20 minutes at a time as often as you like.
-Unless instructed otherwise you should not put any weight down
on your operated extremity until you come back for your first
postoperative visit.
CARE FOR YOUR DRESSING:
-You should not remove your dressing. I will do so when I see
you for your first post-operative visit.
-It is not unusual to have a little bloody staining through
your dressing. However please call the office for any concerns.
-Keep your dressing clean and dry. You will have to cover it
when you bath or shower. If it gets wet please call the office
immediately.
PREVENTION OF BLOOD CLOTS:
-You have been instructed to take medication in order to help
prevent blood clots after surgery. Please take an aspirin 325 mg
every day unless you have been specifically prescribed a
different medication by me. If there is some reason why you
cannot take aspirin please notify my office.
DRIVING:
-My recommendation is that you should not drive if you:
(1)are still taking narcotic pain medications
(2)have any type of immobilization on your right side
(3)are unable to fully bear weight without pain on your right
side
(the above also apply to the ___ side if you have a manual
transmission (stick shift)
-There is no substitute for common sense and safety. If you do
not feel safe driving, do not do so. Practice in an empty
parking lot prior to driving on the road.
-Driving is easy. Stopping in an emergency is hard
WHEN TO CALL:
-Please call the office if you have any questions or concerns
regarding your post-operative care. We need to know if things
are not going well.
-Please make sure you call the office or page the ___ call
orthopaedic physician immediately if you are having any of the
following problems:
1.Fever greater than 101.4
2.Increasing pain not controlled on pain medications
3.Increasing bloody staining on the dressing
4.Chest pain, difficulty breathing, nausea or vomiting
5.Significant asymmetric leg swelling
6.Cold toes, toes that are not normal color (pink)
7.Any other concerning symptoms
Physical Therapy:
NWB LLE
Treatments Frequency:
External fixator placed temporarily ___, now patient s/p
___ foot and mini external fixator placement ___. | The patient was admitted to the Orthopaedic Service from the
Emergency Department after suffering injuries to his ___ foot.
On ___, he underwent external fixation ___ foot with the
Orthopaedic Trauma on call team. He tolerated the procedure
well, and recovered well post operatively on the floor. His
pain was controlled with IV then PO medications. Periop
antibiotics were given and DVT PPX per routine. He was
evaluated by the Physical Therapy team, advanced his diet, and
was voiding without issue.
He chose to remain in the hospital until his definitive surgery.
On ___, He was taken to the OR for removal of ex-fix, ___
___ navicular, talus, ___ metatarsal, and cuboid, with
placement of a mini external fixator. He did well, and
recovered well post operatively on the floor. His pain was
controlled with IV then PO medications. Periop antibiotics were
given and DVT PPX per routine. He was evaluated by the Physical
Therapy team, advanced his diet, and was voiding without issue.
On POD1 he was cleared by ___ for discharge home, and was
discharged in stable condition. All instructions reviewed, and
patient expressed understanding of the plan. | 806 | 196 |
11700821-DS-17 | 26,855,769 | Dear Mr. ___,
It was a pleasure to take care of you during your recent
hospitalization at ___. You
were admitted because you felt like you were choking on one of
your medications at home. You were coughing and wheezing, and we
treated you with nebulizer treatments and anti-cough medication.
In the future, to prevent risk of choking, please take all your
medications while sitting up.
Please take all your medications as prescribed.
Thank you for allowing us to participate in your care.
- Your ___ Team | ___ man with a PMH notable for HIV and hep C as well as
paranoid schizophrenia and hemochromatosis presenting s/p an
aspiration event.
#ASPIRATION: The patient's history is consistent with a small
volume aspiration including a foreign body (ATRIPLA pill).
Initial CXR showed a RLL opacity potentially consistent with
aspiration. CT chest later during ED course showed no evidence
of consolidation, or parenchymal involvement. Antibiotic was
discontinued at that time. The patient's presentation was
consistent with chemical bronchitis not complicated by
aspiration pneumonia or pneumonitis. He was managed
symptomatically with nebulizers and antitussives with
significant improvement in his symptoms by the time of
discharge.
# HIV: last CD4 count in ___ was 1068 and the corresponding
viral load was undetectable. Continued Atripla.
# Paranoid schizophrenia: continued olanzapine, citalopram,
clonazepam.
# HTN: continue amlodipine, lisinopril. | 85 | 130 |
15528228-DS-38 | 26,799,174 | Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with high sugars. You were treated in the ICU and improved.
You were seen by diabetes specialists who recommended that you
start insulin. You were also found to have high potassium
levels. It is important that you take all of your medications
including hydrochlorothiazide and sodium bicarbonate, follow a
low potassium diet and return to have your potassium checked at
your follow up with Dr. ___.
For your diabetes, you should take Lantus (glargine) 4 units in
the morning and at bedtime and continue to check your sugars 4
times per day. You will be contacted with a follow up
appointment by ___.
We wish you the best,
Your ___ Care team | ___ year old male with past medical history of chronic
pancreatitis, diabetes secondary to pancreatic dysfunction
previously on insulin, CKD stage 3, pancytopenia, admitted
___ with suspected DKA, acidosis, hyperkalemia requiring
insulin drip in the ICU, course complicated by persistent
hyperkalemia
# Diabetes Mellitus ___ chronic pancreatitis complicated by
hyperglycemia and ketoacidosis
Patient with history of insulin dependence, with admission ___
___ notable for discontinuation of insulin therapy,
subsequently maintained on repaglinide. He presented this
admission with polyuria, poor appetite, dizziness, found to have
plasma glucose of 1200, HCO3 19 concerning for DKA. He was
treated with insulin gtt and fluid resuscitation. No signs of
infection or ischemia. A1c found to be 12.3% from 6% in ___.
Patient seen by ___ consult service and recommended to start
basal insulin therapy. Course complicated by intermittent
hypoglycemia. The patient's sugars improved and he was
discharged on Lantus 4 units twice daily in additional humolog
sliding scale. The patient was encouraged to take long acting
consistently. He has follow up scheduled with ___ NP within 2
weeks.
# ___
# CKD stage 3
Admitted with Cr 2.2 from baseline 1.3-1.4. Thought to be
pre-renal in the setting. Resolved with IV fluid resuscitation.
Creatinine 1.6 on day of discharge
# Hyperkalemia
Course notable for intermittent hyperkalemia, highest 6.6 on
presentation. The patient has a history of hyperkalemia on
previous admissions. He was seen by Renal at that time and was
evaluated for adrenal insuffiency. He had a repeat AM cortisol
this admission which was elevated. Ultimately, it was determined
that the patient's hyperkalemia is likely related to ___ and
acidosis. He was continued on HCTZ and sodium bicarbonate and
will have repeat potassium checked 2 days after discharge. He
was also provided education regarding a low potassium diet.
# Dysphagia -
While in ICU patient reported chronic dysphagia symptoms of food
"getting stuck". Underwent barium swallow while in ICU--it
distal esophageal dysmotility without structural abnormality.
As transitional issue, would consider follow-up GI appointment
# Pancreatic insufficiency
Continued creon
# History of alcohol abuse
Denied current use. Continued FoLIC Acid, multivitamin
# Depression
Continued Sertraline, Mirtazapine
# Hypertension
Continued labetalol. Hctz initially held while acutely ill.
Restarted once improved.
# Insomnia
Continued Ramelteon
# Pancytopenia
Has chronic that was previously attributed to alcoholism. Labs
notable for continued pancytopenia. He denied recent alcohol
abuse this admission. Blood counts stable through admission.
Would consider outpatient workup for persistent pancytopenia if
not already done
# Abnormal Thryoid Function Tests
Had normal TSH, borderline low fT4 in setting of acute illness.
Would repeat thyroid function test as outpatient once no longer
acutely ill | 128 | 439 |
10410872-DS-7 | 29,300,512 | Ms. ___, you were hospitalized for nausea, vomiting and
diarrhea. While you were here, we worked up the cause of your
symptoms and gave you fluids to replete the volume that you
lost. We performed a CT scan of the abdomen that showed evidence
of colitis and empirically treated you for C. Diff infectious
colitis given your high risk factors of coming from a nursing
home, but discontinued the vancomycin once your C.Diff test
returned negative. The CT abdomen also showed a fluid collection
near the T10-T12 paraspinal space next to the spinal fusion
hardware that had gas and was ring enhancing, which was
concerning for a possible infection. We consulted interventional
radiology who performed a drain and thought it was only a
hematoma as only ___ of blood came out. We sent the specimen
for bacterial and fungal culture analysis, which are pending but
thus far have been negative. There was a left lower lobe
consolidation on the Chest Xray, but it was likely a result of
inflammation from the fluid collection, and not an infection. It
will likely resolve on it's own. Finally, We discussed with your
primary doctor, ___ who recommended holding your
orencia and methotrexate while you are here, which we did. We
scheduled an appointment for you with Dr. ___ in
gastroenterology on ___. | ___ with RA, Anxiety, Chronic pain presenting with N&V found to
have colitis on CT and paraspinal fluid collection.
#Colitis: Etiology is infectious vs ischemic vs inflammatory.
Ischemic and inflammatory less likely given lack of BRBPR, and
absence of acute pain. Colitis of the sigmoid and descending
colon likely infectious, including cdiff colitis given her rehab
home status. We obtained an ID consultation, who recommended
that given her nursing home status combined with high volume
diarrhea, we should empirically treat for Cdiff colitis. We
later discontinued the antibiotics when her Cdiff returned
negative. Additionally, we tested for EBV, CMV which were also
negative. This was thought likely secondary to viral
gastroenteritis.
#Surgical Fluid Collection, paraspinal: large 3cm x4cm x8cm
Concern for infection given gas found on CT and ring enhancing.
We consulted interventional radiology who performed a drainage,
and commented that only ___ ccs of serosanguinous fluid drained,
and that this was likely a residual hematoma from her recent
spinal fusion surgery. The fluid was sent for bacterial, fungal
and AFB culture/stain, which are NGTD at the time of discharge.
#LLL Consolidation: A LLL consolidation was observed on CT,
adjacent to the fluid pocket. Concern for inflammatory process
vs. early PNA from surgical site. No cough, fever, or
leukocytosis rendered PNA less likely. We treated her with
vanc/zosyn for one day, and discontinued it as we felt it was
more likely to be due to adjacent inflammation induced by the
hematoma as opposed to a true infection. Her respiratory
symptoms remained normal throughout the hospital admission.
#Trop elevation: Patient had a mild trop elevation to 0.12,
without EKG changes or symptoms of chest pain/discomfort/SOB. We
subsequently trended her troponin and it decreased to 0.08 and
0.03. This was likely due to demand ischemia in the setting of
severe volume depletion.
#RA: In discussion with Dr. ___ (PCP), we were
recommended to hold methotrexate and orencia during this
hospitalization, which we did. She was asymptomatic throughout
the admission. Given no evidence of infection with above
workup, methotrexate was restarted on discharge | 219 | 342 |
16811254-DS-15 | 20,483,615 | Dear Mr. ___,
You were hospitalized due the symptom of mutism resulting from
an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. There was also seen to be HEMORRHAGIC TRANSFORMATION
within the stroke, meaning that there was bleeding in the brain.
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
-Diabetes
We are changing your medications as follows:
-Stop taking rivaroxaban
-Start taking apixaban 5 mg twice daily
-Decrease atorvastatin to 20mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team | Mr. ___ is an ___ year old man with significant for multiple
prior strokes (chronic bilateral frontal, parietal, cerebellar)
in setting of afib (on xarelto) with baseline residual cogntive
deficits and mRS4 requiring 24hr care who comes in for 2 weeks
of reported mutism with no spontaneous speech output.
OSH CTH notable for subtle area of left parietal cortical
hyperintensity concerning for laminar necrosis vs SAH. In house
MRI brain showed subacute infarct in the L parietal lobe with
hemorrhagic conversion. Continuous EEG without evidence of
epileptiform discharges. Most likely etiology of stroke
cardioembolic given known aftrial fibrillation despite taking
Xarelto. Xarelto and atorvastatin held due to hemorrhagic
transformation. Repeat CTH on ___ showing stable foci of
hemorrhage and apixaban 5 mg BID was started. Given LDL low at
36, atorvastatin restarted at lower dose of 20mg qPM. Patients
mental status waxed and waned throughout hospitalization, but
during bright spots patient was able to follow simple commands,
repeat words, say "hi", and respond appropriately to Y/N
questions. Additionally demonstrated significant sundowning
which responded well to scheduled Seroquel 25 mg qhs.
# Subacute infarct in the L parietal lobe with hemorrhagic
conversion
- LDL:36, TSH:.88, A1c: 9.9; TTE w/out septal defect or obvious
source of thrombus
- Failed Xarelto so was switched to abixaban 5 mg ___ when ___
showed stable hemorrhagic foci
- Atorvastatin 80 mg qhs changed to 20 mg qhs as LDL 36, will
need to follow up lipid panel in 6 months
- Follow up with neurology in 3 months with pre-clinic MRI brain
w/wo contrast
- Patient to return to extended living facility and should
continue to receive ___ therapy
# CV:
1) Afib
- Xarelto switched to Apixaban 5 mg bid
- continue coreg 6.25 mg BID
2) HTN
- continue losartan 100mg qdy
3) CHFpEF
- TTE with LVEF ___
- continue furosemide 60mg qday and other cardioprudent
medications as above
#Diabetes Mellitus
Home regiment: Insulin glargine 58U qhs, SSI, and metformin 1000
mg BID
- Followed ___ Diabetes while in hospital and
dosing of insulin adjusted based on current PO intake and will
be discharged on this regimen
/- PCP to adjust insulin dosing as indicated
#Stage II ulcers to scrotum and gluteus
-Please provide wound care to these areas daily
#Pneumonia- He developed a pneumonia (likely aspiration pna)
with leukocytosis, cough, and LLL consolidation on ___.
Initially treated with Zosyn, transitioned to ciprofloxacin as
outpatient.
-continue ciprofloxacin for 6 days (___)
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________ | 303 | 396 |
17023443-DS-10 | 27,935,263 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
BUE assist.
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: on AM of POD 2 by ___, then daily bt RN; please
overwrao any dressing bleedthrough with ABD's and ACE | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left subtrochanteric femur fracture in the setting of
bisphosphonate use and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for left long TFN, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with the orthopedic trauma team per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 648 | 270 |
12302912-DS-10 | 20,427,389 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You came in with abdominal pain. This is due to
gastroesophageal reflux disease. We treated your abdominal pain
with oxycodone and a GI cocktail. It is important you see your
GI physician, ___ the next 2 days to complete
you GI workup as an outpatient. | ___ with GERD who presents with worsening epigastric pain.
# Epigastric Pain: ___ GERD, poorly controlled with medical
management. Patient followed by ___ physician, ___
___, and ___ as outpatient. Per patient,
he was scheduled for a ___ procedure, however this was
cancelled for various reasons. Patient's abdominal pain was
partially relieved by a GI cocktail and oxycodone (10mg Q6H
PRN). Patient continued to demand IV narcotics despite declining
PO oxycodone when offered. Given that the patient has been able
to tolerate PO (yogurt and smoothies) and denied any weight
loss, ___ medical management was not indicated. We
told the patient that there was no rationale for IV narcotics
and escalating PO oxycodone was potentially more harmful.
Patient reported ___ as the medical attending, resident team,
thoracic surgery fellow, and RN met with the patient. We
reviewed lack of indication for hospitalization and fact that
patient was offerred PO oxycodone through out the day for his
earlier reports of ___ pain but that he declined this
medication. He did say that maalox-viscous lidocaine helped
improve his pain to ___. He was aggreable to take
maalox-vicous lidocaine and oxycodone prior to discharge to see
if it helps his symptoms and also drink and eat. We ordered
these medications and he took a regular diet and I was not
notified that he had worsened pain or inability to keep food
down.
I spoke wiht Dr. ___ and my resident directly
with Dr. ___ both agreed that the patient required
continued workup as an outpatient before definitive treatment.
Neither felt that patient had any compelling reason to remain
hospitalized. He also would not be able to have BRAVO pH probe
test repeated as inpatient since is not available to inpatients.
Patient's previous pH testing indicated malposition of probe
tip making accurate diagnosis of GERD.
Patient was discharged with a 2 day supply of oxycodone as well
as a GI cocktail (lidocaine/maalox). He will continue his
oupatient medications. He was instructed to make an appointmen
with Dr. ___ ___ days of discharge. Patient
demonstrated understanding and was agreeable to the plan.
# Transaminitis: Etiology unclear. He has had transaminitis in
the past with a negative workup. Transaminitis trended down
prior to discharge.
# Anxiety/Psych: Continue the following home meds
-ClonazePAM ___ mg PO TID:PRN anxiety
-Gabapentin 100 mg PO Q8H
-LaMOTrigine 100 mg PO DAILY
-Temazepam 15 mg PO HS:PRN insomnia
-Tizanidine 4 mg PO BID:PRN muscle pain | 57 | 416 |
11993263-DS-11 | 27,025,258 | Dear Mr. ___,
___ were admitted to ___ with
recurrent complicated diverticulitis with an abscess in your
pelvis. A drain was placed by interventional radiology with some
symptom improvement. ___ were then taken to the operating room
on ___ for resection of the diseased segment of your colon and
creation of a colostomy. ___ 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:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until ___ follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
INCISION CARE:
*Please call your doctor or nurse practitioner if ___ have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
___ may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
JP DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
___ may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
OSTOMY DISCHARGE INSTRUCTIONS:
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own. | Mr. ___ is a ___ year old male who presented to ___
___ on ___ with recurrent ___
sigmoid diverticulitis. He was found to have a pericolonic
abscess of greater than 6 x 3 x 3 cm in size, in the same
location as his previous diverticulitis flare. The patient was
admitted to the Acute Care Surgery Service for further
management.
.
The patient was kept NPO on IV fluids. He was started on IV
antibiotics. The patient was taken to interventional radiology
for an abscess drainage procedure on ___ (for details of
the procedure, please refer to the radiology note). The patient
tolerated the procedure well without complication. The patient's
long-term management options were discussed and he elected to
undergo sigmoid colectomy for definitive management of her
diverticulitis.
.
The patient was taken to the operating room on ___ and
underwent an open sigmoid colectomy with ___ and wound vac
placement (midline incision). His ___ drain was removed and a
surgical drain was placed. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complication and was brought to the post
anesthesia care until in stable condition. He was then
transferred to the surgical floor, where he remained throughout
his admission.
.
Post operatively, the patient did well. His ostomy showed signs
of bowel function on POD4, and his diet was slowly advanced as
tolerated. His ostomy function continued to improve throughout
his admission. The patient was seen by the ostomy nurse and
received appropriate teaching.
.
The patient's wound vac was changed on POD3 without issue. We
had planned to discharge the patient home with continued wound
vac therapy and ___. However, the patient was unable to tolerate
wound vac change prior to dispo due to severe pain. A wet to dry
gauze dressing was placed instead with instructions to continue
BID dressing changes at home. His JP drain output was monitored
for signs of infection, of which there were none. He received JP
drain teaching.
.
The ___ hospital course was complicated by issues with
pain control. He had an epidural placed pre-operatively which
failed to work after POD1 and he was switched to a PCA, which
caused intermitted confusion. The geriatric service was
consulted in the setting and provided recommendations regarding
pain control and delirium precautions. His pain control and
mental status improved significantly when he was able to
tolerate PO medications.
.
On ___, the patient was tolerating a regular diet, voiding
spontaneously without issue, ambulating independently, and his
pain was well controlled on oral pain medication alone. He was
deemed ready for discharge to home with ___ services for
dressing changes and JP drain care. He was provided with follow
up instructions and demonstrated understanding. | 583 | 453 |
13536333-DS-25 | 28,828,935 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
***XARELTO: DO NOT RESUME until ___. Hold if urine
pink/bloody and notify your urologist. We excpect that you can
resume the Xarelto after your urine has been clear/yellow for
___ days.
***Please continue the daily aspirin as directed.
***Complete the five day course of antibiotics to reduce your
risk of infection
***Lasix (Furosemide) is listed as an active medication but you
have said you do NOT take this. Please follow-up with your
PCP/Cardiologist to confirm that you should NOT be taking this
medication.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink fluids to
keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house. | ___ year old male with hematuria likely secondary to aspirin and
Xarelta use is admitted to the urology service. He is
catheterized and continous bladder irrigation (___) is
intitiated but this does not clear the hematuria. He is then
bedside hand irrigated for clots. He is admitted to general
surgical floor. Xarelta is held but his aspirin is continued.
Pain medications and antibiotics provided and he is given diet
as tolerated. Within 48hours and after at least two additional
hand irrigations, his urine is clear enough for discharge home.
On date of discharge his complaint is noted to be 'penile pain'
and he is found to have a paraphimosis. This is reduced at
bedside bith manual pressure and manipulation of the foreskin
and successfully protracted over the glans. CBI was then
disconnected and he was discharged home with antibiotics and a
follow up plan for future trial of void. He will resume Xarelta
when his urine has been yellow/clear for ___ days unless
otherwise advised. All of his questions were answered. | 337 | 175 |
18264883-DS-9 | 23,671,178 | Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted because of an abnormal stress test. We performed
cardiac catheterization and did not find any blockages in your
arteries. Your blood pressure was high so we added one
medication to your regimen.
We made the following changes to your medications:
STARTED Chlorthalidone
STOPPED Metformin (please restart on ___ | ___ y/o M PMHx morbid obesity, HTN, DM2, HLD, presented to PCP
___ 2 months of worsening intermittent chest pain concerning
for CAD. Patient recalled to the hospital after an abnormal
pMIBI.
# Chest Pain/Abnormal pMIBI - Patient with significant risk
factors (despite young age) and typical chest pain occuring at
increasing frequency x several months. Positive pMIBI raising
concern for areas of ischemia. EKG without ischemic changes and
cardiac enzymes were negative. Patient developed one episode of
mild chest pain on the morning of admission, not associated with
EKG changes, pain resolved with Tylenol and Ativan. Cardiac
cath showed no coronary artery disease. Recommend outpatient
ECHO, in light of depressed EF on pMIBI.
# HTN: Blood pressure high in the hospital and reportedly at
home. SBP in the hospital 150-180. Could be contributing to
his chest pain episodes. Continued lisinopril, clonidine,
amlodipine, avapro and added chlorthalidone 25mg daily (reported
allergy to HCTZ- fatigue).
# DM2- Humalog sliding scale while inhouse. Advised patient to
restart metformin on ___ (48 hours from cath).
# Chronic sCHF - Per nuclear study, calculated EF 52%, currently
no evidence of volume overload. Patient on prn diuresis/lasix
at home. No diuresis during this hospitalization.
# GERD- Continued protonix
# Asthma - Continued advair, albuterol prn
# Anxiety- Continued prn ativan
# Transitional issues:
- code status: full
- follow up: Dr. ___ ___. recommend outpatient ECHO | 62 | 233 |
14450311-DS-18 | 29,683,317 | Dear Ms. ___,
You came to the hospital with chest tightness. You were found
to have fluid build-up in your lungs and in your legs. This is
called a "heart failure" exacerbation, or flare. To prevent
this from happening, please take torsemide (water pill)
everyday. Please weigh yourself every day and call your doctor
if your weight goes up > ___ lbs. It is important to limit your
fluid intake to < 2 liters per day.
You were also found to have signs of stress or injury to the
kidneys. The left-sided nephrostomy tube was replaced while you
were here. The kidneys were improving at the time of discharge.
Please follow-up with your doctors as below. | SUMMARY:
___ yo F PMHx HFpEF (EF 77%, ___ MR, PASP 58+RAP), severe PH on
echo, ASD, TIA, sinus node dysfunction, metastatic ureothelial
carcinoma s/p bilateral percutaneous nephrostomy tube placement
(right PCNU internalized to JJ stent ___, left PCNU
in place, last exchanged ___ presenting with dyspnea and lower
extremity edema, found to have volume overload ___ acute
decompensated CHF, as well as ___. | 122 | 63 |
17970081-DS-20 | 28,729,873 | Dear Ms. ___,
You were admitted to ___
because of abdominal pain with nausea/vomiting and loose stools.
You had imaging done of your abdomen which showed some
inflammation of the bowel. We conducted some tests and provided
symptomatic control. Please be sure to follow up with your
primary care physician soon after discharge.
It was a pleasure taking part in your care!
Your ___ Team | ___ with PMHx of Type I DM on insulin pump, HTN, HLD, prior
abdominal surgeries (salpingectomy, ovariancystectomy, ex lap,
LOA), NASH, GERD, anxiety/depression who presented with
abdominal pain, found to have colitis.
#Left Sided Colitis: Etiology of colitis unclear. Not likely
infectious in nature as patient never had leukocytosis and
remained afebrile with other vital signs also stable. Symptoms
were acute onset in nature, and based on CT scan findings and
standing narcotic use with intermittent laxative use, this
episode of abdominal cramping/constipation and subsequent loose
stools likely secondary to subacute mild ischemic colitis in
setting of narcotic bowel syndrome and chronic vascular
mesenteric disease. Prior colonoscopies have not shown evidence
of IBD. Stool cultures were pending at discharge, but negative
for norovirus. Patient received flagyl x1 in the ED but no abx
given on the general medicine floor. Symptomatic control
achieved by Tylenol, oxycodone (close to narcotics agreement
dose)and Zofran. Patient was started on BRAT diet and advanced
to regular food. She was able to tolerate food at discharge.
CHRONIC ISSUES:
#Type I DM: Continued Novolog insulin pump
#chronic back pain: Pain controlled as above
#GERD: Continued protonix, ranitidine, sucralfate
#CAD prevention: continued ASA and simvastatin
#anxiety: Continued diazepam.
Transitional Issue
==================
[]Consider tapering oxycodone as tolerated and alternative pain
control regimen. Patient counseled that she should be wary
regarding danger of over-laxative use and the importance of a
stable bowel regimen in this setting. Consider reinforcing at
outpatient appointment.
[]stool cultures pending at discharge, noro negative.
[] consider repeat imaging and/or follow colonoscopy if symptoms
recur or do not fully resolve | 62 | 259 |
19897837-DS-16 | 27,376,452 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a skin infection around your ankle.
- You developed a kidney injury from one of your antibiotics, so
then we treated your kidney.
What was done for me while I was in the hospital?
- Your skin infection on your ankle was treated with antibiotics
and a steroid cream.
- Your kidneys were monitored, and they healed on their own.
- Your scalp rash was treated with medical shampoo.
What should I do when I leave the hospital?
- Please continue taking your home medications.
- Please continue your steroid cream until your ankle is no
longer red.
- Please follow up with the kidney doctors to make sure your
kidneys continue to do well.
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES
==================
[ ] discharge K 5.5
[ ] will have labs drawn by ___.
SUMMARY
========
Mr. ___ is a ___ y/o M w/ hx of CKD, HTN, HLD who
was admitted for cellulitis after initial treatment with
cefpodoxime appeared to cause a rash and fevers. He was changed
to Bactrim and then IV clindamycin for a 7 day course of
antibiotics with some improvement in his cellulitis. However, he
developed a new acute kidney injury thought to be due to the
Bactrim that improved prior to discharge. He also went into
atrial fibrillation for a brief period of time, which resolved
with fluids, and he was discharged in normal sinus rhythm. | 150 | 108 |
16680481-DS-3 | 25,121,395 | You were admitted to the hospital with abdominal distention.
You underwent a cat scan with findings concerning for a small
bowel obstruction. You were placed on bowel rest. After return
of bowel function, you resumed a diet. Your abdominal
distention has decreased and you are preparing for discharge
with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | ___ year old female who was admitted to the hospital with
abdominal distention. Upon admission, the patient was made NPO,
and given intravenous fluids. Two weeks prior to admission,
she reported severe watery diarrhea. She went to an OSH where
she was diagnosed with c. diff and was started on oral
vancomycin. The patient had recently undergone an EGD which was
negative. The patient underwent an MRE which showed mid-gut
mal-rotation, with the majority of small bowel within the right
abdomen, and the large bowel in the left abdomen. She later
underwent a cat scan which showed
a SBO with a transition point in the terminal ileum. The GI
service was consulted and recommended a colonoscopy after the
SBO resolved. During this hospitalization, the patient was
noted to have elevated liver function tests. Further testing
included an ultrasound of the gallbladder which showed distended
small loops of bowel and ascites. The patient underwent an
x-ray of the abdomen after given oral contrast which was noted
in the small bowel. After passage of the contrast, the patient
was started on clear liquids and advanced to a regular diet. Her
abdominal distention had decreased.
The patient was discharged home on HD #7. Her vital signs were
stable and she was tolerating a regular diet. She was voiding
without difficulty and ambulatory. She had completed her
vancomycin course and it was discontinued. Discharge
instructions were reviewed and questions answered. The patient
was instructed to follow-up with the GI service. | 211 | 264 |
15876666-DS-37 | 28,280,113 | Dear Ms. ___,
You came in with shortness of breath. We do not think that you
were having an asthma attack. We did a chest Xray which did not
show a pneumonia. Please make sure to eat slowly, since we think
that sometimes food might go into your lungs when you eat too
quickly.
We are working on setting up an appointment for you to start the
___ day program. This will probably be on ___ (in one
week). Someone will call you to tell you the place and time of
the appointment.
It was a pleasure taking care of you, and we are happy that you
are feeling better!
Your ___ Team | This is a ___ year old female with past medical history of
paranoid schizophrenia, asthma, admitted ___ with quickly
resolving respiratory concerns, subsequent home safety concerns,
now addressed, ready for discharge home with
increased services
# Dyspnea - In the ED patient was reported to having wheezing
and dyspnea. CXR without signs of infection. She was treated
with nebulizers and admitted to medicine. By the time she had
arrived to the floor, her symptoms had resolved--she was quickly
weaned to room air over the subsequent hours. Etiology of her
symptoms are unclear--suspect mild asthma exacerbation vs
nocturnal aspiration (as has been suspected during prior
admissions) vs anxiety. Passed speech/swallow. Continued home
PPI and inhalers. Symptoms did not recur. Of note, during
bedside swallow there was no evidence of oropharyngeal
dysfunction but she did demonstrate poor impulse control--could
therefore also consider aspiration event while eating rapidly.
# Bizarre Behavior / paranoid schizophrenia / cognitive delay -
Patient reported to have increasing frequency of bizarre
behavior over recent months per her HCP. Behavior described as
being withdrawn, speaking to self, with stereotypied movements.
No focal neuro findings, no signs of infection. Initially,
partial complex seizures were suspected given stereotypied
movements, but patient had video EEG negative for signs of
epileptiform activity. Per inpatient psychiatric evaluation,
continued outpatient management was recommended. She was seen
by OT and, with assistance of social work and case management,
was arranged for increase in home services, arranged for an
intake interview with a day program for the patient. Patient
discharged to care of HCP ___, with outpatient follow-up
#paranoid schizophrenia: continued home clozapine, Divalproex,
sertraline
TRANSITIONAL ISSUES
================================================
[] outpatient mental health intake appointment at ___
___ (intake coordinator ___, ph:
___ on ___
[] primary care appointment ___ at 1:30 ___ with Dr.
___ at ___ ___ Floor
- HCP is ___ ___ | 109 | 310 |
14577572-DS-3 | 29,825,439 | Dear Ms. ___,
It was a pleasure taking care of you. You came to the hospital
because you had fever and face pain, and you became weak and
fainted. We found that you had an infection in your sinuses
called sinusitis and we gave you antibiotics to treat this. You
had imaging of your sinuses that did not show any fluid
collection. We think that you fainted because you were
dehydrated and we gave you intravenous fluids. Please continue
to use Tylenol alternating with ibuprofen as needed for
occasional headache. Your new medications are:
Augmentin twice a day (Last day: ___
We wish you the best of health.
- Your ___ Team | Ms. ___ is a ___ y/o woman with well-controlled diabetes
mellitus, hypertension, and atrial fibrillation (on warfarin)
who presented for acute bacterial sinusitis and gait
instability/weakness.
================= | 108 | 26 |
13652979-DS-9 | 27,171,281 | Mrs. ___,
___ were hospitalized with pneumonia and a drop in your blood
counts. We treated the pneumonia with antibiotics. We suspect
that the drop in your blood counts may have been due to dilution
from recent increased oral intake, or perhaps from one bowel
movement containing blood. Regardless, your blood level
increased while hospitalized and ___ remained stable. Please
follow up with your PCP ___.
It was a pleasure taking care of ___!
Your ___ team | ___ yo F with HTN presents to ED with dizziness and cough, found
to have CAP and a slight drop in Hct. CAP treated with 5-day
course of azithromycin and we watched H/H, which uptrended
during hospitalization. Discharged on bid PPI for now in case
of minor GI bleed. Encourage PCP to refer to GI for outpatient
EGD if H/H again falls. | 78 | 65 |
14335377-DS-8 | 28,641,077 | Continue All Care ___
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea returns, constipation,
inability to tolerate food, fluids or medications, yellowing of
skin or eyes, increased abdominal pain, incisional redness,
drainage or bleeding, dizziness or weakness, decreased urine
output or dark, cloudy urine, swelling of abdomen or ankles, or
any other concerning symptoms.
Monitor blood pressure at least twice a day. Call office
immediately if blood pressure reading is less than 80, if the
reading is persistently lower than 110 please call to report
during office hours
No need to return for lab work this week. Return ___ for
labwork and attend all scheduled appointments next week
Otherwise you should have labwork drawn every ___ and
___ as arranged by the transplant clinic, with results to
the transplant clinic (Fax ___ . CBC, Chem 10, AST, T
Bili, Amylase, Lipase, Trough Tacro level, Urinalysis.
On the days you have your labs drawn, do not take your Tacro
until your labs are drawn. Bring your Tacro with you so you may
take your medication as soon as your labwork has been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
Sodium bicarbonate has been discontinued. Do not take Colace or
senna unless you have not had a bowel movement in greater than
24 hours.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. Steri
strips will fall off on their own.
No tub baths or swimming
No driving if taking narcotic pain medications
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. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure if your appetite is not yet back to normal.
Check your blood sugars. Report blood sugars greater than 160 to
the clinic.
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise | ___ year old male 3 and ___ weeks out from combined
kidney/pancreas transplant that returns with large volume
diarrhea and dehydration.
Patient was hydrated with IV fluids and had also apparently been
taking more than recommended Colace dosing. He also stated that
he doesn't drink much fluid on days he comes to clinic or for
lab draws as he is concerned about needing to void on the long
trip in.
Amylase and lipase are improved since his recent discharge and
creatinine is stable at 1.4.
Immunosuppression was left at admission dosing of Mycophenolate
500 QID and Tacro 6 mg BID.
Sodium bicarbonate was discontinues
Patient had relief from diarrhea and was advised to hold off on
bowel meds.
He is otherwise stable, tolerating regular diet and ambulating.
He is discharged to home with All Care ___ to resume services. | 407 | 134 |
11953779-DS-16 | 24,869,839 | Dear Mr. ___,
You were admitted because of facial sensory symptoms caused by a
small bleed into a vascular malformation called a cavernous
angioma, or "cavernoma". Your body will re-absorb this blood
slowly. You should stop your aspirin indefinitely. Do not engage
in any activities that will raise your blood pressure out of the
normal range.
We did see an incidental abnormality to your thyroid. Please
have your primary care physician order ___ thyroid ultrasound and
follow up your TSH that was drawn in hospital and remains
pending at time of discharge.
Your medication list has changed:
STOP aspirin indefinitely
You have follow up scheduled as below.
Please maintain a LOW threshold for calling 911 should you
experience any neurologic symptoms as below. | BRIEF HOSPITAL COURSE: Mr. ___ is a ___ year old man who
presented with facial paresthesias and was found to have a
pontine bleed on head CT that was thought to be a cavernoma.
Hypertensive bleed was considered unlikely.
.
ACTIVE ISSUES:
# Cavernoma: Mr. ___ presented with facial paresthesias
and was found to have a pontine bleed on head CT that was
thought to be a cavernoma after further evaluation with MRI. The
images were reviewed with neurosurgery and they agreed that this
was likely a cavernous angioma which had sustained a small
bleed. Hypertensive bleed was considered unlikely. His aspirin
was held at time of discharge. Given that there are no specific
cardiac or neurologic indications for antiplatelet therapy we
recommend holding for now, to be addressed again on our
outpatient visit.
. | 118 | 133 |
18052788-DS-19 | 25,381,913 | you were hospitalized due to severe constipation and impaction
of barium in the rectum | ___ female here with abdominal pain and found to have severe
constipation with retained barium. | 14 | 16 |
19846426-DS-2 | 28,080,724 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a cardiac catheterization. This is a procedure that
looks at the pictures of your heart. You were found to have
blockages in a blood vessel that required placement of 2
"stents", which help keep the blood vessel open.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please follow up with your primary care provider and your
cardiologist. We have made appointments for you.
- Please take all your medications as prescribed, ESPECIALLY
your aspirin and Brillinta (Ticagrelor), as these will help
prevent another heart attack.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | SUMMARY:
=========
Mr. ___ is a ___ M (___) w/ a PMH significant
for T2DM, HTN, HLD and right>left PVD who went to his PCP ___
___ with complaints of chest pain, found to have an NSTEMI,
underwent cardiac catheterization with placement of 2 stents in
the LAD. | 153 | 46 |
13774492-DS-20 | 26,346,667 | Dear Ms. ___,
You were admitted to ___ for shortness of breath. We found
that you were having an asthma/COPD exacerbation. You were
initially admitted to the intensive care unit, where you had
close monitoring. We placed you on a positive pressure mask to
help you breath. We gave you steroids and antibiotics to help
reduce the inflammation and treat the possibility that an
infection contributed to your symptoms. Your breathing improved
with treatment. However, because you are at high risk for having
a recurrent episode, we are discharging you to rehab for further
treatment.
You will need to be on steroids indefinitely until you follow up
with Dr. ___. You will take azithromycin, an antibiotics,
for a few more days. We also highly recommend stopping smoking,
because it can be a trigger for future attacks. It was a
pleasure to take care of you. Please do not hesitate to contact
us with any questions.
Sincerely,
Your ___ Care Team | This is a ___ year old female with past medical history of COPD,
tobacco abuse, obesity, OSA, seasonal allergies, CAD, recent
admission ___ for COPD exacerbation, who was readmitted
___ with acute hypoxic respiratory failure secondary to
acute COPD exacerbation requiring non-invasive ventilation in
the
ICU, treated with steroids, antibiotics, restarted on home
medications, remaining stable, and able to be discharged to
pulmonary rehab
ACTIVE ISSUES
# Acute and Chronic Respiratory Failure / Severe Asthma / Acute
COPD Exacerbation - patient with severe obstructive disease
based on her PFTs with FEV1 ~38% who presented with hypoxia and
hypercarbia requiring ICU stay for bipap. She received
methylprednisolone 125mg IV once before transitioning to
prednisone 60mg daily and started on pulse of azithromycin x 5
day course. Her respiratory status continued to improve on the
floor, and she was eventually weaned off of 2L nasal cannula.
Given her recurrent symptoms and high risk, she was discharged
to pulmonary rehab. She was discharged on prednisone 60mg daily
with plan for close outpatient follow up to determine long
taper.
# Lactic Acidosis - Admitted with lactate 3.5; thought to be
from respiratory effort and albuterol; no evidence of additional
infection / ischemia;
CHRONIC ISSUES
# Tobacco Abuse: She was counseled on multiple occasions
regarding smoking cessation, and she reported willingness to
quit.
# CAD: Continued home aspirin, atorvastatin, and enalipril.
# GERD: Continued home pantoprazole and ranitidine.
Transitional Issues
- Patient will follow up with her pulmonologist with regards to
duration of steroid taper.
- Patient will be on azithromycin until ___.
- Consider continuing smoking cessation counseling
- Consider allergy workup for triggers
- Patient was started on PCP prophylaxis given prolonged high
steroid course with atovaquone 1500mg daily. | 156 | 275 |
12435720-DS-4 | 21,350,585 | Dear Ms. ___,
You were admitted to the hospital because you were very
nauseous, and you vomited some blood. Your symptoms improved
quickly and your blood counts stayed stable. You were seen by
the gastroenterology and surgical teams because of your large
hiatal hernia, and the decision was made to treat you
conservatively without any procedures.
Please call your doctor if you have intractable nausea or
vomiting, or abdominal distention.
In the hospital, we discussed with your family whether a "do not
hospitalize" order in addition to your DNR/DNI would be
appropriate for you. Please continue this discussion with your
facility's social worker.
Please arrange follow up with a geriatrician or a primary care
doctor for workup of depression in addition to the dementia.
It was a pleasure taking care of you.
-Your ___ Care team | ___ is a ___ w/ dementia, HTN, CKD3, HLD,
hypothyroidism, afib/flutter, and recent cholangitis managed
conservatively who presented for abdominal pain and coffee
ground
emesis c/f UGIB, also found to have a large hiatal hernia
containing the stomach and transverse colon, c/f partial
obstructive gastric volvulus, though her abdominal exam is
currently reassuringly benign with resolution of symptoms. | 131 | 52 |
18255718-DS-6 | 20,398,597 | Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous
exercise should be avoided for ten (10) days. This is to prevent
bleeding from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five
(5) days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications
as directed.
· It is very important to take the medication your doctor
___ prescribe for you to keep your blood thin and slippery.
This will prevent clots from developing and sticking to the
stent.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
· If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
· You will have a small bandage over the site.
· Remove the bandage in 24 hours by soaking it with water
and gently peeling it off.
· Keep the site clean with soap and water and dry it
carefully.
· You may use a band-aid if you wish.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· The medication may make you bleed or bruise easily.
· Fatigue is very normal.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
puncture site.
· Fever greater than 101.5 degrees Fahrenheit
· Constipation
· Blood in your stool or urine
· Nausea and/or vomiting
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason | Ms. ___ was admitted to the intensive care unit on
___ for observation after presenting with symptoms concerning
for intracranial processes related to her past coilings. On
___, she remained stable waiting for a diagnostic angiogram. A
diagnostic angiogram was completed by Dr. ___ showed that
she had right MCA aneurysm but will come back to electively for
treatment. The patient remained neurologically and
hemodynamically stable and was discharged home in stable
conditions in the morning of ___. | 440 | 78 |
16788919-DS-19 | 27,391,598 | Ms. ___,
You were admitted to the surgery service at ___ for evaluation
of abdominal pain and nausea. Your CT on admission revealed post
operative changes. You were given hydration with IV fluid,
Tramadol and Hyoscyamin for pain control and abdominal spasms.
You received Reglan, Scopolamine patch, and Zofran for nausea.
Your diet was slowly advanced and was finally well tolerated.
You are now safe to return home to complete your recovery with
the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns. During off hours, call operator at
___ and ask to ___ team.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | he patient s/p ___ procedure on ___ was admitted to the
HPB Surgical Service from ED for evaluation of the increased
abdominal pain. Chest CTA on admission was negative for PE. CT
abdomen demonstrated post surgical changes. Patient was afebrile
with WBC 11.2. She was started on Tramadol and Hyoscyamine to
control her abdominal pain and spasms. On HD 2, patient
developed nausea with non bilious emesis x 1, and was made NPO.
She received Zofran, Reglan and Compazine for nausea, and
Scopolamine patch was apply. Also her labs were noticeable for
WBC 32K, which thought to be related to steroids patient
received prior CT scan. On HD 3, patient's pain and nausea
improved, her diet was advanced to clears and was well
tolerated. Her WBC started to downward, and she remained
afebrile. On HD 4, diet was advanced to regular and she was
discharged home in stable condition.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 250 | 199 |
14029260-DS-11 | 23,142,876 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for left foot pain and swelling. We believe this was
caused either by a skin infection or possibly arthritis related
to your inflammatory bowel disease. We have given you a
prescription for Augmentin, which is an antibiotic, to take for
the next week. You should avoid NSAIDs (ibuprofen, naproxen,
Advil, Motrin, Aleve) for pain because of your Crohn's disease.
Appropriate pain medications are listed below. Please follow-up
with your outpatient providers as listed below. | ___ with Crohns disease on Humira who was recently discharged
from ___, now presenting with 3 days of left foot pain and
swelling.
# Left foot pain and swelling: Etiology not entirely clear.
Consideration given to cellulitis vs IBD-related arthritis. As
for infection, there was very minimal erythema and no induration
which isn't entirely consistent with cellulitis. He also
remained afebrile with no leukocytosis. He is on Humira, but
just started this medication approximately 1 week prior to
admission and would not expect significant immunosuppression at
this time. Orthopedics was consulted to rule out septic
arthritis, there was no ankle effusion on exam or imaging and
they felt that septic arthritis was very unlikely. His symptoms
may be consistent with type I IBD-related arthritis. His
elevated ESR/CRP, recent Crohn's flare, acute onset and
ologiarticular involvement would be consistent with this
diagnosis. The fact that he also had mild pain in his right foot
also argues against infectious etiologies. Patient also reports
that when he started Remicade ___ year ago, he had similar pain
and swelling in his feet which resolved when he stopped this
medication. While cellulitis was thought to be unlikely, he is
on an immunosuppressive medication and he was given a 7 day
course of Augmentin at discharge given cellulitis can not be
ruled out.
# Crohn's Disease: Patient is without symptoms at this time. His
budesonide was continued. He did not receive Humira during this
admission, as he was not due for it. He will follow-up with his
gastroenterologist 3 days after discharge.
# GERD: Continued home pantoprazole 40mg daily.
# Code status this admission: FULL
# Emergency contact: ___ (mother) ___,
___
# Transitional issues:
-Complete 7 days of Augmentin. Will see PCP ___ 1 week to
evaluate for resolution of foot pain/swelling | 89 | 293 |
19765159-DS-13 | 26,830,726 | Dear Ms. ___,
You were admitted for an episode of fluid overload secondary to
congestive heart failure. You were admitted with shortness of
breath and excess fluid in your legs. We had to titrate the
amount of diuretics (water pill) to decrease the amount of fluid
in your legs and in your lungs. You are doing an excellent job
in complying with your medications and eating a low sodium diet.
You should continue to do so. It is important that you weigh
yourself every day. If your weight goes up by more than 3 pounds
please call your doctor, as you might need to take more of your
torsemide (water pill). We have made the following changes to
your medications going forward. We have added a medication
called metolazone which is synergistic with torsemide in
removing water from your body.
1. Please START 2.5mg of metolazone by mouth 30 minutes before
you take torsemide.
2. Please INCREASE Torsemide 20mg by mouth once a day.
If you experience any of the danger signs listed below please
call your doctor and go to the nearest emergency department. | ___ with COPD and diastolic heart failure here with dypsnea on
exertion improved with diuresis and optimization of medical
therapy.
.
# Diastolic CHF: Patient's dyspnea is mild and primarily on
exertion. She does not have diffuse wheeze or other suggestion
of COPD flare. She has no evidence of cardiac ischemia on EKG
and no chest pain. Her clearest symptom is her weight gain and
lower extremity swelling--although her BNP is at "baseline" it
is being compared to her initial BNP last time she presented
with fluid overload. Today appears to be nearing euvolemic
status. Patient will be discharged home on torsemide 10mg 5
days/wk (holiday on tues and sat) as well as new metolazone, to
be taken as needed for 3 pound weight gain or increased lower
extremity swelling. Patient also with close follow up
appointment with PCP who can monitor patient's fluid status. Dry
weight is 110 pounds, about 8 pounds lower than previously
recorded dry weight. Patient's Cr with slight bump from 1.7-1.8
baseline to 2.1 today, should improve with equilibration and
also with reduction in diuretic dose moving forward. Patient's
electrolytes were repleted as needed and inhalers were
continued.
.
# Chronic renal failure: close to baseline, will monitor as
diurese.
.
# CAD: pravastatin, ASA
.
# Hypertension: Amlodipine
.
# Continue Cymbalta
.
# GERD: Omeprazole
.
# Osteoporosis: Calcium
. | 185 | 244 |
15975668-DS-11 | 25,012,496 | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with staples. You may now wash your
hair as your staples have been removed on ___.
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.
You were on a medication Coumadin (Warfarin)discuss when it is
safe to resume this medication with Dr ___ at your follow
up appointment. Do not begin taking Plavix (clopidogrel)or
Aspirin unless discussed with Dr ___
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
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: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. | ___ y/o M on coumadin for a-fib presents with L SDH and was taken
emergently to the OR for evacuation after INR was reversed with
profilnine, FFP, and vitamin K. A subdural drain was placed and
post operatively he was extubated and transferred to the ICU for
close monitoring. His post operative head CT showed post op
changes and subdural drain in place. Overnight patient remained
stable, subdrual drain had large amount of output. On ___, his
subdural drain continued to put out large amounts. He remained
NPO and close monitoring. On ___, repeat head CT showed small
layering of blood with improvement in pneumocephalus. INR was
1.2 and subdural drain out put was still large so remained in
place. On ___, HR was increased to 160s with movement,
metroplol was increased to 75mg TID. On ___, subdural drain was
removed, metoprolol was increase to 100mg TID for elevated HR.
The patient had episodes of orthostatic hypotension on ___, and
his metoprolol was gradually titrated down to 25mg where the
patient's blood pressure and heart rate was stable. Physical
therapy evaluated him multiple times and felt that due to gait
instability, balance and the need for education regarding his
ongoing orthostatic hypotension, he would benefit from either 24
hour supervision at home or rehabilitation.
On ___, the patient's Keppra 500 BID was stopped per the
medication plan. At the time of discharge on ___,
HOD #10 and POD #8, the patient was doing well, afebrile with
stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, stable neuro exam and pain was well
controlled. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. He was instructed that he was not to restart
Coumdadin. All questions were answered prior to discharge and
the patient expressed readiness for discharge. | 280 | 309 |
16025512-DS-4 | 24,858,588 | Dear Ms. ___,
You were admitted to ___ with mild shortness of breath and
abdominal pain. Once you were admitted to the medical floor, you
no longer had these symptoms and you felt well. We evaluated
your shortness of breath by performing a chest x-ray and we did
not find any abnormalities concerning for pneumonia. We did note
that your feeding tube was too high in your esophagus, so we
advanced it and confirmed that it was in the right place. We
recommend that you continue to get your physical therapy after
discharge. You should continue to get your tube feeds at home
and follow up with your surgeons as previously scheduled.
Sincerely,
Your ___ Team | ___ with a history of autoimmune hepatitis, cirrhosis, hiatal
hernia, CAD s/p MI, who presented to ___
with reported symptoms of dyspnea and upper abdominal pain.
# Dyspnea/abdominal pain: Per the patient's daughter, she was at
home and had some abdominal pain. A visiting nurse felt that she
had crackles in her lungs and recommended that she be evaluated
in the ED. She does not appear to be in respiratory distress and
her abdominal exam was benign on admission. She denied shortness
of breath and abdominal pain durin this hospitalization. On
chest x-ray, her N/G tube was noted to be high in her esophagus
so it was advanced to 50cm and repeat film confirmed its
location in the stomach. Tube feeds were started and were
advanced to goal which the patient tolerated well. Her lipase
was elevated at ___ but was normal at ___.
On re-examination on ___ the Dobhoff tube was found to be
insufficiently advanced. It was subsequently replaced and
bridled at the bedside. On discussion with patient and patient's
daughter the recommendation was made to monitor to ensure
tolerance of resumption of tube feeds, but the patient strongly
preferred to leave immediately. Discharge was therefore arranged
on the day of the procedure. In discussion with the ___
surgery team who performed her procedure, the Dobhoff tube was
confirmed to be in an appropriate location.
# Autoimmune Hepatitis complicated by portal hypertension and
ascites: Stable. The patient had ascites with a fluid wave on
exam and when questioned remarked that this level of abdominal
distention is baseline for her. She did not have asterixis on
exam and she had a normal ammonia on admission. Her home
pantoprazole, spironolactone, and furosemide were continued.
# Hypothyroidism: Stable, home levothyroxine continued.
Transitional issues:
-The patient is weak and requires physical therapy to regain her
strength. Rehab was recommended on a previous hospitalization
but the patient declined. Please consider if her home situation
is safe and whether she is receiving all needed services at
home. | 113 | 336 |
15497612-DS-10 | 26,435,482 | What happened while you were in the hospital:
- You came in with left-sided numbness, weakness, and tingling.
We got imaging (CT and MRI) of your brain and your spinal cord
to make sure you did not have a stroke or spinal cord injury.
All of the imaging was normal, so we were reassured that you did
not have such a stroke or injury.
- You were also short of breath when you came in. We checked
your heart function with a heart ultrasound (ECHO) and your
lungs with a chest X-ray and found that you had some extra fluid
in your lungs. Since the results of your heart testing were
normal, we do not believe that you have congestive heart failure
that could cause this extra fluid in your lungs, and it is most
likely that this was caused by your suboptimal kidney function.
- You were having bleeding from your rectum when you arrived. We
monitored you for concerning signs of bleeding, like a dropping
blood count, and were reassured overall. This bleeding was most
likely due to your hemorrhoids.
What you should do at home:
- Make sure to go to your appointment with Dr. ___ at ___
to follow up on your kidney function.
- Take all your medications as prescribed.
- We stopped giving you the medication called metoprolol (for
high blood pressure) because your heart rate was fairly low. We
feel you should NOT take this medicine at home until you talk to
your primary care doctor. | Patient summary: ___ M with history of Prader-___ syndrome
s/p gastric bypass, pancreatitis, LGIB from external hemorrhoid,
HTN/HLD, and CHF who presented to the ED with dyspnea and BRPBR,
who then developed left-sided hemianesthesia while being
evaluated in the ED. Now ruled out for stroke or cord pathology. | 248 | 48 |
10013643-DS-23 | 27,433,745 | You were admitted to the hospital because you had a fever,
generalized weakness, pain in your lower back, and lack of
appetite. We did not find a cause for your symptoms, and we did
not find a source of infection. While here you did not have any
fevers. You should follow up with your primary care doctor and
with Dr. ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ h/o vascular dementia, recent admissions ___ for fevers
and CP felt to be from PNA and before that an admission in
___ for TAVR c/b heart block requiring pacemaker c/b c.
diff, presents with report of fever, elevated inflammatory
markers, malaise/anorexia and acute on chronic low back pain.
#Fever, generalized weakness, anorexia. One fever reported at
home to 101.4 2 days prior to admission per husband. No
documented fevers while here. In ED WBC 13, lactate 2.2, HDS.
WBC normalized. UA clean, CXR clean. Had recent course of
levaquin for pneumonia, now only with mild cough and clear
sputum; PNA seems unlikely. CTU (originally ordered for ? flank
pain in ED) unrevealing except pericardial effusion; present
since her TAVR, but appears to be possibly increasing on current
CT. No severe or positional CP, EKG is v-paced, ECHO ___ without
worsened effusion, but still would consider pericarditis given
no other obvious cause for fever and systemic inflammation and
enlarging effusion on CT (although this can be over-read). CK
currently low, no myositis. PMR still on the ddx given elevated
ESR/CRP and tender proximal/girdle muscles. Adrenal insuff
unlikely, no hypotension, weight loss, eosinophilia but could
consider if nothing else turns up. Recent TSH normal. Anemia
could be contributing to weakness, but is not severe.
Patient will follow up with PCP, ___.
#Acute on chronic low back pain. Per husband and patient she
gets many aches and pains including low back pain similar to
what she has now, usually responds to percocets at home. Since
her surgery she has had decreased energy and has been more
sedentary, this may be contributing to her musculoskeletal low
back pain. No evidence that this is pyelo, renal calculi, or
neurologic. CK low, not myositis. She is a difficult historian,
but on exam was tender throughout the pelvic girdle, in this
clinical setting this raises concern for PMR as above, and would
consider rheumatology evaluation as an outpatient.
#AS s/p TAVR c/b CHB with PPM. Continued ASA/plavix. Per Dr.
___ will call ___ to overbook in clinic next
___, patient will call Dr. ___ phone to touch
base. Repeat ECHO if Dr. ___ it is indicated.
#Anemia. Has been anemic since ___ after TAVR likely ___
blood loss, received 4u RBC's that admission, and additional 1u
RBC ___ during last admission. Hgb currently 10.7 up from 8's
suggesting appropriate response to recent transfusion, and
likely hemoconcentrated now. Recent iron studies show replete
iron stores and likely low available iron in setting of
inflammation. B12 not current but has been normal in the past.
Recent haptoglobin high. Retic index recently low, marrow likely
suppressed in setting of inflammation. Complains of hemmorhoids
requiring surgery, but currently no symptoms. Stable HCT while
here.
#Hyperglycemia, no known dx of DM. A1C 5.7. Current glucoses
160's-170's, perhaps ___ stress response/inflammation.
#HTN. Held home hctz while here. | 77 | 479 |
17869449-DS-11 | 21,577,406 | Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- We gave you a medicine through your vein called Lasix to help
get rid of the extra fluid in your body that was making it hard
for you to breath. Once your breathing was better, we started
giving you a higher dose of your home oral Lasix to help keep
the fluid from building back up.
- We started you on a new medicine called spironolactone that
will also help keep extra fluid from building up in your body.
- We spoke with the TAVR team and let them know you were in the
hospital. They have scheduled you to have a procedure next
___ to fix your leaky valve.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should take all your medications, as prescribed. You
should now take Lasix 20 mg every day and spironolactone 12.5mg
every day.
- You should follow up with your cardiologist and primary care
doctor.
- You should weigh yourself every morning and call your doctor
if your weight goes up more than 3 lbs. Your weight on the day
you left the hospital was 89.07 lbs.
- You should follow a low sodium diet and drink no more than 2L
of fluid per day.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with a PMH of breast cancer
s/p mastectomy and chemo/XRT (Adriamycin, Herceptin; ___,
ovarian mass of unknown etiology pending tissue diagnosis, and
newly diagnosed HFrEF (EF ___, severe MR and AR (undergoing
TAVR evaluation) now presenting with new orthopnea and dyspnea
and exertion c/f heart failure exacerbation.
#CORONARIES: Normal coronaries, cardiac cath on ___ at ___
___
#PUMP: EF ___, severe MR and AR
#RHYTHM: NSR
ACTIVE ISSUES:
==============
# HFrEF
___ presented with new orthopnea and dyspnea on exertion and
was found to have an elevated pro-BNP to 8000 and exam
consistent with heart failure exacerbation. Her decompensation
was thought to be in the setting of flash pulmonary edema
secondary to hypertension as ___ reported BP of 180's
recorded during EMS run. Initial ECG was stable from prior and
troponins were negative x2. She was treated with IV Lasix and
then transitioned to Lasix 20mg PO daily once euvolemic. A
repeat CXR showed no evidence of pulmonary edema with small
bilateral pleural effusions. ___ was continued on her home
carvedilol and lisinopril, and was started on spironolactone
12.5mg daily.
# Severe AR and MR
___ has history of severe AR/MR and is currently undergoing
TAVR
evaluation with Dr. ___. The ___ team was notified of the
___ admission and planned her procedure for ___.
# Hyponatremia
___ presented with hyponatremia, which initially developed
on ___ during her previous admission. On her past admission,
her hyponatremia was attributed to spironolactone. On re-check,
her sodium was within normal limits.
CHRONIC ISSUES:
==============
# Hypothyroidism
Continued home levothyroxine 75mcg daily.
# Hypertension
Continued home carvedilol and lisinopril, as above.
# Right adnexal mass
Undergoing outpatient evaluation. | 236 | 269 |
10253803-DS-18 | 21,618,989 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you were having
fever, cough, and shortness of breath. You were diagnosed with a
community-acquired pneumonia and you were started on
antibiotics. Your breathing subsequently improved and your fever
resolved. You will continue your current antibiotics for a total
of 14 days (last day ___. You should also use the flutter
valve at least twice a day to help expectorate mucus, as
instructed by our respiratory therapy team.
You also had recently had a gouty attack in your right ankle. We
were not able to give you steroids in the joint space, but we
started you on colchicine. You should continue taking colchicine
twice a day until resolution of the pain, then once daily until
your appointment with rhematology.
We wish you a speedy recovery,
Your ___ Care Team | Mr. ___ is a ___ m with history of MI, CABG, pacemaker/defib
with recent site infection in ___, CHF with EF 20% in ___, tracheobroronchiomalacia s/p tracheobronchoplasty in
___, who presented with fever, cough, and shortness of breath
of 6 days duration. Chest X-ray was consistent with right middle
and lower lobe pneumonia. | 144 | 54 |
13757356-DS-28 | 24,984,274 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
You came to us after feeling dizzy and losing consciousness. At
this time, we think that it is because you are on multiple
medications that slow your heart rate and also decrease your
blood pressure. We also noticed that your blood pressure
decreases when you stand up, which is called "orthostatic
hypotension", and can make people dizzy. As such, we propose to
stop your beta blockers metoprolol and propranolol, and see if
you continue to get dizzy.
We stopped your beta-blocker while you were in the hospital with
us, and gave you some IV fluids. With this, you no longer felt
dizzy when you stood up and were able to ambulate the halls
without any difficulty.
We know that the tremors have significantly affected your life,
and that the propranolol helped. As such, we think that you can
follow up with your neurologist to see if there are other
options for you, versus restarting the propranolol at a lower
dose.
Thank you for giving us the opportunity to participate in your
care.
Please take care, we wish you the best!
Sincerely,
Your ___ Care Team | ___ year old gentleman with history of AVR (s/p bioprosthetic
valve in ___ c/b Strep endocarditis in ___, now s/p redo
sternotomy and replacement in ___, TIA, HLD, CAD, with
recent initiation of propranolol for essential tremor,
reportedly on double beta blockade, who presents with episode of
syncope.
# Syncope: Appears most likely related to orthostatic
hypotension and sinus bradycardia, worsened by double
beta-blockade with propranolol and metoprolol. Patient has
documented orthostatic hypotension in ___ ED with BP
120/82 when lying down and 90/40 on standing. After transfer to
us, he received 500 mL NS bolus and his home metoprolol was
held. He was able to ambulate without any further episodes of
dizziness, although at time of discharge he continued to be
orthostatic by blood pressure criteria (Lying 144/78 47, sitting
121/77 48, standing 132/79 47). No arrhythmias seen on
telemetry, only sinus bradycardia with rate in ___. After
discussion, we held both metoprolol and propranolol, to allow
his HR to recover. If he continues to experience symptoms
despite stopping his beta blocker, can consider exercise stress
test. Can also consider repeat TTE as an outpatient, although we
note that his most recent TTE in ___ in ___ was with
normal valvular function.
# Essential tremor: Patient was evaluated by neurology at ___
on ___ propranolol, which was started by psychiatry, was
reduced from 20 mg PO BID to 10 mg PO BID. Patient reports that
the tremor interfered with many of his daily activities and the
propranolol has improved his symptoms immensely. Unfortunately,
as he remained bradycardic off metoprolol, we are opting to hold
it for now; please consider either re-introducing propranolol at
a lower dose or switching to another medication for essential
tremor such as gabapentin, primidone, topiramate.
# Leg pain with walking: Patient reports pain and weakness of
bilateral calves with walking and decreased exercise tolerance
secondary to pain. Concern for claudication and peripheral
vascular disease given his history; would recommend follow up
ABI for further evaluation.
# Coronary Artery Disease: Patient is s/p cath ___, which
demonstrates a moderate 70% stenosis at ___ diagonal at ostium,
treated with balloon angioplasty only, given unfavorable
anatomic location and small size. We continued aspirin and
atorvastatin and held metoprolol as above given syncopal
episodes and reports of pre-syncope.
# Normocytic anemia: Stable, no e/o hemolysis, iron studies
within normal limits. | 192 | 388 |
12745425-DS-17 | 20,579,209 | Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted with an abnormal heart rhythm
during your outpatient stress test.
You were evaluated by cardiologists and underwent an echo which
did not show any concerning findings. You have been cleared for
discharge home, but it will be important for you to follow-up
with your cardiologist.
Additional tests that you will need:
(1) You will have an outpatient treadmill stress this ___
___ at 8:45 am. No food or caffeine at least 1 hr
prior to exam. Wear comfortable clothing and sneakers. No
Smoking. Continue medications prior to exam.
(2) Please collect 24 hours urine specimen and return to the lab
at ___.
(3) You are being sent home with Holter cardiac monitor. Please
wear it as instructed. | ___ year old male with past medical history of HTN, HLD, and afib
on aspirin s/p PVI in ___ who is being admitted after an
episode of wide complex tachycardia during outpatient stress
test. Patient was asymptomatic at time of admission denying any
chest pain or palpitations. He had no events on telemetry while
in house. He underwent an echo on ___ which showed normal
systolic function with no wall motion abnormalities. ___
hospital course is sumarized by problems below:
# Wide-complex tachycardia: Patient presented following an
episode of wide complex tachycardia on outpatient exercise
stress test. He was asymptomatic on admission with EKG in normal
sinus rhythm. Differential for wide complex tachycardia includes
ventricular tachycardia or supraventricular tachycardia with
aberrancy. Patient with negative troponins and EKG with no acute
ischemic changes. No evidence of cardiac ischemia, heart
failure, electrolyte abnormalities, or drug toxicities.Patient
was monitored on telemetry with no arrythmias recorded. Patient
had echo done which normal biventricular systolic function with
EF greater than 55% and no wall motion abnormalities. Patient
was discharged home on holter monitoring. Additionally he was
scheduled for a stress test on ___. Patient was
started on carvedilol 12.5 BID during this admission.
# HTN: Patient had exaggerated hypertension response on
outpatient stress test with peak blood pressure of 260/100 up
from resting blood pressure of 140/76. Causes of secondary
hypertension will be further investigated. TSH, aldosterone, and
renin were sent off. Patient will do 24 hour urine collection of
metanephrine, normetanephrine as outpatient. He was started on
carvedilol 12.5 BID and will have his blood pressure monitored
further as outpatient. He was continued on home dose of
lisinopril.
# CORONARIES: Patient had negative serial troponins during this
admission. EKG showed no signs of acute ishemic changes and echo
showed no new wall motion abnormalities. Patient was continued
on his home dose of statin, ASA 81, and started on carvedilol
12.5 bid.
Patient was full code during this admission. | 130 | 324 |
19684755-DS-12 | 25,007,014 | Dear Mr. ___,
You were admitted to ___ for chest pain and rapid heart rate.
You were found to have an abnormal rhythm called atrial
fibrillation. We were able to stop your atrial fibrillation with
medications. You need to take these medications everyday on time
in order to prevent return of the abnormal rhythm. You will also
need to take aspirin daily to prevent stroke.
Although you had chest pain and a leak of your cardiac enzymes,
we feel this was due to your rapid heart rate. Still, we
recommend you undergo outpatient nuclear stress testing to rule
out any blockages in your coronary arteries that may have caused
the chest pain.
While you were here, you also had blood in your urine. We think
this is due to multiple kidney stones which were seen on an
ultrasound of your kidneys. When you return home, please make an
appointment with a urologist for further evaluation. | ___ year old man with history of MI s/p PCI x 3 in ___ admitted
with chest pain, found to have atrial flutter with rapid
ventricular response.
#AFlutter: patient initially presented as flutter, but this
turned to atrial fibrillation in house. His rates were difficult
to rate control on metoprolol, received IV dilt drip with good
response. He subsequently converted to sinus rhythm.
Due to his conversion to sinus and low CHADS score, he was not
started on anti-coagulation. He was discharged on metoprolol XL
200mg. An echo was performed and was normal.
# Chest pain/Troponemia: Likely represents demand ischemia in
the setting of tachycardia, as patient became chest-pain free
with resolution of tachycardia. Do not feel that this is ACS.
However, given his prior stent he does have risk and so was
discharged with aspirin and low-dose rosuvastatin. Recommend
obtaining nuclear stress test as outpatient to stratify his
risk.
# Tea-colored urine: New following episode of tachycardia.
Patient without symptoms of UTI. ___ represent hematuria
following intiation of anticoagulation due to an anatomic defect
or stones. A renal ultrasound showed multiple stones in both
kidneys.
HE will need an outpatient urology workup to r/o malignancy in
the urinary tract. | 152 | 199 |
10254097-DS-6 | 27,317,316 | Dear ___,
You were admitted due to continuous seizures in the setting of
pneumonia and urinary tract infection. You underwent CT and MRI
scans of your head which did not show acute abnormalities which
could cause your seizures. You had an ___ lumbar puncture
to get a sample of your spinal fluid, which tested negative for
bacterial infection.
Your infections were treated by antibiotics.
We also performed an MRI of your spine to look for causes of
your leg weakness, but did not find any explanation. This is
chronic. Please contact your PCP to discuss your medical record.
Your medications were changed as follows:
Increased Keppra to 1000mg twice per day
Increased Depakote to 1000mg twice per day
Please take your medications as prescribed.
Thank you for the opportunity to participate in your care.
Sincerely,
Your ___ Neurology Team | ___ with history of adult-onset epilepsy (on levetiracetam and
valoproate), bipolar disorder, HTN and ___
transferred from ___ with seizure and concern for
convulsive status epilepticus. Patient was intubated for airway
protection on ___ and admitted to the TSICU. Later transferred
to NeuroICU. Due to concern for meningitis, patient was started
on empiric meningitis coverage. After 2 failed LP attempts at
bedside, patient underwent ___ guided LP, which was negative for
bacterial meninigitis or HSV. She was found to have Moraxella
CAP and Enterobacter UTI treated with continued vancomycin and
ceftriaxone. She briefly required pressor support on Neo.
Patient extubated on ___. She was diuresed with Lasix but was
hypotensive and required pressor support for another day. She
was transferred to the floor overnight on ___ and monitored
until ___ without any significant events.
# Moraxella PNA and Citrobacter UTI treated with 4 days of
vancomycin and 7 days of ceftriaxone.
#Seizures - Likely due to Moraxella PNA and Citrobacter UTI. No
structural cause on MRI found. Monitored on EEG without further
seizures.
- Valproate increased from 500mg ___ ___ to 1000mg BID.
- Increased Keppra from 750mg BID to ___ BID
#Positive blood culture
- ___ BC bottles growing GPCs in clusters
- was already on Vanc
- repeat BCx negative
#Chronic Leg Weakness - Patient did not recall reason for her
leg weakness which has been present for ___ years per patient.
MRI pan-spine did not show any lesions which would fully explain
the extent of weakness.
#A-Fib with RVR
- briefly overnight in neuroICU
- converted to SR after metoprolol 5 mg x2 and diltiazem 5 mg
x1.
- No further episodes on telemtry
- started on metoprolol 12.5 mg Q8
- likely in setting of acute illness; did not start
anticoagulation
Transitional Issues:
[] ___ need holter for long-term monitor for AFib
[] F/u with PCP ___ ___ weeks
[] Will arrange follow-up with ___ Epilepsy (call ___
if not contacted in next week) | 138 | 323 |
12405516-DS-18 | 26,139,959 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing to the right lower extremity in splint
Weightbearing as tolerated to the left lower extremity in
postop shoe/flat, hard-soled shoe
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
COMPRESSION FRACTURE OF LUMBAR VERTEBRA 2
Please wear your TLSO brace when out of bed for the next month
until you follow up with Dr. ___ in clinic (see below for
follow up instructions). You ___ your TLSO brace at the EOB.
TLSO brace does not need to be worn when in bed.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Weight bearing as tolerated to the left lower extremity in
post-op shoe
Non weight bearing to the right lower extremity in splint
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Call your surgeon's office with any questions. | Ms. ___ is a ___ w/ pmh epilepsy, RA, presented to ___ s/p
MVC at 60mph. No head strike or LOC reported. She initially
presented at ___ where she was found to
have an open right calcaneal fracture, and thereby transferred
to ___ after splinting and administration of ancef. Further
imaging also noted a T2 superior endplate fracture and L2
compression fracture as well as a mildly displaced fracture
involving the anterior process of the left calcaneus extending
to the calcaneocuboid joint.
The patient was admitted to the Trauma Surgery service for
further care. Neurosurgery Spine was consulted for management
of her spine fractures and recommended a TLSO brace. Her
cervical collar was cleared. Orthopedic surgery was consulted
and the patient was taken to the operating room on HD2 where she
underwent washout and debridement open fracture and pinning of
the right calcaneus fracture. The patient tolerated this
procedure well (reader, please refer to operative management for
further details). The patient received oxycodone and
acetaminophen for pain control on the floor. She was started on
a regular diet which she tolerated and IVF were discontinued. A
tertiary exam was performed which was negative for further
injury. The patient received subcutaneous heparin for DVT
prophylaxis and she worked with Physical and Occupational
Therapy. The patient was transferred from the Trauma Surgery
service to the Orthopedic Surgery service on POD #2 (___).
The patient was given ___ antibiotics and
anticoagulation per routine.
The patient returned to the OR on ___ for open reduction
internal fixation of R calcaneus fracture, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated to the left lower extremity in
post-op shoe, as well as, nonweight bearing in the right lower
extremity in splint, and will be discharged on aspirin 325mg
daily x2 weeks for DVT prophylaxis. The patient will follow up
with Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 473 | 481 |
18822446-DS-18 | 21,727,702 | 1. Shower Daily. Wash incision with mild soap & water, rinse,
pat dry
2. No tub bathing or swimming until incision healed
3. No Lotion, Creams or Lotions to incision sites.
4. Daily weights. Keep a log. Adjust diuretics as needed
5. Monitor fingerstick blood sugars. Cover with insulin sliding
scale
6. Monitor HCT, guaiac stools.
7. Monitor BMP & Mg+, replete K+ & Mg+ as needed
8. Please wear a Bra at all times to protect sternal incision | ___ is a ___ year old female with a history of CAD s/p
CABG ___, DM II, atrial fibrillation on Coumadin presenting for
concern for upper GI bleed. Her presenting HCT was 20. She was
transfused with 3 units PRBC, ___ FFP's and Vitamin K to reverse
her INR of 2.8. GI was consulted and she underwent Upper GI
endoscopy which revealed Numerous clean based gastric ulcers and
mild antral erythema. Normal duodenum and esophagus. She was
started on PPI bid for 12 weeks the daily for life.
H. Pylori was positive and she was started on triple therapy for
14 days. Flagyl was also started but discontinued when her C.
diff study was negative. Her HCT remained stable requiring to
further transfusion. Her stools were guaiac negative.
She was also seen by hematology for ongoing leukocytosis of at
least 10 days duration. Differential on ___ revealed
neutrophillic predominance and an
elevated ANC to 26.4K. Peripheral smear at this time not typical
of CML but myeloproliferative process possible. Differential
includes stress response, infection and stress response in
setting of underlying myleoproliferative neoplasm.
which Tissue: BLOOD, NEOPLASTIC is pending. Anticoagulation was
restarted for her atrial fibrillation.
Lopressor was continued for rate control atrial fibrillation.
Her diabetes was well controlled with insulin. Metformin will
restart today. Diuresis was continued.
She was seen by physical therapy who recommended ___
rehab. She was discharged to ___ rehab on HD 5. She will
follow-up with cardiac surgery and GI as an outpatient. | 74 | 256 |
16949038-DS-8 | 21,882,589 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
- You were having trouble breathing and rapid heart rates
- You were diagnosed with anti-synthetase syndrome that may
impact your lung disease
WHAT WAS DONE WHILE I WAS HERE?
- You were given a medicine called amiodarone to treat the rapid
heart rates
- You were given antibiotics
- You were given medicines to support your blood pressure
- You were started on immunosuppression for your lung disease
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should continue to work with your lung and heart doctors
- You should work with physical therapy to get stronger
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ woman with past medical
history of COPD (on 2L home O2), remote pulmonary fibrosis, and
history of bicuspid aortic valve who presenting with volume
overload in setting of NSTEMI, transferred to the MICU for afib
w/ RVR and hypotension with subsequent development of acute on
chronic hypoxic respiratory failure. She was treated for HAP and
loaded with amiodarone. She required phenylephrine gtt for
hypotension with her afib w RVR. She was found to have
anti-synthetase syndrome which was felt to be primary driver of
hypoxemia and started on prednisone and MMF. She was diuresed
and subsequently developed recurrent afib w RVR and unstable BPs
and reloaded w amiodarone in MICU then stabilized on the floor
with amiodarone and metoprolol succinate. | 126 | 125 |
15221763-DS-18 | 24,754,928 | Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for further
evaluation of a fever. You were started on antibiotics to treat
an infection of the urinary tract. You were given IV fluids as
well. You improved clinically and it was determined you were
safe to be discharged to home. Should you develop fevers, pain
with urination, persistent diarrhea or shortness of breath, you
should seek evaluation at a medical facility or at your nearest
emergency department.
You have an appointment with Dr. ___ week. Please get
labs done 1 day before that appointment including a tacrolimus
level.
Please complete the course of antibiotic and keep your follow up
appointments as scheduled.
- Your ___ Team | Ms ___ is a ___ with T1DM s/p kidney-pancreas transplant
___, HTN who presented with urosepsis | 127 | 17 |
12416245-DS-10 | 25,886,878 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___.
Why was I admitted?
- You were admitted because you had a clot in the fistula in
your arm that you use for hemodialysis.
What was done while I was here?
- You had a procedure done to take out the clot in your arm.
- You also received hemodialysis through a catheter in your
neck.
What should I do when I leave the hospital?
- You should follow up with your PCP on ___ at
11:30am.
- You should continue your hemodialysis as scheduled, with your
next appointment being ___ ___.
Be well!
- Your ___ team | Ms. ___ is a ___ year old woman with a history of ESRD on HD,
previous history of AV graft thrombosis, and hypertension who
presents with AV graft thrombosis.
ACTIVE MEDICAL PROBLEMS
=========================
# RUE AV Graft Clot: Pt presented with a right upper extremity
AV graft clot and was hypertensive in the ED. A temporary HD
line was placed for urgent dialysis on ___ by ___. She had a
thrombectomy and AV fistulogram on ___. The revised fistula was
successfully used for hemodialysis on ___. She had the IJ HD
catheter pulled prior to discharge and is instructed to resume
her regularly scheduled hemodialysis sessions starting ___
___.
# ESRD on HD: Etiology is uncertain as above but likely related
to
chronic hypertension. Complicated by hyperkalemia in the ED (K >
7 on presentation) that improved with dialysis. She also
received urgent HD through temporary dialysis catheter while
admitted. We continued home calitriol, calcium acetate and
nephrocaps while inpatient.
# Hypertension: Patient was hypertensive on presentation to ED,
with temporary resolution after receiving HD. Her blood
pressures became elevated again to the 150s-170s systolic, even
after a second round of HD, and was refractory to medication.
She is asymptomatic from this, but will need close monitoring of
blood pressure on discharge.
CHRONIC MEDICAL PROBLEMS
=========================
# Anemia: Hbg seems to be near baseline. Etiology is likely
secondary to ESRD. Her CBC was monitored daily while inpatient.
Receives aranesp weekly (___).
TRANSITIONAL ISSUES
======================
[] Please consider further blood pressure medication management
for hypertension. Patient had elevated blood pressures during
her admission that were only minimally responsive to dialysis.
[] Patient to resume HD on ___. Last HD session was on
___
[] ___ for home ___
>30 minutes spent on discharge planning and care coordination. | 104 | 283 |
18381289-DS-4 | 27,980,052 | You were admitted to the hospital after you were involved in
motor vehicle accident. You underwent a cat scan of the abdomen
and you were found to have a liver laceration. You were
admitted to the intensive care unit for monitoring. Your blood
count and vital signs were closely monitored. Your vital signs
have been stable and you are preparing for discharge home with
the following instructions:
Because you had a laceration to your spleen, please follow these
instructions:
AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having inernal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
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 apply bacitracin ointment to the abrasion on the left
side of your neck | ___ year old gentleman admitted to the hospital after being
involved in a motor vehicle collision. On imaging, he was found
to have a grade ___ liver laceration. Upon admission, he was
made NPO, given intravenous fluids, and underwent serial
hematocrits. He was also reported to have right rib fractures
___. He was admitted to the trauma intensive care unit for
monitoring. He underwent a CTA of his neck to rule out a
vascular injury. There was no evidence of vascular occlusion,
dissection, or aneurysm larger than 2 mm in size. During this
time, he was febrile to 102 and underwent a chest x-ray which
showed atelectasis vs an infectious process. His temperature
curve was closely monitored and normalized. He was started on
sips and gradually progressed to a regular diet. After starting
a diet, he was transitioned from the dilaudid PCA to oxycodone.
Shortly after receiving his first dose, he reported facial and
body tics. The narcotics were discontinued and he remained on
tylenol. His pain regimen was later changed to vicodin without
any further evidence of tics. His liver enzymes have been
decreasing. His hematocrit upon discharge was 33. On hospital
day # 5 he was discharged home. A follow-up appointment was
made with the acute care service and with his primary care
provider. | 305 | 241 |
14426498-DS-22 | 26,880,926 | Dear Mr. ___,
It was a pleasure to care for you at ___.
Why was I here?
- You came to the hospital because you were not feeling well and
were found to have very high blood sugars.
What was done while I was here?
- You were given insulin to help improve your blood sugars.
- You had a procedure called a celiac plexus neurolysis to help
with your pain.
What should I do when I get home?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
- You should resume your blood thinner, ___, on ___
___.
- Now that you had your nerve block, you may find that you are
needing lower doses of oxycodone to treat your pain.
For your diabetes:
- Please check your blood sugars four times daily and record
them.
- You should call the ___ if you notice blood sugars
over 300. Their number is ___.
- You already have a Basaglar pen at home. We have increased
your dose to 20 units at nighttime (was previously 10 units) but
it is OK to keep using the pen that you have with the higher
dose.
- The mealtime and sliding scale insulin is called Novolog (it
is similar to Humalog). You should take 8 units with breakfast,
7 units with lunch and 7 units with dinner plus the sliding
scale for any extra insulin needs.
- You will likely need more sliding scale insulin when you take
dexamethasone for chemotherapy. Please record what your blood
sugars are and how much of the sliding scale you are needing to
take. This will help the diabetes doctors ___ up with a plan
for extra insulin on dexamethasone days for the future.
We wish you the best,
Your ___ Team | SUMMARY:
========
___ ___ pancreatic cancer on Folfirinox not amenable to surgery,
severe abdominal pain, DM, CAD, HTN who presents with poor PO
intake and abdominal pain found to be in DKA.
#Diabetes
#DKA:
Admitted with poor PO intake, abdominal pain, found to be in DKA
on admission. His hyperglycemia was likely related to the
dexamethasone he received following his chemotherapy, which was
then exacerbated by intability to take PO and home diabetes
medications. His DKA may also reflect progression of his disease
and islet cell destruction. He was treated initially with
insulin gtt, IV fluids, and electrolyte repletion. He was
admitted to the ICU briefly, until anion gap closed, and was
transitioned to subcutaneous insulin. At the Oncology ward, his
subcutaneous insulin dosing was increased sequentially until
sugars were under control. ___ was consulted.
They recommended lantus 20 U QHS, Novolog ___ with meals and
novolog sliding scale (1+1:40 for BG >160mg/dL at mealtime and
>200mg/dL at bedtime) on discharge.
#Leukocytosis:
Found to have leukocytosis on admission which may have been in
the setting of DKA with associated N/V. There was no clear
infectious source found with CT chest without consolidation,
normal UA and LFTs. Given his stability, antibiotics were held.
#SMV thrombosis:
Treated with edoxaban at home. This was held in anticipation of
the celiac plexus neurolysis. He was directed to resume this
medication on ___.
#Locally advanced pancreatic cancer:
Determined to be non-resectable, currently on chemotherapy
(Folfirinox ___. Initial CT scan after initiation of
chemotherapy showed mild increase in tumor size, but may have
been too early in to chemotherapy to have seen a result. He had
repeat staging scans on ___ which showed stable disease without
progression. During the admission, he underwent celiac plexus
neurolysis to help with pain control. He was maintained on his
outpatient palliative care regimen of methadone 10mg TID with
oxycodone 45mg Q3H:PRN. He will follow up with
hematology/oncology on discharge as scheduled.
# Anxiety/Depression:
Mr. ___ reported passive SI in clinic. SW was consulted
regarding patient and family coping. He continued his home
lorazepam and mirtazapine was started to help with mood
symptoms. An SSRI was not chosen given potential for increased
bleeding risk with concurrent anticoagulation.
#Esophageal thickening:
#Odynophagia:
#Chest pain:
Presented with complaints of chest pain and odynophagia without
concern for ischemia on EKG and negative troponin. His pain
seemed more consistent with esophagitis exacerbated in setting
of coughing and vomiting. During his last admission he was noted
to have esophageal thickening on CT scan and reported
odynophagia for which he was given empiric BID PPI and given a
course of fluconazole. He was continued on his pantoprazole.
#Hypomagnesemia:
#Hypophosphatemia:
#Severe protein calorie malnutrition:
Noted to have 10 lb weight loss in two weeks prior to admission,
likely ___ ongoing poor PO intake and malnutrition in the
setting of malignancy and chemotherapy. He was seen by nutrition
who recommended 5 days of thiamine and initiation of a
multivitamin. | 292 | 477 |
11761593-DS-22 | 25,663,231 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ is a ___ Male who was recently diagnosed with aortic
valve endocarditis - strep viridans bacteremia complicated by
splenic infarct, history of papillary thyroid cancer, Graves
disease and HTN presents with exertional chest pain, found to
have elevated trops with no EKG changes.
#Chest pain
#NSTEMI: New onset typical chest pain worse with exertion, found
to have elevated trops with no EKG changes. TTE w/ new mild
regional left ventricular systolic dysfunction suggestive of
ischemic event. NSTEMI from either embolus from aortic valve
vegetation vs CAD. No prior caths or stress tests. He was placed
on a heparin gtt. Continued home crestor, aspirin and started on
metoprolol tartrate 12.5mg q6. Left heart cath ___ showed 2
vessel CAD. Distal cutoff in distal LAD appearance is most
likely secondary to distal embolization.
#Aortic valve endocarditis c/b splenic infarct: s/p ___ntibiotics. ___ TEE showed healed vegetation of
unchanged size (0.6x0.65cm), with moderate to severe aortic
regurgitation and perforation of the right coronary cusp.
Vegetation presumably sterile given negative blood cultures
during last 2 admissions. Repeat TTE this admission with larger
moderately-sized (0.8x0.4 cm) vegetation and 4+ severe aortic
regurgitation. Pt with no signs of volume overload, although has
widened pulse pressures. No fevers, chills, nightsweats, and no
leukocytosis to suggest current infection. Physical exam without
___ lesions, Olser nodes, splinter hemorrhages or other
signs of endocarditis. ESR 6 and CRP 2.9. Blood cultures showed
no growth. Per ID team, no need for antibiotics given no
evidence of active infection and no clear infectious
contraindication to aortic valve replacement. The cardiac
surgery team was consulted for anticipated aortic valve
replacement. He underwent preop workup, including panorex,
dental consult, carotid US. He was cleared for surgery by his
endocrinologist from a papillary thyroid cancer standpoint.
# Recent PNA: Had bibasilar consolidations on CXR. Pt was
recently admitted for PNA and now s/p 5d of levofloxacin.
Currently afebrile with no clinical signs of pneumonia.
Consolidation on x-ray likely radiographic lagging of PNA seen
earlier on ___. Pt remained symptom free during admission.
CHRONIC ISSUES:
#HTN: continued home HCTZ, held home atenolol. Started on
metoprolol as above.
#Hyperlipidemia: continued home crestor
#Grave's Disease: TSH 0.09. Continued home methimazole
After completing his pre-operative work up, the patient was
brought to the operating room on ___ where the patient
underwent AVR (27 mm ___ mechanical). Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
Coumadin was started for mechanical valve prophylaxis. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions. | 123 | 542 |
13094848-DS-23 | 24,173,469 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You were admitted because the wounds on your legs were not
healing. Your diabetes was also very poorly controlled.
While you were here several surgical teams evaluated your wounds
and said that there was no need to do any surgical debridement
of the wounds. They also did not appear infected and you
continued to look well without antibiotics. Several studies to
assess the blood vessels in your legs, which showed adequate
blood flow. Throughout your admission, the ___ team was very
involved in your care and insulin management.
When you go home you should follow up with all your doctors as
listed below. Please take all your medications as prescribed.
We wish you the best!
Your ___ Care Team | SUMMARY
==========
___ with hx of CAD s/p CABG, AML in remission, IDDM2 (HbA1c
around 11%), and HTN, who presented with multiple acute and
chronic
lower extremity wounds in the setting of poorly controlled DMII.
The wounds were not felt to be infected and did not require
debridement. ___ was consulted and assisted in insulin
titration.
TRANSITIONAL ISSUES
=====================
[] As discussed below, the patient has historically had very
poor glycemic control and was also intermittently hypoglycemic
in the hospital. Please monitor blood glucose and adjust as
needed.
[] The patient should have continued wound care as an
outpatient. He should also perform regular feet checks given his
significant neuropathy and propensity for wound development.
[] While admitted, the patient demonstrated limited
understanding of his health issues and appeared forgetful and/or
repetitive. Recommend formal neurocognitive evaluation as an
outpatient.
ACUTE ISSUES
=============
# IDDM
The patient has very poorly controlled diabetes for many years
complicated by diabetic foot ulcers and peripheral neuropathy.
Last A1c 11.3% in ___. Numerous discussions were had with
the patient to try to identify barriers for better insulin use
and improved glycemic control. We also reached out to the
patient's PCP to gain more collateral. The patient did not
appear to have access issues or insurance problems, but did
demonstrate lack of appreciation for the importance of his
medications and at times appeared forgetful or repetitive. He
however expressed motivation to be more adherent in the future
to prevent further problems with non healing wounds. ___ was
consulted and assisted in management of his insulin regimen. He
had several episodes of hypoglycemia while in the hospital
possibly because of eating less than he typically does at home.
His insulin was decreased to 70/30 40u in the morning and 15u at
night. The patient was discharged with plans for close ___
follow up.
# Lower extremity ulcerations
The patient presented with numerous ___ wounds in the setting of
poorly controlled DMII. The wounds did not appear infected
however and the patient remained clinically stable off of
antibiotics. Surgical orthopedic and podiatry teams evaluated
his wounds and assessed them as all shallow, not requiring
debridement. Wound care was consulted and his wounds were
cleaned/dressed daily.
# Concern for peripheral vascular disease
As noted above, the patient has many risk factors for peripheral
vascular disease (HTN, HLD, DMII, etc) and also exhibited
elements on exam suggestive of disease in arterial and venous
circulations. However ABIs and venous reflux studies were
reassuringly within normal limits. Vascular surgery deferred any
further intervention or work up. The patient was continued on an
aspirin and statin.
CHRONIC ISSUES
===============
# HTN
Per outpatient cardiology letter, pt is prescribed lisinopril
and
metoprolol. Unclear if has history of AFib (in OMR problem
list),
however HR were stable and patient stated that he did not take
metoprolol at home. The patient was continued on lisinopril,
which was uptitrated per BPs. He was also started on metoprolol,
which is indicated for his history of CAD as well.
# CAD s/p CABG (4 vessel)
Not compliant at home with ASA, statin, or beta blocker. These
were started and continued on discharge.
CORE
=======
#CODE: FULL CODE, confirmed
#CONTACT: ___ (wife): ___
#HCP: ___ (daughter): ___
Greater than ___ hour spent on care on day of discharge. | 127 | 519 |
18230098-DS-31 | 23,139,859 | Dear Ms. ___,
It was a pleasure participating in your care here at ___. You
came to the hospital after falling and hitting your head after
dialysis. Your fall was likely due to low blood sugar and low
blood blood pressure after hemodialysis. Your blood sugar was
found to be 65 in the emergency department and you were given
sugar to bring it up. Your blood pressure dropped when you
stood up, so we gave you 500 mL of fluid to bring it back up. We
also stopped your amlodipine.
You also had a head and neck CT which showed no bleeding in the
brain or injury to the spine. You had a normal EKG and cardiac
enzymes, so you did not have a heart attack or irregular rhythm
causing the fall. Your electrolytes were within normal limits,
so they did not cause the fall. Overall you continued to feel
well after the fall other than a bruise on the left side of your
head.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Medication Changes:
STOP:
-Amlodipine 10 mg PO daily | ___ yo F w/ PMH notable for sCHF (EF 45%), CAD (PCI to RCA in 99,
stent to ostial RCA w 2 BMS, stent to LAD in ___, HTN, HLD,
DMII, PAD, CKD on HD (___) presents with an unwitnessed fall
after HD, likely due to orthostasis and mild hypoglycemia.
.
#Orthostasis: The patient's fall was most likely due to
orthostasis after HD on the day of admission, as well as mild
hypoglycemia (see DM below). She was found to be orthostatic on
exam on ___, with SBP dropping from the 110s to the ___ with
standing, and was symptomatic with some lightheadedness. As
these symptoms appear to be different from her baseline, it is
likely that she became orthostatic in the setting of volume
depletion after HD. She was given a 500cc bolus and improved
symptomatically. Amlodipine was discontinued due to possible
worsening of orthostasis. Note other causes of syncope were less
likely, including aortic stenosis (only mild AS on echo from
___, arrhythmias (NSR on tele), ACS (Troponin flat x3, CK-MB
flat x2), seizure (no history of seizure, history inconsistent),
electrolyte abnormalities, thyroid disease (TSH 2.2 on ___.
.
#Hypoglycemia: As mentioned, the patient was found to be mildly
hypoglycemic on admission the ED, with a FSBG of 65, which
likely contributed to the initial fall. She was given ___ amp
dextrose with good response. Of note, she did compare her
symptoms to prior episodes of syncope in the setting of
hypoglycemia. Once inpatient, her blood sugar was well
controlled on her home regimen of NPH 12 units in AM, with HISS.
.
#S/P Fall: The patient had a head CT in the ED that showed no
hemorrhage; this should be repeated in 1 week to rule out a slow
bleed, particularly in the setting of anticoagulation. She also
sustained a large left temporal hematoma, which was monitored
during admission. Pain was managed with acetaminophen 650 mg q6
hours PRN. Developed right hand pain on day prior to discharge,
but right hand films negative for fracture.
.
#Systolic CHF with EF 45%: No crackles ___ edema on exam; mild
pulmonary congestion on CXR. ProBNP was 4452, but in the setting
of renal failure this is difficult to interpret; this is also
significantly lower than prior proBNP measurements. She was
continued on home carvedilol and torsemide and remained stable.
.
# ESRD on HD: Daily electrolytes were monitored, stable during
admission. Home sevelamer carbonate, calcitriol, calcium
carbonate, and cholecalciferol were continued. Inpatient HD was
done on ___ morning prior to discharge.
.
# Hypertension, difficult to control on multiple agents, was
hypertensive to SBP of 170s in the ED. While inpatient, was
stable with SBP in 110s-140s. All home meds continued initially,
but amlodipine was stopped on ___ due to orthostasis.
.
# CAD: s/p PCA of the RCA in ___, stenting of the ostial RCA
with two overlapping BMS in ___, stenting of the proximal
LAD with BMS in ___. No CP or SOB throughout admission. No
evidence of ischemia on EKG, flat Troponins x3 and CK-MB x2.
Stayed in NSR on telemetry throughtout admission. Home
medications (Imdur, Carvedilol, ASA, Plavix) continued.
.
# Peripheral arterial disease: s/p stents to left common iliac,
external iliac artery stenting and superior femoral artery.
Stable. ASA and Plavix continued.
.
#Dyslipidemia: Continued home pravastatin. Stable.
.
#Goals of care: Full code.
.
#Transitions:
1) Follow up head CT in one week to rule out slow hematoma
2) Follow up scheduled with PCP
3) Follow up scheduled with endocrinology for DM management
4) Follow up with nephrology at dialysis appointment on ___,
___ | 189 | 605 |
13314948-DS-6 | 20,674,655 | You were admitted with a small bowel obstruction. You were
treated conservatively with bowel rest and an NGT to suction and
you improved fairly quickly. Your tube was removed and you
tolerated your medications and advancement to a regular diet.
You will need to follow up closely with your outpatient
providers for further workup as to why you had a bowel
obstruction.
You also complained of headache while here. Your headache was
severe and due to your history of AT3 deficiency you had a CTA/V
of your head which was reassuring. Your headache gradually
improved. I recommend you follow closely with your PCP for
ongoing treatment and workup of headache. It may have been
related to muscle spasms in your upper back and neck. | BRIEF SUMMARY:
This is a ___ with IBD thought to be UC (L sided colitis) in
remission on oral medications who presented with abdominal pain
and was found to have an acute small bowel obstruction. Treated
conservatively with NGT to suction. Quickly improved, tube
removed, diet advanced. Needs ongoing workup for causes of SBO,
highly suspicious for potential Crohn's disease leading to
inflammation/stricture given his personal and family history and
nonsurgical abdomen. | 123 | 72 |
10180971-DS-11 | 21,438,695 | Ms. ___,
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. | Mrs ___ 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. Her bilirubin was elevated to 2.2, therefore an
IOC was performed which did not demonstrate a filling defect in
the CBD. 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.
Her LFTs were trended after surgery. On POD1 her Tbili was
decreased to 0.7 but her other LFTs were mildly elevated
therefore, she was kept overnight to make sure her Tbili remains
low and there are no signs of retained CBD stone. ERCP service
was consulted intraop and after reviewing the intraop IOC, they
agreed there are no signs on CBD stone.
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
POD1 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 . | 731 | 255 |
14001416-DS-17 | 25,773,269 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were transfered from another
hospital because you suffered from a seizure. As a result, a
tube was inserted in your airway to protect your airway. You
were transfered to the intensitve care unit for further
monitoring. In the intensive care unit, you were found to have a
urinary infection and we started you an antibiotics. Because you
have a hisotory of diarrhea with antibiotics we kept you on two
oral antibiotics (vancomycine and flagyl) to help prevent
diarrhea. Also your blood pressure was low without a clear cause
despite several investigations. We started you a medication
called Midodrine which help keep your blood pressure in the
normal range. During you intensive care stay you became more
conscious and we removed the breathing tube. subsequnetly you
had furhter improvement and were transfered to a general ward
were you were observed for 2 days. You continued to be stable
and symptomatic and without further seizures. We adjusted the
dose of your anti-epileptic medication (valproic acid) and
recommend that you remeasure the levels of this medication 1
months from now.
Please continue to take you antibiotic (linezolid) for untill
___ and continue taking vancomycine and flagyl untill
___. Also make sure to continue taking your other
medications regularly. We arranged for you to see a neurologist
one month from your discharge to ___ for the your
anti-epileptic medication levels and follow up on your history
of seizures.
Again it was a pleasure taking care of you at the ___.
We wish you all the best,
Your ___ team | ___ with a PMHx of HCV, EtOH abuse, recurrent cdiff, seizure
disorder who presents with 2 episodes of general tonic clonic
seizures as well as fever and hypotension. Per report from the
nursing home physician the patient had a GTC with
unresponsiveness and shaking of all four extremities for a full
55 minutes before breaking with 11mg of sublingual Ativan. In
the OSH the patient was febrile and started on antibiotics,
steroids, and acyclovir. LP was negative. Patient was
transferred to ___ and then the MICU for further care. Per
Neurology the patient was given valproic acid for seizure
control and started on cvEEG. This was discontinued after 48
hours without any seizure activity. Patient was extubated
without difficulty on ___. Patient was continually hypotensive
while in the MICU requiring low dose Levophed and IVF boluses.
She was later weaned off the levophed and put on midodrine which
she tolerated well maintaining her blood pressure around 110
systolic.
The patient was transferred to the general ward and was treated
for the following issues:
1) VRE unrinary tract infection: thought to be the most likely
percipient of her seizures. The patient was kept on linezolid
which she tolerated well. The patient remained asymptomatic. We
also kept the patient on po vanco and flagyl for prevention of
C.Diff diarrhea. We plan to continue her oral linezolid until
___ and to continue her PO vanc and flagyl until
___.
2) seizures: The patient continued on oral valproic acid ___
TID. She did not have further seizure on the ward. Neurology was
consulted regarding managing her dosage and recommended that she
would follow up with neurology in a month and to measure her VPA
levels prior to the appointment.
3) Stress cardiomyopathy: the patient underwent echo
cardiography on ___ which showed mild regional left
ventricular systolic dysfunction with focal dyskinesis of the
apex and hypokinesis of the surrounding walls. The patient
underwent another Echocardiogram with optison which excluded an
LV thrombus and showed normal LV function. | 267 | 333 |
11453961-DS-4 | 22,854,863 | Mr. ___,
You were admitted to ___ ICU after you had R sided weakness
while teaching ___ at the ___. While you
were here, you had a CT angiogram which showed an occlusion in
one of your arteries, the left internal carotid artery. This
occlusion was causing lack of blood flow to one of the
off-branches from the internal carotid artery called the middle
cerebral artery. An MRI confirmed the findings of a stroke or
blood clot in the middle cerebral artery as it showed lack of
blood flow in parts of the brain normally perfused by the middle
cerebral artery. You were given clot-lysing medication (tPA),
the clot was removed by Interventional Radiology and stents were
placed to bypass your internal carotid artery. While in the ICU,
you had seizures and were therefore started on 3 anti-epileptic
drugs - lacosamide, levitiracetam and fosphenytoin. After your
condition stabilized, you were transferred to the Neurology
floor.
While on the Neurology floor, you were seen and evaluated by the
speech and swallow services and received physical therapy. You
had some mild L eye conjunctivitis, which we treated with
antibiotics (erythromycin ointment). Your strength in the R side
of your body continued to improve and your comprehension
improved, although you continued to be nonverbal.
You were placed on several new medications during your stay
here.
- Aspirin 325mg daily
- Plavix 75mg daily for 1 month
The Aspirin and Plavix are to help prevent blood clots from your
new internal carotid artery stent.
It was a pleasure taking care of you during your hospital stay. | ICU COURSE
Following tPA administration and intraarterial clot retrieval
and stenting of the left ICA the patient was admitted to the
neuro ICU for close monitoring. He remained intubated. Follow up
imaging showed no sign of hemorrhage and he was started on
aspirin and plavix 24hour following tPA administration. On the
morning following admission the patient was found to be
unresponsive despite being off sedation for about 2 hours. Some
bilateral eyelid twitching was noted, raising the concern for
seizure activity. EEG was obtained which showed rhythmic
discharges in the frontal regions. He was loaded with keppra.
Overnight continuous video EEG monitoring showed frequent
seizures, occurring roughly every 15 minutes. He was given an
additional dose of keppra and his standing dose was increased to
1500mg BID. This resulted in reduced frequency of seizure
activity. However, EEG showed continued seizure activity
occurring roughly once per hour and the patient had waxing and
waning levels of alertness clinically. Therefore a 1000mg
fosphenytoin load was given followed by 100mg q8hr dosing.
Lacosamide was also added. Lipid panel revealed LDL of 123 and
atorvastatin 40mg was started. HgbA1c was 5.9%. Echocardiogram
was poor quality but showed no major abnormalities or
intracardiac thrombus. MRI revealed diffuse infarction in the
left MCA distribution as well as a punctate infarct in the right
frontal lobe.
FLOOR COURSE
#NEUROLOGY
His condition stabilized and he was transferred to the Neurology
floor. He was continued on ASA, plavix and statin. His phenytoin
was weaned off while on EEG monitoring, with no seizures. He was
continued on Keppra and Lacosamide. His R body strength
continued to improve with his R leg showing greater improvement
than his R arm. By the time of discharge he was able to walk,
however continued to hold his arm in flexion and was
demonstrated severe expressive aphasia, with a milder receptive
aphasia.
He did not pass his speech and swallow, and eventually a PEG
tube was placed, which went without incident. He then improved
and was able to eat a modified diet, with supplemental tube
feeds as needed.
He was seen by physical therapy who recommended rehabilitation.
#ID
While on the floor, he spiked a 101 degree fever most likely
secondary to atalectasis, as chest xray and UA were
unremarkable. He was not started on antibiotics, fever did not
recur. He also developed a L eye conjunctivitis that was
successfully treated with a 5 day course of erythromycin.
OUTSTANDING ISSUES
[ ] Plavix - please discontinue after one month (___)
[ ] Continue Keppra and Lacosamide - may eventually wean off
[ ] Needs stroke follow up - unable to schedule due to
insurance/registration. Family informed.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL = )
- () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL ___ 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL ___ 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL ___
100 or on a statin prior to hospitalization, reason not
discharged on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A | 257 | 679 |
17128602-DS-37 | 27,559,342 | Dear Ms. ___,
WHY WAS I ADMITTED?
-You were admitted because you were having abdominal pain.
WHAT WAS DONE WHILE I WAS HERE?
-The surgeons were able to fix your hernia
-We drained fluid from your belly and confirmed that it was not
infected
-We placed a tube in your stomach so that you can drain fluid
from your stomach at home
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team | ___ with NASH cirrhosis (Child's ___ A, MELD 13), decompensated
by hepatic encephalopathy, esophageal varices, and ascites,
portal vein thrombosis on Coumadin and diabetes mellitus
complicated by gastroparesis, and small bowel obstruction
secondary to ventral hernia who presented with abdominal pain
and vomiting.
# Abdominal pain ___ intermittent bowel obstruction
# Lactic acidosis
# Incarcerated abdominal hernia, new reduced
Patient with abdominal pain and lactic acid to 5.8 on admission.
However, abdominal pain improved after bedside hernia reduction
with transplant surgery. Furthermore, lactate downtrended. CT
abdomen with small bowel loop in her umbilical hernia. Abdominal
pain after eating and with standing likely secondary to
herniation as well as chronic gastroparesis. ___ guided
paracentesis was negative for spontaneous bacterial peritonitis.
We continued metoclopramide and dicyclomine but held furosemide
and spironolactone on discharge due to her pleurX catheter
placement on admission.
Chronic issues
# NASH Cirrhosis (Child's A cirrhosis, MELD 13)
Patient has history of hepatic encephalopathy, esophageal
varices, s/p TIPS (___), ascites, and history of portal vein
thrombosis on warfarin. She did not have signs of hepatic
encephalopathy. Patient had paracentesis on ___ as outpatient
but no notes that negative for spontaneous bacterial
peritonitis. Last endoscopy ___ with gastritis but with
no evidence of varices. Last abdominal ultrasound ___ and
showed patent portal vein but no liver lesions. The patient
follows with Dr. ___ as an outpatient, and many discussions
about goals of care have been had. However, the patient had not
made a decision about her goals of care. Palliative care and
hospice saw during this admission, and the patient and her
family decided that home with hospice is within her goals of
care. The patient received an ___ Pleurex catheter, stopped her
warfarin, and was discharged to home with hospice. We continued
home lactulose, Rifaximin 550 mg PO BID. Nutrition was consulted
and recommended Glucerna shakes 3 times daily.
# TIPS occlusion, stable
# History of DVT, PVT
Patient has history of DVT, PVT, with stable TIPS occlusion
identified on RUQUS. Per OMR review, INR goal 1.7-1.9 given need
for routine paracenteses making it difficult to stay in
treatment window. Patent portal vein on last abdominal US in
___. We held warfarin given need for paracentesis and after
determining that it was not within her goals of care.
# Chronic diastolic congestive heart failure
We continued home Atorvastatin 10 mg PO/NG QPM and held
furosemide
20 mg PO BID
# Diabetes Mellitus TYPE II. Last HbA1c 10.2 on ___. The
patient follows
at ___. We continued home Insulin glargine 28 units QHS with
Insulin sliding
scale
# Hypertension
We discontinued home spironolactone 50 mg PO DAILY
# Hypothyroidism
We continued home Levothyroxine Sodium 50 mcg PO DAILY
# GERD
We continue home Omeprazole 20 mg PO BID | 82 | 446 |
19638896-DS-12 | 29,913,722 | Mrs. ___,
___ was a pleasure caring for you in the hospital. You were
admitted because of difficulty walking and word finding
difficulties. You were found to have cancer spread to your
brain. You were started on steroids and whole brain radiation.
Please follow up with your oncology team. Please continue your
radiation therapy as instructed.
Your ___ Team | ___ w/ EGFR mutated NSCLC metastatic to pleura on osimertinib
s/p
TPC c/b persistent TPC colonization/infection p/w 3 weeks of WFD
and cognitive dysfunction found to have diffuse brain metastases
on MRI, started on steroids and WBRT.
# Diffuse brain metastatic disease
# Encephalopathy:
# Unsteady gait:
She has no focal findings on exam but has subacute subtle
cognitive dysfunction with inattention and word finding
difficulties. MRI confirmed suspicion for diffuse brain
metastatic disease. Received whole brain XRT without
complications with somewhat decline in physical status.
Hospice was raised with patient and family by palliative
care and the plan at this time is to get the patient home
as soon as possible to maximize her time there with 24hr
support. they will continue to have ongoing discussions re
goals of care as outpatient but in meantime, will continue the
remaining fractions of XRT.
- Dexamethasone 4mg qAM + PPI
- Continue WBRT per RadOnc
- ___ at home
- Hold osimertinib while undergoing WBXRT
# Pleural space colonization by CoNS: Continued growing CoNS on
pleural fluid culture on ___ and ___. Pleural fluid has
downtrending PMN count and LDH. Patient is asymptomatic and
afebrile. Discussed with ID and IP. Will keep for now. She was
drained daily with maximum of 150 ml each time
- Drain TPC daily as tolerated (ok to do every other day)
- hold off abx for now
# Sinus tachycardia: Chronic. Prior CTA without PE and TSH wnl.
# Anxiety:
- Lorazepam 0.5mg po q6 hours as needed
# GERD:
- Continue ranitidine prn
# Glaucoma:
- Continue drops
FEN: Regular
CODE: Confirmed DNR/DNI on ___
COMMUNICATION: Patient
DISPOSITION: home w/ 24/hr care
BILLING: >30 min spent coordinating care for discharge
____________________
___, D.O.
Heme/Onc Hospitalist
___ | 57 | 258 |
17075643-DS-12 | 21,392,214 | Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because you were confused and acting
differently from your baseline. It was discovered that you were
probably taking too much ativan and oxycodone at home. You
should try and limit your intake of these medications. You were
also having back pain; an Xray of your spine showed a worsening
fracture at T12 (probably a metastatic focus). You had an MRI,
which also showed a fracture at T12 and L1. You will need to
follow-up with your oncologist and your primary care doctor
about further treatment for these fractures. We started you on
round-the-clock tylenol and Naproxen (in addition to low dose
oxycodone). You may benefit from Zometa therapy and radiation
therapy. You can talk to your primary oncologist about these
options.
A chest XRAY showed a small pneumonia in your right lung; we are
giving you antibiotics for this, and you should have a repeat
chest XRAY in the next ___ weeks to make sure that the pneumonia
has resolved.
The following changes were made to your medications:
1. START taking cefpodoxime 200mg every 12 hours through ___. START taking azithromycin 250mg every 24 hours through ___. DECREASE dose and frequency of ativan and oxycodone (see
below)
4. STOP trazadone (this medication was probably worsening your
confusion)
Please keep all of your other appointments. Please take all of
your medications as prescribed. | This is a ___ gentleman with a history of metastatic
renal cell cancer s/p IVH s/p evacuation with residual RUE
weakness who presents with altered mental status and confusion
in setting of sedation drugs and +/- pneumonia.
.
CONFUSION: Patient with change in mental status from baseline
as per patient, wife, and outpatient providers. Likely toxic
metabolic in origin, with sedating drugs (ativan and oxycodone)
and ?pneumonia contributing. With antibiotics and judicious
administrating of benzodiazepines/narcotics, patient's mental
status quickly cleared. He was started on levofloxacin for
pneumonia, but this was changed to CTX and azithromycin as not
to lower his seizure threshold. Mr. ___ will be discharged on
cefpodoxime 200mg Q12 hours to finish on ___ and azithromycin
250mg Q24 hours to finish on ___. His urine culture was
negative and blood cultures are still pending. The doses and
frequency of ativan/oxycodone were reduced and trazadone was
stopped.
.
# BACK PAIN: Patient with lumbar back pain. No spinal
tenderness, but paraspinal muscles are sore. Fracture at T12
(likely pathologic) and L1 copmression fracture seen on XRAY.
MRI confirmed no spinal cord compression. Patient was given
tylenol, NSAIDs, and small doses of oxycodone for pain. He may
benefit from Zometa and XRT as an oupatient. This was
communicated to his primary oncologist. Patient was seen by ___
and will be discharged with home ___.
# PLEURAL EFFUSION: New pleural effusion seen on MRI on ___.
Patient without O2 requirment and no complaints of SOB. This
finding will be conveyed to outpatient providers and can be
worked up further as an outpatient.
# METASTATIC RCC: Patient has been off sutent since ___
with evidence of progressive disease. He will have close
follow-up with outpatient oncology team.
.
# ACUTE RENAL FAILURE: Mr. ___ had a creatinine elevation to
1.3 up from a recent baseline of 1.1. Resolved with fluids.
.
# ANEMIA: Patient with baseline anemia, though slightly worse
on this admission. Hemolysis labs negative. No sign of overt
bleeding. Hemaglobin should continue to be followed as an
outpatient.
.
DIET: Patient seen by speech pathology and cleared for thin
liquids and regular food. | 249 | 368 |
13643747-DS-12 | 20,635,298 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted after
getting intravenous and oral contrast for your CT scan along
with intravenous fluids, that caused too much fluid to go into
your lungs. You were treated with medication to remove the
excess fluid, and your symptoms improved. While you were
hospitalized, we did an echo of your heart, and this was
concerning for problems within your coronary arteries. However,
you had a cardiac catheterization, and it was normal.
If you start to develop new shortness of breath, worsening
swelling in your legs, chest pain, or an overall decrease in
your well being and energy level, please seek medical attention.
If your weight increases by more than 3 lbs in 3 days, please
seek medical attention.
We wish you the best of luck in your health!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman with metastatic RCC (s/p
nephrectomy ___, paroxysmal a fib not on anticoagulation (b/c
UGIB ___, SSS s/p dual chamber pacemaker in ___ ___
Scientific ___), hypothyroidism and CVA in ___ (affecting
peripheral vision per pt) presenting with flash pulmonary edema
after volume load post CT scan with contrast.
Ms. ___ was admitted after receiving IV and PO contrast for a
CT scan that is part of a treatment protocol for RCC. She
received IV fluids for precontrast hydration. Shortly after
receiving contrast and IV fluids, her SBP was in the 180s,
oxygen saturations decreased to the ___ on room air, she was
coughing up pink frothy sputum, and she had left sided chest
pain. She was put on a non-rebreather, given 20 mg IV lasix x2,
nitroglycerin. Her chest pain and oxygenation improved. EKG
showed no significant changes and troponins were negative. She
was then brought to the ___ ED, admitted, and had additional
diuresis. After diuresis with IV lasix over the course of 24
hours, she appeared significantly improved. Because we did not
have a recent echo (last one ___ years ago), Echo was obtained.
Echo was significant for mild regional systolic dysfunction with
hypokinesis of the mid to distal anterior septum, apex, and
distal inferior walls concerning for disease in the LAD. She
underwent cardiac catheterization ___, which showed clean
coronary arteries, and wedge pressure of 7. She was started on
metoprolol for rate control given her systolic function and
history of atrial fibrillation. It was thought that the
patient's symptoms were due to acute adminstration of IVF and IV
contrast, as her PCWP and other filling pressures were normal by
the time of discharge. She will need cautious use of IVF in the
future.
In addition, for patient's history of afib, we continued her
home propafenone and started metoprolol as above. She has a
CHADSVASC of 6, and was in sinus rhythm throughout
hospitalization. She is not on anticoagulation chronically
because of an UGIB in ___. Included in transitional issues is
discussion of risk vs benefits for starting anticoagulation.
Upon admission she had a leukocytosis up to 15.3, but with no
localizing signs/symptoms of infection, UCx negative, and
patient was afebrile during hospitalization. Leukocytosis
thought to be secondary to acute physiologic stress and improved
after intervention. WBC downtrended to normal.
For her hypertension we continued amlodipine, clonidine and
losartan. We continued atorvastatin for hyperlipidemia,
omeprazole for GERD, and synthroid for hypothyroidism.
We were in communication with her oncology team, Dr. ___
___ and Dr. ___, throughout her hospitalization.
TRANSITIONAL ISSUES
#F/u echo in one month with Dr. ___ started on
metoprolol 25 mg xl on d/c
#F/u risks-benefits of anticoagulation for afib with CHADSVASC 6
#F/u safety of IV contrast in this patient, as per her this is
the second "reaction" she has had to IV contrast (although this
one was likely secondary to IVF, she said the last time she got
IV contrast she had significant chills and discomfort)
# Given hypotension ( breif episode asx sys bp 89-110's) day of
d/c (after being npo day prior for cardiac cath) home losartan
was halved to 50 mg daily. Please uptitrate back to 100 mg if
patient hypertensive again on follow up
# Given patient's history of structural heart disease, per
outpatient PCP/cardiologist, may consider stopping of exhancing
propafenone with another anti arrythmic.
#started on 25 mg xl metoprolol
#FULL Code
#CONTACT: HCP ___, daughter, ___ | 146 | 573 |
17877811-DS-5 | 23,269,915 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
with shortness of breath, and found to have a pneumonia. You
were started on antibiotics, and you improved. You were also
continued on the antibiotics for your C diff infection.
___ addition, during your hospitalization it was found that your
blood counts are lower than your normal level. There is no
concern for active blood loss, but you should follow up with
your PCP to make sure all your regular cancer screenings are up
to date. Please ensure you are up to date on your mammogram and
colonoscopies.
We wish you the best of luck ___ your health.
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ year old woman s/p L4/L5 laminectomy for
spinal stenosis ___ ___, recent herpes zoster infection,
and active first recurrence of C diff. on oral vancomycin, who
presented with community acquired pneumonia.
#CAP: Patient presented with cough, fever, leukocytosis, and
with radiographic evidence of PNA. No risk factors for MDR
organisms and influenza negative. Legionella negative. Patient
was on room air and breathing comfortably throughout
hospitalization. She was treated with oral levofloxacin, to
complete a 5 day course.
#Moderate CDI, first recurrence: Patient was still having
diarrhea, however, abdominal exam was benign. She was continued
on oral vancomycin, and will need to be treated 14 days past CAP
abx treatment as above (end = ___.
#Hyponatremia: patient was admitted with sodium of 119, urine
lytes consistent with hypovolemic hyponatremia ___ the setting of
poor oral intake due to recent illness. She was given gentle IVF
and improved appropriately.
#Normocytic anemia: Patient noted to have h/h below baseline of
hb 13 to ___, MCV 91. Workup was consistent with anemia of
chronic disease, but she has no known chronic diseases. She
should have age related cancer screening.
#HTN: Continued home atenolol, triamterene/HCTZ.
#HLD: Continued home simvastatin.
#CAD prevention: Continued home ASA. | 120 | 205 |
12385889-DS-22 | 25,650,581 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in splint right lower extremity.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Right lower extremity: Touchdown weight bearing
Treatments Frequency:
Site: Right lower leg
Description: Right leg with ace intact with split cast
underneath
Care: Continue to keep clean dry and intact till post-op visit | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have a right tibia/fibula fracture and was admitted to the
orthopaedic surgery service. The patient was taken to the
operating room on ___ for ORIF R tibia via IMN, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge home with
home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the right lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 573 | 259 |
16651008-DS-9 | 26,829,165 | Dear Ms. ___,
You were admitted to ___ because you had a wound infection.
While you were here, we treated your infection with strong
intravenous antibiotics, and we took you to the operating wound
for surgical debridement of your wound. We also used a wound vac
device to promote healing. You are now safe to be discharged
home with visiting nursing assistance to help with your wound
healing. You should follow up with Dr. ___ as instructed
below to see how your wound is healing.
MEDICATIONS:
Take your medications as prescribed in your discharge
Take pain medication as needed / as prescribed
Remember that narcotic pain medication can be constipating.
Increase your fiber intake
ACTIVITY:
-Do not drive until cleared by your surgeon
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site. | Ms. ___ was admitted to ___ with a large wound infection and
dehiscence of her surgical incision overlying her PTFE graft.
She was taken to the operating room for surgical debridement
twice and a wound vac was placed to continue to drain the fluid
and promote healing. The wound vac was changed every other day
to assess the wound. On ___ during a vac change, the wound
was noted to have necrosis of skin around the edges and necrotic
tissue within the wound. Therefore, the patient was taken to the
OR on ___ for repeat debridement and wound vac replacement.
After this last debridement, the wound began granulating and
seemed to be healing better.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was controlled with PO oxycodone and IV
dilaudid for breakthrough pain and wound vac changes.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. She was
maintained on metoprolol, aspirin, and simvastatin throughout
hospitalization.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, ambulation as she could tolerate, and incentive
spirometry were encouraged throughout hospitalization.
GI/GU/FEN: Renal was consulted to assist with peritoneal
dialysis management. The patient's electrolytes were checked
daily and followed closely with appropriately adjustments in her
peritoneal dialysis dialy. She tolerated a regular diet
throughout hospitalization, but had some nausea which was
temporally related to the administration of her tigecycline
antibiotic. She was treated with zofran as needed for nausea.
ID: The patient's fever curves were closely watched for signs of
infection and her white blood cell count was trended daily. The
infectious disease service was consulted for assistance with her
antibiotic regimen given the culture results of ___ from
the wound growing multi-drug resistant enterococcus and ___.
Prior to the culture results, she was prophylactically started
on Vancomycin, Ciprofloxacin and Flagyl. Blood cultures were
persistently negative throughout the hospitalization and the
patient remained afebrile though with an elevated WBC count. She
was transitioned to tigecycline and fluconazole per ID
recommendations which she is to continue receiving until ___
to complete a 6 week course. She will follow up with the ID team
in clinic after her discharge.
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 she
was encouraged to get up and ambulate as often as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She will be discharged to rehab with her IV
antibiotics and her wound vac which will continue to be changed
every other day to monitor the wound healing progress. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 214 | 476 |
13919174-DS-14 | 27,661,623 | -you will discharge home with ___ for IV therapy assistance with
your antibiotics
-ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-Resume your pre-admission medications except as noted
-You may take acetaminophen ___ ibuprofen as needed per
respective instructions
-AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity until you are cleared by your
Urologist in follow-up. Light household chores/walking are
generally ok. Do not vacuum.
-You may shower but do not tub bathe, swim, soak
-Complete the full course of antibiotics as directed | Mr. ___ is a ___ status post prostate biopsy (revealing
prosate CA)who called in on ___ evening with complaints of
fevers and chills after his biopsy, and he was admitted to ___
___ for post-biopsy sepsis. There he was
originally started on IV abx and Bcx grew E. coli. He was
narrowed to PO Bactrim, however left AMA prior to cultures being
finalized, and they ended up as
ESBL-producing organisms resistant to most PO drugs including
Bactrim. He followed up with his PCP and was directed by
___ to report to ___ ED for admission for appropriate
antibiotics. He arrived to ED feeling well, without fevers,
chills, rigors, malaise, nausea, vomiting, diarrhea, chest pain
or shortness of breath. He did mention he has some dysuria, but
no hematuria. He is also noting severe frequency (urinating
q15minutes), with urgency and feeling of incomplete emptying
which he says is nowhere near his baseline. Our colleagues in
Infectious disease were consulted and he was started on
meropenem. With no growth to date after 48hrs on his repeat
blood cultures, a midline was placed. He was discharged to home
with ertapenem and set up with the ID outpatient department for
follow up. He will also follow up for further discussion of his
prostate cancer. | 116 | 211 |
19799964-DS-18 | 21,550,227 | Mr. ___,
You were admitted for your black stools and biliary duct
obstruction. With a scope we were able to remove the stent in
the biliary tract and open the sphincter, dissolving the stone
obstructing the tract. After your procedure, you were stable
with no signs of gastrointestinal bleeding. We found a possible
hole in your gallbladder wall with some surrounding pus, so you
will need to see our surgeons on ___ to have another CT scan
and discuss whether you need a procedure to drain the pus.
Please restart your warfarin on ___.
It was a pleasure taking care of you.
Your ___ Team | ___ with h/o CAD s/p ___, EtOH abuse, biliary
strictures s/p ERCP x 3 with stents and recent cholangitis on
cipro/flagyl, now with melena x 1 day on ___ with ICU stay with
resolving Hgb/SBP without intervention tx to floors given
further workup of possible GI bleeding and biliary involvement.
#GI Bleeding: Unclear etiology, possible small bowel vs colon.
Now with EGD showing normal gastric/duodenal studies with mild
bleeding from the ampulla. Low concern for varices,
___ tears, or ulcers given EGD. Less likely very
lower GI bleed given melena without hematochezia. Pt was
continued on protonix BID (initially protonix drip). Pt's Upper
GI study showed mild oozing at ampulla which could be probable
source of melena. ERCP on ___ involved a sphincterotomy (in
the setting of continued Plavix/aspirin intake), lithotripsy of
cystic duct obstructing stone, and removal of prior stent.
#Liver lesions: Concerning for mets vs related to cholangitis
on prior CT image. Pt needs to be ruled out for colon cancer in
setting of this GIB, some weight loss but possible related to
stopping etOH. Last colonoscopy per patient was ___ years ago
which was notable for benign polyps. Pt had a triple-phase CT
image study (given that his ICD made him ineligible for MR
studies) which showed resolution of the previously seen liver
lesions and interval development of another lesion, suggesting
possible infectious etiology (see below). Pt also had stable
LFTs at time of discharge and will require a colonoscopy
outpatient.
#Cholangitis: Pt had a recent admission for cholangitis
diagnosed by pus on ERCp. Pt never endorsed fevers chills,
abdominal pain, negative ___. Pt was continued on
cipro/flagyl and will continue these medications through ___.
Repeat CT scan on ___ showed possible gallbladder perforation
with very small adjacent fluid collection. Patient appeared
well clinically and was tolerating PO. Surgery was consulted
and felt he should have repeat CT imaging in several weeks and
if the fluid collection is walled off, he should have
percutaneous cholecystostomy to drain it.
#Afib with RVR and aberrancy. CHADsVasc is 3. CHF + HTN + Age
Pt conintued on home on digoxin, Metoprolol; Plavix and
aspirin. No warfarin in the setting of GI bleeding while
hospitalized but pt can continue this after discharge. It was
deemed not necessary to bridge the pt whiel inpatient.
#CAD s/p DES: Pt with known history. Pt will continue aspirin,
Plavix outpatient. Pt will restart home warfarin dose
outpatient.
TRANSITIONAL
=============
- Pt should continue cipro/flagyl through ___
- Pt will need a colonoscopy outpatient.
- Pt will restart home warfarin starting ___.
- Pt requires surgery followup on ___ and interval CT imaging
for management of gallbladder perforation and fluid collection. | 101 | 439 |
10702026-DS-21 | 24,685,255 | Dear ___,
You were admitted to the hospital with symptoms of left facial
droop, right leg weakness, and profound dysarthria. Your
symptoms were due to an acute ischemic stroke. After extensive
discussions about prognosis and quality of life, you and your
family decided to pursue comfort measures only. You were
comfortable and in no distress throughout the rest of your
hospitalization. | Ms. ___ is a ___ y/o F w/ hx of A fib on dabigatran, HTN,
chronic ___ edema, mild cognitive impairment, L sphenoid ridge
meningioma and multifocal subacute infarcts on MRI on ___ with
residual RLE weakness who presents today with new left facial
droop, dysarthria and worsening of RLE weakness with LKW at 7pm
last night. Patient was not a candidate for tPA given being
outside the window and no thrombectomy given no LVO. MRI
confirmed stroke in the left pons and posterior limb of the
internal capsule. After discussion between the team, patient,
and family, Ms. ___ decided to pursue comfort measures only.
She remained comfortable and in no distress for the remainder of
her hospitalization. She expired on ___ at 7:10 ___. | 60 | 119 |
16259178-DS-6 | 26,209,541 | Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
because you were feeling sick and your liver tests were
elevated. We think this is probably from a virus, and they were
already starting to get better today. We don't know the type of
virus yet, and there are still some tests we are waiting for.
However, we do think that you will keep getting better. You also
had a headache and we did a CT scan (cat scan) of your head,
which was normal.
We think it will be really important for you to go to your
primary care clinic later this week, and you may need some more
labs checked to make sure things are getting back to normal.
Please do not take Tylenol for pain until your doctor tells you
it is ok. If you need to take something for pain, you can take
ibuprofen up to 3 times a day.
Again, it was very nice to meet you, and we wish you the best.
Your ___ Care Team | ASSESSMENT AND PLAN: Ms. ___ is a ___ year old woman, with past
history of migraines who is now presenting with acute onset
hepatitis and persistent headache. She was found to have
elevated LFTs of ALT/AST/TB of 131, 103, 3.5 respectively.
Hepatitis serologies were sent, and were significant for Hep B
core antibody positive. A Hep B viral load was sent, and was
pending at time of discharge. A RUQUS showed no findings. As she
had reportedly taken a lot of Tylenol for her headache, NAC
protocol was started, and patient received 3 doses. A head CT
was done for her headache, which was also negative. The
following day, her LFTs downtrended to 96, 69, 2.0
(ALT/AST/Tbili). She was given toradol for her headache, which
improved, and she was able to be discharged home with close
follow up.
# Acute Hepatitis: In the setting of jaundice, presented to the
ED found to have ALT/AST/TB of 131, 103, 3.5 respectively.
Recent travel raises concern for acute viral hepatitis. Patient
has been using APAP over the past week, but patient denies use
>3g/day. Toxicology and hematology were consulted in the ED and
recommended initiation of NAC given concern for tylenol
ingestion (patient stated she was told to take APAP q3hours).
Patient received 3 doses of NAC and APAP levels were negative.
HBcAb was positive suggesting prior resolved infection or acute
infection within the window period. An HBV viral load was
pending at the time of discharge. ___ positive at titer of 1:40
which likely represents false positive given low levels.
Additional labs pending at the time of discharge include HCV
viral load, HIV, EBV, CMV, and Toxo. Patient will follow up with
her PCP ___ ___ for f/u labs and repeat LFTs to assess for
continued resolution of transaminitis and hyperbiliribinemia.
Patient was instructed to avoid tylenol until liver injury
resolves.
# Atypical lymphocytes: Patient with 10% atypical lymphocytes.
Potential causes include EBV, CMV, Toxo, syphillus, and
hepatitis C. Hepatitis B can also cause this presentation. Most
likely c/w viral syndrome. Plan to assess at f/u on ___ to
assess for resolution.
# Headache. Frontal, bilateral
# H/o migraines
Patient reported moderate to severe headache, not her typical
migraine pattern. A head CT was done in the ED, which was
negative. It was felt that this headache may be due to
dehydration in the setting of nausea along with possible viral
syndrome. She was given 1L NS and toradol with improvement in
her symptoms. She was instructed to continue ibuprofen 600mg TID
for the next ___ days for control of her symptoms.
# Cholelithiasis. Noted on RUQ on admission. No secondary
findings of acute cholecystitis or biliary ductal dilatation.
She remained asymptomatic during her admission.
===============================
TRANSITIONAL ISSUES
===============================
- The following studies were pending at time of discharge: HIV,
HepB viral load, HepC viral load, Toxo IgG and IgM antibody,
___ antibodies, CMV antibodies.
- ___ found to be positive with titer 1:40, which was thought to
be a nonspecific finding.
- Patient should not be given Tylenol until LFTs resolve.
- Patient should have repeat CBC and LFTs at her next
appointment. Noted to have anemia that worsened during
hospitalization. Please assess for resolution.
- A u/a should be rechecked in outpatient setting to look for
resolution of ketonuria and proteinuria.
# CODE: full (presumed)
# CONTACT:
- Mother, ___ ___
- Father, ___ ___ | 183 | 561 |
17801367-DS-18 | 26,071,177 | Dear Ms. ___,
You were admitted to the hospital with L-sided abdominal pain,
likely due to diverticulitis. You improved with antibiotics, and
are being discharged to complete a 10 day course (through ___.
Please slowly advance your diet as able and let your primary
care doctor know if you experience worsening pain or diarrhea.
Your blood pressure was normal on a reduced dose of your home
blood pressure medications, likely due to a more limited diet.
Please continue your atenolol at the usual dose, take half
(160mg) of your valsartan, and do not take your amlodipine or
hydrochlorothiazine until told otherwise by your primary care
doctor.
With best wishes for a speedy recovery,
___ Medicine | Ms. ___ is an ___ female with hx diverticulitis,
mitral valve prolapse, partial pneumonectomy from
bronchiectasis,
hypothyroidism, and hypertension presenting with L-sided
abdominal/flank pain, likely secondary to acute, uncomplicated
diverticulitis.
# L-sided abdominal/flank pain:
# Acute, uncomplicated diverticulitis:
Patient presented with L-sided abdominal/flank pain, with
evidence of descending colon acute uncomplicated diverticulitis
on imaging. No evidence of nephrolithiasis and low suspicion for
UTI (no urinary symptoms, and urine culture suggests
contamination). Of note, patient has hx of diverticulitis, for
which she was previously followed by GI (last ___. She
received
one dose of Zosyn in the ED, transitioned to CTX/flagyl on
admission given her hx of multiple allergies (including PCN,
fluoroquinolones). She tolerated the regimen well, with
resolution of her abdominal/flank pain. She was transitioned to
cefpodoxime/flagyl on ___ to complete a 10d course (___).
She was tolerating a liquid diet with crackers and simple solids
(such as rice) at the time of discharge and will advance her
diet
slowly as tolerated. She will ___ with her PCP and with
outpatient GI (appointments pending at discharge).
# Diarrhea:
Patient reported diarrhea prior to admission that worsened on
___. Likely secondary to acute diverticulitis vs antibiotics
and
resolved spontaneously by the time of discharge. C.diff was
negative.
# Dizziness/lightheadedness:
Patient reported dizziness/lightheadedness on presentation,
likely secondary to dehydration secondary to diverticulitis/poor
PO intake and diarrhea as above. Orthostatics negative on
admission, however, and negative again ___. Low suspicion for
ACS given negative cardiac enzymes and non-ischemic EKG. Home
atenolol was continued and home valsartan continued at half home
dose (160mg in place of 320mg daily). Home HCTZ and amlodipine
were held. Given normotension, regimen was continued at
discharge
pending ___ with PCP.
#HTN:
As above, patient endorsed dizziness on admission. Orthostatics
negative, but home anti-hypertensives adjusted as above given
limited PO intake and resolving diarrhea. Normotensive on this
regimen, which was continued on discharge pending PCP ___.
#Dysthymia and panic disorder:
Continued home bupropion and clonazepam.
#Hypothyroidism:
TSH WNL. Continued synthroid.
#OSA:
Continued home CPAP.
#OTC medications:
Continued patient's home tyrosine BID.
# R adnexal cyst:
CT A/P revealed 2.3 x 2.2 x 2.5 cm R adnexal simple cyst. Per
radiology guidelines, no ___ required based on size criteria.
** TRANSITIONAL **
[ ] continue cefpodxime/flagyl through ___
[ ] resume home BP meds as tolerated/necessary
[ ] ___ with GI for recurrent diverticulitis | 111 | 341 |
10578325-DS-48 | 21,157,506 | Mr. ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you were having chest pain.
Reassuringly both your EKG (test of the electrical activity) of
your heart and blood test demonstrated that you did not have a
heart attack. There was some concern that you may have had a
blood clot in your lungs, so a special scan was done and showed
no clot.
The cause for your chest pain is still not clear, but it is
unlikely to be anything serious. Sometimes problems with your
esophagus can cause pain like this, so we are starting you on a
new medicine called nifedipine to see if this might help the
pain. This will also help control your blood pressure. Your
primary doctor should schedule an endoscopy to take a closer
look at your esophagus to evaluate for this problem.
Changes to your medications:
START nifedipine CR 30 mg daily
Please continue to take all other medications as instructed.
Please feel free to call for any questions or concerns.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure to take care of you at ___ Deaconess! | ___ yo M with morbid obesity (BMI >70), chronic lymphedema and
cellulitis, HTN, depression w h/o suicide attempts,
schizoaffective disorder, and asthma presents with chest pain
with elevated d-dimer, admitted for V/Q scan.
.
ACTIVE ISSUES BY PROBLEM
# Chest pain: The etiology of the patient's chest pain is
unclear. Acute coronary syndrome was felt to be unlikely given
EKG without ischemic changes and 2 sets of negative troponins.
Pain was not reproducible to palpation to suggest MSK etiology.
CXR without signs of PNA. Also without fevers or elevated WBC.
Pt did have elevated D=dimer in 800s, however ___ Dopplers were
negative. He is mimimally mobile which could put him at risk but
states he has been ambulating regularly. Given his body habitus,
a CTA was not possible. He had a V/Q scan which was low
probability, so pulmonary embolism was essentially ruled out. It
is possible that his symptoms could be GI in origin, such as
from intermittent esophageal spasm or stricture. He does also
endorse easily choking on foods at times and spitting up,
especially with steak. He was started on therapeutic trial of
calcium channel blocker with nifedipine, which will also help
control his blood pressure. Should be monitored at rehab for BP
and see if this makes any difference in his chest pain.
Recommend outpatient EGD for further evaluation.
.
# Bradycardia: Patient was noted to have sinus bradycardia
throught admission with HR dipping to the mid ___ while
sleeping. The patient was asymptomatic with stable blood
pressure. He was monitored on telemetry as above.
.
STABLE ISSUES
# Asthma: Uses advair and albuterol at home (says he uses a neb
nightly). He was continued prn albuterol nebulizer treatments
and his home advair.
.
# HTN: Patient was continued on his home lisinopril and started
on nifedipine CR 30 mg for therapeutic trial for esophageal
spasm.
.
# Psychiatric disorders: Patient has a history of
schizoaffective and depression. He was continued on his
outpatient regimen of abilify and wellbutrin.
.
# Anemia: Microcytic, at baseline. Has known hemoglobin C trait.
Hct was at baseline throughout admission.
.
TRANSITIONAL ISSUES
- Chest pain: started therapeutic trial of nifedipine for
possible esophageal spasm, should assess affect on chest pain.
- Recommend EGD to rule out esophageal stricture, possible
esophageal manometry to futher assess for esophageal spasm.
- BP: should have BP monitored at least twice daily for the
first week after starting nifedipine.
- FULL CODE this admission | 204 | 410 |
15161118-DS-3 | 25,147,556 | Dear Ms. ___,
You were admitted to ___
because you fell and fractured your hip. You underwent surgery
to fix this, which you tolerated well. While you were here, you
were also treated with antibiotics for a urinary tract
infection.
You should follow up with your primary care doctor and the
Orthopedic surgery team.
While you were here, some changes were made to your medications.
Please START
1. Enoxaparin 40mg subcutaneous injection in evenings until
___
2. Calcium Carbonate 1000 mg DAILY
3. Vitamin D 400 UNIT DAILY
4. TraMADOL (Ultram) ___ mg every 6 hours as needed for pain
5. traZODONE 12.5-25 mg at bedtime as needed for insomnia
6. Guaifenesin-Dextromethorphan 5 mL PO every 6 hours as needed
for cough
7. Multivitamins 1 CAP DAILY
8. Benzonatate 100 mg three times a day as needed for cough
9. Lisinopril 5mg DAILY
10. Insulin Slididng Scale-see attached
Please continue your previous medications:
1. Atenolol 12.5 mg DAILY | SUMMARY: ___ yo female with history of osteoporosis who was
admitted with left hip fracture following mechanical fall and
altered mental status which was attributed to UTI. She underwent
L hip arthroplasty with Orthopedic surgery team and was started
on ceftriaxone for UTI.
.
# Leukocytosis: Likely secondary to UTI, possibly exacerbated by
acute fracture, however UTI treated and infectious workup
unrevealing of infection; CXR negative, repeat UA essentially
negative (few bact, 5 epis). She is otherwise stable and no
nidus of infection identified at this time. ___ be prolonged
inflammatory response to fracture. She must be followed closely
at rehab, with AM labs tomorrow as well as evaluation by rehab
MD and RN to monitor for source of infection.
.
# Left Hip Fracture: Her fall was witnessed at Stop and Shop.
She had a mildly displaced and angulated left femoral neck
fracture on x-ray. She underwent L hip hemiarthroplasty
___. For pain control, she was treated with standing
acetaminophen and PRN tramadol. For DVT prophylaxis, she was
treated with enoxaparin 40 mg QPM x 2 weeks (until ___. She
was started on calcium and vitamin D for her osteoporosis. At
the time of discharge, she had minimal pain, and felt ready for
physical rehabilitation.
.
# UTI: She was found to have a UTI on admission, with cultures
growing pan-sensitive klebsiella. She was treated with IV
ceftriaxone, and transitioned to ciprofloxacin for a 5-day
course. She has a history of recurrent UTIs per her PCP, most
recently in ___ according to OMR, usually pan sensitive E. Coli
or Klebsiella.
.
# AMS: Likely multifactorial: underlying dementia, sundowning on
admission, infection, and pain from hip fracture. Per reports of
others she has some dementia at baseline. This completely
resolved at the time of discharge.
.
# Elevated lactate: Resolved with fluids.
.
# Tachycardia: resolving. Pt had sinus tachycardia dating back
to ___ with no clear etiology identified. PCP cannot recall at
this time what workup was done but will check paper chart. Most
likely secondary to pain, dehydration, infection, or combination
thereof. She was treated with IV fluids, and her home atenolol
was continued.
.
# GERD: Patient does not take omeprazole at home per daughter.
Stopped on discharge.
.
# Hypertension: Pt does not take atenolol per her daughter. We
restarted her atenolol control BP and HR.
.
#Hyperglycemia: ISS in house and as outpatient for glucose
control.
.
>> TRANSITIONAL ISSUES
- AM labs tomorrow as well as evaluation by rehab MD and RN to
monitor for source of infection
- Code status: DNR/DNI
- Emergency contact: Daughter ___ is HCP. cell:
___. home ___. In case of emergency, ___
nephew ___ also works at ___.
- Remove staples in L hip and L elbow in 4 weeks after discharge
- Studies pending at discharge: blood cultures from ___,
___. | 157 | 458 |
16590876-DS-11 | 27,118,946 | Dear ___ were admitted to ___ after ___ were found to have a fast
heart rate at dialysis and some swelling in your right arm. ___
were given medication to help with your heart rate and ___
received a fistulogram and procedure to open up your fistula and
decrease your arm swelling. While ___ were here we noticed ___
have had a drop in your blood count compared to earlier this
year and we looked into why this might be. We did not find any
sign of active bleeding and your blood counts recovered. Your
blood counts remained stable while ___ were here and we could
not find an immediate explanation for this. ___ received two
sessions of dialysis while ___ were in the hospital. Please take
all your medications as ___ did before coming to the hospital.
It was a pleasure taking care of ___ while ___ were in the
hospital.
Wishing ___ well,
Your ___ care team. | BRIEF HOSPITAL COURSE:
___ year old woman with ESRD on dialysis ___ and history of
subcortical stroke in ___ on Plavix therapy, presenting from HD
with elevated HR 140-150s. New concern for drop in H and H since
___, being evaluated for anemia.
# SVT: Patient found to be tachycardic at HD on ___. Has no
history of tachycardia that she knows of. EKG consistent with
SVT, AVRT/AVNRT. Responded to adenosine 6mg IV, and converted to
sinus tachycardia. Not thought to be of cardiac origin givin
Troponin 0.08, without evidence of ischemic changes on EKG.
Patient remained hemodynamically stable and in sinus rhythm with
regular rates in the ___ and ___ throughout the rest of her
admission. No conern for infectious etiology given negative
blood and urine cultures. Possibley due to anemia/hypovolemia.
Thyroid function WNL.
# Right upper extremity swelling: Patient with swelling of right
hand, she says it has been worse for 2 days, but on further
history gathering, appears to be a chronic issue. No thrombus
seen on US. Received fistologram and angioplasty after central
stenosis and reduced venous outflow was noted. Swelling has now
resolved.
# Hypoxia: Patient developed new oxygen requirement overnight on
___. Received HD ___ and ___. No lung dx reported on
PMH. CXR with atelectasis and volume overload, no evidence of
pneumonia. Patient most likely volume overloaded. Stableized on
room air for 24 hours prior to discharge. Ipratropium nebulizers
were given PRN.
# ESRD on HD ___: did not receive HD on ___ due to
tachycardia. On admission hypoxic, with lung exam consistent
with volume overload. Lung exam improved. Received HD ___ and
___. Continued Cinacalcet 30 mg PO DAILY, Nephrocaps 1 CAP PO
DAILY ,sevelamer CARBONATE 1600 mg PO TID W/MEALS
# elevated troponin: Trop 0.08. No ischemic changes on EKG. Pt
has ESRD, and likely falsely elevated in setting of renal
failure.
# History of TIA and stroke in the past. Continued plavix.
Stopped simvastatin.
# anemia: Pt was admitted with new anemia H/H 8.2/25.5, down
from baseline of 11.1/32.5 in ___. MCV >100. No evidence of
acute bleed. Had ESRD, which could be contributing. B12, folate
WNL. Called Guaiac positive stool in ED however daughter reports
there is usually a small amount of blood in her stool because of
a known fistula. Patient and daughter preferred to follow up on
anemia as an outpatient.
# Hx gout: continued Allopurinol ___ mg PO DAILY | 160 | 406 |
12213317-DS-16 | 23,236,831 | Dear Ms. ___,
You were transferred to ___
from another hospital to manage a condition called Acute Liver
Failure.
What was done during this hospitalization?
- You were admitted to the intensive care unit for close
monitoring.
- You had additional problems with your pancreas and kidneys.
- We looked for specific causes of your liver failure,
pancreatitis and kidney injury. The liver failure was most
likely from taking too much Tylenol and drinking alcohol. The
pancreatitis was also caused by too much alcohol. The kidney
injury happened as an effect of not eating and drinking well for
several days.
- You received medications for pain and fluids.
- You were evaluated by liver (Hepatology), pancreas
(Gastroenterology) and kidney (Nephrology) specialists.
- You recovered well and are safe to go home.
What should you do now that you are leaving the hospital?
- Do not drink alcohol
- Attend the intensive outpatient program you discussed with our
social worker
- Take your medications as prescribed
- Do not take more than 2 grams of acetaminophen per day
- If you are taking NSAIDs (ibuprofen, motrin, aleve) do not use
for more than ___ days in a row or you will hurt your kidneys.
If you are having this much pain, you should make an appointment
to see your doctor soon.
- Attend your follow-up appointments
- Return to the ER or call your doctor if you have any
concerning symptoms including fever > 100.5F, passing out, chest
pain, inability to breathe, vomiting blood, blood in your stool,
sudden or painful swelling in your stomach, stop making urine
for more than 12 hours
It was a pleasure taking care of you. Wishing you the best in
health!
Sincerely,
Your ___ Team | This is a ___ year old woman with a history notable for etOH
abuse who presents with acute hepatitis and pancreatitis, as
well as acute renal failure.
==================================================
MICU Course
___
==================================================
# HYPERACUTE LIVER FAILURE: Suspect APAP toxicity on background
of chronic etOH use (& likely chronic liver disease; cirrhosis
not ruled out based on diffuse infiltration of liver on RUQ US).
Per report, patient took 12 g APAP/day for at least a few days.
N-acetylcysteine started in ED. Stopped after 12 hours, given
INR<2.0, improving LFTs, and negative APAP level. Hepatitis
serologies negative (HAV, HBV & HCV serologies tested).
# PANCREATITIS: markedly elevated lipase on admission, with
abdominal pain. RUQ ultrasound without evidence of gallstones.
CT not suggestive of pancreatitis, however given epigastric
pain, elevated lipase and alcohol abuse, likely has pancreatitis
at this time. Not on medications at home to suggest
medication-induced. Could consider IgG-4 disease, given age,
though etOH history much more suggestive. The patient was given
2L LR later transitioned to bicarb gtt given worsening acidosis.
Her diet was advanced to clears with plans to continue to
advance as tolerated.
# COAGULOPATHY: Likely secondary to acute hepatitis now
improving. No signs of bleeding during ICU stay.
# THROMBOCYTOPENIA: likely sequela of chronic etOH. Without
signs of bleeding at this time.
# ELEVATED ANION GAP METABOLIC ACIDOSIS: lactate only mildly
elevated to mid-2s on admission. BUN also only mildly elevated
to mid-30s. Would not expect AG elevation to mid-20s with mild
acidosis from above causes. Serum Osms normal and normal osmolar
gap. Could suspect 5-oxoproline from APAP playing a role. As
above, after 2L LR, switched to bicarb gtt and discharged from
ICU on bicarb gtt. On discharge, gap had closed.
# HYPONATREMIA: suspected hypovolemic as has had poor PO intake.
Unclear duration. Severity mild. Monitored w/ q8h electrolytes
# ACUTE KIDNEY INJURY: unclear baseline, since no labs in our
system & none recent at Atrius. Precise etiology not clear,
though pancreatitis and hepatitis could be contributing. Poor
prognostic sign for either. In ED, got 2 L LR, and first BMP in
ICU showing Cr continues to rise. Could be related to APAP, but
patient taking OTC analgesics (may have also been taking
NSAIDs). Renal consulted. Peaked at 2.9 and started downtrending
prior to transfer.
# ETOH USE DISORDER: reports drinking 5 large vodka drinks per
day for the past "few" years. Her longest period of sobriety has
been 3 days. She has never had a withdrawal seizure, but has had
minor withdrawal symptoms. Monitored on CIWA protocol x3 days,
no tremor or other withdrawal symptoms.
===================================================
MEDICINE COURSE
___
===================================================
# Acute liver failure: Per above, conceptualized as acute
acetaminophen toxicity and alcoholic hepatitis. LFTs continued
improving s/p NAC. The patient did not receive steroids for
alcoholic hepatitis given improving LFTs. Hepatology consultants
followed the patient. She will be seen in follow-up by them.
# Pancreatitis c/b acute peripancretic fluid collection: As per
MICU Admission, most likely from EtOH. Diet was advanced and on
___ the patient began tolerating solid foods. On ___, with a
rising leukocytosis, CT A/P ordered and demonstrated a
peripancreatic fluid collection. Gastroenterology was consulted.
As the patient remained otherwise stable and tolerated POs, no
intervention pursued this hospitalization. She will have an
appointment w/ GI in ___ weeks with reimaging at that time.
# Acute kidney injury: On transfer, patient had been oliguric.
On ___, began making regular urine and from ___ through
remainder of hospitalization had >2L UOP/d. As above, renal
function peaked on ___ at 2.9 and downtrended to normal range
prior to discharge. Differential remains unclear, thought to be
pre-renal versus intrinsic (ATN or CIN).
# Leukocytosis: Rising leukocytosis daily while on Medicine
course. Focal symptoms were cough and abdominal pain. Exam
notable for diffuse edema. On ___, pursued CT C/A/P, that
demonstrated pulmonary edema, possible hepatosteatosis, and
peripancreatic fluid collection. Given the patient's cough and
ICU exposure, levofloxacin was started once by the primary team
(___), then stopped after 1 dose. It was restarted by
cross-coverage team 2 days (___) later because of increasing
white count. On ___, the patient remained afebrile, with normal
respiratory effort and hemodynamically stable. Upon review,
leukocytosis felt to be most likely attributable to
peripancreatic fluid and resolving hepatitis. Levofloxacin
stopped. Total abx exposure: levofloxacin ___ x1 dose, ___ x1
dose. On the day of discharge, the WBC count was 24.5, and the
patient should have follow-up blood work in 1 week.
# Hyponatremia: Evolving picture during Medicine floor course.
On transfer, patient hypervolemic on exam and receiving bicarb
gtt, thought to be hypervolemic hyponatremia in setting of liver
failure. However, on ___, patient closer to euvolemia by
exam and repeat serum Osm (264), UNa (104), UOsm (284) were more
suggestive of SIADH. This is thought to be secondary to
inflammation and pain from peripancreatic fluid collection and
resolving hepatitis.
# Concern for hematemesis: Reported 1 episode of brown blood on
the evening of ___. PPI was uptitrated to BID. Remained
hemodynamically stable. Had 2 other episodes of NBNB emesis
during hospitalization, regurgitation of meals. No subsequent
hematemesis, coffee ground emesis, hematochezia, melena.
Deferred endoscopy. On discharge, continue BID PPI until seen in
clinic.
# Alcohol Use Disorder: Seen by social work. Amenable to IOP and
naltrexone at time of discharge. Discharged with plan to
follow-up with ___, ___
___ contact information provided in discharge
worksheet.
# Active Smoker: continue nicotine patch while inpatient
# Recent fall: Per Atrius note from ___ pt fell down 13
steps and was found to have rib fracture, denied alcohol was
involved. No mention of domestic violence.
# Splenic aneurysm: Per Atrius records, had been scheduled for
splenic aneurysm coiling ___. Patient stated she rescheduled
this.
TRANSITIONAL ISSUES:
====================
-LABS: Recommend obtaining CBC, BMP, LFTs, Coags within next ___
days for monitoring
-LEUKOCYTOSIS: Discharged w/ rising leukocytosis but no other
signs of infection. Thought to be due to pancreatic fluid
collection. Recommend f/u lab work in next ___ days.
-ACUTE LIVER FAILURE: will need out patient hepatology work up
upon discharge for staging of liver disease seen on ultrasound
and physical exam.
-PANCREATITIS: will need out patient GI f/u (scheduled)
-ALCOHOL USE DISORDER: plan to go to IOP. Please consider
starting naltrexone for cravings
-NUTRITION/HYPONATREMIA: tolerating POs, hyponatremia resolved
w/ fluid restriction.
# CODE: Full
# CONTACT: ___, Friend, ___ | 272 | 1,028 |
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